Outcomes for patients with osteoporotic hip fracture remain poor despite technical advances and clear guidelines. Attempts to improve outcomes have led to evolving approaches to treatment. In older adults, internal fixation for displaced intracapsular hip fractures has largely been replaced by hemiarthroplasty (or ‘partial’ hip replacement), which have lower rates of revision surgery and better overall outcomes.¹ More recently there has been a move towards the increased use of total hip arthroplasty (THA), an intervention used more commonly for arthritis of the hip. It is believed this has the potential for a better return to functional mobility and therefore independence.

In a recent study in the BMJ, Perry and colleagues analysed data from the UK’s national hip fracture database to determine compliance with the National Institute for Health and Care Excellence (NICE) guidelines for  total hip arthroplasty to identify predictors of use of THA.² This large observational study included 114,119 adults aged 60 years or over with displaced intracapsular fractures of the femoral neck. NICE recommends THA for those with good cognitive and physical function who are fit enough for anaesthesia and surgery. However, the study revealed that only 32% of ostensibly eligible adults received THA, and of those who underwent the procedure, 42% did not meet the NICE eligibility criteria.¹

According to Perry et al several variables that increased the odds of receipt of THA after fracture were identified, including younger age, fewer co-morbid conditions, and better mobility before fracture.² More striking however, were the findings that being admitted on a weekday or being of a higher socioeconomic status increased the odds that a patient would receive a THA.

Despite the NICE guidelines there is little conclusive evidence that THA is definitively better than hemiarthroplasty for adults with a displaced intracapsular hip fracture. In addition, there is a lack of consensus among orthopaedic surgeons about best practice. The evidence that patients function better after THA is based on studies with small sample sizes and a lack of adequate blinding. THA carries higher risks than hemiarthroplasty, such as greater intraoperative blood loss, longer operative times and more postoperative complications. These are important considerations in patients who are often frail and have multiple comorbidities.

This study also found that type of treatment varies by geography, socioeconomic status and day of the week, indicating a bias towards personal operator preference and away from systematic adherence to evidence-based protocol. The fact that patients with hip fractures tend to be elderly with attendant comorbidities would favour a multidisciplinary approach to care. Collaborative models sharing care between orthopaedic surgeons and geriatricians, and trends towards very early surgery have both been shown to improve outcomes.²

Not all orthopaedic trauma surgeons are comfortable performing THA, and evidence of superiority of THA will only consolidate further arguments for a change in the way hip fracture care is organised. As Perry et al have shown, treatment is far too variable in the current system. Models of care that are evidence-based and facilitate standardisation of hip fracture care are needed to remove biases in the system and improve outcomes for patients after hip fracture.

Reference

1. Jiang J, Yang CH, Lin Q et al. Does arthroplasty provide better outcomes than internal fixation at mid- and long-term followup? A Meta-analysis. Clin Orthop Relat Res 2015; 473:2672-9
2. Perry DC, Metcalfe D, Griffin XL, Costa ML. Inequalities in use of total hip arthroplasty for hip fracture: population based study. BMJ 2016; 353:i2021