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Management of hip fractures in the elderly
ORTHOPAEDICS IV: LOWER LIMB
Management of hip fractures in the elderly
for trusts if they meet all seven performance indicators (Box 1) for the patient, thus creating an incentive to deliver optimal care.4 For the 2015/16 financial year, this is an additional £1339 per patient,5 and this is to increase to £1353 per patient in 2016/ 17.6 The 2015 NHFD report has shown this is currently achieved for 63.3% patients nationally. The National Institute for Health and Care Excellence (NICE) produced guidelines on the management of hip fractures in adults (Clinical Guideline 124) in 2011, with the latest modification published in 2014.7 These guidelines looked at areas of large variation and controversy. It also undertook a metaanalysis of the relevant randomized controlled trials and a costeffective analysis where appropriate. In some areas, where there was no conclusive evidence, the guideline development group undertook decisions based on humanitarian principles and consensus decisions. As a consequence of recognizing the importance of a multidisciplinary care pathway, there was a renewed emphasis on the care of this patient group, who were often given low priority in the past. This has led to a better understanding of what influences outcomes, as well as providing savings, as it is known that treating well is cheaper than treating badly.
Tim Chesser Govind Chauhan Michael Kelly
Abstract A fracture of the proximal femur (or hip fracture) is a devastating injury to an elderly patient. Nearly all patients require surgery as part of their treatment but their care necessitates complex multidisciplinary involvement. In the last ten years there have been a number of initiatives to help improve care for this challenging patient group, as well as establishment of The National Hip Fracture Database, to allow us to audit the care provided. With this focus, we have seen both mortality and length of stay decrease. The aim of this article is to summarize the current recommendations for patients who suffer a hip fracture.
Keywords Hip fracture; intracapsular fracture; proximal femoral fracture; subcapital fracture; subtrochanteric fracture.; trochanteric fracture
What is a hip fracture? This is a fracture occurring anywhere between the edge of the femoral head and 5 cm below the lesser trochanter (Figure 1). They are divided into intra- or extra-capsular, with extra-capsular fractures further subdivided into trochanteric and subtrochanteric (Figure 2). There is however some overlap between these groups. Fractures at the base of the femoral neck (basicervical fractures), are classified in the trochanteric group and treated as such. Also, both trochanteric and subtrochanteric fractures may extend, thus being labelled as trochanteric fractures with subtrochanteric (distal) extension, or subtrochanteric fractures with trochanteric (proximal) extension.
Hip fractures (or fractures of the proximal femur) in the elderly have an incidence of approximately one per 1000 head of population in western countries and are associated with a significant cost to any healthcare system. Delivery of care to this challenging patient group requires a multidisciplinary approach. Hip fracture outcome is now used as a surrogate marker for how hospitals manage frail, elderly patients.
Guidelines In the UK, there are several initiatives and guidelines for this patient group. The year 2007 saw The British Orthopaedic Association and British Geriatric Association publish a joint ‘Blue Book’ on ‘The care of patients with fragility fracture’, and the ‘Standards for trauma’ (BOAST 1) for hip fractures.1,2 At the same time, the National Hip Fracture Database (NHFD) started a web-based national audit.3 Every hospital in England, Wales and Northern Ireland admitting hip fractures is registered with the NHFD, and in 2014, data for over 64,000 patients were entered, estimated to represent over 95% of cases.3 Following on from this, together with Lord Darzi’s 2008 ‘High Quality Care for All’ report, a ‘best practice tariff’ (BPT) for hip fractures was introduced in 2010. This provides an additional per patient payment
Best practice criteria 2015e20164
Tim Chesser MBBS FRCS (Tr and Orth) is a Consultant Trauma and Orthopaedic Surgeon at Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
C
Surgery within 36 hours from arrival (or diagnosis if inpatient fall) to induction of anaesthesia
C
Admission under the joint care of a consultant geriatrician and consultant orthopaedic surgeon
C
Admitted using a hip fracture protocol
C
Assessed by a geriatrician (ST3 or above) within 72 hours of admission
C
Postoperative, multidisciplinary rehabilitation
C
Bone health and falls prevention assessment
C
An abbreviated mental test score (AMTS) pre- and postoperatively
Govind Chauhan BMBS MRCS is an Orthopaedic Registrar at Southmead Hospital, North Bristol NHS Trust, Bristol, UK. Michael Kelly MBBS MD FRCS (T&O) is a Consultant Trauma and Orthopaedic Surgeon at Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
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Box 1
1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Chesser T, et al., Management of hip fractures in the elderly, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.06.002
ORTHOPAEDICS IV: LOWER LIMB
95% of cases. In those cases where the clinical history is suspicious of a hip fracture, but the radiographs are negative, the recommendation is for an MRI scan. If this is not available within 24 hours, or contraindicated, a CT scan should be undertaken.7
The multidisciplinary approach e ‘The Hip fracture Programme’ Hip fractures should no longer be managed on surgical wards by orthopaedic surgeons in isolation. Recognition of the importance of the multidisciplinary approach is thus implicit. In doing this, not only are the surgical standards met but patients’ medical, cognitive, analgesic, nutritional, social and rehabilitation needs are identified as early as possible and given prominence. A hip fracture programme should exist for these patients, with senior geriatric perioperative medical input, and increasingly taking the lead for postoperative medical care, multidisciplinary rehabilitation (MDR) and discharge planning. From admission, the patients should be offered a formal, acute orthogeriatric or orthopaedic ward-based ‘Hip Fracture Programme’ that includes all of the following:7 orthogeriatric assessment rapid optimization of fitness for surgery early identification of individual goals for MDR to recover mobility and independence, and to facilitate return to prefracture residence and long-term wellbeing continued, coordinated, orthogeriatric and multidisciplinary review liaison or integration with related services, particularly mental health, falls prevention, bone health, primary care and social services clinical and service governance responsibility for all stages of the pathway of care and rehabilitation, including those delivered in the community.
Figure 1
Frequency of each proximal femoral fracture type 6%
11% Type of hip fracture Undisplaced subcapital Displaced subcapital Trochanteric Subtrochanteric
35%
48%
Figure 2
Timing of surgery
Demographics Worldwide the number of hip fractures has been steadily rising. In 1990, there were approximately 1.66 million hip fractures, and that figure is projected to rise to 6.26 million by 2050, with 3.25 million of these in Asia.8 Overall, there is a 40% lifetime risk of fragility fracture coming to clinical attention, and one in four of those presenting with a hip fracture will have had a previous fragility fracture.9 The mean age of the hip fracture patient in England is 83 years and 75% will be female.7 About 20% are unfit for surgery at the time of presentation. One-third of patients have an abbreviated mental test score (AMTS) of 6 or under at presentation.3 The mortality rate at 1 year is 20%.10 About 7.5% will die in the first 30 days following the fracture,11 of whom twothirds will die in hospital and one-third following discharge. In addition there is ongoing morbidity, of which loss of independence with activities of daily living is one of the most striking, and almost 50% of those admitted from home require a change of residence on discharge.3
Whilst there is a paucity of good evidence regarding the timing of surgery, no study has shown an advantage to delaying surgery. When considering the matter, the NICE panel therefore had to refer to it in humanitarian terms and recommended surgery on the day of, or day after injury. All the appropriate investigations should be undertaken with the aim of immediate optimization, but there is no evidence that waiting for ancillary tests such as echocardiograms improves outcome or survival. Therefore surgery should not be delayed by anaemia, volume depletion, electrolyte imbalance, uncontrolled diabetes, uncontrolled heart failure, correctable cardiac arrhythmias or ischaemia, acute chest infections nor exacerbation of chronic chest conditions.7 With regards to anticoagulation, units should have policies in place for reversal of anticoagulants, and in particular, surgery should not be delayed because of clopidogrel therapy.7 It is expected that these can be normally optimized within 24 hours from admission. Currently, 72% of patients have surgery on the day of, or the day after admission.3
Diagnosis of hip fracture
Operating environment
This is apparent from the plain radiographs (an anteroposterior (AP) view of the hips and a lateral view of the affected hip) in
Surgery for hip fractures should take place on planned trauma lists. These should be staffed by consultant or senior
SURGERY --:-
2
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Chesser T, et al., Management of hip fractures in the elderly, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.06.002
ORTHOPAEDICS IV: LOWER LIMB
insertion which is the main reason for the higher re-operation rates. In 2015, collaborative work between anaesthetists, orthopaedic surgeons and orthogeriatricians, led to consensus guidelines aimed at reducing the risk of a significant hypotensive episode that can be associated with the cementing and implant insertion of a cemented hemiarthroplasty. A three-stage process is recommended, with identification of at-risk patients, preoperative preparation and intraoperative management. Intra-operatively, surgeons should inform the anaesthetist prior to instrumenting the femoral canal and prior to cementation, with the anaesthetist acknowledging the message at both stages. The femoral canal should be thoroughly washed and dried, and cementation performed in a retrograde fashion with an intramedullary plug and suction catheter. Vigorous pressurization should be avoided in at-risk patients. Anaesthetists should aim for a systolic blood pressure within 20 mmHg of preinduction throughout surgery and be vigilant for signs of cardiorespiratory compromise.18 Hemiarthroplasty versus total hip replacement e increasingly, hip fracture patients are being considered for total joint replacement. The NICE guidelines are to offer a total hip arthroplasty (THA) to those who were able to walk independently out of doors with no more than the use of one stick prior to the fall, who are not cognitively impaired, and who are medically fit.7 In 2014, 11,722 patients met the NICE criteria for THA, but only 26% of patients underwent THA.3 The published literature on this topic has a significant selection bias in patients under the age of 80 and the population who will benefit has yet to be fully defined. The 2016 NICE CG124 update will include a consideration of the long-term expected functional benefit of the procedure.
orthopaedic surgeons and anaesthetists. The type of anaesthetic does not appear to influence outcome, but there does appear to be advantages to the use of nerve blocks by improving pain control and reducing analgesic requirements.12 The aim of surgery is to allow the patient to fully weight-bear in the immediate postoperative period. This should be instigated with a physiotherapy assessment on the first day after surgery, and thereafter the patient should be seen at least daily by the physiotherapy team.
Surgery for hip fractures Intracapsular/subcapital fractures Undisplaced subcapital fractures: it is generally accepted these are treated with internal fixation with either cannulated screws or a sliding hip screw in situ. The surgeon must ensure that the fracture is undisplaced in both the AP and lateral planes. Again it is important the patient is allowed to fully weight bear in the immediate postoperative period. In some elderly patients, prosthetic replacement is an acceptable alternative treatment. Displaced intracapsular/subcapital fractures Fixation versus arthroplasty e there are theoretical advantages to fixation of the femoral head. The operation is much less invasive and the native femoral head is retained. However, all the larger series suggest that the risks of complications such as non-union (33% for displaced fractures), avascular necrosis (10 e16%) and re-fracture below implants (1%) are higher. Reoperation rates are much higher, and this is particularly pertinent in what is largely a high anaesthetic risk population. Therefore, in the case of a displaced, intracapsular, osteoporotic hip fracture, there is much more robust evidence for arthroplasty. In addition, hip fracture patients do not tolerate restrictions in mobility well. Thus a cemented arthroplasty (either with a hemiarthroplasty or a total hip replacement) should be performed. In addition, the anterolateral approach is recommended for arthroplasty following a hip fracture due to the lower risk of dislocation.7 Choice of prosthesis e NICE guidelines recommend the use of a proven stem with an Orthopaedic Data Evaluation Panel (ODEP) rating of 10A, 10B, 10C, 7A, 7B, 5A, 5B or 3B. Austin Moore and Thomson stems are unsuitable for these patients. Cemented versus uncemented e cemented prostheses are recommended in the treatment of hip fracture because they have a lower risk of revision and complications. There have been reports of excess deaths attributed to cement pressurization in the 1980s and 1990s. As anaesthetic techniques have improved, the rate of these events has dropped to a low level. This issue has been raised recently in the medical and national press13 but a much more robust study by White et al confirmed that whilst there is a higher mortality within 24 hours associated with cement, this reverses by seven days, with an excess mortality in the uncemented group persisting at 30-days and 1 year.14 Indeed, all meta-analyses as well as data from the UK and Norwegian Hip Fracture Databases have shown an overall decreased mortality, lower re-operation rates and better function by 3 months when cemented prostheses are used.15e17 Although the use of uncemented prostheses involves less operative time and blood loss, they are associated with periprosthetic fractures sustained at
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Extra-capsular fractures Trochanteric fractures: trochanteric fractures are divided into stable and unstable types depending on the integrity of the posteromedial buttress. By the nature of the fracture, and the vascularity of the fragments, trochanteric fractures are fixed with the anticipation of healing, albeit with some collapse and medialisation of the femoral shaft, as long as they can be adequately stabilized. There are two methods of fixation, either extramedullary (with a sliding hip screw) or intramedullary (with either a short or long cephalomedullary nail). Meta-analyses show that the results are poorer for the intramedullary nails but much of this is based on older and short implants. Those studies looking at modern intramedullary devices demonstrate that they are, at best, equivalent to sliding hip screws with no clinically significant differences in blood requirement, operative times or radiation exposure. However, these studies also show a very significant cost implication with intramedullary nails between three and five times as expensive as sliding hip screws. As a consequence, NICE recommended use of an extramedullary device, such as a sliding hip screw, for treatment of trochanteric fractures. There is a rarer group of trochanteric fractures where the fracture line is oblique in nature (called reverse oblique, or AO A3, fractures). For these, there is little evidence in the literature and the majority of surgeons would choose to use a long intramedullary device.
3
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Chesser T, et al., Management of hip fractures in the elderly, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.06.002
ORTHOPAEDICS IV: LOWER LIMB
Subtrochanteric fractures: for subtrochanteric fractures, including trochanteric fractures with subtrochanteric extension, the recommendation is to use a long intramedullary device. An adequate reduction is crucial to allow union to occur. This is initially attempted closed, but often requires an open reduction.
4 NHS England. 2015/16 National Tariff Payment System: a consultation notice (section 4.8, page 46). 2014. https://www.gov. uk/government/uploads/system/uploads/attachment_data/file/ 379571/S118_Annex_4A_NTCN1516.pdf. 5 NHS England. 2015/16 Enhanced tariff option spreadsheet. https://www.england.nhs.uk/wp-content/uploads/2015/03/201516-eto-spreadsheet.xlsx. 6 Monitor. 2016/17 National Tariff Payment System: draft prices. https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/487361/National_Tariff_Information_ Workbook_2016-17_18_December_2015__3__amended.xlsx (Sheet ’07. BPTs, Section 7). 7 National Institute for Health and Care Excellence (NICE). Hip fracture; the management of hip fracture in adults. CG124. 2011. London: NICE. https://www.nice.org.uk/guidance/cg124. 8 Cooper C, Campion G, Melton 3rd LJ. Hip fractures in the elderly: a world-wide projection. Osteoporos Int 1992; 2: 285e9. 9 Kanis JA. Diagnosis of osteoporosis and assessment of fracture risk. Lancet 2002; 359: 1929. 10 Leibson CL, Tosteson AN, Gabriel SE, et al. Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. J Am Geriatr Soc 2002; 50: 1644. 11 National Hip Fracture Database (NHFD) 2015 Annual report supplement e An analysis of 30-day mortality in 2014. http://www. nhfd.co.uk/20/hipfractureR.nsf/945b5efcb3f9117580257ebb0 069c820/7cf236c00475272480257f5d00307ad3/$FILE/NHFD% 202015%20annual%20report%20supplement_WEB.PDF. 12 Association of Anaesthetists of Great Britain and Ireland. Management of proximal femoral fractures 2011. Anaesthesia 2012; 67: 85e98. 13 Rutter PD, Panesar SS, Darzi A, Donaldson LJ. What is the risk of death or severe harm due to bone cement implantation syndrome among patients undergoing hip hemiarthroplasty for fractured neck of femur? A patient safety surveillance study. BMJ Open 2014; 4. 14 White SM, Moppett IK, Griffiths R. Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset. Anaesthesia 2014; 69: 224e30. 15 Costa ML, Griffin XL, Pendleton N, Pearson M, Parsons N. Does cementing the femoral component increase the risk of perioperative mortality for patients having replacement surgery for a fracture of the neck of femur? Data from the National Hip Fracture Database. Bone Joint Surg Br 2011; 93: 1405e10. 16 Gjertsen JE, Lie SA, Vinje T, et al. More re-operations after uncemented than cemented hemiarthroplasty used in the treatment of displaced fractures of the femoral neck: an observational study of 11,116 hemiarthroplasties from a national register. J Bone Joint Surg Br 2012; 94: 1113e9. €rrholm J, 17 Leonardsson O, Ka Akesson K, Garellick G, Rogmark C. Higher risk of reoperation for bipolar and uncemented hemiarthroplasty. Acta Orthop 2012; 83: 459e66. 18 Membership of Working Party, Griffiths R, White SM, et al. Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015. Anaesthesia 2015; 70: 623e6. https://www.boa. ac.uk/wp-content/uploads/2016/01/Reducing-the-Risk-ofCemented-Arthroplasty-in-Hip-Fracture-Surgery.pdf.
Surgery as part of terminal care Surgery is the best form of analgesia for a hip fracture. In some cases, a hip fracture may complicate or precipitate a terminal illness. The multidisciplinary team should still consider the role of surgery as part of a palliative care approach that minimizes pain and other symptoms, establishes the patient’s own priorities for rehabilitation and considers the patient’s wishes about their end-of-life care. Surgery should not be denied for these patients if it improves their quality of life (even if only temporarily).
Postoperative rehabilitation Patients have complex rehabilitation requirements, with some being able to achieve their preoperative mobility and others with more limited prospects. It is important to be realistic with both the patient and carers when planning the care pathway. The rehabilitation should be led by the orthogeriatrician with multidisciplinary involvement. Patients should be mobilized on the day after surgery and reviewed by a physiotherapist on a daily basis. Assessments of both bone health and falls risk are integral components of care. Many of these patients have complex medical co-morbidities that often require review whilst inpatients. It is important to constantly monitor for delirium in both the perioperative and postoperative period, and investigate accordingly.
Conclusion The care of hip fracture patients has seen significant improvements over recent years, driven by the NHFD, BPT and NICE. There is a much clearer understanding of the demographics of this group, and of the need for a coordinated multidisciplinary approach to managing these complex and fragile patients. Standards of practice have been established with clear, evidencebased guidelines and continue to evolve as data are gathered. It is incumbent on all those involved in hip fracture care to be familiar with these guidelines and monitor their own practice accordingly to ensure it meets these standards. A REFERENCES 1 British Orthopaedic Association. The care of patients with fragility fracture. 2007. British Orthopaedic Association, http://www.bgs. org.uk/pdf_cms/pubs/Blue%20Book%20on%20fragility% 20fracture%20care.pdf. 2 British Orthopaedic Association. Standards for trauma. BOAST 1, version 2. 2012. https://www.boa.ac.uk/wp-content/uploads/ 2014/12/BOAST-1.pdf. 3 The National Hip Fracture Database (NHFD) Annual report 2015 http://www.nhfd.co.uk/nhfd/nhfd2015reportPR1.pdf.
SURGERY --:-
4
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Chesser T, et al., Management of hip fractures in the elderly, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.06.002
Management of hip fractures in the elderly
for trusts if they meet all seven performance indicators (Box 1) for the patient, thus creating an incentive to deliver optimal care.4 For the 2015/16 financial year, this is an additional £1339 per patient,5 and this is to increase to £1353 per patient in 2016/ 17.6 The 2015 NHFD report has shown this is currently achieved for 63.3% patients nationally. The National Institute for Health and Care Excellence (NICE) produced guidelines on the management of hip fractures in adults (Clinical Guideline 124) in 2011, with the latest modification published in 2014.7 These guidelines looked at areas of large variation and controversy. It also undertook a metaanalysis of the relevant randomized controlled trials and a costeffective analysis where appropriate. In some areas, where there was no conclusive evidence, the guideline development group undertook decisions based on humanitarian principles and consensus decisions. As a consequence of recognizing the importance of a multidisciplinary care pathway, there was a renewed emphasis on the care of this patient group, who were often given low priority in the past. This has led to a better understanding of what influences outcomes, as well as providing savings, as it is known that treating well is cheaper than treating badly.
Tim Chesser Govind Chauhan Michael Kelly
Abstract A fracture of the proximal femur (or hip fracture) is a devastating injury to an elderly patient. Nearly all patients require surgery as part of their treatment but their care necessitates complex multidisciplinary involvement. In the last ten years there have been a number of initiatives to help improve care for this challenging patient group, as well as establishment of The National Hip Fracture Database, to allow us to audit the care provided. With this focus, we have seen both mortality and length of stay decrease. The aim of this article is to summarize the current recommendations for patients who suffer a hip fracture.
Keywords Hip fracture; intracapsular fracture; proximal femoral fracture; subcapital fracture; subtrochanteric fracture.; trochanteric fracture
What is a hip fracture? This is a fracture occurring anywhere between the edge of the femoral head and 5 cm below the lesser trochanter (Figure 1). They are divided into intra- or extra-capsular, with extra-capsular fractures further subdivided into trochanteric and subtrochanteric (Figure 2). There is however some overlap between these groups. Fractures at the base of the femoral neck (basicervical fractures), are classified in the trochanteric group and treated as such. Also, both trochanteric and subtrochanteric fractures may extend, thus being labelled as trochanteric fractures with subtrochanteric (distal) extension, or subtrochanteric fractures with trochanteric (proximal) extension.
Hip fractures (or fractures of the proximal femur) in the elderly have an incidence of approximately one per 1000 head of population in western countries and are associated with a significant cost to any healthcare system. Delivery of care to this challenging patient group requires a multidisciplinary approach. Hip fracture outcome is now used as a surrogate marker for how hospitals manage frail, elderly patients.
Guidelines In the UK, there are several initiatives and guidelines for this patient group. The year 2007 saw The British Orthopaedic Association and British Geriatric Association publish a joint ‘Blue Book’ on ‘The care of patients with fragility fracture’, and the ‘Standards for trauma’ (BOAST 1) for hip fractures.1,2 At the same time, the National Hip Fracture Database (NHFD) started a web-based national audit.3 Every hospital in England, Wales and Northern Ireland admitting hip fractures is registered with the NHFD, and in 2014, data for over 64,000 patients were entered, estimated to represent over 95% of cases.3 Following on from this, together with Lord Darzi’s 2008 ‘High Quality Care for All’ report, a ‘best practice tariff’ (BPT) for hip fractures was introduced in 2010. This provides an additional per patient payment
Best practice criteria 2015e20164
Tim Chesser MBBS FRCS (Tr and Orth) is a Consultant Trauma and Orthopaedic Surgeon at Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
C
Surgery within 36 hours from arrival (or diagnosis if inpatient fall) to induction of anaesthesia
C
Admission under the joint care of a consultant geriatrician and consultant orthopaedic surgeon
C
Admitted using a hip fracture protocol
C
Assessed by a geriatrician (ST3 or above) within 72 hours of admission
C
Postoperative, multidisciplinary rehabilitation
C
Bone health and falls prevention assessment
C
An abbreviated mental test score (AMTS) pre- and postoperatively
Govind Chauhan BMBS MRCS is an Orthopaedic Registrar at Southmead Hospital, North Bristol NHS Trust, Bristol, UK. Michael Kelly MBBS MD FRCS (T&O) is a Consultant Trauma and Orthopaedic Surgeon at Southmead Hospital, North Bristol NHS Trust, Bristol, UK.
SURGERY --:-
Box 1
1
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Chesser T, et al., Management of hip fractures in the elderly, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.06.002
ORTHOPAEDICS IV: LOWER LIMB
95% of cases. In those cases where the clinical history is suspicious of a hip fracture, but the radiographs are negative, the recommendation is for an MRI scan. If this is not available within 24 hours, or contraindicated, a CT scan should be undertaken.7
The multidisciplinary approach e ‘The Hip fracture Programme’ Hip fractures should no longer be managed on surgical wards by orthopaedic surgeons in isolation. Recognition of the importance of the multidisciplinary approach is thus implicit. In doing this, not only are the surgical standards met but patients’ medical, cognitive, analgesic, nutritional, social and rehabilitation needs are identified as early as possible and given prominence. A hip fracture programme should exist for these patients, with senior geriatric perioperative medical input, and increasingly taking the lead for postoperative medical care, multidisciplinary rehabilitation (MDR) and discharge planning. From admission, the patients should be offered a formal, acute orthogeriatric or orthopaedic ward-based ‘Hip Fracture Programme’ that includes all of the following:7 orthogeriatric assessment rapid optimization of fitness for surgery early identification of individual goals for MDR to recover mobility and independence, and to facilitate return to prefracture residence and long-term wellbeing continued, coordinated, orthogeriatric and multidisciplinary review liaison or integration with related services, particularly mental health, falls prevention, bone health, primary care and social services clinical and service governance responsibility for all stages of the pathway of care and rehabilitation, including those delivered in the community.
Figure 1
Frequency of each proximal femoral fracture type 6%
11% Type of hip fracture Undisplaced subcapital Displaced subcapital Trochanteric Subtrochanteric
35%
48%
Figure 2
Timing of surgery
Demographics Worldwide the number of hip fractures has been steadily rising. In 1990, there were approximately 1.66 million hip fractures, and that figure is projected to rise to 6.26 million by 2050, with 3.25 million of these in Asia.8 Overall, there is a 40% lifetime risk of fragility fracture coming to clinical attention, and one in four of those presenting with a hip fracture will have had a previous fragility fracture.9 The mean age of the hip fracture patient in England is 83 years and 75% will be female.7 About 20% are unfit for surgery at the time of presentation. One-third of patients have an abbreviated mental test score (AMTS) of 6 or under at presentation.3 The mortality rate at 1 year is 20%.10 About 7.5% will die in the first 30 days following the fracture,11 of whom twothirds will die in hospital and one-third following discharge. In addition there is ongoing morbidity, of which loss of independence with activities of daily living is one of the most striking, and almost 50% of those admitted from home require a change of residence on discharge.3
Whilst there is a paucity of good evidence regarding the timing of surgery, no study has shown an advantage to delaying surgery. When considering the matter, the NICE panel therefore had to refer to it in humanitarian terms and recommended surgery on the day of, or day after injury. All the appropriate investigations should be undertaken with the aim of immediate optimization, but there is no evidence that waiting for ancillary tests such as echocardiograms improves outcome or survival. Therefore surgery should not be delayed by anaemia, volume depletion, electrolyte imbalance, uncontrolled diabetes, uncontrolled heart failure, correctable cardiac arrhythmias or ischaemia, acute chest infections nor exacerbation of chronic chest conditions.7 With regards to anticoagulation, units should have policies in place for reversal of anticoagulants, and in particular, surgery should not be delayed because of clopidogrel therapy.7 It is expected that these can be normally optimized within 24 hours from admission. Currently, 72% of patients have surgery on the day of, or the day after admission.3
Diagnosis of hip fracture
Operating environment
This is apparent from the plain radiographs (an anteroposterior (AP) view of the hips and a lateral view of the affected hip) in
Surgery for hip fractures should take place on planned trauma lists. These should be staffed by consultant or senior
SURGERY --:-
2
Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Chesser T, et al., Management of hip fractures in the elderly, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.06.002
ORTHOPAEDICS IV: LOWER LIMB
insertion which is the main reason for the higher re-operation rates. In 2015, collaborative work between anaesthetists, orthopaedic surgeons and orthogeriatricians, led to consensus guidelines aimed at reducing the risk of a significant hypotensive episode that can be associated with the cementing and implant insertion of a cemented hemiarthroplasty. A three-stage process is recommended, with identification of at-risk patients, preoperative preparation and intraoperative management. Intra-operatively, surgeons should inform the anaesthetist prior to instrumenting the femoral canal and prior to cementation, with the anaesthetist acknowledging the message at both stages. The femoral canal should be thoroughly washed and dried, and cementation performed in a retrograde fashion with an intramedullary plug and suction catheter. Vigorous pressurization should be avoided in at-risk patients. Anaesthetists should aim for a systolic blood pressure within 20 mmHg of preinduction throughout surgery and be vigilant for signs of cardiorespiratory compromise.18 Hemiarthroplasty versus total hip replacement e increasingly, hip fracture patients are being considered for total joint replacement. The NICE guidelines are to offer a total hip arthroplasty (THA) to those who were able to walk independently out of doors with no more than the use of one stick prior to the fall, who are not cognitively impaired, and who are medically fit.7 In 2014, 11,722 patients met the NICE criteria for THA, but only 26% of patients underwent THA.3 The published literature on this topic has a significant selection bias in patients under the age of 80 and the population who will benefit has yet to be fully defined. The 2016 NICE CG124 update will include a consideration of the long-term expected functional benefit of the procedure.
orthopaedic surgeons and anaesthetists. The type of anaesthetic does not appear to influence outcome, but there does appear to be advantages to the use of nerve blocks by improving pain control and reducing analgesic requirements.12 The aim of surgery is to allow the patient to fully weight-bear in the immediate postoperative period. This should be instigated with a physiotherapy assessment on the first day after surgery, and thereafter the patient should be seen at least daily by the physiotherapy team.
Surgery for hip fractures Intracapsular/subcapital fractures Undisplaced subcapital fractures: it is generally accepted these are treated with internal fixation with either cannulated screws or a sliding hip screw in situ. The surgeon must ensure that the fracture is undisplaced in both the AP and lateral planes. Again it is important the patient is allowed to fully weight bear in the immediate postoperative period. In some elderly patients, prosthetic replacement is an acceptable alternative treatment. Displaced intracapsular/subcapital fractures Fixation versus arthroplasty e there are theoretical advantages to fixation of the femoral head. The operation is much less invasive and the native femoral head is retained. However, all the larger series suggest that the risks of complications such as non-union (33% for displaced fractures), avascular necrosis (10 e16%) and re-fracture below implants (1%) are higher. Reoperation rates are much higher, and this is particularly pertinent in what is largely a high anaesthetic risk population. Therefore, in the case of a displaced, intracapsular, osteoporotic hip fracture, there is much more robust evidence for arthroplasty. In addition, hip fracture patients do not tolerate restrictions in mobility well. Thus a cemented arthroplasty (either with a hemiarthroplasty or a total hip replacement) should be performed. In addition, the anterolateral approach is recommended for arthroplasty following a hip fracture due to the lower risk of dislocation.7 Choice of prosthesis e NICE guidelines recommend the use of a proven stem with an Orthopaedic Data Evaluation Panel (ODEP) rating of 10A, 10B, 10C, 7A, 7B, 5A, 5B or 3B. Austin Moore and Thomson stems are unsuitable for these patients. Cemented versus uncemented e cemented prostheses are recommended in the treatment of hip fracture because they have a lower risk of revision and complications. There have been reports of excess deaths attributed to cement pressurization in the 1980s and 1990s. As anaesthetic techniques have improved, the rate of these events has dropped to a low level. This issue has been raised recently in the medical and national press13 but a much more robust study by White et al confirmed that whilst there is a higher mortality within 24 hours associated with cement, this reverses by seven days, with an excess mortality in the uncemented group persisting at 30-days and 1 year.14 Indeed, all meta-analyses as well as data from the UK and Norwegian Hip Fracture Databases have shown an overall decreased mortality, lower re-operation rates and better function by 3 months when cemented prostheses are used.15e17 Although the use of uncemented prostheses involves less operative time and blood loss, they are associated with periprosthetic fractures sustained at
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Extra-capsular fractures Trochanteric fractures: trochanteric fractures are divided into stable and unstable types depending on the integrity of the posteromedial buttress. By the nature of the fracture, and the vascularity of the fragments, trochanteric fractures are fixed with the anticipation of healing, albeit with some collapse and medialisation of the femoral shaft, as long as they can be adequately stabilized. There are two methods of fixation, either extramedullary (with a sliding hip screw) or intramedullary (with either a short or long cephalomedullary nail). Meta-analyses show that the results are poorer for the intramedullary nails but much of this is based on older and short implants. Those studies looking at modern intramedullary devices demonstrate that they are, at best, equivalent to sliding hip screws with no clinically significant differences in blood requirement, operative times or radiation exposure. However, these studies also show a very significant cost implication with intramedullary nails between three and five times as expensive as sliding hip screws. As a consequence, NICE recommended use of an extramedullary device, such as a sliding hip screw, for treatment of trochanteric fractures. There is a rarer group of trochanteric fractures where the fracture line is oblique in nature (called reverse oblique, or AO A3, fractures). For these, there is little evidence in the literature and the majority of surgeons would choose to use a long intramedullary device.
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Chesser T, et al., Management of hip fractures in the elderly, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.06.002
ORTHOPAEDICS IV: LOWER LIMB
Subtrochanteric fractures: for subtrochanteric fractures, including trochanteric fractures with subtrochanteric extension, the recommendation is to use a long intramedullary device. An adequate reduction is crucial to allow union to occur. This is initially attempted closed, but often requires an open reduction.
4 NHS England. 2015/16 National Tariff Payment System: a consultation notice (section 4.8, page 46). 2014. https://www.gov. uk/government/uploads/system/uploads/attachment_data/file/ 379571/S118_Annex_4A_NTCN1516.pdf. 5 NHS England. 2015/16 Enhanced tariff option spreadsheet. https://www.england.nhs.uk/wp-content/uploads/2015/03/201516-eto-spreadsheet.xlsx. 6 Monitor. 2016/17 National Tariff Payment System: draft prices. https://www.gov.uk/government/uploads/system/uploads/ attachment_data/file/487361/National_Tariff_Information_ Workbook_2016-17_18_December_2015__3__amended.xlsx (Sheet ’07. BPTs, Section 7). 7 National Institute for Health and Care Excellence (NICE). Hip fracture; the management of hip fracture in adults. CG124. 2011. London: NICE. https://www.nice.org.uk/guidance/cg124. 8 Cooper C, Campion G, Melton 3rd LJ. Hip fractures in the elderly: a world-wide projection. Osteoporos Int 1992; 2: 285e9. 9 Kanis JA. Diagnosis of osteoporosis and assessment of fracture risk. Lancet 2002; 359: 1929. 10 Leibson CL, Tosteson AN, Gabriel SE, et al. Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. J Am Geriatr Soc 2002; 50: 1644. 11 National Hip Fracture Database (NHFD) 2015 Annual report supplement e An analysis of 30-day mortality in 2014. http://www. nhfd.co.uk/20/hipfractureR.nsf/945b5efcb3f9117580257ebb0 069c820/7cf236c00475272480257f5d00307ad3/$FILE/NHFD% 202015%20annual%20report%20supplement_WEB.PDF. 12 Association of Anaesthetists of Great Britain and Ireland. Management of proximal femoral fractures 2011. Anaesthesia 2012; 67: 85e98. 13 Rutter PD, Panesar SS, Darzi A, Donaldson LJ. What is the risk of death or severe harm due to bone cement implantation syndrome among patients undergoing hip hemiarthroplasty for fractured neck of femur? A patient safety surveillance study. BMJ Open 2014; 4. 14 White SM, Moppett IK, Griffiths R. Outcome by mode of anaesthesia for hip fracture surgery. An observational audit of 65 535 patients in a national dataset. Anaesthesia 2014; 69: 224e30. 15 Costa ML, Griffin XL, Pendleton N, Pearson M, Parsons N. Does cementing the femoral component increase the risk of perioperative mortality for patients having replacement surgery for a fracture of the neck of femur? Data from the National Hip Fracture Database. Bone Joint Surg Br 2011; 93: 1405e10. 16 Gjertsen JE, Lie SA, Vinje T, et al. More re-operations after uncemented than cemented hemiarthroplasty used in the treatment of displaced fractures of the femoral neck: an observational study of 11,116 hemiarthroplasties from a national register. J Bone Joint Surg Br 2012; 94: 1113e9. €rrholm J, 17 Leonardsson O, Ka Akesson K, Garellick G, Rogmark C. Higher risk of reoperation for bipolar and uncemented hemiarthroplasty. Acta Orthop 2012; 83: 459e66. 18 Membership of Working Party, Griffiths R, White SM, et al. Safety guideline: reducing the risk from cemented hemiarthroplasty for hip fracture 2015. Anaesthesia 2015; 70: 623e6. https://www.boa. ac.uk/wp-content/uploads/2016/01/Reducing-the-Risk-ofCemented-Arthroplasty-in-Hip-Fracture-Surgery.pdf.
Surgery as part of terminal care Surgery is the best form of analgesia for a hip fracture. In some cases, a hip fracture may complicate or precipitate a terminal illness. The multidisciplinary team should still consider the role of surgery as part of a palliative care approach that minimizes pain and other symptoms, establishes the patient’s own priorities for rehabilitation and considers the patient’s wishes about their end-of-life care. Surgery should not be denied for these patients if it improves their quality of life (even if only temporarily).
Postoperative rehabilitation Patients have complex rehabilitation requirements, with some being able to achieve their preoperative mobility and others with more limited prospects. It is important to be realistic with both the patient and carers when planning the care pathway. The rehabilitation should be led by the orthogeriatrician with multidisciplinary involvement. Patients should be mobilized on the day after surgery and reviewed by a physiotherapist on a daily basis. Assessments of both bone health and falls risk are integral components of care. Many of these patients have complex medical co-morbidities that often require review whilst inpatients. It is important to constantly monitor for delirium in both the perioperative and postoperative period, and investigate accordingly.
Conclusion The care of hip fracture patients has seen significant improvements over recent years, driven by the NHFD, BPT and NICE. There is a much clearer understanding of the demographics of this group, and of the need for a coordinated multidisciplinary approach to managing these complex and fragile patients. Standards of practice have been established with clear, evidencebased guidelines and continue to evolve as data are gathered. It is incumbent on all those involved in hip fracture care to be familiar with these guidelines and monitor their own practice accordingly to ensure it meets these standards. A REFERENCES 1 British Orthopaedic Association. The care of patients with fragility fracture. 2007. British Orthopaedic Association, http://www.bgs. org.uk/pdf_cms/pubs/Blue%20Book%20on%20fragility% 20fracture%20care.pdf. 2 British Orthopaedic Association. Standards for trauma. BOAST 1, version 2. 2012. https://www.boa.ac.uk/wp-content/uploads/ 2014/12/BOAST-1.pdf. 3 The National Hip Fracture Database (NHFD) Annual report 2015 http://www.nhfd.co.uk/nhfd/nhfd2015reportPR1.pdf.
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Ó 2016 Published by Elsevier Ltd.
Please cite this article in press as: Chesser T, et al., Management of hip fractures in the elderly, Surgery (2016), http://dx.doi.org/10.1016/ j.mpsur.2016.06.002