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10 Hip Fracture David G. Murray Although a fracture of the hip is not in and of itself potentially fatal, the mortality associated with the occurrence of this injury in the elderly is significant, and the associated morbidity and negative effect on quality of life are important. Moreover, the incidence, which increases rapidly in the Medicare population, places a major demand on health resources, social institutions, and the budget for health care. Any changes that could be brought about to decrease the incidence of hip fracture, facilitate improved treatment, reduce hospitalization, and increase the number of individuals restored to their prefecture lifestyle would have impressive benefits for society. PREVENTION Prevention of fracture of the hip in the elderly involves an increased understanding of etiological factors. Osteoporosis, which to some extent is a natural accompaniment of aging, is an obvious predisposing condition. The extent to which the normal decrease in bone density that occurs during aging plays a role in the predisposition is poorly understood and requires further study. Pathological osteoporosis (itself poorly understood) is an obvious predisposing condition. The various factors affecting this condition, such as alcoholism, smoking, steroids, sedatives, anticoagulants, and diet, need further study. Mechanisms for modifying osteoporosis through diet, activity, or drug therapy are currently being investigated. The vast majority of fractured hips are associated with falls. It has never been clear whether the individual falls because the hip fractures or the hip fractures as a result of the fall. Probably both play a role. Falls in the elderly are influenced by external and internal factors. The external environment, 61

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62 EFFECTIVENESS AND OUTCOMES IN HEALTH CARE which includes obstacles to ambulation such as furniture, slippery floors, and carpets, can obviously be modified once the relationship to falls is clearly understood. The internal factors such as Parkinsonism, malnutrition, Alzheimer's disease, balance problems, and visual impairment may be more difficult to modify. On the other hand, once such internal factors are clearly identified as being associated with an increased incidence of falls and frac- ture, some modifications of the external environment may be able to compensate for them. Data also suggest that there is a geographic variation in the incidence of fracture of the hip. Whether this is due to dietary differences, differences in demographics, or some other factor remains to be explained and deserves further investigation. TREATMENT The diagnosis of fracture of the hip is straightforward. The history of a fall with associated disability in an elderly person is suggestive. X-ray examination confirms the diagnosis and characterizes the fracture as either a fracture of the femoral neck or an intertrochanteric fracture (one involving the upper end of the femur just below the femoral head). The location of the fracture influences the treatment and the prognosis. Fractures of the femoral neck may impair the blood supply to the bone of the femoral head and therefore compromise the results of treatment that retains the femoral head. Intertrochanteric fractures may be complex, and the damage to the bone may preclude replacement with a prosthetic device. Since the 1930s, surgery has been the preferred method of treatment for fractures of the hip. Fixing the fracture in some manner has been shown not only to diminish the length of hospitalization but also to lower significantly the mortality rate and improve the chances of the patient's returning to the prefecture lifestyle. At this point, nonsurgical treatment is reserved for those patients who cannot undergo surgery for medical reasons. Initially, fractures of the hip were treated surgically by internally fixing the fracture with a nail, plate, screws, or some other means of holding the bone ends together. Because the bone ends frequently failed to unite, a prosthesis was introduced to replace the femoral head. Subsequently, total hip replacement was used to treat certain fractures of the hip. At this point no ideal treatment for hip fracture has been established. The method used varies with the preference of the individual surgeon. To some extent economics enters the picture as well. Simply fixing the fracture with a nail or plate carries the previously mentioned risk of nonunion or loss of position of the fractured fragments. Replacement of the femoral head with a prosthesis is sometimes associated with persistent pain in the hip and gradual erosion of the bone of the pelvis by the metallic femoral head.

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IOM CLINICAL CONDITION WORKSHOPS 63 Total hip replacement is a somewhat more complex procedure and is more expensive, both in terms of operating time and equipment and device costs. There is a definite need for outcome studies to clarify the relative advantages and disadvantages of each treatment method. Such outcome studies would include length of hospitalization, in-hospital complications, rate of reoperation, and the overall recovery of the patient. IN-HOSPITAL CARE In addition to the surgical procedure itself, a number of other factors are associated with the initial hospitalization of a patient with a fractured hip. These factors need to be reviewed in terms of their impact on the outcome or effectiveness of treatment. Preoperative evaluation by consultants, including internists, geriatricians, family physicians, cardiologists, urologists, and so on, may have a beneficial effect on the mortality or morbidity associated with the surgical procedure. Following surgery, the involvement of a rehabilitation team has been shown in other countries to have an effect on the length of hospitalization. Hospitalization in the United States is significantly shorter than in other countries, but similar studies should be done to clarify the impact of associated special services on the outcome of the patient's hospital treatment. REHABILITATION A multitude of factors are associated with the ultimate rehabilitation of the patient. Currently it is known that the mortality associated with a fractured hip is elevated over that of a matched population group during the first 6 to 12 months after fracture. In addition, the percentage of individu- als who are converted from independent to dependent lifestyles is sizable. This has been well documented in the literature, along with other factors that may play a role in this conversion. Obviously, the number of persons who become dependent upon the institutions of society affects the overall costs associated with the problem of hip fracture. Mechanisms need to be developed to reduce the number of such individuals. Further data are needed to characterize this group and to show modification of outcome by intervention. This will require improved data collection, including collection of information after hospitalization, and an effective method for assessing function. CONCLUSION The Medicare data bank already provides a mechanism for accumulating information concerning the effectiveness of various types of treatment for hip fracture. By extrapolation, information may be derived concerning epi

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64 EFFECTIVENESS AND OUTCOMES IN lIEALTlI CARE demiology, predisposition, and prevention. Many factors that may play a role in predisposition occur far in advance of the age of 65, however. Clarification of some of these factors depends upon expanding the data collection to younger people. If worthwhile data on long-term functional outcome are to be gathered, the data set must be augmented. Ways of doing this have been identified and appear feasible. If the occurrence of hip fracture is reduced significantly and treatment and rehabilitation of persons with fractures are improved, the quality of life of a large number of elderly persons will be improved. The commensurate savings in health care dollars will more than justify the cost of the effectiveness studies.