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British Orthopaedic Association
Annual Congress 2007, 26-28 September, Manchester Central
This year’s BOA Annual Congress is almost upon us once again, this time returning to the impressive surroundings of Manchester Central, formerly known as the International Convention Centre when it was last there in 2004. If you are planning on attending the congress then make sure you have registered, which can be done by downloading the registration form from www.boa.ac.uk/BOAhome.
As always, BOA has arranged a social event and, as has become the norm, it is co-sponsored by OPN and the event organisers Event Presentations. The Opening Reception is being held on Wednesday 26th September in the foyer of the Exhibition Hall, beginning at 6.15pm. This is an informal reception, with an informal dress code, providing you with an opportunity to wind down and meet in a rather more relaxed atmosphere.
The reception is open to both delegates and exhibitors. Tickets need to be pre-ordered from Janet Mills on 02392 570888 or email event.presentations@virgin.net and cost a reasonable £20. We all look forward to seeing you there.click here to download the floor plan and exhbitors list.
Management Of Sub-capital Fractures
In The Elderly Population £3,000 Travel Bursary Competition Mr Ben Ollivere MBBS MA(Oxon) MRCS, Specialist Registrar Trauma & Orthopaedics, Norfolk & Norwich University Hospital NHS Trust
Orthodynamics Ltd, is a leader in providing implant solutions for complex revision hip arthroplasty. The company also has a range of primary hip, revision knee and infection control devices. In association with the BOA, the company agreed to donate the sum of £3000 as a Travel Bursary to be awarded to a Specialist Registrar on the submission to a judging panel of BOA members, an essay confirming their interest in lower limb arthroplasty.
In his seminal 1961 paper “Low angle fixation in fractures of the femoral neck”1 Garden made the bold statement that “the claim of the femoral neck fracture to being the ‘unresolved fracture’ is increasingly unsecure”. However 45 years later the management of subcapital femoral neck fractures remains controversial.
Fractured neck of femur is sustained in approximately 1% of all falls in the elderly2, equating to 80,0003 fractures per year in the UK. The mortality rate in the UK approaches 30% at one year3.
A literature search will reveal a plethora of published articles, reviews and meta-analysis concerning femoral neck fracture. There are 13297 indexed articles on PubMed (1950-2007) concerning femoral neck fracture.
Although it is currently widely accepted that all femoral neck fractures should be operated on if at all possible, a Cochrane review4 concluded that “Given the lack of available evidence to inform practice and the continued variation in practice… conservative treatment will be acceptable”. This statement reflects the lack and quality of evidence, rather than any real treatment dilemma. The SIGN5 and NCEPOD guidelines recommend operative treatment for femoral neck fracture within 24 hours where at all possible.
The national trauma budget is £7,187,0006 per 100,000 population. Approximately 25%7 of the trauma and injury budget is spent on management of, and care for patients sustaining a fractured neck of femur. This equates to a spend of £1,570,000 and per 100,000 population, or £15 per person per year. Allowing for 48.9% of the population in full time employment8 this equates to a burden on each tax payer of £36.74 every year for treatment of these injuries. This represents one of the largest financial challenges the NHS faces.
The current rate of fractured neck of femur is 110 per 100,000 population annually6 with an estimated total cost of £12,0009 per episode, equating to a cost of £1,320,000 per 100,000 population. Each patient stays an average of 20 days in hospital, resulting in 20% occupancy of orthopaedic beds and 14,000 die annually as a result of femoral neck fractures10.
This demand on health care resources is set to rise. The Office for National Statistics currently estimates the retired population at 18%11. Local PCT predictions suggest a rise of 38% in the number of over 65 year olds over the next ten years. Hollingworth12 estimated that by 2031 1.6 million extra bed days per year and a further £507 million will be required to cover the treatment costs of femoral neck fractures.
If the increasing healthcare needs of these patients are not met they will start to eclipse healthcare provision in other sectors. Prevention of fragility fractures is one area that has been highlighted as a potential method for reducing the future health care burden. A recent report of the Health Care Commissioners stresses the importance of osteoporosis prevention in reducing the incidence of fractured neck of femur9.
There is mixed evidence as to the benefit of osteoporosis prophylaxsis on femoral neck fractures. Non-compliance with osteoporsis prophylaxisis is estimated in the UK at 45%7. This a well recognised problem, and a Dutch population13 study of 2124 new users of all types of bisphosphonates found between only 30 and 42% of users of bisphosphonates were compliant at 1 year. The only positive predictive value for continued use is administration of once weekly regimes.
The 2004 NICE guidelines on falls prevention14 highlights the need for identification of at risk individuals and the implementation of a multifactorial prevention programme. There is strong evidence in the literature that a programme of strength and balance training, home hazard assessment and intervention, vision assessment and referral and medication review will reduce the rate of fragility fractures. However despite the guidance being published three years ago a recent health care commissioners report still identifies adequate implementation of the NICE guidance a number one priority for trauma14.
Although DXA scanning is an accurate method for diagnosing osteoporosis there is no evidence that it predicts fragility fractures. The Royal College of Physicians guidance (1999) does not recommend routine screening, this view is evidenced by preoperative DXA scanning confirming that only 41% of patients suffering a fractured femoral neck are osteoporotic41. The World Health Organisation has developed an algorithm based approach to screening for osteoporosis. This algorithm is based on meta-analysis of twelve cohorts, totalling 250,000 person years of observation, and calculates a country specific 10 year risk of fracture. They have also developed treatment thresholds based on this.
More recently the SCOOP study9 has produced a preliminary report. This pilot study aims to evaluate implementation of a screening programme for osteoporosis based on the WHO algorithm. Although there was a low uptake rate of only 30% based on the preliminary report the MRC gave it’s approval for prospective multicentre study with five year follow up to evaluate the efficacy screening and prophylaxis in fracture prevention.
Classification
Garden classified subcapital fractures on AP radiographs in 19611. He emphasised fracture displacement as a key to determining the severity of the injury (Fig 1). Garden observed “subcapital fractures are of the same essential pattern, and their varying radiological appearance is considered to be due to the different degrees of displacement”. He used a pre-reduction AP radiograph to divide subcapital fractures into 4 groups.
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| Figure 1: Garden’s Classification System |
Garden also observed that the risk of avascular necrosis and non union was much greater in groups 3 and 4. Therefore he used his classification to determine treatment with either fixation (groups 1 and 2) or replacement (groups 3 and 4). The classification suffers from poor inter-observer agreement, Frandsen15 found that only 22% of fractures were classified into the same group by 8 trained observers. Subsequently it has been argued16 that only 2 groups are necessary non-displaced and displaced.
Undisplaced fractures
With a undisplaced fractures the blood supply to the femoral head is less disrupted17 and in line with Garden’s original paper stabilisation with internal fixation is the mainstay of treatment.
Although normally stabilised it is possible to treat these fractures expectantly, although between 8% and 15% will subsequently displace17. Otremski18 published a series of 123 patients with valgus impacted fractures. Counter-intuitively they found the angle of the fracture, the degree of valgus and the degree of retroversion were not predictive of disimpaction. However age was strongly predictive of failure with over 20% of patients over 65 disimpacting their fractures. When this risk is combined with the advantages of early mobilisation it is accepted practice to stabilise these fractures in the elderly19.
Stabilisation can be achieved with either a screw and plate device or cancellous screws. Selvin & Oakley20 conducted a dry bones biomechanical study, measuring peak load to failure of a range of screw configurations. ANOVA analysis was carried out and they concluded that “Triangular configurations had a higher peak load, higher ultimate load, less displacement and more energy absorption before failure than other configurations”
Lindequist21 conducted a similar study on cadaveric femurs. The implanted cancellous screws in various configurations in standardised osteotomised femurs. They used displacement under load as a marker of biomechanical stability and found the proximity of the inferior screw to the calcar and the presence of a posterior neck screw to be the best predictors of biomechanical stability. Using this type of cannulated screw fixation a 96% union rate can be expected with an “acceptable” functional result22.
Intracapsular fracture haematoma has been demonstrated on ultrasound23, and found to produce high intracapsular pressures. In undisplaced fractures with pressures average 66mmHg23. Measurement of femoral neck blood flow24 has shown a compromise in blood flow which was reversed with aspiration. In light of these and similar findings capsulotomy has been advocated in addition to internal fixation in undisplaced or minimally displaced femoral neck fractures.
Displaced Fractures
The first surgery for femoral neck fracture was undertaken by a New York surgeon, Carnochan who in 1840 implanted a wooden block spacer. The results were reported, not surprisingly, to be unsatisfactory. The first designs of hip prosthesis, such as Hey Groves’ ivory hip were not suitable for fracture surgery as they were resurfacings and had no stem.
In 1938 Judet & Judet developed their acrylic prosthesis, which was the first stemmed hemiarthroplasty. A year later both Thompson and Austin Moore developed stemmed stainless steel hemiarthroplasties and replacement for fracture became a possibility. In more recent years the developments of bipolar hemi-arthroplasty and total hip replacements have increased the range of treatment options but there is still no consensus of opinion as to best management.
In 2002 Crossman25 conducted a postal survey concerning treatment of displaced intra-capsular fractured neck of femur. They surveyed surgeons on the treatment of two generic groups ‘Active’ and ‘Frail’. Data concerning prosthesis in use and use of cement was collated from 223 responding hospitals (Fig 2).
Figure 2: Treatment of generic patients with #NOF Reproduced from Crossman et al25
| Prosthesis |
Active |
Frail |
| Bipolar |
41% |
8% |
| Fixation |
37% |
1% |
| Unipolar |
32% |
94% |
|
| Total Hip |
16% |
0% |
| Cemented |
74% |
46% |
Their results show accepted practice in frail patients can be said to be overwhelmingly in favour of unipolar prosthesis, either cemented or cementless. However there is little consensus of opinion concerning active patients. Opinion is equally divided between internal fixation, unipolar and bipolar prosthesis. In addition 16% of surgeons said they would consider total hip replacement in fracture.
Unipolar hemiarthroplasty
Unipolar hemiarthroplasty has been in existence since 1939 with the development of the Austin Moore and Thompson’s prosthesis. Although originally developed for arthritic patients, unipolar hemiarthroplasty remains the commonest treatment in the UK for femoral neck fractures25. Unipolar arthroplasty has the advantage of being a quick and straightforward operation to perform, the prostheses are cheap, and well established uncemented and cemented prosthesis exist. Many surgeons favour unipolar prosthesis sighting low intra-and post-operative complication rates and low revision rates. However concerns have been raised about acetabular wear, with reports in the literature of up to 64%26.
Norrish27 reported a consecutive series of 500 Austin-Moore hemiarthroplasties performed for fracture. Follow up was to eight years. 81% of patients were deceased within the follow up period, highlighting the fragility of this group of patients. The revision rate was reported as just 5% but this equates 25% of survivors at the eight year point.
The safety of cement in fracture surgery was addressed as part of a 2006 Cochrane Review28. Seventeen trials involving 1920 patients were included in the meta-analysis which concluded that cementation results in less post operative pain and better mobility at 1 year with no difference in surgical complications.
Bipolar Hemiarthroplasty
In response to data showing high rates of acetabular erosion and in light of reported high dislocation rates in total joint arthroplasty bipolar prosthesis were developed. Usage became common in the early 1980’s, with a dual articulation acetabular wear has been proposed to reduce, and the modularity of the stem argued to facilitate easy revision. Despite some reports in the literature of zero percentage incidence of acetabular erosion there are many reports29 of erosion rates up to 21%. It seems likely that a bipolar prosthesis confers little added benefit over a unipolar prosthesis.
Screw fixation
Internal fixation would be considered an acceptable treatment option for a fit patient in displaced femoral neck fractures in 36%25 of consultant orthopaedic surgeons in the UK. Although the rates of avascular necrosis are known to be up to 29%22 it has been argued that in fitter patients it is best to try and preserve the femoral head and avoid arthroplasty surgery. In a well conducted randomised controlled trial Tidermark30 randomised 102 patients to internal fixation or total hip arthroplasty. They found the complication rate (36% vs 4%; p<0.001), and the revision rate (42% vs 4%; p<0.001) to be significantly lower in the arthroplasty group. Additionally hip function was significantly better in the THR group at all follow-up reviews. They comprehensively demonstrated that their remains little place for reduction and internal fixation in elderly patients with a displaced femoral neck fracture.
Total hip
Historically total hip replacement has been considered inappropriate for use in the majority of fractured neck of femur patients. Early series reported dislocation rates up to 30 percent, and concerns over increased morbidity and mortality have tended to influence practice towards the more conservative hemiarthroplasty. However with increased life expectancy and up to 30%27 surviving patients requiring revision surgery, the use of total hip replacement is again being examined in the literature.
Blomfeldt31 produced a randomised controlled trial of patients with a displaced intracapsular neck of femur fracture in an attempt to ascertain the difference between bipolar hemiarthroplasty and total hip replacement. Primary outcome measures were post operative hip scores, with secondary measures of complications and quality of life scores. They found in 120 patients that post operative Harris hip scores were significantly better in the total hip replacement group at one year with no increased complication rate.
A three centre randomised control trial32 randomised patients to either a hemiarthroplasty head or total hip replacement using the same (CPT) stem. Eighty one patients were included in the trial, all with normal mini-mental test scores, and able to walk more than 1/2 mile prior to the injury. They used Oxford hip scores as the primary outcome measure. At three years follow up the walking distance and Oxford hip scores were significantly better in the total hip replacement group. There was no statistical difference between major complications (5 revisions in the hemiarthroplasty group, 3 dislocations in the total hip group). This study is particularly significant, as it differs from many other studies by including all grades of surgeon in several operative centres. It is therefore generalisable to most UK centres.
The 2006 Cochrane meta-analysis28 comparing internal fixation and hemiarthroplasty concluded that “Internal fixation is associated with less initial operative trauma but has an increased risk of re-operation on the hip”. They were unable to draw any further conclusions, although noted that “For the survivors, pain and function appear to be better after a cemented arthroplasty”. The authors comment that better reporting of outcome measures would help in any future meta-analysis. However it seems likely that the problem is not lack of evidence, or reporting of that evidence in the literature, but more the attempt to perform a meta-analysis on this topic. The patient group is one with high morbidity and mortality. There are high levels of loss to follow-up and difficulties in obtaining any meaningful five or ten year data due to the poor prognosis of patients who suffer a fractured neck of femur.
One of the only prospective randomised trial to include all treatment modalities was reported by Keating33. Two hundred and seven patients were randomised to either internal fixation, hemiarthroplasty or total joint arthroplasty. Follow up was to two years. They reported reoperation and functional hip scores as primary outcomes. There was no significant difference between reoperation in total and hemiarthroplasty (5% and 9% respectively). However internal fixation resulted in a 36% reoperation rate. They found total hip replacement to have better functional scores at 24 months and be comparable in cost to hemiarthroplasty.
In other studies Parker35 compared patients treated with internal fixation to those treated with an uncemented Austin Moore hemiarthroplasty. The mean cost £4758 for internal fixation and £4350 for hemiarthroplasty. Johansson36 reported a mean cost of €13,100 for internal fixation versus €12,700 for total hip replacement. Both of these studies are limited by only including direct hospital incurred costs, and so underestimate the true socioeconomic burden.
Hoffman34 performed a meta-analysis of 13 trials containing health economic data. They used QALY (quality adjusted life year) as their primary outcome measure and calculated the total cost of each method of fixation (Fig 3). Surprisingly they found that whilst there was little difference in overall cost between hemiarthroplasty and total hip replacement that internal fixation was far more expensive.
Figure 3: Cost per Quality adjusted life years
| Prosthesis |
QALY |
$ |
$/QALY |
| THR |
4.5 |
23,551 |
5233 |
| Hemi |
3.6 |
22,208 |
6168 |
| Screws |
2.6 |
29,733 |
11435 |
These differences are not as surprising as they might seem, as the total cost of the implant is only a fraction of the overall cost of hospital stay it is estimated in the UK that a single inpatient day costs £14,837 and that visits from a district nurse in the community cost £14,638. Implant costs40 range from £120 for Cannulated Screws to £1600 for a cemented total hip replacement. The health economic argument probably moves towards the implant which costs least in aftercare, which in many cases will be the implant with the best functional outcomes.
These findings contrast sharply with the current NHS national tariff39 (Fig 4), both in terms of absolute and relative values. The latest figures from the department of health suggest a total cost of £12,000 per hip fracture, financial reports from PCTs would suggest that 63% (£7,560)7 of this is met by hospitals. The national tariff only meets this cost for patients with a femoral neck fracture treated with arthroplasty.
Figure 4: Reproduced from 2007 v 2a NHS national tariff
| H82 |
Extracapsular Neck of Femur Fracture with Fixation w cc |
5,556 |
| H83 |
Extracapsular Neck of Femur Fracture with Fixation w/o cc |
4,777 |
| H84 |
Intracapsular Neck of Femur Fracture with Fixation w cc |
5,255 |
| H85 |
Intracapsular Neck of Femur Fracture with Fixation w/o cc |
4,588 |
| H86 |
Neck of Femur Fracture with Hip Replacement w cc |
7,979 |
| H87 |
Neck of Femur Fracture with Hip Replacement w/o cc |
6,030 |
Hoffman and others have shown that not only is arthroplasty cheaper, but it has a lower cost per QALY. It is reasonable therefore to suggest that from a health economic point of view there is no place for internal fixation in femoral neck fractures, and that total hip arthroplasty should be considered more frequently due to accumulating evidence of better functional outcomes coupled with lower total cost and decreased cost per QALY.
Conclusion
The only certainty in management of subcapital fractures of the hip is that we are currently uncertain in almost every area. It is possible to treat patients in almost any manner and find current evidence in the literature to support this. Garden’s prediction of 40 years ago could not have been more wrong.
Attempts to perform major meta-analysis are hampered by non-standardised outcome measures and difficulties in obtaining adequate follow up data in this group of patients. However contrary to the conclusions of most meta-analysis there are some useful conclusions that can be drawn.
There is accumulating evidence that total hip arthroplasty is the treatment of choice in patients who are fit enough for the procedure. Not only does it offer better functional outcomes in the hands of a variety of surgeons, but the complication rate is acceptable, and despite a higher implant cost the total cost, and cost per QALY is lower.
References
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- Hayes WC, Myers ER, Robinovitch SN, Van Den Kroonenberg A, Courtney AC, McMahon TA. “Etiology and prevention of age-related hip fractures.” Bone. 1996 Jan;18(1 Suppl):77S-86S
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- “Review of Orthopaedics”, Editor M. Miller. 2004 Lippincort Williams, London
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- Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults (Review) Parker MJ, Gurusamy K. Cochrane Medical Library 2006 Issue 4
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- R. Blomfeldt, H. Törnkvist, K. Eriksson, A. Söderqvist, S. Ponzer, and J. Tidermark “A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients” J Bone Joint Surg Br, Feb 2007; 89-B: 160 - 165.
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- Source : Charlotte Hilton, Norfolk & Norwich University NHS Trust Theatre Manager
- Heetveld MJ, Raaymakers EL, van Eck-Smit BL, van Walsum AD, Luitse JS. “Internal fixation for displaced fractures of the femoral neck. Does bone density affect clinical outcome?” J Bone Joint Surg Br. 2005 Mar;87(3):367-73.
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