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OCR for page 8
The-Knowledge Base for
Key Clinical Issues in Hip Fracture
DEFINITIONS
The term hip fracture is something of a misnomer. It actually refers
to a fracture of the upper end of the thigh bone (femur). The anatomic
characteristics of hip fractures are important for three reasons. First, the
hip joint and its attached muscles are critical in the ability to stand and to
wale Second, this part of the skeleton is subject to complex forces and
stresses during the activities of daily living. These forces and stresses are
very different from those that occur during a fall. The hip, in effect, is
designed to withstand the stresses associated with daily living but is poorly
designed to withstand the impact from a fall. Third, the location of the
fracture, as well as its severity, influences the choice of therapy (i.e., type
of surgery).
Fractures are categorized into one of three groups according to what
part of the bone is involved (see Figure 1~. One group involves the
femoral neck, which is just below the head of the femur. Another involves
fractures around the intertrochanteric crest; this bane links the greater and
lesser trochanters, which are prominent bony eminences situated essentially
between the femoral neck and the upper part of the main shaft of the femur,
to which the major skeletal muscles are attached. Subtrochantenc fractures
start at or below the lesser trochanter and involve the femoral shaft itself.
A final important aspect of hip fracture is the effect of the fracture
and subsequent treatment and healing on the acetabulum, which is the cup-
shaped depression in the pelvis into which the head of the femur fits. Of
concern is pre-existing damage or deformity of the acetabulum or injury to
the cartilage resulting from the fracture or subsequent treatment. In such
cases the socket does not provide a smooth or congruent receptacle for
8
OCR for page 9
Least Severe
\ 30°
/
Femoral Neck Fracture
Intertrochanteric Fracture
to=, ~ Greater
A Trochanter
<' // \
Lesser
Trochanter
~V:
/
Subtrochanteric Fracture
FIGURE 1 Examples of Main lopes of Hip Fracture
9
Most Severe
~\N )
'Con
I'm' l
VY \
)41\
11.',~
,
OCR for page 10
10
EFFECTIVENESS INlTLATl~E
cases the socket does not provide a smooth or congruent receptacle for
the femoral head, and this may significantly influence the type of treatment
selected.
EPIDEMIOLOGIC AND CLINICAL ASPECTS OF HIP FRACTURE
The investment in hip fracture research is large and growing. A1-
though efficacy studies contribute immensely to the lmowledge base, results
of those studies do not address all the major clinical questions and pop-
ulation groups. One reason for selecting patient management topics for
effectiveness studies, therefore, is to identify the remaining unanswered
questions and to determine whether they can be addressed by alternatives
to RCIs.
Several subjects, which are briefly reviewed here, provided the context
for the committee's discussions of those unanswered questions.) They in-
clude epidemiology, risk factors and prevention, surgery issues, nonsurgical
treatment options, and rehabilitation.
Epidemiology
Frequency
Hip fracture causes significant morbidity and mortality. There are
260,000 hip fractures in the United States each year, and they occur
almost entirely among elderly people.2 The medical, social, and economic
consequences for hip fracture victims are severe, for instance, resulting
in an excess 1-year mortality of 12 to 25 percent, impaired ambulation,
and institutionalization for 33 percent or more of hip fracture survivors.
In some studies, as many as 50 percent of hip fracture victims require
long-term care for the rest of their lives. Total direct medical care costs
are estimated to be $6 billion per year, much of which is reimbursed by
Medicare or Medicaid.
i]
Demographic Aspects
Hip fracture risk is related to age, sex, and race. Incidence rates
women are nearly twice those in men. Rates in whites are greater
~ This section is based on materials submitted by several members of the committee who have
special expertise in hip fracture. In part it reflects information Contained in the literature cited
in the bibliography at the end of this report. Ibe topics themselves were not debated during the
workshop.
2The annual incidence of hip fracture among people age 65 and older, of whom there are
31,800,000, is 8.2 per 1,000.
OCR for page 11
HIP FRACTURE
11
than those in Hispanics, which, in turn, are greater than those for Asians
and blacks. Incidence rises dramatically with age; in North America and
northern Europe, it begins to rise at about age 40 and doubles every 5 to
7 years through age 90. Rates approach 6 per 1,000 women per year for
those between the ages of 75 and 79, 21.4 per 1,000 for those between the
ages of 85 and 89, and 48.6 per 1,000 for those over age 90. For white
women over age 85, rates as high as 30 to 50 per 1,000 per year have been
observed.
Relationship to Aging
The interaction of hip fracture and age is not well understood. Some
individuals are described as "doing really well until they broke a hip and
went downhill quickly." For them, the hip fracture was the "beginning of
the end," a signal of compromised ambulation, greater risk of post-surgical
complications, especially delirium, an increased sense of frailty3 associated
with the fear of falling, and of need for use of an aid in walking. At the
other extreme, hip fracture may signal an "end of the beginning," a clinical
manifestation of aging and frailty that was previously subclinical or the
cumulative effect of small declines reaching a threshold that precipitates
the hip fracture. Most clinicians suspect that both perspectives are valid.
For some patients hip fracture is a precipitating event, and for others it
signals decline that is well underway.
There are different implications depending where in relation to these
conditions a particular individual is. If the fracture is an acute injury
that can precipitate a major decline in an otherwise intact individual,
treatment strategies must be developed accordingly and adverse side effects
or inadequate rehabilitation must be avoided. If, by contrast, it reflects
a clinical manifestation of decline, the patient might not be expected to
return to prefecture levels of functioning. Other aspects of choice of
treatment and long-term support then come into play. Research is needed
to determine how to classic patients and how to apportion scarce resources
to achieve the maximum recovery level for each patient.
As people age, changes occur in the cardiovascular, musculoskeletal,
and neurological systems, and they occur at different rates. Subtle physio-
logical changes over time influence the susceptibility threshold or margin
of safety against severe (or even minor) illness, that is, an individual's
31be term frailty is used throughout this report but has no specific meaning. The term is a
shorthand for any one or more of a set of attributes or circumstances that are associated with an
unusually high probability of some adverse event, hip fracture in this instance. The task of identi-
fying specifically the determinants of the adverse event of fracture is the first step in the research
agenda. Determining elective ways to alter risk-promoting attributes i.e., prevention is the
second step.
OCR for page 12
12
EFFECTIVENESS INITIATIVE
ability to return to homeostasis after physical or biological trauma. These
are all considered physiological changes, not frailty per se. Being able
to assess these changes and relate them to probabilities of outcomes will
enhance the medical profession's ability to select appropriate interventions
and treatments rather than making decisions based largely on age.
Risk Factors and Prevention of Hip Fractures
lathe concept of postponement is critical in the prevention of hip
fracture. Given the exponential increase in the hip fracture rate (doubling
every five to seven years) with age, the incidence of the condition might be
reduced by as much as 50 percent if the onset of this exponential rise could
be uniformly postponed by only five years. This suggests that important
opportunities for prevention exist within the Medicare population if the risk
factors for hip fracture could be better understood. For example, a person
who enters Medicare at age 65 will have an 8-fold to 16-fold increase in
the risk of hip fracture over the next 20 years. Even a moderate reduction
in the progression of these incidence rates could reduce both suffering and
costs.
Most hip fractures result from moderate trauma, usually a fall from a
standing height. Thus, the risk factors for hip fracture include those for
falls and those for sustaining an injury during the fall (such as decreased
bone strength resulting from osteoporosis and the severity of the fall itself).
Prevention must focus on reducing the risk of falls, on reducing the injury
potential of those falls that do occur, and on increasing bone strength.
Falls
Falling is a common event for elderly people. Between 30 and 50
percent of the elderly surer at least one fall per year, and a subset of this
group is at risk for more frequent falls. Those in the latter group have the
highest risk of fracture. A major determinant of whether a fall results in a
fracture is thought to be bone strength, although other factors such as the
type of fall (e.g., direction and site of impact),4 muscle mass, and protective
4 Some experts argue that falls and, in particular, the severity of the fall (including its direction,
site of impact, and use of protective mechanisms) may well dominate fracture risk in comparison
with issues of bone strength and osteoporosis. Data are not yet available to allow a simultaneous
assessment of both bone density and fall severity; this is a critical question because its answer
influences the potential efficacy of intervention efforts aimed at maintaining bone strength, re-
ducing falls, or reducing the severity of falls that do occur. Intervention efforts aimed at either
maintaining bone strength or reducing the number of falls have not conclusively shown signifi-
cant reductions in hip fracture incidence. It remains to be seen whether interventions aimed at
reducing the injury potential of falls would be as or more effective.
OCR for page 13
HIP FRACTURE
13
responses during the fall are also important. Falls are caused by various
combinations of environmental, intrinsic, and activity-related factors.
As many as half of all falls involve environmental conditions such
as structural hazards, icy sidewalks, inadequate lighting, frayed rugs, and
electrical cords. These factors are less important in precipitating falls in
institutionalized populations.
Host factors include acute or chronic disease (such as Parkinson's
disease), mental or necrologic impairment, abnormalities of gait or balance,
muscle weakness, and use of certain medications. A small percentage of
falls result from a single, overwhelming event such as fainting.
Psychotropic medications have been consistently associated with a two-
to-three-fold increase in the risk of falls and hip fractures. Geriatricians
advise that psychotropic drugs should be prescribed only when they are
absolutely necessary, that doses be as low as possible, that they be given for
the shortest possible duration, and that selected drugs within a therapeutic
class be used. For example, if a benzodiazepine is prescribed, then one of
the drugs with a short half-life should be chosen.
Although evidence from controlled trials is not available, one can
reasonably assume that careful assessment and targeted interventions may
decrease the risk of elderly people falling. This involves identification of
the presence and severity of certain diseases and disabilities, especially
problems of sight, balance, necrologic functioning, musculoskeletal deficits,
and systemic disease. Assessment also involves identification of relevant
medications and environmental factors. It calls for careful observation of
balance and gait and review of previous fall situations. Based on such
assessment, a combination of medical, rehabilitative, and environmental
interventions may help prevent hip fractures without compromising func-
tioning and morbidity. Intervention strategies to reduce the severity of falls
should also be considered.
Bone Mass and Osteoporosis
Fracture pathogenesis is complex and involves abnormalities that are
intrinsic and extrinsic to the skeleton. Low bone mass is the most critical
skeletal abnormality relating to hip fracture. Osteoporosis is the gradual
loss of bone mass with aging. Although the pathophysiology of osteoporosis
is incompletely understood, it may arise from disorders of the physiologic
systems that regulate calcium balance.
Risk factors associated with osteoporotic fractures include white race,
female sex, post-menopausal status, low body mass index (weight over
height squared), sedentary life-style and physical inactivity, and possibly
alcohol and tobacco use. Diet and nutrition, especially calcium intake
OCR for page 14
14
EFFECTIVENESS INITIATIVE
during rapid growth, climate, and genetic factors may also influence bone
mass. Continued research is needed on these and other risk factors.
The major determinant of bone loss among early post-menopausal
women is estrogen deficiency; osteoporosis can be retarded and bone
loss largely prevented with estrogen replacement therapy. Late in life,
calcium deficiency may develop because of insufficient calcium intake and
calcium malabsorption. Common wisdom has been that the prevention
of osteoporosis must begin early in life because available therapies can
preserve bone mass but cannot replace lost bone to any great extent.
The protective effects of instituting osteoporosis prevention measures for
women in their 40s and 50s, especially estrogen replacement therapy, may
be dramatic in reducing the incidence of hip fractures among women in
their late 80s and 90s.
Medications have complex effects on bone mass. As implied above,
estrogen replacement therapy decreases the risk of hip fracture in newly
menopausal women, but whether it has similar benefits for women age 65
and older is unknown. Thiazide diuretics, which decrease urinary calcium
loss and which are used commonly, have been associated with increased
bone mass and decreased hip fracture risk in people aged 65 and older.
For some individuals, however, thiazide diuretics may cause orthostatic
hypotension (especially in the initial phase of therapy) resulting in fainting
when rising from a seated or horizonal position and hence raising the risk of
falls. Other potential therapies include the antiresorptiYe agents calcitonin
and biphosphonates. Anticonvulsants, corticosteriods, and replacement
thyroid hormone may increase bone loss and, thus, increase fracture risk.
Clinical trials and other research efforts are needed to quantify the risk
of hip fractures associated with use of these medications, assess potential
prophylaxis, and identify less hazardous alternative therapies.
Surgical Issues
Several different treatment options exist for each type of hip fracture,
and professionals are uncertain as to which technique consistently offers
the best outcome. Before 1930, the treatment options for a patient with
a fractured hip consisted of bed rest with traction, cast immobilization,
or simple mobilization with disregard to the fracture. With the advent of
internal fixation in the 1930s, operative management became the preferred
method of treatment unless the risks of surgery were prohibitive. Surgical
approaches at the time consisted of a single nail or multiple pins for
treatment of a fractured femoral neck or a nail-plate combination for
intertrochanteric and subtrochanteric fractures. These approaches led to
earlier mobilization of the patient and lowered mortality significantly.
OCR for page 15
HIP FRACTURE
15
Failure of the fracture to heal, a source of continued complications,
prompted the development of a prosthesis to replace the femoral head. Use
of this prosthesis allowed immediate weight-bearing without requiring the
lengthy convalescence needed for union of the bone itself. Nevertheless,
in the 1950s and 1960s, complications with femoral head replacement
persisted, including unexplained postoperative pain in the hip and a high
infection rate.
With the advent in the 197Qs of total hip replacement techniques
(sometimes called total hip arthroplas~, which is a procedure in which the
acetabulum and the femoral head are both replaced), yet another treatment
became available for the management of fractured hips.5 The advantages of
total hip replacement included, as before, early weight-bearing without the
need to wait for bony union, -more consistent relief of pain, and elimination
of the acetabular erosion that occasionally occurred with the simple femoral
head replacement. The disadvantages included a more complex operation
and considerably more expensive implantable devices.
Surgical Treatment Options
Although several surgical treatment options are available, clinicians
generally agree that open reduction and fixation of the fracture fragments
are the appropriate treatments for intertrochanteric and subtrochanteric
fractures. A major controversy relates to defining objectively the appropri-
ate treatment options for 'femoral neck fractures. The options are briefly
described below.
Intertrochanteric Fractures
Intertrochanteric fractures are nearly always treated with some form
of internal fixation and an implanted device such as a pin and 'plate or
intramedullary rods (rods that run along the center of the bone and that
stabilize the fracture fragments). Because this is frequently a difficult
fracture to manage, multiple surgical approaches are used, but in virtually
all'cases the patient's own bone stock is preserved. The most commonly
used fixation device for an intertrochanteric fracture is a collapsible nail
plate or screw plate device that allows bone impaction (i.e., the bone being
pressed together by ambulation after surgery into a stable position).
5Total hip replacement is performed for reasons other than fractures, for instance, to reduce
severe pain or significant constraints on physical mobility owing to problems with the hip joint
and, perhaps, to forestall possible falls should the hip joint give way suddenly secondary to severe
deterioration. Although the appropriate indications for total hip replacement are themselves a
matter of controversy, the focus of this report is on the clinical condition of hip pactwe and the
relationship of total hip replacement as a therapeutic intervention for that clinical event.
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16
Subtrochantenc Fractures
EFFECTIVENESS INITIATIVE
The use of intramedullary devices is now recommended for treatment
of the true subtrochanteric fracture. This requires open reduction and
internal fixation of the fracture. More complex approaches such as in-
terfragmentary fixation (screwing multiple fragments together) or cerclage
wiring (tying fragments together) are often needed to reconstruct a stable
bony situation to prevent subsequent shortening of the leg. In certain
severe cases, bone grafting is recommended.
Femoral Neck Fractures
Fractures of the femoral neck are classified on radiographs in four
"Garden stages"6 (in ascending order of severity): I, incomplete or im-
pacted fracture; II, complete but nondisplaced fracture; III, complete and
partially displaced fracture; and IV, complete and totally displaced fracture.
Different treatment options exist, depending on the stage. Although clini-
cians agree that most of these fractures should be treated surgically, they
do not agree about the type of surgery.
The original approach to femoral neck fracture was to use some form
of internal fixation device such as a nail or a nail and plate. This technique
is still used, but the incidence rates of non-union (failure of the fracture
to heal) and of avascular necrosis of the femoral head (i.e., decay and
death of bony tissue owing to the lack of needed blood supply) well
over 20 percent are significant. Furthermore, both problems, singly or
in combination, produce a poor result and may require further surgery,
leading to replacement of the femoral head. For these reasons, many
orthopedic surgeons elect to treat femoral neck fractures of the Garden
III and Garden IV stages almost routinely with some form of prosthetic
replacement.
Anatomic reduction and stable internal fixation produce the best long-
term outcome (in terms of bone strength) when healing occurs primarily.
This is the most common way to treat Garden stage I and II fractures and
is associated with a high rate of success. The shift of the bone fragments is
very little and the blood supply is usually intact. If reduction is necessary,
it is achieved by closed means if possible. If not, open reduction is carried
out. Although two- and three-point fixation with multiple pins appears to
offer better stability and long-term outcomes than the use of one large pin
6This classification system is different and more detailed than the taxonomy presented in Figure
1. Garden stage I is an incomplete fracture a so-called impacted fracture. Garden stage II
fractures are complete but undisplaced. Garden stage III fractures are complete and displaced
but the fragments remain in contact with each other. Complete displacement occurs in Garden
stage IV.
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HIP FRACTURE
17
(according to some orthopedists), excellent results have been obtained with
either method of fixation.
Controversy exists in use of the treatment options available for the
more severe Garden stage III and IV fractures. Few useful criteria exist to
assist a practitioner in determining when and under what circumstances a
particular displaced femoral neck fracture should be reduced and internally
fixed, treated by primary hemiarthroplasty (replacement of the femoral
head with a prosthesis as the primary procedure), or treated by primely
total hip arthroplasty.
One disadvantage of internal fixation of the fractured femoral neck has
been the need for the gradual resumption of full weight-bearing. Elderly
patients have difficulty with balance, with manipulation of crutches or
walkers, and with understanding the concepts of partial weight-bearing and
bone healing. For that reason, the alternatives of femoral head replacement
or total hip replacement have certain advantages. Specific indications for
the last two treatment options are present in individuals with Parkinson's
disease, Alzheimer's disease, or severe osteoporosis.
nvo major questions arise about treating femoral neck fracture. First,
is internal fixation or replacement of the femoral head the best treatment
method? Second, is total hip replacement being carried out in patients with
appropriate indications? With respect to internal fixation, issues include
the extent of healing, non-union rates, avascular necrosis, and other com-
plications. For prosthetic replacement, issues include complications such as
dislocation, infection, loosening, and need for reoperation. Although at the
extremes of the distribution of femoral neck fractures the indications for
appropriate treatment may be fairly clear, there are no data to guide treat-
ment selection for the large majority of fractures. Most physicians elect to
treat femoral neck fractures based on their own personal experience. The
utility of this approach needs to be evaluated.
Managing Postoperative Complications and Ambulation
Historically, better postoperative management of patients with hip
fractures has helped to reduce death rates from hip fractures. In the past
decade, however, despite advances in treatment, the one-year mortality
of 12 to 25 percent over the norm has remained high and unchanged.
The practice of ambulating patients as soon as possible after surgery has
significantly lowered the incidence of thrombophlebitis and consequent
pulmonary embolism (clots that obstruct blood circulation); the latter can
be life-threatening. Early mobilization probably remains the single most
effective method for reducing the incidence of these complications. Var-
ious other prophylactic measures are also employed, including the use
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18
EFFECTIVENESS INITIATIVE
of antiembolism stockings, continuous passive motion of the hip, and anti-
blood-clotting medications such as coumarin and heparin. Special attention
to the nutritional status of patients may also be important.
Early ambulation has a direct impact not only by forestalling certain
medical complications but also by increasing the potential for the individual
patient to return to his or her prefecture environment. Limited ambula-
tion can force an elderly individual who enjoyed independent living to be
admitted to a managed living environment.
Nonsurgical Treatment Issues
With the many advances in medical care and technology over past
decades, physicians are now confronted with a group of very elderly, infirm
patients with moderate to severe mental and functional impairments who
sustain hip fractures. These injuries frequently occur in protected envi-
ronments such as nursing homes and hospitals. Orthopedic surgeons have
continued to apply the accepted standard of care to patients with these
injuries that essentially all such patients should operated upon.
Although firm data are not available, experienced clinicians believe
that the results of surgery in these debilitated patients are usually poor and
that complication rates are high. Many of these patients die within a short
period of time, although not necessarily during the acute hospitalization.
Further, patients in this category may continue to suffer from significant
postoperative symptoms, remain severely impaired functionally, and fre-
quently never return to their prior functional level. Epidemiologically, such
patients tend to include:
· very elderly patients
· patients residing in nursing homes or other protected environments
· patients with moderate or severe mental impairment or dementia
· bedridden or severely physically disabled patients
· patients with severe or progressive comorbid conditions.
Given the poor expectations for many of these patients, it is appropriate
to ask whether they should be treated surgically at all. Instead they might
be given nonsurgical care that focuses on alleviation of pain, prevention
of complications, and ease of care-giving. The problem from an ethical
point of view is that the outcome in unoperated patients is almost always
predictably poor, with multiple complications, continued pain, and possibly
death occurring in a short period of time. One question is whether it is
possible to identify a group of patients in whom the outcomes of surgery
are virtually certain to be so poor that nonoperative support treatment only
should be rendered. This question involves measurement of the medical
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HIP FRACTURE
19
and functional aspects of treatment and attention to the patient's and
family's desires (e.g., the right to refuse surgical treatment).
Rehabilitation
The goal of rehabilitation is to return an individual to as normal a
life as possible. For elderly people with hip fractures, the goal is to return
them to the same level of independence and activity that existed before
their injury. Rehabilitation addresses not only the ability of individuals to
wale and perform other activities requiring mobility. It also concerns their
opportunity to live independently; to function within the community; to
participate in social activities; and to continue other activities they might
wish to perform.
Many services can be offered: effective limb and joint mobilization and
alignment; passive resistive exercises of nonaffected joints; other physical
therapy and occupational therapy to regain mobility and independence;
restorative nursing services (e.g., range-of-motion exercises) as a follow-up
phase to active rehabilitation; training in major areas of life function (such
as mobility and self-care); physician monitoring of care or progress; and
psychological support when indicated. The optimal setting to provide these
rehabilitation services for a particular patient depends on four factors: the
number of problems needed to be addressed to achieve full rehabilitation;
the severity of functional deficits; the severity of any comorbid conditions;
and access to alternative services and settings.
Rehabilitation programs can vary significantly by the type of insti-
tution, comprehensiveness of services, intensity of program delivery, and
rehabilitation goals. Institutions include acute-care hospitals, rehabilitation
hospitals or units, long-term-care facilities (skilled nursing and intermediate
care), outpatient facilities, and homes. Some address only mobility through
physical therapy services. Others address mobility, self-care, community
activities, social and psychological adjustment, recreation, and other goals
through the services of a wide array of professionals physicians, nurses,
psychologists, physical therapists, occupational therapists, social workers,
recreational therapists, and others.
The goals of a given rehabilitation program determine its compre-
hensiveness and intensity. Some individuals with hip fracture may receive
monthly physician visits in association with biweekly physical therapy treat-
ments. Other patients receive services from multiple therapists twice a day
during the initial period of their rehabilitation. These needs, in turn, usually
influence the setting in which the services are delivered. Some individuals
may go directly home from the hospital and receive home or outpatient
rehabilitation care. Others may go through a series of institutions, such as
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20
EFFECTIVENESS INITL4TIVE
the rehabilitation hospital or unit or the skilled nursing facility, or both,
before receiving services in the home setting.
Because of the enormous variation in these aspects of rehabilitation,
decisions regarding the site and intensity of rehabilitation services should
be determined through an assessment of the needs of the individual that
establishes clear rehabilitation goals. However, the availability of insurance
(or the extent of covered benefits in Medicare), the desire of the patient,
and the preferences of individual physicians who manage the acute phases
of injury of the individual with a hip fracture may influence these decisions.
Nevertheless, both historical and clinical experience suggests that active
rehabilitation that focuses broadly on the various needs of an individual
results in better outcomes than does more limited services. At present,
most rehabilitation professionals believe it is preferable for an individual
to receive comprehensive services in a setting somewhat more intense than
necessary, rather than risk having a patient fail to receive comprehensive
services because of efforts to reduce short-term costs.
Representative terms from entire chapter:
femoral neck
