Medical problems in hip fracture patients

Increasing number of older patients are admitted to hospital with hip fractures. This review evaluates the common medical problems that arise as a consequence of having a hip fracture. Older patients with fractures commonly have co-morbidities that require evaluation prior to and after surgery. Joint acute orthopaedic–geriatric units have been established to provide comprehensive orthopaedic and medical care with some studies showing a reduction in postoperative complications and mortality. Recommendations surrounding the care of the older orthopaedic patient include early surgical fixation, the use of prophylactic antibiotics and thromboembolic prophylaxis, good perioperative pain control to improve ambulation, delirium detection and management to decrease the risk complications, such as institutionalisation, the avoidance of malnutrition, urinary tract management, osteoporosis management and the promotion of early mobilisation to improve functional recovery. Physicians are well placed to manage these patients with orthopaedic surgeons during the perioperative period. Sufficient evidence exists for most recommendations for fracture patients, but further research is needed in most areas.     

Hip fractures and best practice tariffs

Hip fractures or proximal femur fractures describe fractures of the proximal femur from the femoral head to 5 cm below the lower border of the lesser trochanter. Most hip fractures occur in elderly patients whose bones have become weakened by osteopenia or osteoporosis, i.e. a fragility fracture. The prevalence of hip fractures is increasing steadily due to the ageing population. Due to the patient demographic (elderly, likely with multiple comorbidities) numerous guidelines are put in place and continually revised to facilitate best patient outcomes. It is now widely accepted that effective management of hip fractures requires collaborative care between orthopaedic surgeons and orthogeriatricians as part of a Hip Fracture Programme, with a focus on prompt surgery, re-establishing the patient's independence/pre-fracture mobility, and preventing further fractures by assessing falls risk and bone health. The NHS financially incentivizes Healthcare Trusts in the UK to achieve a set of Best Practice Tariffs (BPTs), which were introduced by the British Geriatric Society and the British Orthopaedic Society. The mainstay treatment for hip fractures is surgery, and the choice of surgery depends on the radiological classification of the hip fracture into an intracapsular vs extracapsular fracture and whether the fracture is displaced or non-displaced. This is due to the high risk of avascular necrosis of the femoral head with displaced intracapsular fractures. Other important considerations are the age of the patient, pre-fracture functionality, and comorbidities. This paper will describe hip fractures (particularly fragility hip fractures) including their classification, management and how gold standard care is incentivized by the best practice tariffs.     

Hip fractures in nonagenarians: perioperative mortality and survival

The nonagenarian population is increasing yet there is little known about their survival and mortality rates following hip fractures. The aim was to review and evaluate all the nonagenarians who underwent surgery for intra- or extracapsular hip fracture at the Trauma Unit of the Department of Surgery at the Academic Medical Center (AMC) in Amsterdam in the past 20 years. In this retrospective study, 155 nonagenarians sustaining hip fractures between 1982 and 2001 were included and reviewed. In this population there were 128 women (83%) and 27 men (17%). Mortality in women was higher than in men. In men more intracapsular fractures (70%) were diagnosed compared to extracapsular fractures. The opposite, 38% intracapsular and 62% extracapsular fractures were found in women (p=0.002). A trend in higher perioperative mortality for extracapsular fractures and increasing ASA-classification was observed. Mean survival for the whole population, men and women was 756, 544 and 787 days, respectively. This study shows that ASA-II nonagenarians with hip fractures have comparable life expectancy compared to nonagenarians without a hip fracture. Shortening of hospital stay after hip fracture surgery reduces the costs and will benefit the patient.     

Intracapsular hip fractures in end-stage renal failure

Patients with end-stage renal failure (ESRF) have metabolic bone disease. This increases the risk of femoral neck fracture and increases the risk of complications associated with fracture fixation such as non-union and avascular necrosis (AVN). We report the results of treatment in a consecutive series of 15 intracapsular fractures of the hip occurring in 13 patients with ESRF over a 5-year period. Six intracapsular hip fractures (of which five were undisplaced) were treated by internal fixation. Five out of these six (mean=83.3%) required conversion to total hip arthroplasty because of non-union or AVN. In all six of these patients, internal fixation was considered adequate post operatively. Of the remaining nine intracapsular hip fractures treated by hemiarthroplasty, only one required conversion to total hip arthroplasty because of stem subsidence (mean=11%). The difference in the revision rate for the two groups i.e. primary fixation versus primary hemiarthroplasty was statistically significant (p-value=0.01). The six patients with undisplaced intracapsular fractures treated by internal fixation required a total of 14 major operations, at an average rate (including initial fracture fixation and revision surgery) of 2.3 per patient. The 9 displaced fractures treated by hemiarthroplasty required just 10 operations in total, at an average rate of 1.1 per patient. (The difference was significant; p-value=0.006.) The 1-year mortality in the whole group (13 patients with 15 fractures) was 44.4%. We suggest that patients with ESRF with an intracapsular fracture of the neck of femur should be treated by replacement arthroplasty irrespective of femoral head displacement because of the high risk of revision surgery associated with internal fixation.     

Müller straight stem total hip arthroplasty for fractured neck of femur

We present the results of a retrospective review of 50 Müller straight stem total hip replacements performed for femoral neck fracture over a 10-year period. PATIENTS AND METHODS: Between 1992 and 2002, 50 Müller straight stem total hip replacements were performed for femoral neck fracture in 42 female and 8 male patients with a mean age of 74 years. RESULTS: No hips have required revision surgery. Two patients have suffered early dislocations and there have been three major medical complications. The mean Merle D'Aubigne-Postel score was 15.1. Of the 25 radiographs available for review there were no cases of radiological loosening. DISCUSSION: This is further evidence that total hip replacement in the right hands provides good results for the treatment of displaced intracapsular femoral neck fractures. The Müller straight stem gives acceptable results in a select group of patients.     

Fractures of the hip: does the type of fall really affect the site of fracture?

The purpose of this study was to test accepted theories relating the characteristics of a fall to the anatomical site of hip fracture in the elderly. Twisting injuries are said to result in intracapsular fractures and falls directly onto the side are said to result in extracapsular fractures. 618 consecutive patients with a hip fracture were studied prospectively by being questioned with regard to the nature of their fall. After exclusions, 552 patients were left in the study. Of these, 324 patients sustained intracapsular fractures and 228 extracapsular fractures. More intracapsular fractures were associated with a fall onto the affected side than extracapsular fractures and rotation at the hip during the fall had a significant association with extracapsular fractures. In this study 84 per cent of all fractures occurred by falling directly onto the affected side. The clinical significance of this finding is that protective padding on the hip might be beneficial.     

Proximal femoral fracture. Range of hip motion as a predictor of fracture type

A cadaveric study has shown that the femoral neck impinges on the posterior part of the acetabulum at an average of 54.5 degrees external rotation and that an intracapsular fracture can be reproduced by an impact load onto the greater trochanter with the hip in external rotation. A clinical study of hip rotation of the contralateral uninjured hip in 100 patients after proximal femoral fracture was done to compare the degree of external rotation between extracapsular and intracapsular fracture. The mean value for intracapsular fracture was 62.1 degrees and for extracapsular fracture was 48.9 degrees. A retrieval study of the femoral head and neck from patients undergoing hip hemiarthroplasty for intracapsular fracture showed a consistent pattern of fracture with posterior comminution suggesting neck impingement. Previous work has suggested that an intracapsular fracture occurs during a fall when external hip rotation thrusts the femoral neck against the posterior margin of the acetabulum. The current investigation would support this hypothesis and suggests that the natural degree of external hip rotation is a predictor of fracture type.     

Surgery for hip fractures: Does surgical delay affect outcomes?

Hip fractures are associated with a high rate of mortality and profound temporary and sometimes permanent impairment of quality of life. Current guidelines indicate that surgeons should perform surgery for a hip fracture within 24 hours of injury because earlier surgery is associated with better functional outcome and lower rates of perioperative complications and mortality. Proponents of early treatment argue that this approach minimizes the length of time a patient is confined to bed rest, thereby reducing the risk for associated complications, such as pressure sores, deep vein thrombosis, and urinary tract infections. Those favoring delaying surgery beyond the guideline recommendations believe that this approach is required to medically optimize patients, and therefore decrease the risk for perioperative complications. Further challenges to resolving this debate is the lack of an accepted definition of what should constitute an “unacceptable delay” for hip fracture surgery and the fact that outcomes associated with surgical delay are based on observational data alone (i.e., not randomized controlled trials). The effect of preoperative timing on mortality and other patient-important outcomes across various age groups remains controversial and warrants a large randomized controlled trial to offer clear insights into the effects associated with early versus delayed surgery among hip fracture patients.     

Proximal femoral geometry and hip fractures

There is increasing evidence that proximal femoral geometry has an important role in the aetiology of hip fractures. We performed a simple radiological study to investigate the relationship between proximal femoral geometry and intracapsular and extracapsular fractures of the proximal femur. Measurements of proximal femoral geometry were made on pelvic radiographs on the contralateral hip of 50 consecutive patients with intracapsular and 50 with extracapsular fractures. The groups were matched for age and sex with a mean age of 79 and a female :male ratio of 4 :1. There were no statistical differences in head diameter, neck width or Head Trochanter Length between the two groups of fractures. Hip Axis Length, neck length and the neck length :width ratio were significantly greater in the intracapsular group, suggesting an aetiological link. This may have implications for future screening and prevention of proximal hip fractures, particularly intracapsular fractures.     

Ipsilateral hip and femoral shaft fractures

Over a 20-year period, 24 patients were treated for ipsilateral hip and femoral shaft fractures. The majority of the hip fractures were extracapsular. All resulted from high-energy impaction injuries (motor vehicle accidents and falls from over 15 feet), with 25% being open. There were numerous associated injuries, many requiring multiple operations. One-third had an associated knee injury, with 75% occurring in those with extracapsular fractures. The diagnosis and treatment of three hip fractures were delayed, but all healed without avascular necrosis. Patients were treated by traction and various internal fixation methods, either alone or in combination. Fifty percent had major complications, predominantly patients treated only in traction. At a mean follow-up examination of 9.5 years, two-thirds had a good result and one-third a fair result. Those with extracapsular fractures had the same result as those with intracapsular fractures. Patients treated by fixation of one or both fractures had a significantly shorter hospital stay than those treated by traction alone. Extracapsular fractures have a high incidence (43%) of associated knee injuries. Treating both fractures with internal fixation allows early mobilization, easier patient care, fewer complications, and a shorter hospital stay. Despite the severity of multiple injuries, and the diversity of treatment with many complications, when stability is achieved the patients generally recover good function.     

The association between aspirin and blood loss in hip fracture patients

This is a cohort study involving 98 patients who presented to a regional orthopaedic unit with a hip fracture. Blood loss was assessed by pre and post operative haemoglobin concentrations, and transfusion requirements were used as outcome measures. The influence of pre-operative aspirin use and fracture type was analysed with respect to these outcome measures. Forty two percent of patients were regular aspirin users, and were comparable to the non aspirin group, apart from having a significantly greater prevalence of atherosclerotic vascular disease. There was no significant difference between the aspirin and non aspirin groups in terms of preoperative haemoglobin concentrations, perioperative changes in haemoglobin levels and transfusion requirements. Fifty one percent of patients had extracapsular hip fractures, and these patients were comparable in terms of demographic characteristics, including aspirin use, to the group with intracapsular hip fractures. The extracapsular hip fracture group were found to have significantly increased peri-operative blood loss as measured by changes in the haemoglobin level, and in transfusion requirements when analysed against the intracapsular hip fracture group. We found that it is the fracture site, rather than aspirin use pre-operatively, that is predictive of blood loss and transfusion requirements in patients presenting with hip fractures.     

Are there advances in the treatment of extracapsular hip fractures in the elderly?

While the rate of failure following hip fracture surgery for extracapsular hip fractures in the elderly is low, an incidence of implant cutout from the femoral head remains regardless of whether fixation is by sliding hip screw or intramedullary nail. In general, a well-executed osteosynthesis is the best assurance of a good outcome with few complications, and typically a less than ideal placement of the implant in the femoral head is the reason for cut-out and failure of the operation. It is clear that there is no difference in the incidence of complications or functional outcome between a sliding hip screw and an intramedullary nail for pertrochanteric fractures (AO/OTA 31-A1 and A2), while the implant of choice in the elderly for the true intertrochanteric fracture (AO/OTA 31-A3; reverse intertrochanteric) is a nail. However, what is less clear is whether there are newer ideas and/or implant designs that represent true advances in the treatment of extracapsular fractures in the elderly. The following review focuses on just this issue.     

Mortality in patients sustaining a periprosthetic fracture following a previous extracapsular hip fracture fixation

BackgroundMortality rates following hip fractures are decreasing. As these outcomes improve, it increases the potential for further falls and the potential to sustain a periprosthetic fracture. The aim of this study was to analyse the 1 year mortality of periprosthetic fractures around an implant used to treat an extracapsular hip fracture. Secondary outcomes included 30 day mortality, complications and risk factors associated with mortality.MethodsA retrospective case note and radiographic review of all patients who presented to a single institution with a periprosthetic femoral fracture around an implant previously used to treat an extracapsular hip fracture between 1st January and 2008 and 31st May 2015.Results29 patients with a mean age of 75.8. 6 males and 23 females. 20 (69.0%) patients had capacity to consent for surgery. Pre-operatively 34.5% mobilised independently without any walking aids. 79.3% lived at home. 62.1% had a Charlson co-morbidity score of 0 or 1, 27.6% a score of 2 or 3, 6.9% a score of 4 and 5, and 3.4% a score of more than 5.3.4% was ASA grade 1, 13.8% ASA2, 65.5% ASA 3 and 17.2% were ASA 4. The previous implant a dynamic hip screw in 75.9% dynamic hip screws and an intramedullary nail in 24.1%. There were 4 (13.8%) in-patient deaths. The 30 day mortality 17.2% (5 patients) was and the 1 year mortality was 44.8% (13 patients). There were 0 complications that required return to surgery during admission. 1 patient with a revision intramedullary nail had dynamisation performed due to delayed union 7 months following surgery. 1 patient required removal of metalwork 2 years following surgery for infection. When comparing risk factors for mortality, there were no significant risk factors found in this study for 30 day and 1 year mortality.ConclusionsThis paper suggests that periprosthetic fractures sustained after the surgical treatment of extra capsular neck of femur fractures have higher mortality rates than hip fractures. These patients should be given the same priority as these patients in there management.     

One-year outcome for elderly patients with displaced intracapsular fractures of the femoral neck managed non-operatively

The outcome of patients with a displaced intracapsular femoral neck fracture treated non-operatively was assessed at 1 year and compared with patients managed operatively over the same time period. Data were collected prospectively for 102 consecutive patients. 80 patients underwent hemiarthroplasty and 22 were managed non-operatively. Patients were managed non-operatively if they were felt to have an unacceptably high risk of death within the perioperative period despite medical optimisation. Non-operative management entailed active early mobilisation without bed rest or traction.Patients managed non-operatively had a greater 30-day mortality compared with operatively managed patients. Deaths were due to pre-existing medical conditions or events, which had occurred at the time of hip fracture. No patient in the non-operative treatment group developed pneumonia, pressure sores or thrombo-embolic events. Patients treated non-operatively, who survived 30 days after fracture, had a mortality rate over the following year comparable with those who had undergone surgery.At 1 year, all non-operatively managed patients were able to transfer without pain and 6 of the 11 surviving patients were able to mobilise with walking aids. At 1 year, the majority of surviving non-operatively managed patients were living in their own homes.Surgical intervention is the treatment of choice for the majority of elderly patients with a displaced intracapsular femoral neck fracture. However, in patients with life-threatening medical co-morbidity, non-operative treatment with early mobilisation can yield acceptable results.     

Management of an unusual intra- and extra-capsular subcapital femoral neck fracture

Femoral neck fractures are common in the elderly after low-energy falls. They are broadly grouped into either intracapsular or extracapsular fractures. We report an unusual subcapital femoral neck intra-extracapsular fracture and discuss the management of such a case with its inherent problems.     

Perioperative management of proximal hip fractures in the elderly: the surgeon and the anesthesiologist

The comprehensive management of proximal hip fractures in elderly patients requires dedicated and responsive teamwork. Elderly patients often present with several comorbidities and the immediate treatment of a fracture has to optimize both medical therapy and analgesic control in order to reduce surgical and anesthetic complications and to preserve as much cognitive functioning as possible. The elderly are uniquely exposed to complications related to bed rest, delirium and postoperative cognitive dysfunction (POCD), which appear to be independent factors of morbidity. Anesthetic management that includes good perioperative pain management can influence the patient's inflammatory response and possibly decrease the incidence of POCD. The best choice of surgical treatment depends on the type of fracture as well as the patient's age and medical condition. However, the type of anesthesia management, which includes neuraxial blocks, peripheral nerve blocks and/or general anesthesia, has to be tailored towards generated the best outcome. We present a review from a surgical and anesthetic perspective on the most common perioperative issues in proximal fracture repair.     

Two cannulated hip screws for femoral neck fractures: treatment of choice or asking for trouble?

Introduction: Undisplaced intracapsular fractures are predominantly treated with a minimally invasive fixation technique, whereas the standard treatment for displaced intracapsular fractures is still a subject of discussion. The purpose of this study was to identify the determinants influencing the outcome of intracapsular femoral neck fractures, treated with two cannulated hip screws. Patients and methods: From January 1998 through December 2002 data of all consecutive patients with an intracapsular femoral fracture, treated with two cannulated screws, were documented. Consolidation was chosen as the primary endpoint, mortality and a reoperation for replacement of osteosynthesis were defined secondary endpoints. Results: One hundred and twelve patients were included in the study. Fifty six percent of the intracapsular fractures healed within 1 year. Consolidation was accomplished in 95% of the stable fractures. Consolidation rates were negatively influenced by unstable fractures and inadequate anatomical reduction. The position of the screws did not influence consolidation rates. Reintervention rates were related to the number of local complications and the fracture type. Conclusion: In conclusion, the results of this study show that in case of operative treatment, undisplaced femoral neck fractures can be adequately fixated by two cannulated hip screws. Unstable, anatomically reduced femoral neck fracture (Garden III/IV) may be treated with a more stable implant (e.g. DHS) to avoid redisplacement. If adequate reduction cannot be achieved, endoprosthetic replacement is recommended.     

Should Femoral Shaft fractures in Patients Age Over 60 Years be Managed Using a Hip Fracture Pathway?

IntroductionThe British Orthopaedic Association published 2019 guidelines ‘The Older or Frail Orthopaedic Trauma Patient’. This implements principles of the hip fracture pathway to all fragility fractures. Like hip fractures, femoral shaft fractures in the elderly are also suggested to represent fragility fractures. Femoral shaft fractures in older patients are rare and there is scarce literature detailing their outcomes. We aim to review outcomes of femoral shaft fractures in patients age 60 years and over at our institution and compare them to that of the hip fracture population.Materials and Methods: We retrospectively reviewed clinical records of a consecutive cohort of patients aged 60 years and over, who sustained a femoral shaft fracture, over a five-year period at our institution. Outcome measures studied were time to surgery, mean length of admission, readmission rate within 30 days, medical and orthopaedic complications, one month and one year mortality.ResultsWe identified 53 patients with a mean age of 78.7 years. On average patients each had 2.7 medical comorbidities. Mean length of admission was 20.0 days and readmission rate within 30 days was 19.1% (n=9). Medical complications affected 41.5% of patients (n=22) and orthopaedic complications affected 9.4% of patients (n=5). Two patients demonstrated nonunion and one patient required revision surgery. Thirty day mortality rate was 13.2% (n=7) which increased to a one year mortality of 26.4% (n=14).ConclusionPatients age 60 years and over with femoral shaft fractures have poor medical outcomes and prolonged length of admission. Compared to patients with hip fractures, medical complication rates are at least twice the 13-20% reported for hip fractures. The 30 day mortality rate in patients with femoral shaft fractures was also more than double the 6.1% reported for hip fracture patients by The National Hip Fracture Database in 2018. Femoral shaft fractures are associated with high medical morbidity and mortality. The hip fracture pathway is encompassed in the British Orthopaedic Association guidelines and emphasizes early medical input and a multidisciplinary approach to patient management. Hence, our study supports implementation of these guidelines with aim to improve morbidity and mortality of this vulnerable patient group.     

多学科协作构建老年髋部骨折"绿色通道"

目的评价新型冠状病毒肺炎疫情前后多学科协作模式治疗老年髋部骨折的效果，探索常态化疫情防控形势下进一步完善临床诊疗路径的突破点。 方法回顾性收集自2019年1月至2020年12月间北京积水潭医院老年创伤骨科以多学科协作模式治疗的老年髋部骨折患者的相关信息进行分析比较，包括年龄、性别、骨折类型、美国麻醉医师协会（ASA）评分、手术治疗率、受伤至急诊时间、急诊至入院时间、入院至手术时间、入院48 h内手术率、住院时间、围手术期并发症发生率及院内死亡率等。 结果本研究共纳入老年髋部骨折患者2 275例，平均年龄79.7岁（65~105岁）；男性663例（29.1%），女性1 612例（70.9%）；股骨颈骨折1 219例（53.6%），股骨粗隆间骨折1 016例（44.7%），股骨粗隆下骨折40例（1.8%）；ASA评分高分级占比49.6%；手术治疗率为97.7%；院内死亡率为0.2%（4例）。相较于2019年，2020年所收治患者受伤至急诊平均时间明显延长（1.7 d VS. 3.4 d，P=0.000），急诊至入院平均时间无明显变化（23.4 h VS. 24.0 h，P=0.109），入院至手术平均时间略有增长（30.7 h VS. 38.3 h，P=0.000），入院48 h内手术率有所下降（82.1% VS. 72.4%，P=0.000），平均住院时间略有延长（4.1 d VS. 4.3 d，P=0.005）；围手术期并发症发生率明显增加（16.9% VS. 22.5%，P=0.001），主要体现在压疮、肺部感染及泌尿系感染的发生率明显上升。 结论基于多学科协作的老年髋部骨折"绿色通道"诊疗模式院内死亡率极低；有效地缩短术前等待时间，可能降低围手术期并发症发生率。     

Die minimal-invasive Schraubenosteosynthese der medialen Schenkelhalsfraktur im höheren Lebensalter

Increasing life expectancy has led to an increase of medial femoral neck fractures. Treatment by hip arthroplasty is a major surgical procedure for geriatric patients and imposes high healthcare costs. Manninger developed a cannulated screw system which allows a joint-sparing, less invasive, and stable internal fixation for the management of intracapsular femoral neck fractures. In a prospective study from January 1998 to August 2002, 63 patients older than 70 years with Garden type I to III fractures were treated by closed reduction and internal fixation with two Manninger screws on a traction table within the first 6 h after trauma. Mean time of follow-up was 21.5+/-16 months. Of the patients examined, 88.5% regained their preoperative stage of mobility. Two patients needed secondary hip arthroplasty. Due to low complication and failure rates and less medical expenses compared to treatment by hemiprosthesis the joint-sparing, less invasive internal fixation with two cannulated Manninger screws presents a safe and cost-efficient surgical technique for geriatric patients.