Hip fracture
BMJ 2006; 333 doi: https://doi.org/10.1136/bmj.333.7557.27 (Published 29 June 2006) Cite this as: BMJ 2006;333:27
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Effective delivery of orthogeriatric care is likely to be a key
determinant of outcome after hip fracture, but systems to deliver it are
very diverse. The description given by Parker and Johansen(1) of five
broad categories of rehabilitation is based on studies from Sweden and
Australia, and studies mainly from the 1980s in the UK(2). Those
conclusions may not be generalisable in the current UK context, and
evidence regarding the effect of inpatient care delivered in community
hospitals to this patient group is almost entirely absent.
In the UK, community hospitals (CH) play a major part in post-acute
care, facilitating early transfer from acute hospitals(3). Community
hospitals are well supported by local communities, but viewed as expensive
by cash-poor PCTs, and ambivalently by Government(4). One recent study(5)
showed that care in CH was associated with greater independence for older
people than care in wards in a district hospital. Other studies have
reported no benefits(6-8).
Care is usually led by local General Practitioners (GP), and less
commonly by geriatric medicine specialists, sometimes supported by non-
consultant career grade doctors or doctors in training. Nurse-led or
therapist-led units are rare, unless one includes the recent and poorly
evaluated profusion of inpatient intermediate care projects. There is
little evidence to show which of GP, geriatrician, or nurse-led care is
most clinically effective or cost effective in this setting.
This is a subject which undoubtedly requires further research, in the
interests of the health economy and patients.
1. Martyn Parker and Antony Johansen. Hip fractures.
BMJ 2006; 333: 27-30
2. Cameron I, Crotty M, Currie C, Finnegan T,
Gillespie L, Gillespie W, et al. Geriatric
rehabilitation following fractures in older
people: a systematic review. Health Technology
Assessment 2000; 4(2).
3. Martin Hensher, Naomi Fulop, Joanna Coast, and
Emma Jefferys. The hospital of the future: Better
out than in? Alternatives to acute hospital care.
BMJ, Oct 1999; 319: 1127 – 1130.
4. Adrian O’Dowd. Keep community hospitals open,
primary care trusts told. BMJ April 2006; 332:873.
5. John Green, John Young, Anne Forster, Karen
Mallinder, Sue Bogle, Karin Lowson, and Neil
Small. Effects of locality based community
hospital care on independence in older people
needing rehabilitation: randomised controlled
trial. BMJ, Aug 2005; 331: 317 – 322.
6. C Hine, VA Wood, S Taylor, and M Charny Do
community hospitals reduce the use of district
general hospital inpatient beds? J. R. Soc. Med.
1996 89: 681-687.
7. JE Baker, M Goldacre, and JA Gray. Community
hospitals in Oxfordshire: their effect on the use
of specialist inpatient services. J. Epidemiol.
Community Health, Jun 1986;40: 117 – 120.
8. Peter J.Cook and Leonard Porter. Community
hospitals and district general hospital medical
bed use by elderly people: a study of 342 general
practitioner beds in Oxfordshire. Age Ageing, May
1998; 27: 357 - 361.
Competing interests:
None declared
Competing interests: No competing interests
Dear Sir,
The issue of thromboembolic prophylaxis for hip fracture is not as
clear cut as suggested by Dr Jenkinson1 and one needs to take a more
critical view of the literature. Regrettably the evidence base remains
weak and until randomised trials of sufficient size are undertaken, we are
left with conflicting opinions regarding the relative merits of different
preventative measures.
The very frail elderly people who typically suffer hip fracture have
a high prevalence of medical and psychiatric comorbidity, are in receipt
of substantial numbers of other medications and will have suffered local
bleeding at the fracture site even before surgery. Poor outcome is common
and complex in nature, with symptomatic venous thromboembolism playing a
relatively smaller part in this than in other clinical situations. These
patients cannot be assumed to require, or to benefit from, the same
approaches recommended for other patient groups.
There are many observational studies which support the use of
thromboembolic prophylaxis, but likewise one can quote studies which
question the need. Many of the studies on this topic were small, used
limited outcome measures or limited follow-up, and were sponsored by the
pharmacological industry – all factors that may exaggerate the benefit and
minimise the adverse complications of heparin use. 2
The British guidelines mentioned by Dr Jenkinson3 were focused on the
results of the Cochrane review of heparins after hip fracture,4 but this
focus does not justify the recommendation included in the guideline. The
Cochrane review demonstrated a reduction in the incidence of ‘venographic
thrombosis’ with the use of heparins, but no difference was demonstrated
between placebo and heparin groups for the crucial clinical outcomes of
pulmonary embolism and mortality. If thromboembolic complications are
responsible for many of the deaths after hip fracture, then one would
expect at least a trend for a reduction in mortality with prophylaxis. In
fact the trend is the opposite direction; towards increased mortality with
heparins.
Clinical practice has changed since many of these studies were
undertaken, and patients now wait for shorter periods before operation and
are mobilised earlier. This may have altered the incidence of
thromboembolic complications, and the balance between benefit and harm
from prophylaxis may have changed.
This deficiency in the evidence base is reflected in the clinical
guidelines, which do not all support the use of heparin. The SIGN
guidelines favour aspirin,5 whilst the New Zealand guidelines suggest
either aspirin or heparin.6 Unlike heparin, aspirin has been shown to
reduce the incidence of pulmonary embolism after hip fracture. Whilst no
reduction in mortality after hip fracture has been shown with aspirin, at
least the trend in mortality is in favour of aspirin.7
There is no clear justification for the use of extended heparin
prophylaxis after hip fracture. Such a policy would have large
administrative and cost implications and should not be considered until a
solid evidence base exists for this approach.
In summary, there is a need to stop arguing what may or may not be of
benefit and concentrate on establishing an evidence base with properly
conducted independently run studies on this topic.
Competing Interests: None declared.
References
1. Michael L Jenkinson. Low molecular weight heparin is recommended to
reduce the risk of thromboembolic complications. BMJ rapid response 2 July
2006.
2. Lexchin J, Bero LA, Djulbegovic B, Clark O. Pharmaceutical
industry sponsorship and research outcome and quality: systematic review.
BMJ 2003;326:1167-70.
3. Baglin T, Barrowcliffe TW, Cohen A, Greaves M; British Committee
for Standards in Haematology. Guidelines on the use and monitoring of
heparin. Br J Haematol 2006;133:19-34.
4. Handoll HHG, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Milne
AA, Gillespie WJ. Heparin, low molecular weight heparin and physical
methods for preventing deep vein thrombosis and pulmonary embolism
following surgery for hip fractures. (Cochrane Review). In: The Cochrane
Library, 2002; Issue 4, Chichester, UK: John Wiley & Sons Ltd.
5. Scottish Intercollegiate Guidelines Network (SIGN). Prevention and
Management of Hip Fractures in Older People. A National Guideline.
Edinburgh 2002; SIGN. No.56. (www.sign.ac.uk).
6. Acute management and immediate rehabilitation after hip fracture
amongst people aged 65 years and over. New Zealand Guidelines Group. 2003.
www.nzgg.org.nz
7. Pulmonary embolism prevention (PEP) trial collaborative group.
Prevention of pulmonary embolism and deep vein thrombosis with low dose
aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000;355:1295-
302.
Yours Sincerely
Martyn Parker
Antony Johanson
Competing interests:
None declared
Competing interests: No competing interests
EDITOR- I read this paper with interest[1] in particular the authors'
views on chemo-thromboprophylaxis. The point the authors have made
provides a much needed balance on this contentious issue. While there is
agreement that the routine use of chemo-thromboprophylaxis does reduce the
incidence of deep vein thrombosis (DVT) in patients undergoing surgery for
hip fractures and major joint arthroplasty there is still no evidence of a
reduction in overall mortality rates in the increasing use of routine
chemothromboprophylaxis in large patient study groups in the United
Kingdom[1,2]. As this seems to be the case I question the basis and actual
value for the increasing attempts at the introduction of these guidelines
in clinical practice. One effect of such guidelines will be the instances
when nursing staff continue to administer the low molecular weight heparin
to their patients with serious un-noticed post-operative bleeding just
because they are told to follow the guidelines. While the evidence would
suggest that routine chemo-thromboprophylaxis does not cause an increase
in post-operative bleeding this is not my observation in clinical
practice. It would be logical to expect an increase in post-operative
bleeding if chemo-thromboprophylaxis has such a marked effect in the
reduction of incidence of DVT.
The other concern often raised is the effect of post-operative DVT on
future risks of venous ulceration. Again there is no evidence of such an
effect [4].
References
1.Parker M. Johansen A. Hip fracture. BMJ 2006;333:27-30
2. Stephen E Roberts and Michael J Goldacre. Time trends and
demography of mortality after fractured neck of femur in an English
population, 1968-98: database study BMJ 2003; 327: 771-775
3. C. Howie, H. Hughes, A. C. Watts Venous thromboembolism associated
with hip and knee replacement over a ten-year period: A POPULATION-BASED
STUDY. Scottish Arthoplasty Project J Bone Joint Surg Br 2005 87-B: 1675-
1680.
4. S. D. Muller, F. M. Khaw, R. Morris, A. E. Crozier, and P. J.
Gregg. Ulceration of the lower leg after total knee replacement. J Bone
Joint Surg Br, Nov 2001; 83-B: 1116 - 1118.
Competing interests:
None declared
Competing interests: No competing interests
EDITOR- Hip fracture thromboembolic prophylaxis is a contentious
issue as Parker and Johansen state in their review of hip fracture[1], but
in a somewhat different way to what they imply. Well might eye brows be
raised by their failure to recommend any form of low molecular weight
heparin thrombo-prophylaxis contrary to the latest American and British
guidelines [2] . The current debate, driven by epidemiological data and
recent clinical trials, is not the benefit of low molecular weight heparin
preparations at proven doses, but rather the likely inadequacy of typical
5 to 10 day courses, rather than longer and more inconvenient ones of 28
days or more[3] .
The authors further appear to imply that with heparin it is best to
give nothing because of the risk of bleeding complications. This might be
their own opinion, but their referenced 2002 Cochrane review states there
is a lack of power to identify outcomes of clinical importance apart from
a reduction in deep vein thrombosis. Actually the evidence base has moved
on from 2002. There are concerns about wound infection rates with those on
low molecular weight heparin [4] but no reason to be concerned about
bleeding complications in the total context of the entire evidence base
and correctly timed thrombo-prophylaxis doses of heparin, taking into
account spinal anaesthesia. Considering the well characterised evidence
base from studies in many countries that consistently shows that
clinicians tend to undertreat with anticoagulants patients such as the
elderly at highest risk of thromboembolism, and overtreat patients at low
risk such as the fit young coming in for elective operations[5], the
article does a gross disservice to a very important issue.
Failing to make recommendations consistent with international
guidelines in a review article on the management of the fractured hip
could unnecessarily help perpetuate the under-treatment of one of the
highest risk groups of patients for thrombotic complications.
Competing Interests: None declared.
References
1. Parker M. Johansen A. Hip fracture. BMJ 2006;333:27-30
2. Baglin T, Barrowcliffe TW, Cohen A, Greaves M; British Committee
for Standards in Haematology. Guidelines on the use and monitoring of
heparin. Br J Haematol. 2006;133(1):19-34.
3. Arcelus JI, Kudrna JC, Caprini JA. Venous thromboembolism
following major orthopedic surgery: what is the risk after discharge?
Orthopedics. 2006;29(6):506-16.
4. Sanchez-Ballester J, Smith M, Hassan K, Kershaw S, Elsworth CS,
Jacobs L. Wound infection in the management of hip fractures: a comparison
between low-molecular weight heparin and mechanical prophylaxis. Acta
Orthop Belg. 2005;71(1):55-9.
5. Deheinzelin D, Braga AL, Martins LC, Martins MA, Hernandez A,
Yoshida WB, Maffei F, Monachini M, Calderaro D, Campos W Jr, Sguizzatto
GT, Caramelli B; Trombo Risc Investigators. Incorrect use of
thromboprophylaxis for venous thromboembolism in medical and surgical
patients: results of a multicentric, observational and cross-sectional
study in Brazil. J Thromb Haemost. 2006;4(6):1266-70.
Competing interests:
None declared
Competing interests: No competing interests
Randomised, controlled trial should have deserved mention.
Dear Editor
We read with interest the clinical review article (1) addressing the
management of patients with fractured neck of femur. We totally agree that
the prevention and management of hip fractures involves a wide range of
disciplines. The complexity of care needed for hip fractures makes the
condition a real test and a useful marker of the integration and
effectiveness of modern health care.
However we were disappointed that little mention was made of the
anaesthetic management of such patients and in particular the study of
Sinclair et al (2). This was prospective, randomised controlled trial
comparing conventional intra-operative fluid management with repeated
colloid fluid challenges guided variables derived from Oesophageal Doppler
Measurements. The study showed that postoperative recovery was
significantly faster in the protocol patients, with shorter times to being
declared medically fit for discharge ( median 10 days vs 15 days, P
<_0.05 and="and" a="a" _39="_39" reduction="reduction" in="in" hospital="hospital" stay="stay" _12="_12" days="days" vs="vs" _20="_20" days.="days." they="they" concluded="concluded" that="that" intra-operative="intra-operative" intravascular="intravascular" volume="volume" loading="loading" to="to" optimal="optimal" stroke="stroke" resulted="resulted" more="more" rapid="rapid" postoperative="postoperative" recovery="recovery" significantly="significantly" reduced="reduced" stay.="stay." the="the" paper="paper" was="was" not="not" however="however" able="able" demonstrate="demonstrate" significant="significant" change="change" peri-operative="peri-operative" mortality.="mortality." these="these" findings="findings" if="if" reproduced="reproduced" across="across" nhs="nhs" would="would" have="have" cost="cost" impact.="impact." p="p"/>We feel that, as this paper is likely to become a major source of
reference for any doctors caring for such patients (including
anaesthetists), the paper by Sinclair et al (2) should have deserved
mention.
References
1-M. Parker, A. Johansen. Clinical Review –Hip fracture: BMJ. 2006; 333:
27-30. (1 July)
2-S. Sinclair, S. James, M. Singer. Intraoperative intravascular
volume optimisation and length of hospital stay after repair of proximal femoral
fracture: randomised controlled trial: BMJ.1997;315:909-912. (October)
Dr. Hamzeh Hussein--Senior House Officer/ Anaesthetics
Dr.Nial Quiney--Consultant Anaesthetist
Anaesthetic Department,
Royal Surrey County Hospital,
Egerton Road,
Guildford GU2 7XX
hamzeh_hussein@yahoo.co.uk
Competing interests:
None declared
Competing interests: No competing interests