Martyn Parker Peterborough England

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Martyn ParkerPeterboroughEngland
Optimum hip fracture management
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The answer

•  The treatment of a hip fracture is early
  effective surgery with discharge home as soon as
  practical

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Key reference

• Sign guideline number 56
• Prevention and management of hip fracture in
  older people
• www.sign.ac.uk
• An evidence based guideline of key aspects of
  care

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Randomised trials of hip fracture management

• Cochrane review on hip fractures
• www.Cochrane.Org
• Summarises all randomised trials on hip fracture
  care

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A E MANAGEMENT

• Analgesia
• Assessment, bloods, ECG
• Intravenous fluids
• Avoids excessive delays

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Pre-operative care

• Resuscitation and fluid balance
• Thromboembolic prophylaxis (heparin,
  aspirin, mechanical)
• Analgesia
• Minimise delays to theatre
• Pressure area care
• Planning for discharge

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Thromboembolic prophylaxis

• Early surgery
• Early mobilisation
• Spinal anaesthesia
• Avoid over transfusion (post-op hb
  9g/100ml)
• ALSO ONE OR MORE OF
• Low molecular weight heparin or aspirin
• (foot pumps)
• (Compression stockings)

The lack of a good evidence base means there can
be no firms recommendations
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Timing of surgery

• Surgery should be as soon as possible after
  admission
• Delays of more than 48 hours from admission will
  increase morbidity (pressure sores,
  thromboembolic, pneumonia, UTI)
• For every 8 hours of delay results in an
  increased of hospital stay of 1 day

Siegmeth AW, Gurusamy K, Parker MJ. Delay to
surgery prolongs hospital stay in patients with
fracture of the proximal femur. J Bone Joint Surg
200587-B1123-1126.
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Acceptable reasons for delaying surgery

• Anaemia (Haemoglobin lt about 90g/l)
• Dehydration or acute uraemia
• Severe electrolyte imbalance (Na lt 120 or gt
  150 K lt 2.8 or gt 6.0 mmol/l)
• Uncontrolled diabetes
• Uncontrolled heart failure
• Correctable cardiac arrhythmia
• ? Acute chest infection or exacerbation of
  chronic chest

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Unacceptable reasons for delaying surgery (gt24
hours from admission)

• Medical assessment
• Unnecessary investigations
• Minor electrolyte abnormalities
• Warfarin with high INR
• Aspirin, clopidogrel
• Lack of consent
• Lack facilities

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Warfarin with high INR

• Acute trauma causes a rise in the INR
• The INR may take days to fall in the elderly
• All hospitals should have a policy on emergency
  surgery and warfarin, this involves the use of
  low dose vitamin K, fresh frozen plasma or
  coagulation factors

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Clopidogrel

• Some centres delay surgery for 7 days
• The adverse consequences of delaying surgery are
  likely to be more than the potential
  complications of bleeding

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Unnecessary investigations

• For example, delaying a patient whilst waiting
  for an echocardiogram probably carries more risk
  than any possible benefit

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Anaesthesia

• Spinal anaesthesia slightly better than general
  anaesthesia
• Experienced anaesthetist

Parker MJ, Handoll HHG, Griffiths R. Anaesthesia
for hip fracture surgery in adults (Cochrane
Review). In The Cochrane Library, Issue 4, 2001.
Oxford Update Software.
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Surgery

• Must be performed by experienced staff
• Minimally invasive
• Technically correct to allow unrestricted
  mobilising

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Unacceptable aspects of surgery

• Unsupervised junior staff
• Operations lasting more than one hour
• Poor surgery resulting in complications (cut-out,
  sepsis, dislocation)

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Post-operative care

• Unrestricted mobilisation the day after surgery

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Post-operative care

• Nutritional supplements
• Often neglected in modern care

Duncan, Beck, Hood, Johansen. Age Ageing 2006
35148-153
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Rehabilitation different models of care

• Acute orthopaedic ward
• Transfer to geriatric or rehabilitation ward
• Discharge to community rehabilitation homes
• Hip fracture ward
• Early supported discharge at home

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Optimum method of rehabilitation

• Admission to and discharge from a hip fracture
  unit which has medical and surgical care
• Early supported discharge of patients wherever
  possible
• Avoidance of transferring of patients

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Who should manage hip fracture patients pre and
post-operatively?

• Orthopaedic staff
• Anaesthetists
• Geriatricians

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• Should these patients be managed by a specialised
  physician or geriatrician who requests the help
  of the appropriate technical staff ? (surgeon
  anaesthetist)

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Role of specialised physician

• Preparation for theatre
• Post-operative care
• Manage associated medical conditions
• Treat post-operative complications
• Rehabilitation
• Social care assessment
• Fracture prevention

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Peterborough hip fracture project
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Peterborough hip fracture project

• Early assessment of patients and treatment plan
• Early effective surgery
• Immediate mobilisation
• Early discharge

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Operative or conservative

• Currently 98 of patients in Peterborough are
  treated surgically

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Scottish hip fracture audit - 36 days
Dr Foster, England 26 days
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England national average 13
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Immediate outcome

• 88 discharged back home
• 5 need change of residence
• 7 die in hospital

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Outcome at one year

• 57 same residential status
• 10 more dependent
• 33 died

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Patients from own home at one year

• 67 Own home
• 6 Residential home
• 2 Nursing home
• 1 Hospital
• 24 Died

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Patients from residential or nursing homes

• 1 Own home
• 43 Institution
• 56 Died

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The future

• Despite preventive measures hip fractures are
  with us for the foreseeable future
• Will be earlier discharge of patient after less
  invasive surgery