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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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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What did the WHiTE 3 and WHiTE 8 Trials show about implant and cement choice in hemiarthroplasty for displaced intracapsular hip fractures?

 

WHiTE 3 Trial

• Compared traditional cemented monoblock Thompson hemiarthroplasty with modern cemented polished taper stems (Exeter/Unitrax)

• In patients ≥60 years with displaced intracapsular fractures.

• Found no significant difference in patient-reported outcomes (EQ-5D-5L), mortality, or mobility.

• Conclusion:

  • Traditional Thompson implants provide outcomes comparable to modern polished taper stems.

 

WHiTE 8 Trial

• Compared single-antibiotic cement (gentamicin; Palacos) with dual-antibiotic cement (gentamicin + clindamycin; COPAL)

• In cemented hemiarthroplasty for patients ≥60 years.

• Dual-antibiotic cement showed a small, non-significant reduction in deep surgical site infection, with no difference in mortality or function.

• Conclusion: Routine use of dual-antibiotic cement is not supported by current evidence.

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Would You Use a Bipolar or Unipolar Implant?

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Both are acceptable options for hemiarthroplasty, but bipolar implants may offer advantages in selected patients.

 

Potential Advantages of Bipolar Implants

• Less acetabular erosion due to dual articulation

• Improved range of motion

• Lower reoperation rates in some studies

• Greater modularity

 

Practical Advantages

• Adjustable stem sizing

  • (Thompson stems are uniform in width)

• Helpful in tight femoral canals when a Thompson stem is difficult to insert

• Easier conversion to THA if acetabular erosion develops later

 

Clinical Application: Useful in borderline patients who may benefit functionally from THA but are not fit enough for primary THA initially.

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Which patients should receive THA? What is potential advantages / disadvantage of THA compared to hemiarthroplasty?

 

Total Hip Arthroplasty for NOF#

 

Fit, independent elderly patients with displaced fractures who:

• Walk independently (±1 stick)

• Cognitively intact / Medically fit

• Expected ADLs beyond 2 years

 

Advantages (controversial)

• Better function

• Less pain than hemiarthroplasty

• Preferred if pre-existing OA or RA

 

Disadvantages

• Slight ↑ in dislocation risk vs. hemiarthroplasty

• Likely due to posterior approach being used over Hardinge

 

Note: In exam may ask what approach would you use for THA. In practice most hip surgeons will perform a posterior approach for THA as this is a comfortable approach and the dislocations rates are low in experienced hands. Can add in Dual mobility implant to reduce dislocation risk if required (see below)

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What were the findings of the HEALTH Trial? 

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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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When might a dual mobility implant be used in hip fracture surgery?

 

Dual Mobility Implant

 

Dual mobility (DM) implants may be used in hip arthroplasty for fracture patients who are at high risk of dislocation.

 

DM implants offer enhanced stability by having two articulating surfaces:

• Small femoral head articulates with a mobile polyethylene liner

• Liner articulates with the metal acetabular shell

• This increases the “jump distance” and reduces risk of dislocation

 

Used in displaced intracapsular NOF fracture in:

• Elderly patients

• Poor muscle tone or cognition

• Patients with neuromuscular disease or Parkinson’s

 

 

What were the findings of the N-DURE study?

 

N-DURE Study – 2023, Hoggett

 

• Design: Retrospective multicentre cohort study (9 UK hospitals)

• Population: 295 total hip arthroplasties (THA) for neck of femur fractures

• Comparision: conventional acetabular bearings to dual mobility bearings

• Key Findings:

  • Risk of dislocation four times higher with conventional bearings compared to dual mobility components in THA for NOF fractures

  • No significant difference in:

    • Mortality

    • Periprosthetic fracture

    • Revision rate

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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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