Evidence-Based Approach to Hip Fractures

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A group of orthopedic surgeons from four well-known orthopedic clinics took the time to review available studies on hip fractures. In this report, they summarize the evidence around treating femoral hip fractures. The information was gathered from the Cochrane database and the Scottish Intercollegiate Guidelines Network (SIGN) database. Both of these organizations are well respected for their critical reviews of the literature.

The concern about treating hip fractures is very timely. More adults are reaching age 65 and older -- a time when falls and fractures are so common. And with the increasing number of people expected to reach this age in the next 20 to 30 years, we may expect to see more and more of this kind of injury.

Femoral neck fractures were the focus of this study. There are two basic types of femoral neck fractures: nondisplaced and displaced. Nondisplaced means the bone is broken but the fracture line has not separated. Displaced refers to the fact that the two sides of the broken bone have moved apart and no longer line up.

Both types of fractures, their assessment, and their treatment are discussed. Nondisplaced fractures can be handled nonsurgically (conservative care) or with surgery. The decision is made based on severity of the fracture, the patient's general health, mental status, and function before the fracture.

Some people aren't stable enough medically to undergo surgery with the anesthesia or to face the possible complications from the operation. If the patient isn't in pain and/or the patient has dementia, nonoperative care may be the best choice. There are no surgical complications to further compromise their health.

But nonoperative care comes with a high death rate (90 per cent within the first year). Mortality is linked with pneumonia, pressure ulcers (bed sores), and pulmonary emboli (blood clots to the lungs). Sometimes conservative care is tried but later the patient has to have a total hip replacement. Such cases are referred to as conversions.

Surgery is almost always required to repair a displaced femoral fracture. The risk of nonunion and osteonecrosis (death of bone) is too great without repair of the injury. Surgical fixation is also advised for anyone who is active and mobile. The longer a person is immobile, the greater their risk of problems from blood clots and bed sores. But the surgeon must weigh the risks of surgery, too. Patients can develop wound infections after surgery or complications from the anesthesia.

Surgery for a displaced femoral neck fracture can include: 1) closed reduction and internal fixation (ORIF), 2) hemiarthroplasty (partial hip replacement), and 3) total hip replacement (THR). The authors review each of these options and compare them to one another.

In the case of internal fixation, they tried to find out if one method works better than another. Type of screws (or other fixation used), placement of internal fixation, need for hardware removal, and complications such as nonunion and osteonecrosis were reviewed.

They also looked at surgical times, amount of blood loss, rate of wound infection, and reoperation rate. There was no significant difference from one group to another. It didn't seem to matter if they used screws, smooth pins, or supportive plates. The bottom-line was the surgeon should use whatever he or she is most familiar and comfortable with.

What about using internal fixation versus a hemiarthroplasty (partial) or complete hip replacement? And is it better to hold the implant in place with cement or go with a cementless approach? How about type of implant? Does the unipolar hemiarthroplasty work better than a bipolar type? And finally, should the surgeon use an anterolateral (front/side) incision or go with a posterior (from the back) approach?

The literature was reviewed with each of these questions in mind. The authors found that for a displaced femoral neck fracture:

  • Internal fixation (compared to hemiarthroplasty) had a faster surgical time and less blood loss and lower infection rate.
  • A second (revision) surgery was more common after internal fixation (40 per cent compared to only five percent with hemiarthroplasty).
  • Deaths from either internal fixation or hemiarthroplasty were about the same.
  • Complication rates were lower and hip function higher among the patients with a total hip replacement (compared to internal fixation).
  • All things considered, cemented implants seems to be the preferred technique. Outcomes are better with less pain, faster recovery, and improved function.
  • It was difficult to separate results using type of surgical approach as the variable from type of implant and postoperative care provided. No strong recommendations could be made in this area.

    In summary, there isn't a cut and dried approach to femoral hip fractures in the elderly. The best available evidence does not strongly support one treatment method over another. For displaced femoral neck fractures, hemiarthroplasty seems to win out over internal fixation. Many variables and factors are taken into consideration when proposing a plan of care. The surgeon must examine each patient on a case-by-case basis.

    Ryan G. Miyamoto, MD, et al. Surgical Management of Hip Fractures: An Evidence-Based Review of the Literature. I: Femoral Neck Fractures. In Journal of the American Academy of Orthopaedic Surgeons. October 2008. Vol. 16. No. 10. Pp. 596-607.

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