Journal Article:

nejmcp1611090

Summary:

Management of Acute Hip Fracture

Mohit Bhandari, MD, PhD and Marc Swiontkowski MD

Why do we care about hip fractures?

• Globally:
  • 5 million disabilities each year
  • Among the top 10 causes of disability
• By 2040, estimated annual health care cost in the US will be approximately $9.8 billion
• Increased risk of cardiovascular, pulmonary, thrombotic, infectious, bleeding complications
• One-month mortality approximately 10%; one-year mortality approximately 36%
• Even if community-dwelling prior to hip fracture, after the incident, 11% are bedridden, 16% are in LTC facility, and 80% use a walking aid one year later
• High risk of reoperation (approximately 10%-49%)
• Fracture displacement and disruption of blood supply that feeds the femoral head (lateral circumflex femoral artery) = avascular necrosis, malunion, nonunion

Basically, it affects a lot of people, leading to morbidity, disability and death, and costs a lot of money.

How are hip fractures classified?

• Anatomically:
  • The hip capsule is used as a reference point
    • Intracapsular
      • At the Femoral Neck
    • Extracapsular
      • Intertrochanteric
      • Subtrochanteric
        • Occurs below the lesser trochanter

What is the incidence of different classifications of hip fracture?

• Majority = intertrochanteric and femoral neck fractures; similar frequency

What are the Femoral Neck Fracture Types?

• Discussed in terms of displacement
  • Nondisplaced = 1/3 of femoral neck fractures
  • Displaced
• Garden Type
  • Nondisplaced or impacted fracture = Garden Type I or II
  • Displaced fracture = Garden Type III or IV

How do you treat hip fracture?

• Standard of care or “mainstay of treatment” = timely surgical intervention
  • Single-center retrospective study showed that non-operative treatment significantly increased risk of death (at one year, it was 4x as high; at two years, it was 3x as high)
• Early mobilization is recommended
  • Retrospective study showed that non-operative treatment with bed rest had one-month risk of death 3.8x as high as those with non-operative treatment and early mobilization. In this study, mortality was not significantly different between operative treatment and non-operative treatment with early mobilization.
• Femoral Neck Fracture (Garden Type Fractures)
  • Options = internal fixation (multiple cancellous screws versus sliding hip screw) or arthroplasty (hemiarthroplasty versus total hip arthroplasty)
    • What is the difference between hemiarthroplasty and total hip arthroplasty?
      • Hemiarthroplasty = insertion of metal prosthesis in proximal femur
      • Total Hip Arthroplasty = insertion of metal femoral prosthesis AND addition of acetabular component for hip socket
    • If nondisplaced (Garden Type I or II) = internal fixation
      • Multiple cancellous screws versus single, large compression screw with a side plate = noninferior
        • Recent large trial named Fixation Alternative in the Treatment of Hip Fractures (FAITH) (n = 1079) = random assignment to multiple cancellous screws versus sliding hip screw = no significant difference in risk of reoperation over 2 years.
      • If displaced (Garden Type III or IV), or located at the base of the femoral neck, or fracture with more vertically oriented fracture line, use sliding hip screw
        • Suggested in subgroup analysis of FAITH trial and laboratory testing
        • Especially in younger patients with high-energy hip fracture (MVA)
      • If displaced AND >65 yo = arthroplasty
        • Low-energy, fragility-type fractures
        • Meta-analysis of 14 RCT (n=1907) arthroplasty has lower risk of reoperation than internal fixation
        • Hemiarthroplasty and total hip arthroplasty = better functional outcome, QOL measured at 1 year after surgery (versus internal fixation). Randomized trial (n = 100) showed hip function at 17 years post-op (Harris Hip Score) better after total hip arthroplasty than internal fixation.
        • Arthroplasty risks = infection, dislocations
          • Meta-analysis showed higher risk of infection with arthroplasty versus internal fixation
        • Debate concerning hemiarthroplasty versus total hip arthroplasty (especially in populations <60y/o)
          • Meta-analysis of 14 trials (n = 1890) showed lower risk of reoperation in favor of total hip arthroplasty (versus hemi-)
            • Confounding Variable = not blinded
          • Hip function follow-up at 12-48 months favored total hip arthroplasty
          • Risk of dislocation following total hip arthroplasty was significantly greater than hemi-
          • Current RCT (n = 1500) comparing treatments; HEALTH Clinical Trial, FAITH-2 Trial
        • Benefits of internal fixation (rare) versus arthroplasty
          • Less invasive
          • Reduced infection risk
          • Preferred by many patients when given alternative options
        • Intertrochanteric Fractures
          • Internal Fixation
            • Sliding hip screw versus intramedullary nail
            • If stable, no significant difference in RCTs regarding functional outcomes, though sliding hip screws are more cost-effective
            • If unstable (e.g. large posteromedial fragment, reverse-oblique orientation of fracture line) use intramedullary nails
              • Meta-analysis of 8 RCTs (n = 1322) showed improved mobility versus sliding hip screw
            • Subtrochanteric Fractures
              • Least common
              • Almost always are unstable fractures
              • Variant of this fracture type = atypical femur fracture; associated with long-term bisphosphonate use or newer antiresorptive agents
              • Internal Fixation
                • Failure rates may approach 35%
                • Intramedullary nails are standard of care
                  • Meta-analysis (n = 232); intramedullary nails were favorable (lower risk of reoperation and nonunion versus extramedullary plates and screws)
                  • Comparison of mortality and function at 1y were similar (versus extramedullary plates and screws)

What are risk factors for short-term/intermediate-term death in patients with hip fracture?

• Age
• Male sex
• Socioeconomic deprivation
• Comorbidities
• Dementia
• Nursing home residency

What are the three major decisions surgeons face when dealing with acute hip fracture?

• Is the patient a surgical candidate? Is surgery an option given the patient’s health?
  • Preoperative assessment of cardiac risk often assessed with guidelines by Canadian Cardiovascular Society
• How quickly can the surgery be performed?
• What surgery is required given location of the fracture, displacement, and physiological condition of the patient?

What is the optimal time frame that surgical intervention should be accomplished within?

• Guidelines = Within 48h
  • Recommendation based on observational studies
    • Earlier surgical intervention associated with improved patient outcomes
  • New Research
    • Recent study suggests time to surgery within 6 hours associated with greater reduction in one-month postoperative complications (versus >6 hours)
    • Meta-analysis of observational studies (n = 4208), earlier surgery = lower mortality versus later surgery. Another analysis suggested decreased risk of in-hospital pneumonia.
    • Researchers recognize that a significant confounder may be that sicker patients (those more likely to die irrespective of the hip fracture) tend to experience delays in surgical intervention
    • Therefore, small, randomized, pilot trial (clinical trial) named Hip Fracture Accelerated Surgical Treatment and Care Track (HIP ATTACK) with n = 60 performed and showed major perioperative complications of 30% in early intervention group (<6h) versus 47% with standard care (>6h)
      • Currently, a large, international trial of early versus late surgical intervention is being performed
        • Intervention <6h versus >6h looking at primary outcomes like death, serious perioperative complications

What kind of perioperative care optimizes patient outcomes?

• Comprehensive, interdisciplinary care in geriatric wards
  • Geriatrician, physical therapy, occupational therapy
  • Significant improvement in mobility, ADLs, QOL (versus orthopedic ward)
• Aggressive and early mobilization
• Venous thromboprophylaxis, antibiotic prophylaxis, evaluation and treatment of osteoporosis
  • Ca2+ and Vitamin D, initiation of bisphosphonates recommended after fracture
    • These interventions do not adversely affect healing
  • DEXA to assess BMD

For more information on guidelines:

NIH, Care Excellence, American Academy of Orthopedic Surgeons, National Hip Fracture Model of Care and Toolkit