Clinical Evidence Concise
A Publication of BMJ Publishing Group
Am Fam Physician. 2007 Jan 1;75(1):93-96.
What are the effects of surgical interventions for hip fracture?
UNLIKELY TO BE BENEFICIAL
Conservative vs. Operative Treatment for Most Types of Hip Fracture
One small randomized controlled trial (RCT) identified by a systematic review showed limited evidence that conservative treatment of undisplaced intracapsular fractures increased the risk of nonunion compared with internal fixation of the fracture. The review provided limited evidence that, compared with operative treatment, conservative treatment of extracapsular fractures increased the proportion of persons who remained hospitalized after 12 weeks and the occurrence of leg shortening and varus deformity. The review identified no RCTs including persons with displaced intracapsular fracture. The review provided insufficient evidence to assess whether significant differences exist between conservative and operative treatment in medical complications, mortality, long-term pain, or loss of independence.
Short Cephalocondylic Nail (e.g., Gamma Nail) vs. Sliding Hip Screw for Extracapsular Hip Fracture
One systematic review showed no significant difference between intramedullary fixation with a short cephalocondylic nail (e.g., Gamma nail) and extramedullary fixation with a sliding hip screw in mortality, pain at follow-up, ability to return to a previous residence, and ability to walk after three to 12 months. The review also showed no significant difference between treatments in wound infection or cutout of the implant, but the review showed that cephalocondylic intramedullary fixation increased intraoperative and later femoral fractures and reoperation rates.
LIKELY TO BE INEFFECTIVE OR HARMFUL
Older Fixed Nail Plates vs. Sliding Hip Screws for Extramedullary Fixation of Extracapsular Fracture
One systematic review showed no significant difference between older fixed nail plates and sliding hip screws in mortality, pain at follow-up, or mobility. The review showed that sliding hip screws reduced the risk of fixation failure in persons with extracapsular hip fracture.
Intramedullary Fixation with Condylocephalic Nails (e.g., Ender Nails) vs. Extramedullary Fixation for Extracapsular Fracture
One systematic review showed that intramedullary fixation with condylocephalic nails increased reoperation rates and the incidence of leg shortening and external rotation deformity compared with extramedullary fixation. However, the review showed that condylocephalic nails reduced length of surgery, the incidence of deep wound sepsis, and operative blood loss.
TRADE-OFF BETWEEN BENEFITS AND HARMS
Internal Fixation vs. Arthroplasty for Intracapsular Hip Fracture
Two systematic reviews and two subsequent RCTs including older persons with displaced intracapsular fractures showed that internal fixation increased the need for subsequent revision surgery compared with arthroplasty. Internal fixation, however, was associated with less operative trauma, including reduced operative blood loss and transfusion requirements, and reduced deep wound sepsis. There were no clear differences in mortality or long-term functional outcome.
Choice of Implant for Internal Fixation of Intracapsular Hip Fracture
One systematic review provided insufficient evidence to determine the best implant for internal fixation of intracapsular fracture.
Different Types of Arthroplasty for Intracapsular Hip Fracture
One systematic review provided insufficient evidence to determine the best type of arthroplasty (cemented and uncemented prostheses; unipolar and bipolar hemiarthroplasty; or hemiarthroplasty and total hip replacement) for persons with intracapsular fracture.
Arthroplasty vs. Internal Fixation for Extracapsular Fracture
One RCT with weak methods identified by a systematic review provided insufficient evidence to compare arthroplasty with internal fixation in persons with extracapsular fracture.
Extramedullary Implants Other Than Older Fixed Nail Plates vs. Sliding Hip Screw for Extracapsular Fracture
One systematic review provided insufficient evidence on the relative effects of sliding and fixed extramedullary implants other than older fixed nail plates in persons with extracapsular hip fracture.
External Fixation for Extracapsular Fracture
One RCT identified by a systematic review provided insufficient evidence on the relative effects of external fixation compared with the sliding hip screw in persons with extracapsular hip fracture.
What are the effects of perioperative medical interventions on surgical outcome and prevention of complications?
Perioperative Prophylaxis with Antibiotics
One systematic review showed that multiple-dose perioperative and single-dose preoperative antibiotic prophylaxis reduced deep and superficial wound infection after hip surgery compared with control or no antibiotics.
LIKELY TO BE BENEFICIAL
Perioperative Prophylaxis with Antiplatelet Agents
One systematic review and one subsequent large RCT showed that perioperative and postoperative antiplatelet prophylaxis reduced the incidence of deep venous thrombosis (DVT) and pulmonary embolism compared with placebo or no prophylaxis. There was no significant effect on mortality. The review and subsequent RCT showed that more persons who received antiplatelet treatment had bleeding complications.
Cyclical Compression of the Foot or Calf to Reduce Venous Thromboembolism
One systematic review showed that cyclical compression devices (i.e., foot or calf pumps) reduced DVT and pulmonary embolism compared with no compression. However, compression devices were associated with noncompliance to therapy and skin abrasion.
Oral Multinutrient Feeds as Nutritional Supplementation After Hip Fracture
One systematic review including persons who had had hip fracture surgery showed limited evidence that nutritional supplementation consisting of oral protein and energy feeds reduced unfavorable outcomes (i.e., postoperative complications or death) compared with control.
UNLIKELY TO BE BENEFICIAL
Preoperative Traction to the Injured Leg
One systematic review showed no significant difference in preoperative pain relief or subsequent ease and fracture reduction at the time of surgery between routine preoperative traction and control.
TRADE-OFF BETWEEN BENEFITS AND HARMS
Perioperative Prophylaxis with Heparin to Reduce Venous Thromboembolism
One systematic review showed that perioperative prophylaxis with unfractionated heparin or low-molecular-weight heparin (LMWH) reduced the incidence of DVT compared with placebo or no treatment. The review provided insufficient evidence to determine whether heparin reduced pulmonary embolism risk or mortality. It also provided insufficient evidence to determine whether heparin increased bleeding and other complications, although another systematic review of unfractionated heparin in persons undergoing general, orthopedic, and urologic surgery showed that, overall, heparin increased excessive bleeding or the need for transfusion compared with control.
Regional vs. General Anesthesia for Hip Fracture Surgery
One systematic review of persons after hip fracture surgery provided limited evidence that regional anesthesia reduced the risk of acute postoperative confusion compared with general anesthesia. The review provided insufficient evidence to draw conclusions about mortality or other outcomes.
Nerve Blocks for Pain Control Before and After Hip Fracture
One systematic review of small RCTs showed that nerve blocks reduced total analgesic intake compared with no nerve block.
Operative Day (Less Than 24 Hours) vs. Extended Multiple-Dose Antibiotic Regimens
Two systematic reviews provided limited evidence, from two and three RCTs, respectively, that there is no significant difference in wound infection between operative day and extended multiple-dose antibiotic regimens in persons undergoing hip fracture surgery.
Single-Dose (Long-Acting) vs. Multiple-Dose Antibiotic Regimens
Two systematic reviews provided limited evidence that there is no significant difference in wound infection between some single- and some multiple-dose antibiotic regimens in persons undergoing hip fracture surgery.
LMWH vs. Unfractionated Heparin to Reduce Venous Thromboembolism After Hip Fracture Surgery
Five weak RCTs identified by a systematic review provided insufficient evidence to establish whether LMWH reduced DVT compared with unfractionated heparin. A second systematic review including persons undergoing orthopedic surgery provided no evidence that there is a difference in bleeding complications between LMWH and unfractionated heparin.
Graduated Elastic Compression to Prevent Venous Thromboembolism
We found no RCTs of thromboembolism stockings for prevention of thrombotic complications in persons with hip fracture. Two systematic reviews of persons undergoing surgery, including elective total hip replacement, showed that graduated elastic compression reduced the risk of DVT compared with control.
Nasogastric Feeds for Nutritional Supplementation After Hip Fracture
One systematic review provided no evidence that nasogastric feeding tubes for nutritional supplementation reduced mortality compared with control. However, the four RCTs were small, had flawed methods, and included persons with differing nutritional status. There was insufficient evidence to assess other outcomes.
What are the effects of rehabilitation interventions and programs after hip fracture?
LIKELY TO BE BENEFICIAL
Coordinated Multidisciplinary Approaches for Inpatient Rehabilitation of Older Persons
One systematic review comparing coordinated multidisciplinary care for inpatient rehabilitation with usual care (often orthopedic) in older persons showed no significant difference in mortality or the combined outcomes of death or institutional care, death or deterioration in functional status, or death or rehospitalization. However, more persons receiving multidisciplinary care tended to have better outcomes, and there was limited evidence that multidisciplinary care resulted in fewer complications. It was not possible to define the best method of multidisciplinary care from the various models assessed in the review.
Mobilization Strategies Initiated Soon After Hip Fracture Surgery
One systematic review and one subsequent RCT provided insufficient evidence to determine the effects of various mobilization strategies initiated soon after hip fracture surgery.
Early Supported Discharge Followed by Home-Based Rehabilitation
Two RCTs showed no significant difference in overall quality of life, mortality, falls, or rehospitalization between early supported discharge (followed by home-based rehabilitation) and hospital-based rehabilitation in less-disabled persons with a favorable home situation. One RCT showed that early supported discharge reduced caregiver burden at 12 months compared with hospital-based rehabilitation. Both RCTs showed that early supported discharge reduced length of hospital stay but increased the overall length of rehabilitative care.
Systematic, Multicomponent Home-Based Rehabilitation
One RCT comparing a systematic, multicomponent home-based rehabilitation program with usual care showed no significant difference in recovery to prefracture self-care levels, home management, social activity, balance, or lower extremity strength after 12 months.
A hip or proximal femoral fracture refers to any fracture of the femur from the hip joint's articular cartilage to a point 5 cm below the distal part of the lesser trochanter. Femoral head fractures are not included in this definition.1 Hip fractures are divided into two groups (intracapsular or extracapsular) according to their relationship to the capsular attachments of the hip joint. Intracapsular fractures occur proximal to the point at which the hip joint capsule attaches to the femur and can be subdivided into displaced and undisplaced fractures.2 Undisplaced fractures include impacted or adduction fractures. Displaced intracapsular fractures may be associated with disruption of the blood supply to the head of the femur, causing avascular necrosis. Extracapsular fractures occur distal to the hip joint capsule.1 A subtrochanteric fracture occurs in the most distal part of the proximal femoral segment (below the lesser trochanter). There are numerous other subclassifications of intracapsular and extracapsular fractures.1,2
Hip fractures occur at any age but are most common in persons older than 65 years. In industrialized societies, the mean age of persons with hip fracture is about 80 years, and about 80 percent of these persons are women. In the United States, the lifetime risk of hip fracture after 50 years of age is about 17 percent in white women and 6 percent in white men.3 A U.S. study reported a prevalence increase from about three out of 100 women 65 to 74 years of age to 12.6 out of 100 women 85 years and older.4 The age-stratified incidence also has increased in some societies; persons are living longer, and the incidence of fracture in each age group may have increased.3 An estimated 1.26 million hip fractures occurred in adults in 1990, and this number is predicted to increase to between 7.3 and 21.3 million by 2050.5
Hip fractures usually are caused by a fall from a standing height or less. The incidence pattern is consistent with an increased risk of falling, loss of protective reflex mechanisms, and loss of skeletal strength from osteoporosis—all of which are associated with aging.
Reported mortality rates after hip fracture in adults vary considerably. One-year mortality rates vary from 12 to 37 percent,6 with about 9 percent of deaths directly attributable to the hip fracture.7 A 15- to 25-percent decrease in the ability to perform activities of daily living is expected after hip fracture, and about 10 to 20 percent of survivors will require a more dependent residential living situation.8
search date: August 2004
Adapted with permission from Handoll H, Parker M. Hip fracture. Clin Evid 2006;15:409–13.
1. Parker MJ. Trochanteric and subtrochanteric fractures. In: Bulstrode C, Buckwalter J, Carr A, et al., eds. Oxford Textbook of Orthopaedics and Trauma. Oxford, U.K.: Oxford University Press, 2002:2228–39.
2. Thorngren KG. Femoral neck fractures. In: Bulstrode C, Buckwalter J, Carr A, et al., eds. Oxford Textbook of Orthopaedics and Trauma. Oxford, U.K.: Oxford University Press, 2002:2216–27.
3. Cummings SR, Melton LJ. Epidemiology and outcomes of osteoporotic fractures. Lancet. 2002;359:1361–7.
4. Hochberg MC, Williamson J, Skinner EA, et al. The prevalence and impact of self-reported hip fracture in elderly community-dwelling women: the Women's Health and Aging Study. Osteoporos Int. 1998;8:385–9.
5. Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporos Int. 1997;7:407–13.
6. Lyons AR. Clinical outcomes and treatment of hip fractures. Am J Med. 1997;103(2A):51S–64S.
7. Parker MJ, Anand JK. What is the true mortality of hip fractures? Public Health. 1991;105:443–6.
8. Rosell PA, Parker MJ. Functional outcome after hip fracture: a 1-year prospective outcome study of 275 patients. Injury. 2003;34:529–32.
This is one in a series of chapters excerpted from Clinical Evidence Concise, published by the BMJ Publishing Group, Tavistock Square, London, U.K. Clinical Evidence Concise is printed twice a year and is updated monthly online. Each topic is revised every 12 months, and subscribers should view the most up-to-date version at http://www.clinicalevidence.com. If interested in contributing to Clinical Evidence Concise, e-mail: CEcommissioning@bmj.com. The complete text for this topic also is available as a PDF at http://www.aafp.org/afp/20070101/bmj.html. The evidence on this topic is available at http://www.clinicalevidence.com/ceweb/conditions/msd/1110/1110.jsp.
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