Strategies to improve recruitment rate to the WHiTE 8 trial and investigating the effectiveness and safety of the use of antibiotic loaded bone cement in hip fractures

Background
Hip hemiarthroplasty is commonly performed in hip fractures. Strategies to reduce surgical site infection (SSI) should be evaluated through randomised control trials (RCT). Additionally, strategies to improve recruitment rate to trials need to be investigated to improve efficiency and reduce research waste.

Aims
This thesis investigates the effectiveness of antibiotic loaded bone cement (ALBC) in hip fractures and safety on the risk of acute kidney injury (AKI). Additionally, it investigates two strategies to improve recruitment rate to the WHiTE 8 trial.

Methods
I conducted a cohort study on hip fracture receiving a cemented hemiarthroplasty and analysed the effect of different gentamicin containing systemic and ALBC regimens on AKI rate. In my factorial RCT I evaluated two interventions; an enhanced trainee principal investigator (TPi) package and a digital nudge to determine the effect on recruitment rate to the WHiTE 8 trial. Finally, I evaluated the use of ALBC in hip fractures through a systematic review.

Results
There were no differences in AKI rates between differing gentamicin systemic and ALBC regimens in hip fractures receiving a cemented hemiarthroplasty. My factorial RCT showed benefit on recruitment (IRR 1.23 95% 1.09 to 1.40, p=0.001) from utilizing an enhanced TPi education intervention. The digital nudge intervention had no impact on recruitment (IRR 0.89 95% CI 0.79 to 1.01, p=0.07). My systematic review showed that ALBC were shown to be favourable over plain bone cement for SSI prevention but there were mixed results when comparing different gentamicin concentrations in ALBC.

Conclusions
This thesis supports the use of low dose single ALBC, though, further RCTs are needed to determine if high dose dual ALBC confers any added benefit in SSI prevention. Recruitment rate to RCTs can be improved with an enhanced TPi package. There are mixed results with
a digital nudge intervention and should be used cautiously used in RCT trial design.