Proximal femoral factures (PFFs) constitute a heavy medical, social, and economic burden. Overall, orthopaedic conditions vary widely in France regarding the patients involved and treatments applied. For PFFs specifically, data are limited. Moreover, the ongoing expansion of geriatric orthopaedics holds promise for improving overall postoperative survival. The objectives of this retrospective study of a nationwide French database were: 1) to describe the pathway of patients with PFFs regarding access to care, healthcare institutions involved, and times to management; 2) to look for associations linking these parameters to post-operative mortality.

Across France, variations exist in healthcare service availability and time to management for patients with PFFs.

A retrospective analysis of data in a de-identified representative sample of statutory-health-insurance beneficiaries in France (Échantillon généraliste des bénéficiaires, EGB, containing data for 1/97 beneficiaries) was conducted. All patients older than 60 years of age who were managed for PFFs between 2005 and 2017 were included. The following data were collected for each patient: age, management method, Charlson's Comorbidity Index (CCI), home-to-hospital distance by road, and type of hospital (public, non-profit private, or for-profit private), and time to surgery were collected. The study outcomes were the incidence of PFF, mortality during the first postoperative year, changes in mortality between 2005 and 2017, and prognostic factors.

In total 8026 fractures were included. The 7561 patients had a median age of 83.8 years and a mean CCI of 4.6; both parameters increased steadily over time, by 0.18 years and 0.06 points per year, respectively (p<10⁻⁴ for both comparisons). Management was by total hip replacement in 3299 cases and internal fixation in 4262 cases; this information was not available for 465 fractures. The overall incidence increased from 90/100,000 in 2008 to 116/100,000 in 2017 (p=0.03). Of the 8026 fractures, 5865 (73.1%) were managed in public hospitals (and this proportion increased significantly over time), 1629 (20.3%) in non-profit private hospitals (decrease over time), and 264 (3.3%) in for-profit private hospitals. The home-to-hospital distance ranged from 7.5 to 38.5km and increased over time by 0.26km/year (95% confidence interval [95%CI]: 0.15–0.38) (p<10⁻⁴). Median time to surgery was 1 day [1–3 days], with no significant difference across hospital types. Mortality rates at 90 days and 1 year were 10.5% (843/8026) and 20.8% (1673/8026), respectively. Two factors were significantly associated with day-90 mortality: the CCI (hazard ratio [HR], 1.087 [95%CI: 1.07–1.10] [p<10⁻⁴]) and time to surgery>1 day (HR 1.35 [95%CI: 1.15–1.50] [p<0.0001]). Day-90 mortality decreased significantly from 2005 to 2017 (HR 0.95 [95%CI: 0.92–0.97] [p<10⁻⁴]), with no centre effect.

The management of PFF in patients older than 60 varied widely across France. Time to surgery longer than 1 day was a major adverse prognostic factor whose effects persisted throughout the first year. This factor was present in over half the patients. Day-90 mortality decreased significantly from 2005 to 2017 despite increases in age and comorbidities.

IV Retrospective cohort study.