The management of hip fracture in older adults

Background

Hip fracture is one of the biggest challenges facing patients and healthcare systems. Worldwide there are 1.3 million hip fractures with more than 70,000 hip fractures in the UK every year. These figures are projected to rise to more than 100,000 by 2020 in the UK and more than 6 million by 2050 worldwide. The global cost of this clinical problem is estimated at 1.75 million disability adjusted life years lost and represents 1.4% of the total healthcare burden in established market economies. Hip fracture is the focus of 29 separate Cochrane Reviews; NICE has published clinical guidance and quality standards. This major health problem is the source of considerable ongoing research.

To minimise the impact on the individual as well as the healthcare system, it is important that decisions about hip fracture management are based on reliable and robust evidence. Recently NIHR funded a Systematic Reviews Programme of work to develop a suite of Reviews that would provide up to date evidence to support clinical decision makers and health technology appraisal organisations such as NICE in the development of guidance.

This special collection highlights Reviews in the Cochrane Library from Cochrane Anaesthesia, Cochrane Bone, Joint and Muscle Trauma, Cochrane Dementia and Cognitive Improvement and Cochrane Vascular. It includes those funded by this programme as well as other Reviews of interventions and strategies relevant across the recovery journey for people with hip fracture.

Perioperative Care

Two reviews assessed common interventions used in the perioperative period: treatments to prevent bleeding as a consequence of both injury and surgical intervention and to prevent venous thromboembolism, as well as the effectiveness of advanced methods to manage fluid therapy during this period. In addition, an overview is due for publication soon which summarises the evidence from systematic reviews of pharmacological treatments to reduce the need for allogenic blood transfusion.

Anticoagulants to reduce the risk of VTE

16 studies with 24, 930 participants. These studies evaluated the effectiveness of thromboprophylaxis given for an extended duration. It includes evidence for heparin, vitamin K antagonists, direct oral anticoagulants (DOACs) and other classes of drug. Further studies are needed to better understand the association between VTE and extended‐duration oral anticoagulants in relation to hip fracture.
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Fluid management following hip fracture

5 studies with 403 study participants. Studies included the following treatments: advanced haemodynamic monitoring, a protocol using standard measures and standard care. Outcomes included mortality, length of hospital stay, return to pre-fracture accommodation, return to pre-fracture mobility, and major adverse events. Estimates were imprecise but there was no evidence that fluid optimization strategies improved outcomes for participants undergoing surgery.
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Interventions for reducing red blood cell transfusion after hip fracture: an overview of reviews

17 reviews with 29 RCTs evaluated tranexamic acid, and 9 reviews with 7 RCTs evaluated iron. Tranexamic acid likely reduces the need for allogenic blood transfusion in adults undergoing hip fracture surgery with likely little or no difference to adverse events. Results for intravenous iron use are less certain because of limited evidence. Publication due soon.

Anaesthesia and Analgesia

These reviews assessed the effects of different treatments given to people with hip fractures either during surgery to induce anaesthesia or in order to provide analgesia before or after surgery. Treatments assessed in these reviews included:

  • General anaesthesia (using inhalational agents, or total intravenous anaesthesia).
  • Neuraxial blocks (epidural, spinal, or combined epidural/spinal).
  • Peripheral nerve blocks (posterior lumbar (psoas) plexus blocks, with or without sacral plexus blocks, or any other peripheral nerve blocks).

Nerve blocks for hip fracture

49 studies with 3061 study participants. This review assessed the effects of peripheral nerve blocks given for pre-operative or postoperative analgesia or as a supplement to general anaesthesia compared with no nerve block or a sham nerve block. Blocks reduced pain on movement within 30 minutes after block placement, risk of acute confusional state and probably also reduced the risk of chest infection and time to first mobilisation.
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Anaesthesia for hip fracture surgery

31 studies with 3231 study participants. Most of the evidence compared general anaesthesia with neuraxial blocks. Primary outcomes of interest included mortality, pneumonia, and myocardial infarction. The evidence was low certainty and heterogenous; there was no evidence of any difference between types of anaesthesia.
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Surgery

These reviews assessed the effects of different treatment options for intracapsular or extracapsular hip fractures. Treatments included:

  • Internal fixation with pins, screws, and fixed angle plates.
  • Arthroplasties fixed in place with or without bone cement using hemiarthroplasties (bipolar or unipolar), and total hip arthroplasties (single or dual-mobility articulation).
  • Non-operative treatment.
The benefits and harms of these treatments at three time points were reviewed: early (within four months of surgery), at 12 months after surgery, and late (after 24 months from surgery). Outcomes included activities of daily living, delirium, functional status, health‐related quality of life, mobility, mortality, and unplanned return to theatre for treating a complication resulting directly or indirectly from the primary procedure.

Internal fixation for intracapsular fractures

38 studies with 8585 study participants. This review includes comparisons of smooth pins versus fixed angle plates; screws versus fixed angle plates; smooth pins versus screws; and a combined group of smooth pins and screws versus fixed angle plates. The evidence was low certainty but indicated that there may be little or no difference for most outcomes between these different implants.
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Arthroplasties for hip fractures

58 studies with 10,654 study participants. This review assessed the effects of different types of arthroplasties for the treatment of hip fractures in adults. Most studies compared cemented with uncemented hemiarthroplasties, bipolar versus unipolar and total hip arthroplasties versus hemiarthroplasty. It was likely that cemented implants yield an improved global outcome. There was no evidence to suggest a bipolar is superior to a unipolar prosthesis. Any benefit of total hip arthroplasty compared with hemiarthroplasty was likely to be small and not clinically appreciable.
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Surgical treatments for intracapsular fractures: a NMA

Network meta-analysis including 119 studies with 17,653 study participants. 75 studies with 11,855 study participants contributed data for at least two of these treatments in network meta-analyses for mortality, health-related quality of life and unplanned return to theatre. Cemented modern arthroplasties tended to more often yield better outcomes than alternative treatments and may be a more successful approach than internal fixation. There was no evidence of a difference between total hip arthroplasty and cemented modern hemiarthroplasty.
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Nails versus plates for extracapsular fractures

76 studies with 10,979 study participants with stable and unstable trochanteric fractures and subtrochanteric fractures. Nails were either short or long or mixed, and plates had either static or dynamic designs. Plates, most commonly the sliding hip screw, yielded very similar functional outcomes to nails. There was a reduced risk of infection and non‐union with nails, however there was an increased risk of implant‐related fracture that is not attenuated with newer designs.
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Surgical treatments for extracapsular fractures: a NMA

This network meta-analysis included 184 studies with 26,073 study participants. 73 studies with 11,126 participants contributed data for at least two of these treatments in network meta-analyses for mortality, health-related quality of life, and unplanned return to theatre. There was considerable variability in the ranking of each treatment such that there was no one outstanding superior treatment. However, static implants such as condylocephalic nails and static fixed angle plates did yield a higher risk of unplanned return to theatre. Short nails and dynamic fixed angle plates yielded similar outcomes. These comparisons included people with both stable and unstable extracapsular fractures. Few studies addressed the benefits or harms of arthroplasty.

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Rehabilitation

These reviews considered the additional support that people may need whilst recovering from surgery – either whilst still in hospital or after discharge. They also looked specifically at the additional needs in this patient group, who may be malnourished at the time of their fracture or have poor food intake whilst in hospital, or who may have dementia.

Rehabilitation after fracture

28 studies with 5351 study participants. Critical outcomes were a composite of death or reduction in independent living, health-related quality of life, mortality, activities of daily living, mobility, and pain. In a hospital inpatient setting, there was moderate‐certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, resulted in fewer cases of ‘poor outcome’. The evidence for early supported discharge and multidisciplinary home rehabilitation was very low certainty.
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Rehabilitation after fracture for people with dementia

7 studies with 555 study participants. Studies compared models of enhanced care in the inpatient setting with conventional care, an enhanced care model provided in inpatient settings and at home after discharge with conventional care, and a geriatrician‐led care in‐hospital with conventional care led by the orthopaedic team. There was limited evidence that some of the models of enhanced rehabilitation and care may show benefits over usual care for preventing delirium and reducing length of stay for people with dementia; however, the certainty of these results was low.
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Supplements after fracture

41 studies with 3881 study participants. Most studies compared oral multinutrient supplements with a control. There was low‐certainty evidence that oral multinutrient supplements started before or soon after surgery may prevent complications within the first 12 hours but that they have no clear effect on mortality. There was very low‐certainty evidence that oral supplements may reduce death or complications and do not result in an increased incidence of vomiting and diarrhoea.

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Improving mobility after fracture

40 studies with 4059 study participants. Mobility strategies given in hospital may lead to a moderate, clinically meaningful increase in mobility and a small improvement in walking speed. Strategies given in a post-hospital setting lead to a small, clinically meaningful increase in mobility and a small improvement in walking speed. Whilst post-hospital strategies lead to an improvement in functioning and health-related quality of life, this may not be a clinically meaningful difference. The review also looks at the effectiveness of different types of strategies according to the ProFaNE classification.

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