I. From pre-hospital care to emergency room management.
The SIGN guidelines set out detailed pre-hospital management specifications: for patients with a history of hip injury, hip pain and shortened or rotated deformity of the affected limb, hip fracture should be highly suspected 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 the 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 scene. Therefore, the goal of hospitalization within 2 hours 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: SIGN guidelines suggest early surgery, NICE and NHMRC guidelines recommend surgery within 36 h, and AAOS guidelines recommend within 48 h. In conclusion, if the patient’s medical condition allows, surgery should be performed as early as possible (on the day of admission or day 2). 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, and the complications mainly include 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. 1 Meta-analysis reported that patients operated after 48 h had a 41% and 32% increase in morbidity and mortality at 30 d and 1 year after surgery, respectively, compared with patients operated within 48 h.
The incidence of postoperative complications was higher in patients with more preoperative medical complications. 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, arrhythmias, etc., the operation can be postponed as appropriate, and the general condition of the patient can be improved through treatments such as blood volume supplementation to correct anemia, blood pressure control, correction of coagulation dysfunction and electrolyte disorders, blood sugar regulation, and control of heart failure, in order 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: NHMRC, SIGN and AAOS guidelines do not recommend the routine application of preoperative skin traction or bone traction (grade A), and several papers point out that preoperative traction cannot reduce pain or reduce the amount of anesthetic drugs, and can cause pain at the traction. At present, 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. Pre-operative pressure sore prevention: All patients should in principle use anti-pressure sore pads (grade A), but most primary hospitals lack the relevant facilities, so doctors should try to apply anti-pressure sore pads and provide standardized anti-pressure sore care according to the actual situation.
4. Oxygen: All patients should be assessed for oxygen status from admission to 48 h postoperatively and given oxygen if necessary (Class B). the NHMRC guidelines recommend that oxygen should be administered for 12 h postoperatively regardless of oxygen status, and that oxygen should be continued after 12 h depending on oxygen status.
5. Prevention of deep vein thrombosis: The risk of thrombosis is high after hip fracture surgery. SIGN guideline recommends the application of sodium fondaparinux 6 h after hip fracture to prevent deep vein thrombosis (grade A) for 28 d, except for contraindications. Our 2012 Expert Consensus on Prevention of Perioperative Venous Thromboembolism in Chinese Orthopaedic Trauma Patients formulated specific protocols 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 sulfadodeca) should be applied 6 to 24 h after surgery (for patients with delayed removal of the epidural cavity catheter, it should be applied 2 to 4 h after removal of the catheter ); oral direct factor Xa inhibitor (rivaroxaban): 6 to 10 h after surgery (for patients with delayed epidural catheter removal, 6 to 10 h after extubation). (2) Low-molecular heparin: apply the regular dose from the time of hospitalization until 12 h before surgery and continue after 12 h postoperatively (for patients with delayed removal of the epidural cavity catheter, it should be applied 2-4 h after extubation). (3) Vitamin K antagonists: not recommended prior to 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.
In patients with subarachnoid anesthesia, the preoperative use of sodium sulforaphane is not recommended because it can cause intracanalicular hematoma. Heparin alone is not recommended for postoperative thromboprophylaxis (grade D). If the patient has contraindications to anticoagulation, physical prophylaxis (foot pump, gradient compression compression compression stockings) should be used.
6. analgesia: preoperative and postoperative analgesia should be adequate and incorporated into nursing 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. .
Preventive antibiotics: Both the SIGN and NHMRC guidelines support the prophylactic use of antibiotics for all patients (Grade A). The SIGN guidelines for antibiotic use recommend that antibiotics be administered intravenously within 60 min prior to surgery (vancomycin should be administered within 90 min prior to surgery). For joint replacements, the combination of intraoperative bone cement mixed with antibiotics is associated with lower rates of postoperative reoperation, aseptic loosening, and infection compared to intravenous antibiotics alone. There is no domestic consensus in this regard, and we generally apply antibiotics intravenously 30 min before surgery and give 1 to 2 d after surgery.
8. Nutritional support: NHMRC and AAOS guidelines both recommend that all patients should be assessed for nutritional status and given the necessary nutritional support (level B). AAOS guidelines suggest that nutritional support for postoperative hip fracture patients can improve the nutritional status of patients and reduce the morbidity and mortality rate, while poor nutrition can significantly increase the incidence of postoperative wound infection and other complications. Therefore, all patients should be evaluated for nutritional status and given protein and other energy nutrient solutions if necessary to promote recovery, complication rate and morbidity and mortality.
III. Surgical procedures.
(I) Type of anesthesia.
Anesthesia for hip fracture surgery includes subarachnoid anesthesia and general anesthesia. There is no evidence that there is a significant difference between the two types of anesthesia in terms of morbidity and mortality, and AAOS guidelines point out that there is no significant difference in the effect of the two types of anesthesia applied to hip fracture surgery. The NHMRC guidelines state that patients should avoid general anaesthesia to reduce the incidence of postoperative delirium (Grade A), especially in the elderly, and that general anaesthesia is not recommended because general anaesthesia is often followed by increased sputum or difficulty in expelling sputum, requiring nebulised inhalation. The SIGN guideline recommends the use of subarachnoid or epidural anaesthesia, 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.
(ii) Surgical approach.
According to the relationship between the fracture site and the joint capsule, hip fractures can be divided into intracapsular fractures and extracapsular fractures. Intracapsular fractures include subtrochanteric fractures and transcapsular fractures, and extracapsular fractures include basal fractures of the femoral neck, intertrochanteric fractures and subtrochanteric fractures. Regardless of the type of surgery, minimally invasive methods should be used as much as possible and the operation time should be shortened, especially for elderly patients, to reduce soft tissue injury, blood loss and surgical complications.
1. intracapsular fractures without displacement: surgical treatment with internal fixation (grade A) should be chosen. surgical treatment allows patients to exercise early postoperatively and prevent fracture displacement. patients with incomplete femoral neck fractures or insertional fractures (Gardon type I) on X-ray in adults should also be treated early with internal fixation with hollow screws. Our study proves that adults without incomplete fractures of the femoral neck and those with incomplete fractures of the femoral neck (Gardon type I) on X-ray are actually complete fractures without displacement and require internal fixation with hollow screws.
2.Displaced intracapsular fracture: Displaced intracapsular fracture can be selected for joint replacement or internal fixation surgery (Grade A). The hemi-acetabular joint replacement (femoral head replacement) is more invasive than 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, with higher reoperation rates in elderly patients and female patients. The short-term (3-5 years) outcome of hemi hip replacement is good, and patients with longer life expectancy are more suitable for total hip replacement. Therefore, fracture type, age, pre-injury function, pre-injury mental status, and bone and joint condition should be taken into consideration when deciding on surgical access or prosthesis selection. We assign a score to the patient’s age, fracture type, bone density, ability to perform daily activities, and medical complications, and use the total score to represent the overall assessment of the patient, according to which different surgical approaches are selected. 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 aged <70 years with displaced fractures within the joint capsule should be treated first with internal fixation, and elderly patients aged ≥70 years should preferably be treated with arthroplasty to reduce complications. Complications after internal fixation depend on the type of fracture, quality of repositioning and fixation method. We define this type of fracture as a "hard-to-replace femoral neck fracture", i.e., a femoral neck fracture that cannot be optimally repositioned after three manipulations. Traditionally, these fractures are treated by incisional internal fixation, but it is very traumatic, bleeding and easy to 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 that either is better or worse. The SIGN guidelines recommend the use of cemented prostheses for hemiarthroplasty, especially in elderly patients with osteoporosis, with the exception of those with cardiopulmonary complications (Class C). Both the SIGN and AAOS guidelines recommend the anterior approach for hemiarthroplasty (Class C) because the incidence of dislocation of the prosthesis or deep vein thrombosis in the lower extremity is higher with the posterior approach, but the anterior approach has a longer operative time, more bleeding, and a higher risk of infection, and the operator should choose the approach with which he is more familiar.
A Meta-analysis pointed out 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. However, patients with comorbid 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 hemi hip replacement, the results are better. The SIGN guidelines suggest that total hip replacement should be preferred for patients with previous joint disease, moderate to high mobility, or a certain life expectancy (Class A).
The SIGN guidelines recommend that all inter-rotor fractures should be treated surgically, except for combined medical contraindications (Class B). Common contraindications include uncontrolled deep vein thrombosis, surgical site or systemic infection, and severe organ insufficiency.
Surgical methods for treating intertrochanteric fractures include extramedullary and intramedullary fixation, and the choice of surgical method remains controversial. For two-part inter-rotor fractures (AO/OTA 31-A1 type), 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. For stable inter-rotor fractures, powered hip screw fixation can be used. Intramedullary nailing has the advantages of good biomechanical properties, minimally invasive implantation and a 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). Absorbable thread should be used to close the incision, which has a lower incision complication rate than metal staple closure.
IV. Postoperative treatment.
1.Postoperative analgesia: adequate analgesia can effectively reduce the risk of various complications such as cardiovascular system, respiratory system, digestive system diseases and psychiatric problems in patients, and is also beneficial to early rehabilitation exercises and early discharge of patients.
2.Oxygenation: Patients with hypoxemia need oxygen (level C). SIGN guidelines recommend routine oxygenation for 6 to 24 h after surgery and continuous oxygenation for those with hypoxemia (level C).
3. Maintain 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: SIGN and AAOS guidelines both point out that patients with hemoglobin ≥ 80 g/L and no anemia symptoms may not be transfused (level 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 a few 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. Catheterization: Avoid long-term indwelling catheters, and it is recommended to remove catheters as early as possible after surgery, otherwise it will increase the risk of urinary tract infection (Grade B).
6. Nutritional status: All patients should be assessed for nutritional status and given energy supplements if necessary (level B). 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.
7. Reduce postoperative delirium: SIGN guidelines point out that patients with postoperative delirium need to pay attention to their oxygen saturation, blood pressure and nutritional status, and early exercise and management of various complications will reduce the occurrence of postoperative delirium (level B). NHMRC guidelines point out that the prophylactic application of low-dose haloperidol can reduce the severity of delirium attacks and shorten the duration of attacks and hospitalization days.
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 condition allows, for rapid recovery, with the assistance of a multidisciplinary rehabilitation team. Early rehabilitation exercises can reduce the occurrence of pressure sores or deep vein thrombosis. Walker assistance can speed up postoperative recovery and shorten hospital stay (Level B). Aerobic training of the upper extremities 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.