Timing and Outcome of Surgery in Hip Fractures

Hip Joint


Ball and Socket joint.

Hip fracture is any fracture involving Interochanteric region head, neck or acetabulum.


310,000 Hip fractures in the United State in 2003
   1/3rd - receive a hip replacement.
   10.3 - 15.2 billion dollars / year
Elderly – Vast Majority  Co-morbidities



Femoral Neck Fracture

Fracture Healing is delayed due to
        - Intracapusular neck- No Cambium layer
        - Synovial fluid clears out haematoma and inhibits fracture union
        - Haematoma causes pressure on head

Mechanism of injury 

•Directly on lateral hip
•Twisting mechanism
•Fatigue or insufficiency fracture, then fall
•In younger - RTA /  fall from a height


Risk Factors of Hip Fractures  

•Osteoporosis and Falls
  Lifetime risk -17.5 percent for women : 6 percent for men 
•Average -   women 77 years old  :  men 72 years old
•Low socioeconomic status
• Cardiovascular disease
•Endocrine disorders -  Diabetes ,   Hyperthyroidism
•Medications

Assessment in Hip Fractures 
•Comorbidities
 •Ischemic heart disease
•Determine the cause of the fall
 •Syncope
• Physical examination
  Additional injuries
    Intracranial hemorrhage
   Cervical spine fracture
    Dehydration,  Signs of  Rhabdomyolysis

Management 
Prevention of fall, osteoporosis treatment
Neck of Femur Fractures -  Definite Management 
•Assessing Patient's Preinjury level
•Ambulatory patients  
  Restore Pre-injury level of activity soon

 Non-operative Managaement

   Nonoperative management -  Reserved for Debilitated  patients
  Stable, Impacted fractures
  Complications  -  Mortality - 16 %   
  Infection
  Thromboembolism

Operative Management of femoral neck fractures 
ORIF    
CCS  
Hemiarthroplasty  
Total Hip Replacement 
There is benefit of giving beta blockers and clonidine in patients with hip fractures perioperatively.
Rehabilitation

Outcomes in Hip Fracture Management 
Outcome
 Two  Variables
  A. Depend on successful fracture management
 
  B. Perioperative complications and co-illness management

Risk of major morbidity in the elderly
  Cardiac complications   –   8%
     Pulmonary complications   –   4 %
  Gastrointestinal bleeding  -  2 %
  Others – VTE , TIA or CVA , isolated Hypotension,     -  1 %

  Risk of death in the elderly
  In-hospital mortality rates -   1 to 10 %
  1-year mortality after hip fracture -  14% to 58%
Femoral Neck Fracture outcome
AO Foundation
 -  Better results if operated within 48 hours after injury
  -  > 3 medical comorbidities -  benefit from a bit longer attempt
  at  medical optimization, but generally should have surgery
  within 4 days

IT and Neck of femur fracture have same mortality rate.
Revised Cardiac index can help predicting mortality in patients with hip fractures depending on different co-illnesses.




http://www.uptodate.com/contents/medical-consultation-for-patients-with-hip-fracture source=see_link
Kates.The 1-Year Mortality of Patients Treated in a Hip Fracture Program for Elders. Geriatr Orthop Surg Rehabil. 2010 Sep; 1(1): 6–14.








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