Hip fracture management - plenty of guidelines, not enough evidence

A coordinated treatment plan for hip fracture comprises acute assessment of the fracture and co-morbidities, pain relief, early surgery, prevention of complications, rehabilitation, discharge planning and also secondary prevention to reduce the risk of further falls and manage osteoporosis. The difficulty is making all of this happen in a timely and seamless way.

That's where guidelines, pathways and standards come in.  In England, much has been achieved by the 'Blue Book' on fragility fracture care published jointly by the BGS and the British Orthopaedic Association in 2007, and by the National Hip Fracture Database and the associated tariff, which denies full funding for hip fracture care unless certain standards are achieved.  

Alongside all of this, NICE updated both its 2011 Clinical Guideline (CG124) and the associated 2012 Quality Standard (QS16), in 2017. The most difficult and controversial new recommendation relates to surgery - instead of using the time-honoured cemented hemiarthroplasty for intracapsular fractures, it is now required that patients "who were able to walk independently out of doors with no more than the use of a stick and are not cognitively impaired and are medically fit for anaesthesia and the procedure" should have a total hip replacement.  There is evidence that this gives better long-term outcomes, but at the expense of a bigger and longer operation which is not in the repertoire of every trauma surgeon. So getting the surgery done by a specialist hip surgeon without delay (the tariff requires surgery within 36 hours) presents a major challenge for a fairly small and distant advantage.  

Contrast this with stroke management.  For the ortho-geriatrician, Graeme Hankey's review in the Lancet last year made for sobering reading. Statement after statement was evidenced by studies performed in stroke patients: research covering not just the stroke itself, but related aspects of management such as thromboprophylaxis and nutrition. Where similar studies have been attempted in hip fracture patients, the results have seldom been robust and consistent, and we are left extrapolating from evidence in other patient groups.

NICE recognises this, and includes five recommendations for research in CG124: comparison of CT and MRI for occult fractures, regional versus general anaesthesia, management of undisplaced intracapsular fractures, intensity and frequency of physiotherapy, and early supported discharge with rehabilitation for patients already in care homes.  

To this we might add more generic aspects of care that may still be particular to the hip fracture population:  

•  Thrombo-embolic prevention stockings do more harm than good in stroke patients, yet we still half-heartedly persevere with their use in hip fracture.  
•  Anaemia, both pre-and post-operatively, is a common problem: what are the optimum transfusion threshold and target?  Might iron infusions reduce post-operative anaemia?   
•  Malnutrition is common - might early tube feeding or the oral carbohydrate pre-loading used in 'enhanced recovery' programmes for other types of surgery be of benefit? 
•  Secondary prevention - how best to prevent falls and to manage osteoporosis after a hip fracture.  

Most importantly, we need to know whether our interventions affect outcomes that matter to patients themselves such as mortality, ambulatory function and pain, length of time spent in care, readmission or destination of discharge.  The stroke world has led the way - we now need to get the same level of evidence for all aspects of management of the hip fracture patient.  

The article reviewing the 2017 updates to the NICE quality standard and guideline for hip fracture was published in the Age and Ageing journal 

Roger Jay
Consultant Geriatrician, Newcastle upon Tyne Hospitals NHS Foundation Trust
Daniel Hipps
Research Fellow and Orthopaedic Registrar