Clinical Scenario
NOF#
(Elderly Patient)

Please interpret the radiograph and tell me what you are concerned about in this patient?

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An AP radiograph is presented of both hips in a 76-year-old female. There is evidence of a right sided intra-capsular neck of femur fracture with significant displacement. I would want further orthogonal imaging with a lateral of the right hip to assess for the degree of AP displacement and AP pelvis.

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Key Concerns

1. NOF# - Manage as per guidelines:

   1. NICE Guidelines: Hip Fracture Management [1]

   2. BOAST: Management of Frail Orthopaedic Trauma Patients [2]

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How would you manage this patient?

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ATLS

“This patient has a likely high energy injury mechanism; I would therefore ensure that the patient was managed via ATLS principles. With a trauma call, introduction of team members and assignment of roles followed by a primary and secondary survey to identify and treat any life / limb threatening injuries.”

 

History

• Allergies

• Medication

• Past medical history

• Last ate

• Events

  • ?Collateral history

  • Mechanism of injury

  • SOCIAL HISTORY - nursing home resident?

  • MOBILITY - Frame or sticks? How far can they mobilise?

  • Abbreviated Mental Test Score (AMTS)

 

Note: should be filled out in a NOF# proforma. With calculation of NHFS. 

 

Examination

• Axial loading

• Pin rolling

• N+V intact

 

Investigations

• Bloods (incl. G&S)

• CXR + Urine Dip + ECG

• Orthogonal views

  • AP + Lateral Hip

  • AP Pelvis

• ?Full length femur

• CT / MRI

 

Management

• FIB

• Regular medications

• VTE assessment

• Analgesia + IVF

• NBM 2am

• Added to trauma list

• Orthogeriatric review

• Consented + Marked

• Consideration of DNAR discussion

• Discussion with NoK

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As per NICE Guidelines [1] what are the aims of surgery in NOF# surgery? 

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• Operative on patients with the aim to allow them to fully weight bear in the immediate post-operative period

• Operate on patients within 48 hours (Note: BPT is <36hours)

• Orthogeriatrics review within 72 hours

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What operation would you offer this patient? Why?

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Top Candidate Answer: 

"In this patient I would perform a Hemiarthroplasty. Utilising a proven cemented femoral stem via a Hardinge approach as per NICE Guidelines" 

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NICE Guidelines [1]

 

As per NICE Guidelines displaced intracapsular NOF# should be offered replacement arthroplasty with a total hip replacement (THR) or hemi-arthroplasty. 

 

THR should be offered to patients who are:

• Able to walk independently out of doors with no more than the use of a stick

• Do not have a condition or comorbidity that makes the procedure unsuitable for them

• Are expected to be able to carry out activities of daily living independently beyond 2 years.

 

Hemi-arthroplasty should be offered to patients who do not meet the above criteria (such as in this patient) 

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​What is a proven femoral stem? Would you use a cemented or uncemented implant? What approach would you use?

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Operative arthroplasty procedures should use:

• A proven femoral stem

  • This is a term for stems that have a <10% revision rate at 10 years

• Cemented implants - reduced risk of peri-prosthetic fractures

• Consider an anterolateral approach in favour of posterior approach when performing a hemi-arthroplasty - reduced dislocation risk

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Why are cemented stems recommended over uncemented stems in NOF# surgery? 

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Because the rates of complications higher with uncemented prosthesis = notably of peri-prosthetic fracture

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Note: Uncemented stems in patients with osteoporotic bone can lead to perforation of femoral cortex and fracture

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This patient is on Warfarin with a raised INR (3.2) how would this affect your management? 

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• 5% of patients with hip fractures take warfarin

• Should follow local hospital guidelines on management of patients taking warfarin

• In general

  • INR <2 - for surgery

  • INR <1.5 - for spinal anaesthesia

• Bridging LMWH should be prescribed

• Reversal Agent needed prior to surgery

  • Vitamin K (IV/PO) can be used for reversal of warfarin

  • Prothrombin complex (e.g. Beriplex) allows rapid reversal of warfarin but is usually not indicated and is expensive

  • State you would give Vitamin K 10mg IV then reassess INR 

• Warfarin can usually be recommenced 24 hours after surgery

 

If any doubt about peri-operative anticoagulation then should consult haematologist

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Can you describe the Garden’s Classification for NOF#?

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Garden’s Classification [3]

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Based on completeness of fracture and degree of displacement:

• Type 1     Incomplete # + undisplaced

• Type 2     Complete # + undisplaced

• Type 3     Complete # + partially displaced

• Type 4     Complete # + completely displaced

 

Garden’s Type 3/4 - should undergo arthroplasty due to the risk of AVN due to interruption of the retinacular vessels (retrograde blood supply to femoral head)

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Are you aware of any scoring systems that help to predict mortality following a NOF#?

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Nottingham Hip Fracture Score (NHFS) [4]

 

NHFS is a validated risk assessment tool that has been shown to be reliable in predicting 30 day and 1 year mortality following NOF#s.

 

Based upon:

• Age

• Sex

• AMTS

• Haemoglobin on admission

• Residence (living in institution)

• Co-morbidities

• Active malignancy

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What is the National Hip Fracture Database (NHFD)?

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National Hip Fracture Database (NHFD) [5]

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Developed in 2007 by BOA and British Geriatric Society. 

 

• Nationwide Audit within the NHS

• Aim: Evaluate management and outcomes of patients with hip fractures

• Standards:

  • Key Performance Indicators (KPIs) based on NICE guidelines standards – “The Management of Hip Fractures”

    • Includes Length of stay

    • Morbidity and Mortality

• Key successes

  • Orthogeriatric review

  • Reduced mortality (30-day mortality fallen from 10% to 6.1%)

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What is the Best Practice Tariff (BPT)?

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Best Practice Tariff (BPT)

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BPT came into effect in 2010 following Lord Darzi’s: NHS next stage review report [6]. With the aim of offering financial incentives to improve patient care for high volume areas with unexplained variation in the quality of care received. The BPT is monitored via the NHFD.​

 

BPT Indicators:

• Time to surgery <36 hours from arrival in ED

  • Or if admitted time from diagnosis in hospital

• Assessment by Orthogeriatrician within 72 hours of admission

• AMTS to be performed before surgery

• Assessment by physiotherapist on the day of OR day following surgery

• Falls and bone health assessment

• Nutritional assessment during admission

• Delirium assessment using 4AT screening tool during admission

 

The renumeration for hitting the best practice tariff is around £445 higher than the base tariff

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Do you know of any clinical trials surrounding hip fracture management?

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HEALTH Trial [7]

(Hip Fracture Evaluation with Alternatives of Total Hip Replacement versus Hemiarthroplasty)

 

Methodology

• Multicentre Randomised Control Trial (RCT)

• 1495 patients

• Inclusion Criteria:

  • >50 years with displaced femoral neck fracture

  • Able to mobilise independently

• Randomised into two groups

  • Hemiarthroplasty Vs. THR

 

Primary Outcome Measure

• Secondary hip procedure within 2 years

• Secondary outcomes:

  • Quality of life questionnaires

  • Complications

  • Adverse Events

 

Results

• No significant difference in re-operation rates

• THR no conferred no significant advantage in function / quality of life over 24 months

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References

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[1] NICE. Hip Fractures: Management. Available at: https://www.nice.org.uk/guidance/cg124 

 

[2] BOA. BOAST – The Care of the Older or Frail Orthopaedic Trauma Patient. Available at: https://www.boa.ac.uk/resources/boast-frailty.html [Accessed June 2022]

 

[3] Garden RS. Stability and union in subcapital fractures of the femur. J Bone Joint Surg Br. 1964;46:630-47

 

[4] Maxwell MJ, Moran CG, Moppett IK. Development and validation of preoperative scoring system to predict 30-day mortality in patients undergoing hip fracture surgery. Br J Anaesth, 2008;101:511-7

 

[5] Royal College of Physicians. The National Hip Fracture Database. Available at: https://www.nhfd.co.uk/ 

 

[6] Department for Health. High Quality Care For All: NHS Next Stage Review Report. Available at: https://www.gov.uk/government/publications/high-quality-care-for-all-nhs-next-stage-review-final-report 

 

[7] Bhandari M, Einhorn TA, Guyatt G, Schemitsch EH, Zura RD, Sprague S, et al. Total hip Arthroplasty or Hemiarthroplasty for hip fracture. N Engl J Med. 2019;381(23):2199–2208.

 

[8] Fixation using Alternative Implants for the Treatment of Hip fractures (FAITH) Investigators. Fracture fixation in the operative management of hip fractures (FAITH): an international, multicentre, randomised controlled trial. Lancet. 2017 Apr 15;389(10078):1519-1527. 

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