The effect of the grade of surgeon on blood loss in fractured neck-of-femur surgery.

Abstract

Significant blood loss in neck-of-femur (NOF) fracture surgery contributes to the high morbidity and mortality. Since the introduction of the European Working Time Directive, trainee surgeons are more junior and inexperienced. We assessed NOF surgical blood loss in relation to the surgeon grade and experience. We assessed a prospective consecutive cohort of 105 acute NOF fracture patients treated surgically. Blood loss was calculated as the difference between the pre- and post-operative haemoglobin levels. Warfarin was reversed pre-operatively where necessary. There were 32 male and 73 female patients, with mean age 83.8 years (range 48-98). One patient died peri-operatively and was excluded. There were 49 intra-capsular fractures and 55 extra-capsular fractures, with no significant difference in group characteristics. Mean haemoglobin drop was 2.8 g/dL [intra-capsular fractures, 2.5 g/dL; extra-capsular fractures, 3.1 g/dL (p = 0.019)]. The difference in blood loss between different surgeon grades was not significant: consultants 2.4 g/dL (21 cases), senior staff grades 2.7 g/dL (17 cases), junior staff grades 3.1 g/dL (15 cases) and registrars 2.9 g/dL (50 cases). Whilst mean haemoglobin drop was least for consultants, the mean for trainees was only marginally higher than for experienced staff grade surgeons and lower than for their junior counterparts. Mean blood loss for patients taking anti-platelet agents was not significantly different (aspirin 2.7 g/dL, clopidogrel 3.7 g/dL, 4.4 g/dL for those taking both) compared to patients taking neither agent (2.8 g/dL). We conclude that surgeon grade does not significantly impact peri-operative haemoglobin drop, regardless of pre-operative morbidity. It is safe for trainees to operate, with adequate supervision where appropriate, on all NOF fracture patients without compromising blood loss.