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Outcome of femoral fractures care as a measure of trauma care between level I and level II trauma systems in Israel
  1. A Khoury,
  2. Y Weil,
  3. M Liebergall,
  4. R Mosheiff
  5. The Israeli Orthopedic Trauma Group
    1. Hadassah University Hospital, Jerusalem, Israel
    1. Correspondence to Dr Amal Khoury, Orthopedic Trauma and Reconstructive Surgery, Hadassah Hospital & Hebrew University School of Medicine, Ein-Kerem, Jerusalem 91120, Israel; akhoury{at}


    Background Our hypothesis in this study was that the outcome of patients with femur fractures would be favorable in a level I trauma center (LITC).

    Methods A prospective multicenter cohort study. 5 LITC and 6 regional (level II) trauma centers (RTCs) were enrolled to participate in the study. A total of 238 patients suffering from a femoral fracture were recruited to the study. 125 patients were treated in LITCs and 113 in RTCs. Data were extracted from the emergency medical services ambulances, emergency department records, patient hospitalization and discharge records, operating room records, and the national trauma registry (for LITCs). A study questionnaire was administered to all participating patients at discharge, 6 weeks and 6 months postoperatively. The following parameters were studied: mechanism of injury, time from injury to the hospital, Injury Severity Score, classification of femoral fracture, additional injuries, medical history, time to surgery, implant type, skill level of the surgical team, type of anesthesia, length of stay and intensive care unit (ICU) stay, postoperative and intraoperative complications and mortality.

    Results There was a significant difference in the modality of patient transfer between the 2 study groups—with the LITC receiving more patients transported by helicopters or medical intensive care. Time to surgery from admission was shorter in the LITC. Length of stay, ICU stay, and mortality were similar. In the LITCs, 47% of the procedures were performed by residents without the supervision of an attending surgeon, and in the RTCs 79% of the procedures were performed with an senior orthopaedic surgeon. Intraoperative and immediate complication rates were similar among the 2 groups.

    Conclusions A femoral shaft fracture can be successfully treated in an LITC and RTC in the state of Israel. Both research and policy implementation works are required. Also, a more detailed outcome analysis and triage criteria for emergency are desired.

    Level of evidence II.

    • health care policy
    • femur fracture
    • Efficiency

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    • Collaborators The Israeli Orthopedic Trauma Group: M Liebergall, R Mosheiff, A Khoury, Y Weil, Hadassah Ein Kerem,* Y Bar-Ziv, Asaf Harofeh Medical Center, B Kish, Meir Hospital, A Korngreen, Soroka Medical Center, N Ron, Hillel-Yaffemedical Center, N Rozen, Rambam Healthcare Campus, S Sagiv, Kaplan Medical Center, N Shazar, Sheba Tel Hashomer Medical Center, Tantzman M. Ha'Emek Medical Center, S Velkes, Rabin Medical Center, G Volpin, Galil Ma'aravi Medical Center of Nahariya.

    • Contributors YW has equally contributed to the writing of the manuscript as AK.

    • Funding The Israel National Institute for Health Policy and Health Services Research. Grant number 712002/χ.

    • Competing interests None declared.

    • Patient consent Obtained.

    • Ethics approval The study was approved by the local ethics committee in each of the participating centers.

    • Provenance and peer review Not commissioned; externally peer reviewed.

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