- Email: [email protected]
Management of hip fractures in the elderly
ORTHOPAEDICS: LOWER LIMB
Management of hip fractures in the elderly
Best practice criteria for hip fracture patients, 2013e2014 C
Tim Chesser
C
Michael Kelly
C C C C
Abstract
C
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 few years there have been a number of initiatives to help improve care for this challenging patient group, as well as establishment of National Hip Fracture Databases, 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.
Admission to a hip fracture unit within 4 hours Involvement of an orthogeriatrician within 72 hours Surgery within 36 hours of admission Participation in the National Hip Fracture Database Osteoporotic and falls prevention assessment A multidisciplinary pathway A mental test score on admission and postoperatively
should be a measure of quality, even though outcomes are sometimes difficult to assess. In the UK the National Institute for Health and Care Excellence (NICE) produced guidelines on The Management of Hip Fracture in Adults (Clinical Guideline 124).5 These guidelines looked at areas of large variation and controversy. It also undertook a meta-analysis of the randomized controlled trials and a costeffective analysis where appropriate. In some areas, such as timing of surgery, where there was no evidence, the guideline development group undertook decisions based on humanitarian principles. The document was first published in June 2011 and supported much of what was considered to be best practice with a strong evidence base, and has recently undergone an evidence update.6 As a consequence of recognizing the importance of a multidisciplinary care pathway, there has been a renewed emphasis on the care of this patient group, who were often given low priority in the past. This is leading to a better understanding of what factors influence outcomes and cost savings, as it is known that treating patients well is cheaper than treating them badly.
Keywords Hip fracture; intracapsular fracture; proximal femoral fracture; subcapital fracture; subtrochanteric fracture; trochanteric fracture
Hip fractures (or fractures of the proximal femur) have an incidence of approximately 1 per 1000 head of population in western countries and are associated with a very 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. Over the last few years in the UK there have been several initiatives and guidelines for this patient group. The British Orthopaedic Association and British Geriatric Association published a joint ‘Blue Book’ on ‘the care of patients with fragility fractures’ and the published standard for trauma (BOAST 1) for hip fractures.1,2 At the same time the National Hip Fracture Database (NHFD) started a web-based data collection.3 In the last 5 years there have been over 250,000 entries and every hospital admitting hip fractures is registered. It is believed that data are submitted on over 95% of the hip fractures sustained in England and Wales. More recently there has been the introduction of a ‘Best Practice Tariff’ (BPT) for hip fractures.4 This uses key performance indicators, recorded via the National Hip Fracture Database (Box 1). If all those performance indicators are achieved the hospital will receive an uplift of the tariff for that particular patient.3 It is believed these performance indicators
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). It includes subcapital (or intracapsular), trochanteric and subtrochanteric fractures. Even though they are usually classified into these three groups there is some overlap. Those fractures at the base of the femoral neck (called basicervical fractures) are treated and classified in the trochanteric group (Figure 2). Both trochanteric and subtrochanteric fractures may extend proximally and distally. These are either labelled as trochanteric fractures with subtrochanteric extension, or subtrochanteric fractures with trochanteric extension.
Demographics Worldwide, the number of hip fractures has been steadily rising. In 1950 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. Overall there is now a 50% lifetime risk of a fragility fracture and 1 in 4 of those presenting with a hip fracture will have had a previous fragility fracture. Hip fracture will occur in 1 in 3 women and 1 in 7 men over the age of 50. The mean age of the hip fracture patient in England is 83 years
Tim Chesser MBBS FRCS (Tr and Orth) is a Consultant Trauma and Orthopaedic Surgeon at Frenchay Hospital, North Bristol NHS Trust, Bristol, UK. Conflicts of interest: none declared. Michael Kelly MBBS MD FRCS (T&O) is a Consultant Trauma and Orthopaedic Surgeon at Frenchay Hospital, North Bristol NHS Trust, Bristol, UK. Conflicts of interest: none declared.
SURGERY 31:9
456
Ó 2013 Elsevier Ltd. All rights reserved.
ORTHOPAEDICS: LOWER LIMB
The multidisciplinary approach e ‘The Hip Fracture Programme’ Hip fractures should no longer be managed in isolation on surgical wards by orthopaedic surgeons. Recognition of the importance of the multidisciplinary approach is thus implicit. In doing this, not only are the surgical standards met but the patient’s medical, cognitive, analgesic, nutritional, social and rehabilitation needs are identified as early as possible and given prominence. It has now been accepted that a hip fracture programme should exist for these patients, with the geriatric medical team contributing to joint preoperative patient assessment, 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: orthogeriatric assessment and rapid optimization of fitness for surgery early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture 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%
Timing of surgery There is a paucity of good evidence regarding the timing of surgery. In particular, no study has shown that there is 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. The document suggested that all the appropriate investigations should be undertaken with the aim of immediate optimization but that there was no evidence that waiting for ancillary tests such as echocardiograms improved outcome or survival. Therefore surgery should not be delayed by anaemia, anticoagulation, volume depletion, electrolyte imbalance, uncontrolled diabetes, uncontrolled heart failure or correctable cardiac arrhythmias or ischaemia. It is expected that this can be normally optimized within 24 hours of admission.
48%
Figure 2
and 75% will be female. About 20% are unfit for surgery at the time of presentation. About 30% of those presenting will have dementia and a further 20% will have impaired cognitive function related to the hip fracture episode. The mortality rate at 1 year is 24% and 2% will die prior to surgery. About 9% will die in the first 30 days following the fracture, of whom two-thirds 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. Approximately 40% of those admitted will require a change of residence on discharge.3
Operating environment Surgery for hip fractures should take place on planned trauma lists. These should be staffed by consultant or senior 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.7 The aim of surgery should be to allow the patient to weight-bear without restriction in the immediate postoperative period. This should be instigated with a physiotherapy assessment on the day after surgery unless there are specific medical or surgical contraindications and thereafter the hip fracture patient should be seen at least daily by the physiotherapy team.
Diagnosis of hip fracture This is apparent from the plain radiographs (an anteroposterior view of the pelvis and a lateral view of the affected hip) in 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 a CT scan should be undertaken.
SURGERY 31:9
457
Ó 2013 Elsevier Ltd. All rights reserved.
ORTHOPAEDICS: LOWER LIMB
Surgery for hip fractures
stick prior to the fall, who are not cognitively impaired, and who are medically fit. It is thought that up to 20% of patients sustaining a displaced subcapital fracture would be suitable, but the published literature has a significant selection bias in patients under the age of 80 and the population who will benefit has yet to be fully defined. In summary, for displaced subcapital fractures it is recommended to treat the fractures with replacement arthroplasty, using a total hip replacement for those who are both medically and physically fit.
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. Again it is important the patient is allowed to fully weight-bear in the immediate postoperative period. However, in the elderly patient prosthetic replacement should be considered as an alternative treatment, as the risk of failure and re-operation with internal fixation is high. Displaced 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 meaning that there is much better stability and possibly range of motion. However, all the larger series suggest that the risks of complications such as non-union (33% for displaced fractures), avascular necrosis (10e16%) and refracture below implants (1%) are higher. Re-operation rates are much higher and this is particularly pertinent in what is largely an unfit and high anaesthetic risk population. Therefore in the majority of cases of an osteoporotic hip fracture, particularly where there is any displacement, there appears to be 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. Choice of prosthesis e many prostheses, such as the Austin Moore and Thompson hemiarthroplasty, are still being used in hip fracture care despite being unacceptable in any other patient group undergoing hip arthroplasty. 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. Cemented versus uncemented e lack of consensus regarding the method of fixation of the femoral prosthesis stems from 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. On the other hand, although the use of uncemented prostheses involves less operative time and blood loss, they are associated with a higher complication rate. This is mainly due to periprosthetic fractures sustained at insertion. Excess thigh pain has previously been associated with now outdated uncemented stems, but has largely been addressed by modern prosthetic designs. However, re-operation rates remain higher. Given the lower risk of complications and revisions, the use of cemented implants is recommended. Whilst the recent literature may suggest a marginal higher mortality in the first perioperative day, all meta-analyses have shown an overall decreased mortality and better function by 3 months. Recent analysis of the UK and Norwegian Hip Fracture Databases has been published showing lower mortality, re-operation rates and better function with the use of cemented implants.8e10 Hemiarthroplasty versus total hip replacement e the recommendations are for an arthroplasty to treat displaced subcapital hip fractures. Increasingly, hip fracture patients are being considered for total joint replacement. The NICE guidelines are to offer a total hip arthroplasty to those who were able to walk independently out of doors with no more than the use of one
SURGERY 31:9
Trochanteric fractures These are broadly classified as trochanteric (including basicervical) and subtrochanteric fractures. The 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 medialization 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. These studies also show a very significant cost implication with their use. The intramedullary nails are between three and five times as expensive as sliding hip screws with no advantage to the patient. As a consequence, NICE recommended use of an extramedullary device such as a sliding hip screw for treatment of trochanteric fractures. There is a rare group of trochanteric fractures where the fracture line is oblique in nature (called reverse oblique, or AO A3, fractures) e for these there is little evidence in the literature and the majority of surgeons would choose to use an intramedullary device. Subtrochanteric fractures For subtrochanteric fractures the recommendation is to use a long intramedullary device. An adequate reduction (which often has to be performed through an open incision) is crucial to allow union to occur.
Surgery as part of terminal care Surgery is the best form of analgesia for a hip fracture. Rarely, a hip fracture may also 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
458
Ó 2013 Elsevier Ltd. All rights reserved.
ORTHOPAEDICS: LOWER LIMB
2 British Orthopaedic Association Standards for Trauma (BOAST). Hip fracture in the older person. BOAST 1, version 2, 2012. http://www. boa.ac.uk/LIB/LIBPUB/Documents/BOAST%201%20Version%202% 20-%20Hip%20Fracture%20in%20the%20Older%20Person%20-% 202012.pdf. 3 Best Practice Tariff. 2012. http://www.dh.gov.uk/health/2012/02/ confirmation-pbr-arrangements/. 4 The National Hip Fracture Database. National report, 2012. http://www. nhfd.co.uk/003/hipfracturer.nsf/NHFDNationalReport2012_Final.pdf (BPT). 5 National Institute for Health and Clinical Excellence. Hip fracture; the management of hip fracture in adults. London: NICE. CG124, 2011. http://www.nice.org.uk/nicemedia/live/13489/54918/54918.pdf. 6 2013. http://www.evidence.nhs.uk/evidence-update-34. 7 Association of Anaesthetists of Great Britain and Ireland. Management of proximal femoral fractures 2011. Anaesthesia 2012; 67: 85e98. 8 Costa ML, Griffin XL, Pendleton N, Pearson M, Parsons N. Does cementing the femoral component increase the risk of peri-operative mortality for patients having replacement surgery for a fracture of the neck of femur? Data from the National Hip Fracture Database. J Bone Joint Surg Br 2011 Oct; 93: 1405e10. 9 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 Aug; 94: 1113e9. 10 Leonardsson O, K€arrholm J, Akesson K, Garellick G, Rogmark C. Higher risk of reoperation for bipolar and uncemented hemiarthroplasty. Acta Orthop 2012 Oct; 83: 459e66. http://dx.doi.org/ 10.3109/17453674.2012.727076. Epub 2012 Sept. 24.
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. Assessment of both bone health and risks of falls are integral components of care. Many of these patients have complex medical co-morbidities that often require review whilst inpatients. Patients should be mobilized on the day after surgery and reviewed by a physiotherapist on a daily basis. It is important to constantly monitor for delirium in both the perioperative and postoperative period.
Conclusion The care of hip fracture patients has been under intense scrutiny in recent years. As a result 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. Patient care and outcomes have improved and treatment has become much more efficient with tangible cost savings. Standards of practice have been established with clear, evidence-based guidelines and 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. British Orthopaedic Association, 2007. http://www.boa.ac. uk/Publications/Documents/The%20Care%20of%20Patients%20with %20Fragility%20Fracture.pdf.
SURGERY 31:9
459
Ó 2013 Elsevier Ltd. All rights reserved.
Management of hip fractures in the elderly
Best practice criteria for hip fracture patients, 2013e2014 C
Tim Chesser
C
Michael Kelly
C C C C
Abstract
C
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 few years there have been a number of initiatives to help improve care for this challenging patient group, as well as establishment of National Hip Fracture Databases, 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.
Admission to a hip fracture unit within 4 hours Involvement of an orthogeriatrician within 72 hours Surgery within 36 hours of admission Participation in the National Hip Fracture Database Osteoporotic and falls prevention assessment A multidisciplinary pathway A mental test score on admission and postoperatively
should be a measure of quality, even though outcomes are sometimes difficult to assess. In the UK the National Institute for Health and Care Excellence (NICE) produced guidelines on The Management of Hip Fracture in Adults (Clinical Guideline 124).5 These guidelines looked at areas of large variation and controversy. It also undertook a meta-analysis of the randomized controlled trials and a costeffective analysis where appropriate. In some areas, such as timing of surgery, where there was no evidence, the guideline development group undertook decisions based on humanitarian principles. The document was first published in June 2011 and supported much of what was considered to be best practice with a strong evidence base, and has recently undergone an evidence update.6 As a consequence of recognizing the importance of a multidisciplinary care pathway, there has been a renewed emphasis on the care of this patient group, who were often given low priority in the past. This is leading to a better understanding of what factors influence outcomes and cost savings, as it is known that treating patients well is cheaper than treating them badly.
Keywords Hip fracture; intracapsular fracture; proximal femoral fracture; subcapital fracture; subtrochanteric fracture; trochanteric fracture
Hip fractures (or fractures of the proximal femur) have an incidence of approximately 1 per 1000 head of population in western countries and are associated with a very 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. Over the last few years in the UK there have been several initiatives and guidelines for this patient group. The British Orthopaedic Association and British Geriatric Association published a joint ‘Blue Book’ on ‘the care of patients with fragility fractures’ and the published standard for trauma (BOAST 1) for hip fractures.1,2 At the same time the National Hip Fracture Database (NHFD) started a web-based data collection.3 In the last 5 years there have been over 250,000 entries and every hospital admitting hip fractures is registered. It is believed that data are submitted on over 95% of the hip fractures sustained in England and Wales. More recently there has been the introduction of a ‘Best Practice Tariff’ (BPT) for hip fractures.4 This uses key performance indicators, recorded via the National Hip Fracture Database (Box 1). If all those performance indicators are achieved the hospital will receive an uplift of the tariff for that particular patient.3 It is believed these performance indicators
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). It includes subcapital (or intracapsular), trochanteric and subtrochanteric fractures. Even though they are usually classified into these three groups there is some overlap. Those fractures at the base of the femoral neck (called basicervical fractures) are treated and classified in the trochanteric group (Figure 2). Both trochanteric and subtrochanteric fractures may extend proximally and distally. These are either labelled as trochanteric fractures with subtrochanteric extension, or subtrochanteric fractures with trochanteric extension.
Demographics Worldwide, the number of hip fractures has been steadily rising. In 1950 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. Overall there is now a 50% lifetime risk of a fragility fracture and 1 in 4 of those presenting with a hip fracture will have had a previous fragility fracture. Hip fracture will occur in 1 in 3 women and 1 in 7 men over the age of 50. The mean age of the hip fracture patient in England is 83 years
Tim Chesser MBBS FRCS (Tr and Orth) is a Consultant Trauma and Orthopaedic Surgeon at Frenchay Hospital, North Bristol NHS Trust, Bristol, UK. Conflicts of interest: none declared. Michael Kelly MBBS MD FRCS (T&O) is a Consultant Trauma and Orthopaedic Surgeon at Frenchay Hospital, North Bristol NHS Trust, Bristol, UK. Conflicts of interest: none declared.
SURGERY 31:9
456
Ó 2013 Elsevier Ltd. All rights reserved.
ORTHOPAEDICS: LOWER LIMB
The multidisciplinary approach e ‘The Hip Fracture Programme’ Hip fractures should no longer be managed in isolation on surgical wards by orthopaedic surgeons. Recognition of the importance of the multidisciplinary approach is thus implicit. In doing this, not only are the surgical standards met but the patient’s medical, cognitive, analgesic, nutritional, social and rehabilitation needs are identified as early as possible and given prominence. It has now been accepted that a hip fracture programme should exist for these patients, with the geriatric medical team contributing to joint preoperative patient assessment, 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: orthogeriatric assessment and rapid optimization of fitness for surgery early identification of individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to facilitate return to pre-fracture 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%
Timing of surgery There is a paucity of good evidence regarding the timing of surgery. In particular, no study has shown that there is 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. The document suggested that all the appropriate investigations should be undertaken with the aim of immediate optimization but that there was no evidence that waiting for ancillary tests such as echocardiograms improved outcome or survival. Therefore surgery should not be delayed by anaemia, anticoagulation, volume depletion, electrolyte imbalance, uncontrolled diabetes, uncontrolled heart failure or correctable cardiac arrhythmias or ischaemia. It is expected that this can be normally optimized within 24 hours of admission.
48%
Figure 2
and 75% will be female. About 20% are unfit for surgery at the time of presentation. About 30% of those presenting will have dementia and a further 20% will have impaired cognitive function related to the hip fracture episode. The mortality rate at 1 year is 24% and 2% will die prior to surgery. About 9% will die in the first 30 days following the fracture, of whom two-thirds 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. Approximately 40% of those admitted will require a change of residence on discharge.3
Operating environment Surgery for hip fractures should take place on planned trauma lists. These should be staffed by consultant or senior 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.7 The aim of surgery should be to allow the patient to weight-bear without restriction in the immediate postoperative period. This should be instigated with a physiotherapy assessment on the day after surgery unless there are specific medical or surgical contraindications and thereafter the hip fracture patient should be seen at least daily by the physiotherapy team.
Diagnosis of hip fracture This is apparent from the plain radiographs (an anteroposterior view of the pelvis and a lateral view of the affected hip) in 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 a CT scan should be undertaken.
SURGERY 31:9
457
Ó 2013 Elsevier Ltd. All rights reserved.
ORTHOPAEDICS: LOWER LIMB
Surgery for hip fractures
stick prior to the fall, who are not cognitively impaired, and who are medically fit. It is thought that up to 20% of patients sustaining a displaced subcapital fracture would be suitable, but the published literature has a significant selection bias in patients under the age of 80 and the population who will benefit has yet to be fully defined. In summary, for displaced subcapital fractures it is recommended to treat the fractures with replacement arthroplasty, using a total hip replacement for those who are both medically and physically fit.
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. Again it is important the patient is allowed to fully weight-bear in the immediate postoperative period. However, in the elderly patient prosthetic replacement should be considered as an alternative treatment, as the risk of failure and re-operation with internal fixation is high. Displaced 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 meaning that there is much better stability and possibly range of motion. However, all the larger series suggest that the risks of complications such as non-union (33% for displaced fractures), avascular necrosis (10e16%) and refracture below implants (1%) are higher. Re-operation rates are much higher and this is particularly pertinent in what is largely an unfit and high anaesthetic risk population. Therefore in the majority of cases of an osteoporotic hip fracture, particularly where there is any displacement, there appears to be 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. Choice of prosthesis e many prostheses, such as the Austin Moore and Thompson hemiarthroplasty, are still being used in hip fracture care despite being unacceptable in any other patient group undergoing hip arthroplasty. 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. Cemented versus uncemented e lack of consensus regarding the method of fixation of the femoral prosthesis stems from 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. On the other hand, although the use of uncemented prostheses involves less operative time and blood loss, they are associated with a higher complication rate. This is mainly due to periprosthetic fractures sustained at insertion. Excess thigh pain has previously been associated with now outdated uncemented stems, but has largely been addressed by modern prosthetic designs. However, re-operation rates remain higher. Given the lower risk of complications and revisions, the use of cemented implants is recommended. Whilst the recent literature may suggest a marginal higher mortality in the first perioperative day, all meta-analyses have shown an overall decreased mortality and better function by 3 months. Recent analysis of the UK and Norwegian Hip Fracture Databases has been published showing lower mortality, re-operation rates and better function with the use of cemented implants.8e10 Hemiarthroplasty versus total hip replacement e the recommendations are for an arthroplasty to treat displaced subcapital hip fractures. Increasingly, hip fracture patients are being considered for total joint replacement. The NICE guidelines are to offer a total hip arthroplasty to those who were able to walk independently out of doors with no more than the use of one
SURGERY 31:9
Trochanteric fractures These are broadly classified as trochanteric (including basicervical) and subtrochanteric fractures. The 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 medialization 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. These studies also show a very significant cost implication with their use. The intramedullary nails are between three and five times as expensive as sliding hip screws with no advantage to the patient. As a consequence, NICE recommended use of an extramedullary device such as a sliding hip screw for treatment of trochanteric fractures. There is a rare group of trochanteric fractures where the fracture line is oblique in nature (called reverse oblique, or AO A3, fractures) e for these there is little evidence in the literature and the majority of surgeons would choose to use an intramedullary device. Subtrochanteric fractures For subtrochanteric fractures the recommendation is to use a long intramedullary device. An adequate reduction (which often has to be performed through an open incision) is crucial to allow union to occur.
Surgery as part of terminal care Surgery is the best form of analgesia for a hip fracture. Rarely, a hip fracture may also 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
458
Ó 2013 Elsevier Ltd. All rights reserved.
ORTHOPAEDICS: LOWER LIMB
2 British Orthopaedic Association Standards for Trauma (BOAST). Hip fracture in the older person. BOAST 1, version 2, 2012. http://www. boa.ac.uk/LIB/LIBPUB/Documents/BOAST%201%20Version%202% 20-%20Hip%20Fracture%20in%20the%20Older%20Person%20-% 202012.pdf. 3 Best Practice Tariff. 2012. http://www.dh.gov.uk/health/2012/02/ confirmation-pbr-arrangements/. 4 The National Hip Fracture Database. National report, 2012. http://www. nhfd.co.uk/003/hipfracturer.nsf/NHFDNationalReport2012_Final.pdf (BPT). 5 National Institute for Health and Clinical Excellence. Hip fracture; the management of hip fracture in adults. London: NICE. CG124, 2011. http://www.nice.org.uk/nicemedia/live/13489/54918/54918.pdf. 6 2013. http://www.evidence.nhs.uk/evidence-update-34. 7 Association of Anaesthetists of Great Britain and Ireland. Management of proximal femoral fractures 2011. Anaesthesia 2012; 67: 85e98. 8 Costa ML, Griffin XL, Pendleton N, Pearson M, Parsons N. Does cementing the femoral component increase the risk of peri-operative mortality for patients having replacement surgery for a fracture of the neck of femur? Data from the National Hip Fracture Database. J Bone Joint Surg Br 2011 Oct; 93: 1405e10. 9 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 Aug; 94: 1113e9. 10 Leonardsson O, K€arrholm J, Akesson K, Garellick G, Rogmark C. Higher risk of reoperation for bipolar and uncemented hemiarthroplasty. Acta Orthop 2012 Oct; 83: 459e66. http://dx.doi.org/ 10.3109/17453674.2012.727076. Epub 2012 Sept. 24.
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. Assessment of both bone health and risks of falls are integral components of care. Many of these patients have complex medical co-morbidities that often require review whilst inpatients. Patients should be mobilized on the day after surgery and reviewed by a physiotherapist on a daily basis. It is important to constantly monitor for delirium in both the perioperative and postoperative period.
Conclusion The care of hip fracture patients has been under intense scrutiny in recent years. As a result 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. Patient care and outcomes have improved and treatment has become much more efficient with tangible cost savings. Standards of practice have been established with clear, evidence-based guidelines and 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. British Orthopaedic Association, 2007. http://www.boa.ac. uk/Publications/Documents/The%20Care%20of%20Patients%20with %20Fragility%20Fracture.pdf.
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