Operative management of hip fractures: a review of the NICE guidelines
Hip fractures are a major health concern in older age. Each year around 70 000 patients are admitted to hospital with hip fractures and within an ageing demographic this figure is set to rise (British Orthopaedic Association, 2007).
Available from: Henrik Palm
- "We recommend keeping surgical pathways strict and simple like the one by Palm et al.for achieving a high compliance among surgeons[6,24]. But even so, surgeon compliance should not be expected above 90– 95%[6,24], as the last percentages of patients probably have individual characteristics worth taking into account, as well illustrated by Parker and GurusamyAlthough compliance should be aimed high, an algorithm does not release the individual surgeons from the responsibility of ensuring optimal treatment adapted to the individual patients' treatment needs. Therefore , it is still important to spread awareness among staffmembers of the overall status of hip fracture research and treatment choices. National guidelines should therefore also cover the reasons for pathway choices – which is very profoundly performed in the English guideline. "
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In hip fracture surgery, the exact choice of implant often remains somewhat unclear for the individual surgeon, but the growing literature consensus has enabled publication of evidence-based surgical treatment pathways. The aim of this article was to review author pathways and national guidelines for hip fracture surgery and discuss a method for future pathway/guideline implementation and evaluation.
By a PubMed search in March 2015 six studies of surgical treatment pathways covering all types of proximal femoral fractures with publication after 1995 were identified. Also we searched the homepages of the national heath authorities and national orthopedic societies in West Europe and found 11 national or regional (in case of no national) guidelines including any type of proximal femoral fracture surgery.
Pathway consensus is outspread (internal fixation for un-displaced femoral neck fractures and prosthesis for displaced among the elderly; and sliding hip screw for stabile- and intramedullary nails for unstable- and sub-trochanteric fractures) but they are based on a variety of criteria and definitions - and often leave wide space for the individual surgeons' subjective judgement. Appearing neither exhaustive nor exclusive, most of the pathways seem difficult to evaluate scientifically, which might explain why only very few have been evaluated for compliance, reliability and complications after implementation in an actual clinical setting. We therefore introduce a model for step-wise pathway implementation including proper scientific evaluation.
Surgical treatment pathways for proximal femoral fractures are available in literature and nationally with somewhat evidence based treatment consensus, but the scientific evaluation of the pathways them selves needs to be optimised.
Available from: Lars Nordsletten
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ABSTRACT: Displaced femoral neck fractures usually are treated with hemiarthroplasty. However, the degree to which the design of the implant used (cemented or uncemented) affects the outcome is not known and may be therapeutically important.
In this randomized controlled trial, we sought to compare cemented with cementless fixation in bipolar hemiarthroplasties at 5 years in terms of (1) Harris hip scores; (2) femoral fractures; (3) overall health outcomes using the Barthel Index and EQ-5D scores; and (4) complications, reoperations, and mortality since our earlier report on this cohort at 1-year followup.
We present followup at a median of 5 years after surgery (range, 56-65 months) from a randomized trial comparing a cemented hemiarthroplasty (112 hips) with an uncemented, hydroxyapatite-coated hemiarthroplasty (108 hips), both with a bipolar head. Results were previously reported at 1-year followup. Harris hip scores, Barthel Index, and EQ-5D scores were assessed by one research nurse and one orthopaedic surgeon. Complications and reoperations were determined by chart review and radiographs examined by three orthopaedic surgeons. Sixty patients (56%) had died in the cemented group and 63 (60%) in the uncemented group. Respectively, three and two patients (2.7% and 1.9%) were completely lost to followup.
Harris hip scores at 5 years were higher in the uncemented group than in the cemented group (86.2 versus 76.3; mean difference 9.9; 95% confidence interval [CI], 1.9-17.9). The prevalence of postoperative periprosthetic femoral fractures was 7.4% in the uncemented group and 0.9% in the cemented group (hazard ratio [HR], 9.3; 95% CI, 1.16-74.5). Barthel Index and EQ-5D scores were not different between the groups. Between 1 and 5 years, we found no additional infections or dislocations. The mortality rate was not different between the groups (HR, 1.2; 95% CI, 0.82-1.7).
Both arthroplasties may be used with good medium-term results after displaced femoral neck fractures. The uncemented hemiarthroplasty may result in higher hip scores but appears to carry an unacceptably high risk of later femoral fractures.
Level I, therapeutic study. See the Guidelines for Authors for a complete description of levels of evidence.
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