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Review
| How best to fix a broken hip | par 0 |
| par 1 |
| par 2 |
| LM March, AC Chamberlain, ID
Cameron, RG Cumming, AJM Brnabic, T Finnegan, S Kurrle, JM Schwarz,
SML Nade, TKF Taylor and members of the Fractured Neck of Femur
Health Outcomes Project Team* | par 3 |
| Electronically published Monday 22 March 1999. This is the unedited version published immediately on acceptance after internet peer review. Click here for the final edited version. Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company
Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia | par 4 |
| par 5 |
| Abstract | par 6 |
|
Introduction: Each year more than 15,000 elderly men and women are admitted to Australian hospitals with hip fractures. Due to an average length-of-stay (LOS) in excess of 13 days, this imposes a significant burden on the health care system. | par 6a |
|
Objectives: To develop evidence-based guidelines for the treatment of proximal
femoral fractures and to to optimise functional outcome while minimising hospital LOS.
| par 7 |
| Data sources: systematic literature search of MEDLINE and CINHAL computer data bases, bibliographies, current contents of key journals for years 1966 to december 1995. | par 7a |
| Study selection: English language randomised controlled trials of all aspects of acute hospital treatment of proximal femoral fracture among subjects aged 50 years and over with non-metastatic proximal femoral fractures. | par 7b |
|
Data extraction: Two independent reviewers, blinded to authors, institution and study results, assessed study quality and treatment conclusions following a standard cochrane collaboration protocol. Where necessary a third review was performed to reach a consensus.
| par 8 |
| Results: Of the 120 articles published between January 1966
and December 1995, 97 met the inclusion criteria. Fifteen clinical interventions were
reviewed. Four were supported by NHMRC level I evidence (prophylactic
anticoagulants, prophylactic antibiotics, regional anaesthesia and pressure relieving
mattresses), two had no supporting, randomised, controlled trial evidence (delay in time to
surgery, time to mobilisation after surgery) and the remainder were classified as having Level
II evidence. A review of current practice identified wide variability in these
interventions across five acute hospitals in the Northern Sydney Health Service Area.
| par 9 Comment.1 Comment.2 |
| Conclusions: Guidelines for the management of hip fracture should
be evidence-based to optimise functional outcome while minimizing hospital length-of-stay.
Randomised controlled trial evidence (NH&MRC Levels I & II) exists for many, but not all,
aspects of hip fracture treatment. A wide variability was found in current practice, supporting the need for evidence-based guidelines and for changes to be made to some aspects of current practice. | par 10 Comment.1 |
Introduction | par 11 |
| Each year, fractures of the
proximal femur (hip fracture) affect 4% of women and 2% of men aged
85 years or more. In 1995 this led to approximately 15,000 hospital
admissions across Australia. Given current age specific hip fracture rates and the expected ageing of the population (Australian Bureau of Statistics), by the year 2021 this will more than double (pers comm A/Prof. R. G. Cumming).
Conservative estimates of the current costs of acute inpatient care
for these patients are $7.8 million in the Northern Sydney Area
Health Service and $46.3 million for NSW1. This does not include other costs such as rehabilitation, support services,
residential care, family assistance and changes in quality of life. The death rate in the
subsequent 12 months is approximately 25%, which is four times greater than for
community-living age-matched controls
2 . Most survivors do not return to their prefracture
level of independence and physical abilities
3. | par 12 Comment.1 Comment.2 |
| The main objective of this study
was to answer the questions: What is the right thing to do? Are we
doing the right thing? and then to develop evidence-based clinical
guidelines. A systematic approach was taken with a focus on health
outcomes, whereby we aimed to make recommendations that would optimise functional outcome while minimising hospital length-of-stay.4. | par 13 |
| Methods | par 14 |
"What is the right thing to do?" - Literature Review. | par 15 |
| A systematic review of all
randomised, controlled trials (RCTs) and meta-analyses that included
hip fracture patients older than 50 years was performed. Cochrane
Collaboration guidelines for the assessment of study quality were
followed5. Guidelines for ranking
the level of evidence were taken from the National Health & Medical Research Council
(NH&MRC)
6. Where no RCTs were identified (time delay to
operation and timing of weight-bearing after surgery), a search for observational studies was
undertaken. | par 16 |
| The main source of literature was English
language articles identified from MEDLINE and CINAHL 1966 to December 1995. Search
words used were: "Hip fractures", "proximal femoral fractures", "fractured
neck of femur", together with specific interventions and clinical indicators (see Table 1). The searches were limited to English language, RCTs, meta-analyses, age >= 50 years and non-metastatic proximal femoral fractures. | par 17 Comment.1 Comment.2 Comment.3 Comment.4 |
| In addition, manual searches of
current issues of key specialty and general journals were conducted,
with examination of reviewers’ personal literature, libraries,
bibliographies of the identified published articles and personal
contact with those working in areas relevant to hip fracture,
including the Cochrane Collaboration Musculoskeletal Injuries
Group. | par 18 |
| Articles were distributed
randomly to the assessors by the use of a random numbers table.
Reviewers were experienced in the critical appraisal of scientific
literature and were blinded to the authors, institutions and journal
in which the reviewed articles were published. Articles were read
independently by two assessors. Results and study-quality data were
recorded following the Cochrane Collaboration criteria.
Disagreements were resolved by a third assessment and a consensus
meeting. | par 19 Comment.1 |
"Are we doing the right thing?" - Medical Record Audit. | par 20 |
| The study population came from
the five acute Northern Sydney Area Health Service public hospitals
during the 1993/94 financial year. All admissions over the 12 month period were included. Patients with multiple injuries
or fractures due to metastatic cancer were excluded. Data were
extracted by trained medical record reviewers. Patients were
identified with ICD-9 codes 820 and 821 and by Procedural codes
79.15, 79.35, 81.51-53. | par 21 Comment.1 Comment.2 |
| Validation was carried out using
a second independent audit by experienced reviewers on a 10% (n=73)
random sub-sample across all hospitals. For reporting purposes,
patients, surgeons and hospitals were identified by code number
only. | par 22 Comment.1 Comment.2 |
| Development of Evidence-Based Guidelines | par 23 |
| The key steps in the process of care for the acute
management of hip fracture had been identified (see Table 1) and a
specific clinical question asked for each, e.g. "Do low-pressure mattresses reduce the number
and severity of pressure sores?" All supporting trial evidence was summarised in table format
with author, year, interventions being tested, number of subjects, ranking of bias (low,
moderate, high), adequate concealment of allocation to groups (yes/no), summary of results of the individual papers
with odds ratios and 95% confidence limits, a calculation of the number needed to treat where
possible and an assessment of Cochrane Treatment Conclusions (see legend, Table 1). Data were in a suitable
format for meta-analysis to be performed for antibiotic prophylaxis
and type of anaesthesia but summary statistics were not generated for the other treatment modalities. Full details of all articles and these summaries are available at www.mja.com.au/public/issues/iprs2/march/fnof.pdf [In pdf format; requires Adobe Acrobat Reader]. | par 24 Comment.1 Comment.2 Comment.3 Comment.4 Comment.5 Comment.6 |
| From these tables, a one page
summary was generated for each clinical intervention, with
recommendations for clinical practice and suggestions for future
study. These were circulated for comment among the review team and
the orthopaedic clinical groups. | par 25 Comment.1 Comment.2 |
| The results of the medical
literature review and medical record audit were presented to medical
and nursing staff in each hospital in oral and written form. Local
practice was compared to the other hospitals and to evidence-based
best practice. | par 26 |
| Following all these steps, a
single page of draft guidelines was developed with NH&MRC levels
of evidence listed for each clinical recommendation. These were
circulated and presented for further discussion before being
adopted. They formed the basis of an evidence-based clinical pathway
which will be the subject of a separate paper. | par 27 |
| Results | par 28 |
"What is the right thing to do?" | par 29 |
| Table 1 presents the results of
the systematic literature review and the evidence-based clinical
guidelines. | par 30 |
Legend -
Table 1
| par 31 | ||||||||||||||||||||||||||||
| Our conclusions from the
literature review addressed 15 issues and, on the basis of available
evidence, we found: | par 32 |
| Time to surgery (Level III) - No randomised, controlled trial evidence is available and observational studies give a range of conclusions. Early surgery (within 24-36 hours) is recommended for the majority of patients once medical assessment has been made and the patient’s condition stabilised appropriately. Undue delay to surgery inevitably increases length of stay and may lead to more complications, including more pressure sores, pneumonia and confusion. | par 33 Comment.1 Comment.2 |
| Pre-operative traction (Level II) - Pre-operative skin and tibial pin traction should be abandoned for routine use. Pain should be adequately controlled with narcotic analgesia and/or nerve block. | par 34 |
| Prevention of pressure sores (Level I) - Patients should be nursed on one of a range of foam-based low pressure mattresses rather than standard hospital mattresses. Very high risk patients should ideally be nursed on a large cell alternating pressure air mattress or similar pressure-decreasing bed. | par 35 |
| Peri-operative oxygen therapy (Level II) - Some evidence supports its routine use for the first 72 hours after surgery. All patients should have oximetry assessment from time of Emergency admission to 48 hours after surgery and oxygen administered as necessary. | par 36 |
| Anticoagulants (Level I) - Patients should receive unfractionated low dose heparin (LDH) or low-molecular weight heparin (LMWH), with a preference for the latter. This should commence as soon as possible after admission. | par 37 |
| Pressure gradient stockings (Level II) - should be in place as soon as possible after admission. | par 38 |
| Anaesthesia (Level I) - Regional anaesthesia (spinal or epidural) appears to be associated with reduced short-term mortality and morbidity (confusion and thromboembolism) when compared with general anaesthesia and is recommended for the majority of patients.. | par 39 |
| Analgesia - Pain should be adequately controlled with narcotic analgesia before and immediately after surgery. Femoral nerve blocks are useful in selected cases (Level II). | par 40 |
| Antibiotics (Level I) - Prophylactic antibiotics by vein should be given at induction of anaesthesia and continue for 24 hours. Prolonged antibiotic use is of no proven benefit for prophylaxis of wound infection. | par 41 |
| Type of Surgery
-
| par 42 |
| Undisplaced intra-capsular fractures (Level I) - should have internal fixation with a widely used treatment that is familiar to the surgeon (cancellous screws or compression screw and plate). | par 43 |
| Displaced intra-capsular fractures (Level II) - there is no clearly superior surgical treatment. The options for surgical treatment of this fracture are internal fixation or arthroplasty. Internal fixation is associated with a higher risk of implant failure than hemiarthroplasty (femoral head replacement). At present the choice of treatment is best determined by patient factors (including age, presence of arthritis, availability and cost of the different types of treatment, surgeon experience and preference). | par 44 |
| Extra-capsular (trochanteric) fractures (Level
I) - Should be treated surgically. A sliding hip screw and plate has
less chance of failure leading to re-operation, than a fixed device
and may prove to be more cost-effective in the long term.
| par 45 |
| Drains (Level II) - May not be required as often as currently used and early removal is advised (around 24 hours after insertion). | par 46 |
| Urinary catheterisation (Level II) - Avoid in-dwelling catheters where possible. Intermittent catheterisation is preferable and has been shown not to increase the incidence of urinary tract infections. | par 47 |
| Protein supplementation (Level II) - All patients should have nutritional assessment so that protein supplementation can be given as indicated. | par 48 |
| Weight-bearing after surgery (Level III) - no randomised, controlled trial evidence was available but a review of studies related to types of surgery 1 concluded that almost all patients should be mobilised on the first or second day, taking as much weight on the fractured leg as the patient can tolerate. | par 49 |
| Rehabilitation
(Level II) - Early assessment (within 3 days of admission) and
active rehabilitation as soon as mobilising on a support frame is
recommended for those who had been independent before their
fracture.
| par 50 |
| Local consensus was that acute
surgical ward nursing care was no longer required by most patients
4-5 days after surgery. | par 51 |
| These recommended guidelines can
be applied to most, but not all,
patients who sustain a proximal femoral fracture. Individual
circumstances and co-morbidities will always influence decision
making. It is also recommended that these guidelines continue to be
updated as new evidence becomes available. | par 52 |
|
"Are we doing the right thing?" | par 53 Comment.1 Comment.2 |
| Seven hundred and twenty nine
consecutive admissions were audited and will be the subject of a
more detailed report evaluating the implementation of the
guidelines. No significant variation was shown among the five acute
care hospitals with respect to the patients’ age ( mean 82.4
years, 18% => 90 years), gender (81% female), admissions from
nursing homes (28.7%) and fracture type (51% intra-capsular, 43%
extra-capsular, 6% unknown). All patients had at least one
co-morbidity, 71.7% had two or more and almost one third had five or
more. | par 54 Comment.1 Comment.2 Comment.3 Comment.4 Comment.5 Comment.6 Comment.7 |
| There was some variation in
patient outcomes. Mortality at 12 months was 18% 1 for non-nursing home patients(range
across the five hospitals: min 12%, max 25%) and 38% for nursing
home patients (min 31%, max 44%). At four month follow-up, the
percentage of patients requiring a new nursing home admission was
16% (min 11%, max 23%). | par 55 |
| There was considerable
variation in the process of care(see table 1), particularly evident for waiting time for surgery, pre-operative traction, use of pressure gradient stockings, spinal anaesthesia and urinary catheterisation..
| par 56 Comment.1 |
| [par 57 deleted] | par 57 |
| [par 58 deleted] | par 58 Comment.1 |
| While prophylactic antibiotics (by
vein) were used in all hospitals, most continued
their use for longer than the 24 hours after surgery that the
evidence and basic principles suggest is required. The prescription
of additional oral antibiotics, for which there is no supporting
evidence, was also common practice (min 32%, max 83%). | par 59 |
| Wound drains were used almost universally, with the majority remaining beyond 24 hours. | par 60 |
| [par 61 deleted] | par 61 |
| Median time to ambulation after
surgery was three days (min 2, max 5 days). Delay in walking after
surgery was associated with an increased length of stay. The
hospital with the longest delay also had the greatest acute care
length of stay (median of 13 days compared to the overall median of
9 days). | par 62 |
| Three quarters of those who were
admitted from their own home were discharged to a rehabilitation
facility. The median acute length of stay for these patients before
transfer to that facility was 11 days (min 8 days, max 16
days). | par 63 |
| Median length of stay for those
patients returning to a Nursing Home was six days (min 5 days, max 9
days). | par 64 |
| The day of the week on which a patient was admitted was also found to be associated with the acute care length of stay. This effect was shown both between and within the five hospitals. Patients admitted on a Thursday were likely to spend an extra two days in the acute care facility (median 11 days) compared with those admitted on other days (median 9 days). | par 65 Comment.1 Comment.2 |
| par 66 Comment.1 |
| Discussion | par 67 |
| This study reports the completion
of a project which followed a structured approach to health outcomes
research as advocated by the NSW Health Department 4. Evidence- based guidelines for the
treatment of proximal femoral fractures were developed. The
methodology adhered closely to the process guidelines published by
the NH&MRC 6. To our knowledge, this guideline development is the first
to be performed within the context of clinical practice. Therefore,
the recommendations for interventions that are considered to be best
practice are realistic. The levels of evidence for each
recommendation were made explicit with all the supporting evidence
available for discussion. The clinical staff were involved
throughout the entire process. Each step of the process was
systematically developed and evaluated. The support for our
conclusions, therefore, is robust. | par 68 Comment.1 |
| Current practice, identified by
medical record audit, was compared to evidence-based best practice
and areas of care requiring modification were identified. A number
of steps in patient treatment were supported by high level evidence
but wide variability in the routine use of these treatments was seen
among the five participating hospitals in this single health service
area. | par 69 |
| Some common practices, including
pre-operative traction and drains, had little or no supporting
evidence for their continued use. Although not measured systematically the authors observed great variability in clinicians’ response to
this information ranging from relief to frank disbelief; many showed
considerable reluctance to drop a "time-honoured
practice". | par 70 Comment.1 |
| Prevention strategies involving
medical therapies such as prophylactic anticoagulants and
antibiotics were in widespread use and compared favourably with
other audits. However, non-pharmaceutical prevention strategies,
including pressure-decreasing mattresses, oxygen saturation
monitoring and nutritional supplements, were not in routine use in
any hospital. | par 71 |
| Despite high level evidence for
the use of prophylactic anticoagulants, optimal timing of the
initiation of anticoagulation remains in doubt, with surgical and
anaesthetic staff expressing concern about its use in combination
with regional anaesthesia where there is an extremely small, but never-the-less serious, risk of
spinal haematoma. On the balance of available evidence the benefits appear to outweigh the risk of harm but it remains a controversial area suggesting further trials on types and timing of anticoagulants are required for this patient group. | par 72 |
| The evidence that regional
anaesthesia was associated with reduced mortality and morbidity
compared with general anaesthesia also met with mixed response,
anaesthetists being completely polarised in their views. The
published meta-analysis40 did have flaws (duplication of patients, not all RCTs) but
the review team re-assessed the original articles according to the standard Cochrane Collaboration protocol and performed a repeat
analysis excluding studies which appeared to be duplicated and
reached the same conclusion, albeit with a more conservative
estimate of benefit (summary odds ratio = 0.68 for mortality with 95% CI 0.49,0.96). | par 73 Comment.1 Comment.2 Comment.3 |
| The optimum time delay from
admission to surgical operation has long been a vexed question.
Observational studies,7-11 with their inherent biases and conflicting
results, were the only ones available on which to make
recommendations. Delay to surgery is likely to increase the risk of
complications and the total length of stay and no harm has been
shown by early surgery on patients who are medically stable. There
was considerable variability in delay to surgery in this study with
up to 20% waiting longer than 72 hours. This may reflect the lack of
availability of out-of-hours surgical facilities and, to a lesser
extent, the achievement of medical stability, but these patients
continue to be ‘poor surgical relations’ and do not
receive the priority they deserve. | par 74 Comment.1 Comment.2 |
| Earlier time to ambulation also
carries resource implications and is partly dependent on the
availability of physiotherapy staff but also on a patient’s
general condition. While there are no randomised, controlled trials
on the optimal time for mobilisation, a review of all trials of
surgical treatment showed that ambulation on the first or second day
after surgery had no adverse effects,55-87,97 and a cohort study has now been published with the same conclusions. 104 | par 75 Comment.1 |
| Hospital administrators were not
always able to accommodate the changes needed to implement the
recommendations for early surgery and early mobilisation despite the
approval of the medical and nursing staff. The day of admission
appeared to influence both time delay to surgery and overall acute
length of stay, suggesting that the practice of adding these
patients to a routine list, rather than making special arrangements
for them, may be a factor in prolonging length of stay. | par 76 Comment.1 |
| Patients requiring transfer to a
rehabilitation facility generally stayed several days longer in the
acute care ward than those discharged to Nursing Home care. Since
all patients should be clinically stable, and most should have
attempted to walk, before discharge, this suggests a need to address
difficulties with the process of assessment for rehabilitation
and/or the availability of rehabilitation beds. It is proposed that costs of the initial hospitalisation could be reduced by earlier transfer to rehabilitation from the more expensive acute care ward. Whether this translates into longer term cost savings remains to be determined. | par 77 |
| This study identified
considerable variation in current management of patients who have
sustained hip fractures. It has some limitations being restricited to English language and only relating to evidence published up to january 1996. However, we would recommend that these guidelines should be applied to the majority of elderly patients being admitted with a hip fracture as we have shown that sufficient information now exists to
challenge treatments based solely on tradition or individual
perceptions. The current epidemic of proximal femoral fractures
makes it essential for the best possible use to be made of scarce
resources to achieve the best possible outcomes. | par 78 Comment.1 |
| References
| par 79 |
| 1. March L, Chamberlain A, Cameron I et al. Prevention, treatment and rehabilitation of fractured neck of femur. Report from the Northern Sydney Area Health Service Fractured Neck of Femur Health Outcomes Project. 1996. ISBN 07310 9633 9 | par 80 |
| 2. Katelaris AG, Cumming RG. Health Status before and Mortality after Hip Fracture. Am J. Pub. Health 1996 ;86(4):557-560. | par 81 |
| 3. Cumming RG, Klineberg R, Katelaris A. Cohort study of risk of institutionalisation after hip fracture. Aust NZ J Pub Health, 1996 ;20(6):579-582. | par 82 |
| 4. Irwig L (1993) An Approach to Evaluating Health Outcomes. NSW Public Health Bulletin 4 (12), NSW Department of Health, Sydney. | par 83 |
| 5. The Cochrane Collaboration Handbook 1994. Section VI: Preparing and maintaining systematic reviews. Pages I-75. | par 84 |
| 6. NH&MRC Quality of Care and Health Outcomes Committee. Guidelines for the development and implementation of clinical practice guidelines. 1995. AGPS. ISBN 0644 356766 | par 85 |
| 7. Bredahl C, Nyholm B, Hindsholm KB, et al. Mortality after hip fracture: results of operation within 12 hours of admission. Injury 1992;23(2):83-86. | par 86 |
| 8. Dolk T. Operation in hip fracture patients - analysis of the time factor. Injury 1990; 21(6):369-372. | par 87 |
| 9. Hoerer D, Volpin G, Stein H. Results of early and delayed surgical fixation of hip fractures in the elderly: a comparative, retrospective study. Bull Hosp Joint Dis 1993;53(1):29-33. | par 88 |
| 10. Parker MJ, Pryor GA. The timing of surgery for proximal femoral fractures. J Bone Joint Surg Br 1992;74(2):203-205. | par 89 |
| 11. Villar RN, Allen SM, Barnes SJ. Hip fractures in healthy patients: operative delay versus prognosis. Br Med J Clin Res Ed 1986;293:1203-1204. | par 90 |
| 12. Anderson GH, Harper WM, Connolly CD, et al. Preoperative skin traction for fractures of the proximal femur: a randomised, prospective trial. J Bone Joint Surg Br 1993; 75(5):794-796. | par 91 |
| 13. Finsen V, Borset M, Buvik GE, Hauke I. Pre-operative traction in patients with hip fracture. Injury 1992;23(4):242-244. | par 92 |
| 14. Needoff M, Radford P, Langstaff R. Pre-operative traction for hip fractures in the elderly: a clinical trial. Injury 1993;24(5):317-8. | par 93 |
| 15. Hofman A, Geelkerken RH, Wille J, et al. Pressure sores and pressure-decreasing mattresses: controlled clinical trial. Lancet 1994;343(8897):568-571. | par 94 |
| 16. Nuffield Institute of Health, University of Leeds and the NHS Centre for Reviews and Dissemination. How effective are pressure-relieving interventions for the prevention and treatment of pressure sores? Effective Health Care Bulletin 1995;2(1). University of York. | par 95 |
| 17. Brown AG, Visram AR, Jones RD et al. Pre-operative and post-operative oxygen saturation in the elderly following spinal or general anaesthesia - an audit of current practice. Anaesth Intensive Care 1994;22(2):150-4. | par 96 |
| 18. Fugere F, Owen H, Ilsley A et al. Changes in oxygen saturation in the 72 hours after hip surgery: the effect of oxygen therapy. Anaesth Intensive Care 1994;22:724-728. | par 97 |
| 19. Agnelli G,Cosmi B, Di Fillipo P, et al. A randomised, double blind, placebo controlled trial of dermatan sulphate for prevention of DVT in hip fracture. Thromb Haemost 1992;67(2):203-8. | par 98 |
| 20. Antiplatelet Trialists’ Collaboration. Collaborative overview of randomised trials of antiplatelet therapy III: Reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients. BMJ 1994 ;308:235-296 | par 99 |
| 21. Barsotti J, Gruel Y, Rosset P, et al. Comparative, double-blind study of two dosage regimens of low-molecular-weight heparin in elderly patients with a fracture of the neck of the femur. J Orthop Trauma 1990;4(4):371-375. | par 100 |
| 22. Bergqvist D, Efsing HO, Hallbook T, Hedlund T. Thrombo-embolism after elective and post-traumatic hip surgery: A controlled, prophylactic trial with dextran 70 and low-dose heparin. Acta Chir Scand 1979;145(4):213-218. | par 101 |
| 23. Bergqvist D. Orgaran in hip fracture surgery. Haemostasis 1992;22(2):104-108. | par 102 |
| 24. Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by peri-operative administration of subcutaneous heparin: overview of results of randomized trials in general, orthopedic and urologic surgery. NEJM 1988;318(19):1162-73. | par 103 |
| 25. Gerhart TN, Yett HS, Robertson LK, et al. Low-molecular weight heparinoid compared with warfarin for prophylaxis of deep vein thrombosis in patients who are operated on for fracture of the hip. J Bone Joint Surg Am 1991;73(4):494-502. | par 104 |
| 26. Imperiale TF, Speroff T. A meta-analysis of methods to prevent venous thrombo-embolism following total hip replacement. JAMA 1994;271(22):1780-1785. | par 105 |
| 27. International Consensus Statement: Prevention of venous thrombo-embolism: a meta-analysis. 1995. unpublished. | par 106 |
| 28. Lahnborg G. Effect of low dose heparin and dihydroergotamine on frequency of post-operative deep vein thrombosis in patients undergoing post-traumatic hip surgery. Acta Chir Scand 1980;146(5):319-22. | par 107 |
| 29. Lassen MR, Borris LC, Christiansen HM et al. Clinical trials with low-molecular weight heparins in the prevention of post-operative thrombo-embolic complications: a meta-analysis. Semin Thromb Hemost 1991;17 (S3):284-290. | par 108 |
| 30. Morris GK, Mitchell JR. Warfarin sodium in the prevention of deep venous thrombosis and pulmonary embolism in patients with fractured neck of femur. Lancet 1976;2(7991):869-872. | par 109 |
| 31. Morris GK, Mitchell JR. Preventing venous thrombo-embolism in elderly patients with hip fractures: studies of low-dose heparin, dipyridamole, aspirin and flurbiprofen. BMJ 1977;1(6060):535-537. | par 110 |
| 32. Nurmohamed MT, Rosendaal FR, Buller HR et al. Low molecular weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis. Lancet 1992;340(8812):152-156. | par 111 |
| 33. Oertli D, Hess P, Durig M et al. Prevention of deep vein thrombosis in patients with hip fractures: low-molecular weight heparin versus dextran. World J Surg 1992;16(5):980-984. | par 112 |
| 34. Pini M, Spadini E, Carluccio L et al. Dextran/aspirin versus heparin/ dihydro-ergotamine in preventing thrombosis after hip fractures. J Bone Joint Surg Br 1985;67(2):305-309. | par 113 |
| 35. Powers PJ, Gent M, Jay RM, et al. A randomised trial of less intense post-operative warfarin or aspirin therapy in the prevention of venous thrombo-embolism after surgery for fractured hip. Arch Intern Med 1989;149(4):771-774. | par 114 |
| 36. Rogers PH, Walsh PN, Marder VJ et al. Controlled trial of low-dose heparin and sulfinpyrazone to prevent venous thrombo-embolism after operation on the hip. J Bone Joint Surg Am 1978;60(6):758-762. | par 115 |
| 37. Stranks GJ, McKenzie NA, Grover ML et al . The A-V Impulse System reduces deep-vein thrombosis and swelling after hemiarthroplasty for hip fracture. J Bone Joint Surg Br 1992;74(5):775-778. | par 116 |
| 38. Williams JW, Eikman EA, Greenberg SH et al. Failure of low-dose heparin to prevent pulmonary embolism after hip surgery or above the knee amputation. Ann Surg 1978;188(4):468-474. | par 117 |
| 39. Fisher CG, Blachut PA, Salvian AJ et al. Effectiveness of pneumatic leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: a prospective, randomised study of compression alone versus no prophylaxis. J Orthop Trauma 1995;9(1):1-7. | par 118 |
| 40. Sorenson RM, Pace NL. Anesthetic techniques during surgical repair of femoral neck fractures: a meta-analysis. Anesthesiology 1992;77(6):1095-1104. | par 119 |
| 41. Coad NR. Post-operative analgesia following femoral neck surgery: a comparison between 3-in-1 femoral nerve block and lateral cutaneous nerve block . Eur J. Anaesthesiol 1991;8(4):287-290. | par 120 |
| 42. Hood G. Post-operative analgesia after triple nerve block for fractured neck of femur. Anaesthesia 1991;46(2):138-140. | par 121 |
| 43. Bodoky A, Neff U, Heberer M, Harder F. Antibiotic prophylaxis with two doses of cephalosporin in patients managed with internal fixation for a fracture of the hip. J Bone Joint Surg Am 1993;75(1):61-65. | par 122 |
| 44. Boyd RJ, Burke JF, Colton T. A double-blind, clinical trial of prophylactic antibiotics in hip fractures. J Bone Joint Surg Am 1973;55(6):1251-1258. | par 123 |
| 45. Buckley R, Hughes GN, Snodgrass T, Huchcroft SA. Perioperative Cefazolin prophylaxis in hip fracture surgery. Can J Surg 1990;33(2):122-127. | par 124 |
| 46. Ericson C, Lindgren L, Lindberg L. Cloxacillin in the prophylaxis of post-operative infections of the hip. J Bone Joint Surg Am 1973;55(4):808-813,843. | par 125 |
| 47. Garcia S, Lozano ML, Gatell JM, et al. Prophylaxis against infection: single dose cefonicid compared with multiple dose cefamandole. J Bone Joint Surg Am 1991;73(7):1044-1048. | par 126 |
| 48. Gatell JM, Garcia S, Lozano L et al. Perioperative cefamandole prophylaxis against infections. J Bone Joint Surg Am 1987;69(8):1189-1193. | par 127 |
| 49. Hedstrom SA, Lidgren L, Sernbo I et al. Cefuroxime prophylaxis in trochanteric hip fracture operations. Acta Orthop Scand 1987;58(4):361-364. | par 128 |
| 50. Hjortrup A, Sorensen C, Mejdahl S, et al. Antibiotic prophylaxis in surgery for hip fractures. Acta Orthop Scand 1990;61(2):152-153. | par 129 |
| 51. Karachalios T, Lyritis GP, Hatzopoulos E. Antibiotic prophylaxis in the surgical treatment of peri-trochanteric fractures: a comparative trial between two cephalosporins. Chemotherapy 1990;36(6):448-453. | par 130 |
| 52. McQueen MM, Littlejohn MA, Miles RS, Hughes SP. Antibiotic prophylaxis in proximal femoral fracture. Injury 1990;21(2):104-116. | par 131 |
| 53. Nungu KS, Larsson S, Wallinder L, Holm S. Bone and wound fluid concentrations of cephalosporins: oral cefadroxil and parenteral cefuroxime compared in 52 patients with a trochanteric fracture. Acta Orthop Scand 1995;66(2):161-165. | par 132 |
| 54. Tengve B, Kjellander J. Antibiotic prophylaxis in operations on trochanteric femoral fractures. J Bone Joint Surg Am 1978;60(1):97-99. | par 133 |
| 55. Aune AK, Ekeland A, Odegaard B et al. Gamma nail vs compression screw for trochanteric femoral fractures. Acta Orthop Scand 1994 ;65(2):127-130. | par 134 |
| 56. Bannister GC, Gibson AG, Ackroyd CE et al. The fixation and prognosis of trochanteric fractures: a randomised, controlled trial. Clin Orthop 1990;254:242-246. | par 135 |
| 57. Bridle SH. Fixation of intertrochanteric fractures of the femur: a randomised, prospective comparison of the gamma nail and the dynamic hip screw. J Bone Joint Surg Br 1991;73(2):330-334. | par 136 |
| 58. Chapman MW, Bowman WE, Csongradi JJ et al. The use of Ender’s pins in extra-capsular fractures of the hip. J Bone Joint Surg Am 1981;63(1):14-28. | par 137 |
| 59. Dalen N, Jacobsson B, Eriksson PA. A comparison of nail-plate fixation and Ender’s nailing in pertrochanteric fractures. J Trauma 1988;28(3):405-406. | par 138 |
| 60. Davis TR, Sher JL, Checketts RG, Porter BB. Inter-trochanteric fractures of the femur: a prospective study comparing the use of the Kuntscher-Y nail and a sliding hip screw. Injury 1988;19(6):421-426. | par 139 |
| 61. Desjardins AL, Roy A, Paiement G et al. Unstable inter-trochanteric fracture of the femur: a prospective, randomised study comparing anatomical reduction and medial displacement osteotomy. J Bone Joint Surg Br 1993;75(3):445-447. | par 140 |
| 62. Esser MP, Kassab JY, Jones DH. Trochanteric fractures of the femur: a randomised, prospective trial comparing the Jewett nail-plate with the dynamic hip screw. J Bone Joint Surg Br 1986;68(4):557-560. | par 141 |
| 63. Gargan MF, Gundle R, Simpson AH. How effective are osteotomies for unstable intertrochanteric fractures? J Bone Joint Surg 1994;76(5):789-792. | par 142 |
| 64. Goldhagen PR, O’Connor DR, Schwarze D, Schwartz E. A prospective, comparative study of the compression hip screw and the gamma nail. J Orthop Trauma 1994;8(5):367-372. | par 143 |
| 65. Hogh J, Lund B, Lucht U. Trochanteric and subtrochanteric fractures: the operative results in a prospective, comparative study of Ender nailing and McLaughlin osteosynthesis. Acta Orthop Scand 1981;52(6):639-643. | par 144 |
| 66. Hornby R, Evans JG, Vardon V. Operative or conservative treatment for trochanteric fractures of the femur: a randomised, epidemiological trial in elderly patients. J Bone Joint Surg Br 1989;71(4):619-623. | par 145 |
| 67. Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peri-trochanteric fractures: a randomised, prospective study in elderly patients. J Bone and Joint Surg Br 1992;74(3):345-351. | par 146 |
| 68. Lund B, Hogh J, Lucht U. Trochanteric and sub-trochanteric fractures. One year follow-up of a prospective study of Ender and McLaughlin osteosynthesis. Acta Orthop Scand 1981;52(6):645-648. | par 147 |
| 69. Nungu S, Olerud C, Rehnberg L. Treatment of intertrochanteric fractures: comparison of Ender nails and sliding screw plates. J Orthop Trauma 1991;5(4):452-457. | par 148 |
| 70. Pitsaer E, Samuel AW. Functional outcome after intertrochanteric fractures of the femur: does the implant matter? a prospective study of 100 consecutive cases. Injury 1993;24(1):35-36. | par 149 |
| 71. Sernbo I, Johnell O, Gardsell A. Locking and compression of the lag screw in trochanteric fractures is not beneficial. A prospective, randomised study of 153 cases. Acta Orthop Scand 1994;65(4):24-26. | par 150 |
| 72. Sernbo I, Johnell O, Gentz CF, Nilsson JA. Unstable inter-trochanteric fractures of the hip: treatment with Ender pins compared with a compression hip-screw. J Bone Joint Surg Am 1988;70(9):1297-1303. | par 151 |
| 73. Stark A, Brostrom LA, Barrios C et al. A prospective, randomised study of the use of sliding hip screws and Ender nails for trochanteric fractures of the femur. Int Orthop 1992;16(4):359-362. | par 152 |
| 74. Emery RJ, Broughton NS, Desai K et al. Bipolar hemiarthroplasty for sub-capital fracture of the femoral neck: a prospective, randomised trial of cemented Thompson and uncemented Moore stems. J Bone Joint Surg Br 1991;73(2):322-324. | par 153 |
| 75. Elmerson S, Andersson GB, Irstam L, Zetterberg C. Internal fixation of femoral neck fracture: no difference between the Rydell four-flanged nail and Gouffon’s pins. Acta Orthop Scand 1988;59(4):372-376. | par 154 |
| 76. Lu-Yao GL, Keller RB, Litternberg B, Wenberg JE. Outcomes after displaced fractures of the femoral neck: a meta-analysis of one hundred and six published reports. J Bone Joint Surg Am 1994;76(1)15-25. | par 155 |
| 77. Madsen F, Linde F, Andersen E et al. Fixation of displaced femoral neck fractures: A comparison between sliding screw plate and four cancellous bone screws. Acta Orthop Scand 1987;58(3):212-216. | par 156 |
| 78. Kuokkanen H, Korkala O, Antii-Poika I et al. Three cancellous bone screws versus a screw angle plate in the treatment of Garden I and II fractures of the femoral neck. Acta Orthop Belg 1991;57(1):53-57. | par 157 |
| 79. Olerud C, Rehnberg L, Hellquist E. Internal fixation of femoral neck fractures: two methods compared. J Bone Joint Surg Br 1991;73(1):16-19. | par 158 |
| 80. Radford PJ, Needoff M, Webb JK. A prospective, randomised comparison of the dynamic hip screw and the gamma locking nail. J Bone Joint Surg Br 1993;7(5):789-793. | par 159 |
| 81. Rehnberg L, Olerud C. Fixation of femoral neck fractures: comparison of the Uppsala and von Bahr screws. Acta Orthop Scand 1989;60(5):579-584. | par 160 |
| 82. Sernbo I, Johnell O, Baath L, Nilsson JA. Internal fixation of 410 cervical hip fractures: a randomised comparison of a single nail versus two hook-pins. Acta Orthop Scand 1990;61(5):411-414. | par 161 |
| 83. Sikorski JM, Barrington R. Internal fixation versus hemiarthroplasty for the displaced subcapital fracture of the femur: a prospective, randomised study. J Bone Joint Surg Br 1981;63B(3):357-361. | par 162 |
| 84. Skinner P, Riley D, Ellery J, et al. Displaced subcapital fractures of the femur: a prospective, randomized comparison of internal fixation, hemiathroplasty and total hip replacement. Injury 1989;20(5):291-293. | par 163 |
| 85. Sorensen JL, Varmarken JE, Bomler J. Internal fixation of femoral neck fractures. Dynamic Hip and Gouffon screws compared in 73 patients. Acta Orthop Scand 1992; 63(3):288-292. | par 164 |
| 86. Svenningsen S, Benum P, Nesse O, Furset OI. Internal fixation of femoral neck fractures: compression screw compared with nail plate fixation. Acta Orthop Scand 1984;55(4):423-429. | par 165 |
| 87. van Vugt AB, Oosterwijk WM, Goris RJ. Osteosynthesis versus endoprosthesis in the treatment of unstable intra-capsular hip fractures in the elderly: a randomised, clinical trial. Arch Orthop Trauma Surg 1993;113(1):39-45. | par 166 |
| 88. Cobb J P. Why use drains? J Bone Joint Surg Br 1990;72(6):993-5. | par 167 |
| 89. Varley GW, Milner SA, Turner GM et al. Ultrasound assessment of the efficacy of wound drains. J R Coll Surg Edinb 1994;39(2):97-99. | par 168 |
| 90. Varley GW, Milner SA. Wound drains in proximal femoral fracture surgery: a randomised, prospective trial of 177 patients. J R Coll Surg Edinb 1995;40(6):416-418. | par 169 |
| 91. Skelly JM, Guyatt GH, Kalbfleisch R et al. Management of urinary retention after surgical repair of hip fracture. Can Med Assoc J 1992;146(7):1185-1189. | par 170 |
| 92. Bastow MD, Rawlings J, Allison SP. Benefits of supplementary tube feeding after fractured neck of femur: a randomised, controlled trial. BMJ 1983;287:1589-1591. | par 171 |
| 93. Delmi M, Rapin CH, Bengoa JM, et al. Dietary supplementation in elderly patients with fractured neck of femur. Lancet 1990;335(8696):1013-1016. | par 172 |
| 94. Sloan JP, Wing P, Dian L, Meneilly GS. A pilot study of anabolic steroids in elderly patients with hip fractures. J Am Geriatr Soc 1992;40(11):1105-11. | par 173 |
| 95. Tkatch L, Rapin CH, Rizzoli R et al. Benefits of oral protein supplementation in elderly patients with fracture of the proximal femur. J Am Coll Nutr 1992;11(5):519-525. | par 174 |
| 96. Zauber NP, Zauber AG, Gordon FJ et al. Iron supplementation after femoral head replacement for patients with normal iron stores. JAMA 1992;267(4):525-527. | par 175 |
| 97. Brostrom LA, Barrios C, Kronberg M, et al. Clinical features and walking ability treatment of trochanteric hip fractures in the early post-operative period after hip fracture. Ann Chir et Gyn 1992;81:66-71. | par 176 |
| 98. Cameron ID, Lyle DM, Quine S. Accelerated rehabilitation after proximal femoral fracture. Disab Rehab 1993;15(1):29-34. | par 177 |
| 99. Fordham R,Thompson R, Holmes J et al. A cost-benefit study of geriatric-orthopaedic management of patients with fractured neck of femur. Centre for Health Economics, University of York. Discussion paper 1986. | par 178 |
| 100. Gilchrist WJ, Newman RJ, Hamblen DL, Williams BO. Prospective randomised study of an orthopaedic-geriatric inpatient service. BMJ 1988;297(6656):1116-1118. | par 179 |
| 101. Kennie DC, Reid J, Richardson IR et al. Effectiveness of geriatric rehabilitative care after fractures of the proximal femur in elderly women: a randomised clinical trial. BMJ 1988;297(6656):1083-1086. | par 180 |
| 102. Oyewole MF, Moloney A. A randomised, controlled trial of a high-support hospital discharge team for elderly people. Age and Ageing 1994;23:228-234. | par 181 |
| 103. Reid J, Kennie DC. Geriatric
rehabilitative care after fractures of the proximal femur: one year
follow-up of a randomised, clinical trial. BMJ 1989;299(6690):25-26.
| par 182 |
|
Acknowledgments: | par 183 |
| The authors acknowledge the
support and assistance of the NSW Health Department’s Health
Outcomes Program Grants Scheme, the Cochrane Musculoskeletal
Injuries Group, the staff and administration of the five acute
public hospitals, the Northern Sydney Public Health and Health
Service Development Units and the Swedish Hip Fracture Group.This
study would not have been possible without the help of the other
members of the Project team*: Dr.Don Holt, Wayne Salvage, Peter
Whitecross, Barbara Carfrae, Bronwyn Christiansen, Loray Dudley,
Catherine Ferry, Jill Makaroff, Sarah Michael, Melanie Saunders,
Katherine Scott, Julia Sweeney, Lorraine Heaslett, Carolyn Cole,
Terry Black. Positions at time of study: | par 184 |
| Dr Lynette M March Senior Staff
Specialist in Clinical Epidemiology, | par 185 |
| NSAHS Public Health Unit.
| par 186 |
| Ms Anne C Chamberlain Project
Officer, Fractured Neck of Femur | par 187 |
| Health Outcomes Project.
| par 188 |
| Dr Ian D Cameron Director,
Rehabilitation & Aged Care Services, | par 189 |
| Hornsby Ku-ring-gai
Hospital. | par 190 |
| Dr Robert G Cumming Senior
Lecturer, Department of Public Health and | par 191 |
| Community Medicine, University of
Sydney. | par 192 |
| Mr Alan Brnabic Statistician,
NSAHS Public Health Unit. | par 193 |
| Dr Terry Finnegan Senior Staff
Specialist, Department of Aged Care and Rehabilitation, The Royal
North Shore Hospital. | par 194 |
| Dr Susan Kurrle Staff Specialist,
Rehabilitation & Aged Care Services, | par 195 |
| Hornsby Ku-ring-gai
Hospital. | par 196 |
| Ms Jennifer M Schwarz Research
Assistant, Fractured Neck of Femur Health Outcomes Project.
| par 197 |
| Professor Sydney ML Nade Clinical
Professor, Department of Surgery, University of Sydney. | par 198 |
| Professor Tom FK Taylor Head,
University of Sydney Department of Orthopaedics & Traumatic
Surgery, Royal North Shore Hospital. | par 199 |
| Correspondence to: Assoc.Prof Lyn
March, | par 200 |
| Department of
Rheumatology, | par 201 |
| The Royal North Shore
Hospital, | par 202 |
| St. Leonards, NSW 2065 | par 203 |
| Tel: 02-9926-7351 | par 204 |
| Fax: 02-9906-1859 | par 205 |
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