Hip fractures account for 7, 01% of total body fractures in adults and 23, 79% of total body fractures in older adults over 65 years of age [1]. China has entered an aging society and it is speculated that the medical costs for hip fractures in China will reach $60 billion by 2020 and approximately $240 billion by 2040 [2]. Hip fractures in the elderly are often improperly treated, and only 30% of patients can return to their pre-injury state of life, causing a heavy economic burden to the patient’s family and society.
Many countries have developed guidelines for the treatment of hip fractures, including the 2011 National Institute for Health and Clinical Excellence (NICE) guidelines on hip fractures [3] and the 2009 Scottish Intercollegiate Guidelines (SIG). The Scottish Intercollegiate Guidelines Network (SIGN) published guidelines on hip fracture in 2009 [4] and the National Health and Medical Research Council (NHMRC) of Australia published guidelines on hip fracture in 2009 [5]. Guidelines for hip fractures in the elderly [5] and the 2014 guidelines for hip fractures in the elderly developed by the American Academy of Orthopaedic Surgeons Annual Meeting (AAOS) [6]. In this paper, based on the guidelines of each country and the allocation of medical resources, we interpret the prehospital treatment, emergency room management, preoperative preparation, timing of surgery, thrombosis prevention and control, anesthesia methods, analgesia, prophylactic antibiotics, fracture internal fixation methods, nutritional support and rehabilitation, respectively, based on the guidelines of each country and the current medical situation in China.
In order to elaborate the original viewpoint, the recommended grades [4] are quoted in this article, including 4 levels.
Level A: Level 1++ evidence from at least one Meta-analysis, systematic analysis, or randomized controlled trial study [4] that is directly applicable to the target population; or a series of predominantly level 1+ studies with direct applicability to the target population and showing overall consistency of results.
Level B: a series of level 2++ research evidence that is directly applicable to the target population and shows consistency in the overall results; or evidence extrapolated from level 1++ or l+ research evidence.
Level C: A series of Level 2+ studies, directly applicable to the target population and showing consistent overall results; or evidence extrapolated from Level 2++ research evidence.
Level D: Level 3 or 4 research evidence; or evidence extrapolated from Level 2+ research evidence.
I. From prehospital care to emergency room management
The SIGN guidelines establish detailed pre-hospital management protocols: patients with a history of hip injury, hip pain and shortened or rotated deformity of the affected limb should be highly suspected of hip fracture and transported to the hospital as soon as possible. Relevant information should also be collected, such as the patient’s injury history, disease and treatment history, pre-injury limb function and cognitive level. Analgesic treatment may be given during transport, and attention should be paid to the prevention of pressure sores. If transport takes a long time, indwelling urinary catheters may be considered.
For patients suspected of hip fracture, patients should be evaluated within 1 h of entering the emergency room and admitted to the hospital within 2 h (level D). There is still a gap between the domestic emergency network and developed countries in Europe and America, and the average ambulance can arrive at the scene about 5 min after the occurrence of trauma in developed countries in Europe and America, while the average arrival time in Shanghai, an economically developed city in China, is 15 min, and it takes 30 min to arrive at the Therefore, the treatment goal of hospitalization within 2 h after injury is not realistic in China.
The assessment includes: risk of pressure ulcers, nutritional status, water and electrolyte balance, pain, temperature, medical complications, mental status, pre-injury mobility and function (grade D), symptomatic management and imaging (X-ray, CT or MRI scan).
Second, preoperative preparation
1. Timing of surgery.
The SIGN guideline recommends early surgery, the NICE and NHMRC guidelines recommend surgery within 36 hours, and the AAOS guideline recommends surgery within 48 hours. In conclusion, if the patient’s medical condition allows, surgery should be performed as early as possible (on the day of admission or on the second day). Early surgery can reduce patients’ pain and early functional exercise, which can reduce the risk of postoperative complications. patients operated after 48 h are more than twice as likely to have complications than those operated early [8], with complications mainly including pressure sores, pulmonary infections, urinary tract infections, deep vein thrombosis and pulmonary embolism. In addition, the timing of surgery also affects the expected survival of patients, with 1 Meta-analysis reporting a 41% and 32% increase in morbidity and mortality at 30 d postoperatively and 1 year postoperatively in patients operated after 48 h compared with those operated within 48 h, respectively [9].
The incidence of postoperative complications is higher in patients with more preoperative medical complications [10]. Therefore,the relevant complications should be clearly diagnosed as early as possible and treated aggressively and symptomatically. For medical complications that can be corrected in the short term, such as anemia, hypertension, hypoproteinemia, coagulation dysfunction, blood volume deficiency, electrolyte disorders, diabetes mellitus, heart failure, and arrhythmia, surgery can be postponed as appropriate, and the general condition of the patient can be improved through treatment such as blood volume supplementation to correct anemia, blood pressure control, correction of coagulation dysfunction and electrolyte disorders, regulation of blood glucose, and control of heart failure to create conditions for early surgery.
The NHMRC and SIGN guidelines also state that patients taking anti-platelet aggregation drugs may not delay surgery. For patients who are routinely taking warfarin anticoagulation, preoperative warfarin should be stopped and combined with intravenous or intramuscular vitamin K (1.0-2.5 mg) to attenuate the anticoagulant effect of warfarin (B); fresh frozen plasma is not recommended as it can produce a variety of adverse effects, such as infection, allergy, acute lung injury and hemolysis.
2. Preoperative traction.
The NHMRC, SIGN, and AAOS guidelines do not recommend the routine preoperative application of skin traction or bone traction (grade A), and several papers point out that preoperative traction does not reduce pain or decrease the amount of anesthetic drugs and can cause pain at the traction site [11,12,13,14,15,16]. There is no consensus in China, and the general practice is that skin traction should be given to patients who cannot complete surgery within 24 h, and bone traction should be given to those who cannot complete surgery within 48 h.
3. Preoperative pressure sore prevention.
In principle, all patients should use anti-pressure sore pads (grade A), but most primary care hospitals lack the relevant facilities, so physicians should try to apply anti-pressure sore pads and provide standardized anti-pressure sore care according to the actual situation.
4. Oxygenation.
All patients should be assessed for oxygen status from admission to 48 h postoperatively and given oxygen if necessary (Grade B). NHMRC guidelines recommend that oxygen should be administered within 12 h postoperatively regardless of oxygen status, and that the decision to continue oxygenation after 12 h should be made according to oxygen status.
5. Prevention of deep vein thrombosis.
The risk of thrombosis is high after hip fracture surgery. It has been reported in the literature that even with pharmacological prophylaxis, deep vein thrombosis occurs in 1,34% of patients, especially in elderly patients with or without clinical symptoms of deep vein thrombosis and pulmonary embolism [17].The SIGN guidelines recommend the application of sulfadepril sodium for the prevention of deep vein thrombosis (grade A) 6 h after hip fracture, for 28 d, except for contraindications. Our 2012 Expert Consensus on the Prevention of Perioperative Venous Thromboembolism in Chinese Orthopaedic Trauma Patients established a specific protocol for the prevention of surgical thrombosis in hip fractures (choose one of the following drugs for use): (1) factor Xa inhibitor: indirect factor Xa inhibitor (sodium fondaparinux) 6 to 24 h after surgery (for patients with delayed epidural cavity catheter removal, it should be 2 to 4 h after removal) Application; oral direct factor Xa inhibitor (rivaroxaban): 6-10 h after surgery (for patients with delayed removal of the epidural lumen catheter, 6-10 h after extubation). (2) Low-molecular heparin: apply the regular dose from the time of hospitalization until 12 h before surgery and discontinue it 12 h after surgery (for patients with delayed removal of the epidural catheter, it should be applied 2-4 h after extubation). (3) Vitamin K antagonists: not recommended before epidural anesthesia surgery; postoperative use should be monitored with an international standardized ratio with a target of 2,5 and a range of 2,0 to 3,0. (4) Aspirin: the application of aspirin for thromboprophylaxis is controversial and aspirin alone is not recommended for prophylaxis; the recommended duration of drug prophylaxis is 10 to 35 d [18].
In patients undergoing subarachnoid anesthesia, preoperative use of sodium sulforaphane is not recommended because it can cause intravertebral hematoma. Heparin alone is not recommended for postoperative thromboprophylaxis (grade D). If the patient has a contraindication to anticoagulation, physical prophylaxis (foot pump, gradient compression compression stockings) should be used.
6. Analgesia.
Pre- and post-operative analgesia should be adequate and incorporated into care. the NICE guideline also mentions that patients should be given adequate analgesic drugs to facilitate various examinations, cooperate with nursing care and rehabilitation exercises. The NHMRC guideline mentions that a triad of nerve blocks (femoral nerve, lateral femoral cutaneous nerve, and closed foraminal nerve) can be used for preoperative analgesia (grade A) and postoperative analgesia (grade A) in patients with hip fractures [19,20].
7. prophylactic use of antibiotics.
Both the SIGN and NHMRC guidelines support the prophylactic use of antibiotics for all patients (grade A).Meta-analysis of the literature indicates that preoperative prophylactic antibiotics significantly reduce peri-incisional infections, superficial and deep infections, and also reduce urinary tract infections, but do not reduce morbidity and mortality [21].The NHMRC guidelines also mention that there is no evidence that prolonged antibiotic use is beneficial in preventing infection The SIGN guidelines for antibiotic use recommend that antibiotics be administered intravenously within 60 min before surgery (vancomycin should be administered within 90 min before surgery) [23]. For joint replacements, intraoperative combination of bone cement mixed with antibiotics is associated with lower rates of postoperative reoperation, aseptic loosening, and infection compared with intravenous antibiotics alone [24]. There is no domestic consensus in this regard, and we generally apply antibiotics intravenously 30 min before surgery and give them for 1 to 2 d after surgery.
8. nutritional support.
Both the NHMRC and AAOS guidelines recommend that all patients should be assessed for nutritional status and given the necessary nutritional support (level B), and the AAOS guidelines suggest that nutritional support for postoperative hip fracture patients can improve their nutritional status and reduce morbidity and mortality, and that poor nutrition significantly increases the incidence of postoperative wound infection and other complications [25]. Therefore, all patients should be evaluated for nutritional status, and the administration of protein and other energy nutrients, if necessary, can promote recovery, complication rates, and morbidity and mortality.
III. Surgical procedure
(I) Type of anesthesia
There is no evidence that there is a significant difference between the two types of anesthesia in terms of morbidity and mortality, and the AAOS guidelines point out that there is no significant difference between the two types of anesthesia applied to hip fracture surgery [6]. The literature reports a slightly lower incidence of postoperative delirium in patients undergoing subarachnoid anaesthesia than in patients undergoing general anaesthesia [26].The NHMRC guidelines state that patients should avoid general anaesthesia to reduce the incidence of postoperative delirium (Grade A), especially in the elderly, and general anaesthesia is not recommended as sputum is often increased or difficult to expel after general anaesthesia, requiring nebulised inhalation.The SIGN guidelines recommend the use of either arachnoid The SIGN guideline recommends the use of subarachnoid or epidural anesthesia, and the NICE guideline recommends the use of intraoperative nerve blocks as an adjunct to reduce the amount of opioids or other analgesic drugs and adverse effects.
Antiplatelet aggregation therapy with aspirin or clopidogrel alone does not cause intravertebral hematoma, but can cause intravertebral hematoma when combined with heparin or warfarin, therefore, subarachnoid or epidural anaesthesia should be avoided in patients with combined antiplatelet agents [27,28].
(ii) Surgical approach
According to the relationship between the fracture site and the joint capsule, hip fractures can be divided into intracapsular and extracapsular fractures, with intracapsular fractures including subtrochanteric head fractures and transcapsular fractures, and extracapsular fractures including basal femoral neck fractures, intertrochanteric fractures and subtrochanteric fractures. Regardless of the procedure, minimally invasive methods should be used as much as possible and the operative time should be shortened, especially for elderly patients, to reduce soft tissue injury, blood loss and surgical complications [29,30].
1. nondisplaced intracapsular fractures.
Surgical treatment with internal fixation (grade A) should be chosen, and surgical treatment allows patients to exercise early postoperatively and prevent fracture displacement. patients with incomplete femoral neck fractures or insertion fractures (Gardon type I) on radiographs in adults should also be treated with early internal fixation with hollow screws. Our study proved that adults without incomplete femoral neck fractures [31] and those with incomplete femoral neck fractures (Gardon type I) shown on X-ray were actually complete fractures without displacement and required internal fixation with hollow screws.
2. Displaced intracapsular fractures.
Displaced intracapsular fractures can be selected for joint replacement or internal fixation surgery (Grade A). Hemipelvic joint replacement (femoral head replacement) is a more invasive operation compared to internal fixation, but the postoperative prosthesis fixation failure rate and reoperation rate are low. The reoperation rates for internal fixation and hemiarthroplasty have been reported in the literature to be 17% to 36% and 5% to 18%, respectively [32,33,34,35], with higher reoperation rates in elderly patients and female patients [36,37,38]. Patients with good short-term (3-5 years) outcomes of hemiarthroplasty and longer life expectancy are more suitable for total hip replacement [36,39,40,41]. Therefore, fracture type, age, pre-injury function, pre-injury mental status, and bone and joint condition should be considered when deciding on surgical access or prosthesis selection [42]. We assign a score to the patient’s age, fracture type, bone density, daily mobility and medical complications, and the total score represents the overall assessment of the patient, according to which different surgical approaches are selected [43]. In general, young patients or patients with good functional status and physical condition should undergo internal fixation; elderly patients with reduced mobility and short life expectancy should opt for hemi-hip replacement. The current widely used clinical standard is that patients with displaced fractures within the joint capsule aged <70< span=""> years should first be treated with reduction internal fixation, and elderly patients aged ≥70 years should preferably be treated with arthroplasty to reduce complications [35]. Complications after internal fixation depend on the type of fracture, quality of repositioning and fixation [44,45], and patients with femoral neck fractures are often seen in clinical practice to have failed manual repositioning due to interposition of the fracture ends. We define this type of fracture as a “hard-to-replace femoral neck fracture”, which is a fracture of the femoral neck that cannot be optimally repositioned after three manipulations [46]. These fractures are traditionally treated by incisional internal fixation, but they are very traumatic, bleed a lot, and damage the blood supply to the femoral head.
The hemiarthroplasty prosthesis can be either single- or double-acting head type, and there is no evidence to suggest that either is better or worse [29,47,48]. Intraoperative complications may occur with cemented prostheses, but can be avoided with new techniques such as medullary lavage [48,49], and bioprosthetic stems may cause thigh pain and impair function [50,51,52,53].The SIGN guidelines recommend cemented prostheses for hemiarthroplasty, especially in elderly patients with osteoporosis, except for those with cardiopulmonary complications (Class C). Both the SIGN and AAOS guidelines recommend the anterior approach for hemiarthroplasty (Class C) because of the higher incidence of prosthesis dislocation or lower extremity deep vein thrombosis in the posterior approach, but the anterior approach has a longer operative time, more bleeding, and higher risk of infection [54,55,56,57], and the operator should choose the one he is more familiar with. The operator should choose the approach with which he or she is more familiar.
A Meta-analysis indicated that total hip replacement was more effective than hemiarthroplasty in patients aged 75 to 80 years with pre-injury hip fractures with good joint motion, mainly because hemiarthroplasty produces acetabular wear [58]. However, patients with combined dementia are not suitable for total hip replacement, and the rate of prosthesis dislocation is higher in this group of patients. Although total hip replacement takes longer to perform than hemiarthroplasty, the results are better. In addition, total hip replacement can be used as an alternative after failure of internal fixation [58]. the SIGN guidelines recommend that total hip replacement should be preferred for patients with previous joint disease, moderate to high mobility, or a certain life expectancy (Class A).
3. inter-rotor fractures (extra-articular capsule hip fractures).
Inter-rotor fractures should not be treated conservatively, and conservative treatment in elderly patients has high rates of disability and death [59]; surgical treatment can reduce the rates of disability and death, shorten the length of hospital stay, and help rehabilitation exercises [60].SIGN guidelines recommend that all inter-rotor fractures should be treated surgically, except for combined medical contraindications (grade B), and common contraindications include uncontrolled deep vein thrombosis in the affected limb, surgical Common contraindications include uncontrolled deep vein thrombosis in the affected limb, surgical or systemic infection, and severe organ insufficiency.
Surgical methods for the treatment of inter-rotor fractures include extramedullary fixation and intramedullary fixation, and the choice of surgical method remains controversial. For two-part inter-rotor fractures (type AO/OTA 31-A1), the reoperation rates for powered hip screws and intramedullary nailing are 2,4% and 4,2% at 1 year and 4,5% and 7,1% at 3 years postoperatively, respectively, but the intramedullary nails included in this study were all early-design intramedullary nails [61]. For stable inter-rotor fractures, powered hip screws can be used for fixation. Intramedullary nailing has the advantages of good biomechanical properties, minimally invasive implantation, and low complication rate and is suitable for all inter-rotor fractures (grade A), especially for reversal of intertrochanteric fractures, transverse fractures, and subtrochanteric fractures (grade A).
(iii) Incision management
NHMRC guidelines do not recommend routine placement of drains, and if they are placed, they should be removed as early as possible (usually 24 h postoperatively) (Grade A) [62,63]. Absorbable threads are used to close the incision, which has a lower incision complication rate than metal staple closure [64].
IV. Postoperative management
1. postoperative analgesia.
Adequate analgesia can effectively reduce the risk of various complications such as cardiovascular system, respiratory system, gastrointestinal system diseases and mental problems in patients, and it is also beneficial for early rehabilitation exercises and early discharge of patients.
2. Oxygenation.
Patients with hypoxemia need oxygen (level C), and SIGN guidelines recommend routine oxygenation for 6 to 24 h after surgery and continuous oxygenation for those with hypoxemia (level C).
3. Maintenance of water and electrolyte balance with strict volume management.
Possible water and electrolyte disturbances should be monitored and corrected promptly, especially for elderly patients (Grade B). It is important to ensure perfusion of vital organs while avoiding heart failure caused by excessive rehydration. This kind of medically induced heart failure is not uncommon in clinical practice, therefore, attention should be paid to total volume control and speed control when rehydrating.
4. Postoperative blood transfusion.
Both SIGN and AAOS guidelines point out that patients with hemoglobin ≥ 80 g/L and no anemia symptoms can be excluded from blood transfusion (grade B). There is no evidence-based medical evidence in this regard in China, but in clinical practice we take hemoglobin 90 g/L as the threshold value. It should be noted that such patients should be transfused in small amounts several times to avoid heart failure and pulmonary edema caused by too much blood transfusion at one time, and fresh whole blood can be transfused to increase resistance if available.
5. Urinary catheterization.
Avoid long-term indwelling catheterization, and it is recommended to remove the catheter as early as possible after surgery, otherwise it will increase the risk of urinary tract infection [5] (Grade B).
6. nutritional status.
All patients should be assessed for nutritional status and given energy supplementation if necessary (level B) [65,66,67]. Application of protein and other energy nutrition solutions can improve the general condition of patients, and enteral nutrition should be applied as much as possible to promote recovery, reduce complications, and decrease the morbidity and mortality rate [68].
7. reduction of postoperative delirium.
The SIGN guidelines state that for patients with postoperative delirium attention needs to be paid to their oxygen saturation, blood pressure, and nutritional status, and that early exercise and management of various complications will reduce the occurrence of postoperative delirium (grade B.) The NHMRC guidelines state that prophylactic application of low-dose haloperidol can reduce the severity of delirium episodes and shorten the duration of episodes and hospitalization days [69].
V. Postoperative rehabilitation
The SIGN guidelines define the goal of rehabilitation as returning to the patient’s pre-injury level of activity as soon as possible. Rehabilitation exercises should be started within 6 h postoperatively, as soon as the patient’s general status allows, for rapid recovery, with the help of a multidisciplinary rehabilitation team. Early rehabilitation exercises can reduce the occurrence of pressure sores or deep vein thrombosis [70,71]. Walker assistance accelerates postoperative recovery and shortens the length of hospital stay (Level B). Aerobic training of the upper extremity can be added to the patient’s rehabilitation program to increase adaptation and utilization of oxygen (Level B), and patients should be discharged home with weight-bearing exercises to enhance balance (Level B). Physician-directed out-of-hospital rehabilitation exercises are more helpful in improving physical function and quality of life.