|
Review
|
How best to fix a broken
hip - unrevised version
| par 0 |
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 |
Objectives: To develop guidelines for the treatment of proximal
femoral fractures and to describe current practice in a metropolitan health area.
| par 7 |
Methods: A systematic literature review of randomised,
controlled trials on the treatment of proximal femoral fracture was performed, with two
independent assessors making judgements about study quality and treatment conclusions. A
medical record audit of 729 consecutive patient admissions over 12 months was also
conducted.
| 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 NH&MRC 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. The retrospective audit of current practice highlighted wide variability of these
interventions across five acute hospitals in the Northern Sydney Health Service Area.
| par 9 |
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
aspects of hip fracture treatment. A wide variability was found in current practice and
evidence emerged from this study to recommend that changes be made.
| par 10 |
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. By the year 2021 this is expected
to have more than doubled (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 NSW 1. 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 |
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
4.
| par 13 |
"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
followed 5. 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).
| par 17 |
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.
|
"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.
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 |
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.
|
| 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
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.
| par 24 |
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 |
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 |
"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.
Table 1:
Evidence Based Guidelines For Acute Management Of Proximal Femoral
Fractures
|
|
|
Reference
number
|
Australian NH&MRC
level of evidence
|
Cochrane
treatment conclusion
|
|
Time
to surgery
|
Within
24 hours of admission
|
7
- 11
|
III
- 1
|
2A
|
|
Preoperative
traction
|
Not
necessary - adequate analgesia should be given.
|
12-14
|
II
|
2B
|
|
Pressure
Care mattress
|
To
be in situ as soon as possible after admission to Emergency
|
15,16
|
II
|
2A
|
|
Oxygen
therapy
|
O2 saturation
monitored from time of admission
O2 administered
for 48 hrs after surgery and if O2 saturation < 95%
|
|
|
|
|
Prophylactic
anticoagulants
|
To
commence as soon as possible after admission to Emergency
|
19-38
|
I
|
1A
|
|
Pressure
gradient stockings
|
To
be applied as soon as possible after admission to Emergency
|
39
|
II
|
2A
|
|
Anaesthesia
|
Regional
anaesthesia recommended for most patients
|
40
|
I
|
2A
|
|
Analgesia
|
Femoral
nerve block in selected cases
|
41,42
|
II
|
2A
|
|
Prophylactic
IV antibiotics
|
At
induction of anaesthetic and for first 24 hours postop
|
43-54
|
I
|
1A
|
|
Type
of surgery
|
Extra-capsular
fractures: compression screw device;
Intra-capsular: hemi-arthroplasty
|
|
|
|
|
Surgical
wound drains
|
Remove
as soon as possible – consider from 24 hours
|
88-90
|
II
|
2B
|
|
Urinary
catheterisation
|
Avoid
indwelling catheters where possible
|
91
|
II
|
2B
|
|
Nutritional
status
|
Routine
assessment - provision of protein supplements as needed
|
92-96
|
II
|
2A
|
|
Mobilisation
|
Early
assisted ambulation - by 48 hours after surgery
|
55-87,97
|
III
|
2A
|
|
Rehabilitation
|
Early
assessment by specialist team
|
98-103
|
II
|
2A
|
|
Acute
hospital length-of-stay
|
Early
discharge to Nursing Home
Early
transfer to rehabilitaton
|
|
IV
|
|
| par 30 |
Legend -
Table 1
|
Level
of evidence - NH&MRC (Australia)
|
|
I
|
Evidence
obtained from a systematic review of all relevant RCTs
|
|
II
|
Evidence
obtained from at least one properly designed RCT
|
|
III
- 1
|
Evidence
obtained from well-designed controlled trials without randomisation
|
|
III
- 2
|
Evidence
obtained from well-designed cohort or case-control analytic studies preferebly from more than
one centre or research group
|
|
III
- 3
|
Evidence
obtained from multiple time series with or without the intervention. Dramatic results in
uncontrolled experiments could also be regarded as this type of evidence
|
|
IV
|
Opinions
of respected authorities, based on clinical experience, descriptive studies, or reports of expert
committees.
|
|
Treatment
conclusions – Cochrane
|
|
1A
|
Forms
of care that improve outcome
|
|
1B
|
Forms
of care that should be abandoned in light of the available evidence
|
|
1C
|
Forms
of care that involve important trade-offs between known benefits and known adverse effects.
|
|
2A
|
Forms
of care that appear promising, but require further evaluation.
|
|
2B
|
Forms
of care that have not been shown to have the effects expected from them, but which may
require further attention
|
|
2C
|
Forms
of care with reasonable evidence that they are not effective for the purpose for which they
have been used.
|
|
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 |
| 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 before surgery.
| 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.
| 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 commence at induction of anaesthesia and continue
for 24 hours. Prolonged antibiotic use is of no proven benefit.
| par 41 |
| 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 is 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. The amount of weight to be taken on the fractured leg
should be as much 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.
|
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.
|
"Are
we doing the right thing?"
| par 53 |
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 |
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 also considerable variation in the
process of care. Almost 20% of patients waited more than 72 hours for surgery (min 7%, max
40%). Pre-operative single limb traction was applied to over half of the patients (min 41%,
max 64%). The use of pressure-relieving mattresses, oxygen saturation monitoring and
nutritional assessment were not routine.
| par 56 |
Fifteen percent of patients did not receive
pre-operative prophylactic anticoagulant treatment and there was wide variation in the use of
pressure gradient stockings across the three hospitals where these data were collected (min
16%, max 70%). The hospital with the lowest recorded use of prophylactic anticoagulants
was the most frequent user of pressure gradient stockings.
| par 57 |
In two of the three hospitals where data on
anaesthesia type were collected, spinal anaesthesia was given predominantly while the reverse
was true for the third hospital (min 14%, max 75%).
| par 58 |
Prophylactic antibiotics (by vein) were used in the
vast majority of 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 |
There was considerable variation across the
hospitals in the approach to surgical prosthesis type with 61.6% (min 52.0%, max 67.4%) of
intra-capsular fractures being treated with hemiarthroplasty and 28.8% (min 7%, max 40%)
being internally fixed with compression screw and plate devices. The younger, more
independent patients admitted from their own homes with an intra-capsular fractures were
more likely to have the internal fixation devices than patients residing in a nursing home at the
time of their fracture. Very few total joint arthroplasties were performed. The treatment of
extra-capsular fractures was more uniform with almost all (94.2%) being internally fixed with
combined compression screw and plate devices. Wound drains were used almost universally.
| par 60 |
Two thirds of patients had indwelling bladder
catheterisation (min 40%, max 90%).
| 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 |
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 |
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.
There
was 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 |
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 risk of spinal haematoma.
| 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-analysis did have flaws (duplication of patients) but the review team re-read the original
articles 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.
| par 73 |
The optimum time delay from admission to
surgical operation has long been a vexed question. Observational studies, 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 |
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.
| par 75 |
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 |
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. Costs
could be reduced by earlier transfer to rehabilitation from the more expensive acute care ward.
| par 77 |
This study identified considerable variation in
current management of patients who have sustained hip fractures. Sufficient information now
exists to challenge treatments based solely on tradition or individual perceptions. The
imminent 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 |
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|
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 |
Ms Anne C Chamberlain
Project
Officer, Fractured Neck of Femur
| par 187 |
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.
|
Correspondence to:
Assoc.Prof
Lyn March,
| par 200 |
Department of
Rheumatology,
| par 201 |
The Royal North
Shore Hospital,
| par 202 |
|
