Improved outcome after hip fracture surgery in Norway

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Abstract

Background and purpose

The operative treatment of hip fractures in Norway has changed considerably during the last decade. We used data in the Norwegian Hip Fracture Register to investigate possible effects of these changes on reoperations and 1-year mortality.

Patients and methods

72,741 femoral neck (FFN) fractures and trochanteric fractures in patients 60 years or older were analyzed. The fractures were divided into 5 time periods (2005–2006, 2007–2008, 2009–2010, 2011–2012, 2013–2014). Cox regression models were used to calculate unadjusted and adjusted (age group, sex, and ASA class) relative risks (RRs) of reoperation and of 1-year mortality in the different time periods.

Results

For undisplaced FFNs treatment with hemiarthroplasty increased from 2.1% to 9.7% during the study period. For displaced FFNs treatment with arthroplasty increased from 56% to 93%. The use of intramedullary nails increased from 9.1% to 26% for stable 2-fragment (AO/OTA A1) trochanteric fractures, from 15% to 33% for multifragment (AO/OTA A2) trochanteric fractures, and from 27% to 61% for intertrochanteric fractures (AO/OTA A3)/subtrochanteric fractures. Compared with the first time period the adjusted 1-year RR for reoperation was 0.43 (95% CI: 0.37–0.49) for displaced FFNs in the last time period. The adjusted 1-year mortality in the last time period was lower for all fractures (RR: 0.87 (0.83–0.91)), displaced FFNs (RR: 0.86 (0.80–0.93)), AO/OTA A1 trochanteric fractures (RR: 0.79 (0.71–0.88)), and AO/OTA A2 trochanteric fractures (RR: 0.87 (0.77–0.98)) when compared with the first study period.

Interpretation

Hip fracture treatment in Norway has improved: The risk of reoperation and the 1-year mortality after displaced femoral neck fractures have decreased over a 10-year period. National registration is useful to monitor trends in treatment and outcomes after hip fractures.

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Most cited references 17

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Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database.

, John N Weinstein, J Anglen (2008)

A new method of fixation for intertrochanteric hip fractures that involves the use of an intramedullary nail that interlocks proximally into the femoral head was introduced in the early 1990s. Anecdotal observation of practice patterns during the Part II (oral) American Board of Orthopaedic Surgery examination suggested that the use of this method had increased substantially in recent years in comparison with the more traditional sliding compression screw technique. A study of the Part II database was undertaken to detect changing patterns of care for intertrochanteric fractures. During the process of Board certification, candidates for the Part II (oral) examination submit a six-month surgical case list and patient data into a secure database. The database was searched for all intertrochanteric fractures (International Classification of Diseases, Ninth Revision, code 820.20 or 820.21) over a seven-year period (1999 through 2006). The cases were categorized by intramedullary nail or plate fixation on the basis of surgeon-reported Current Procedural Terminology codes. Relative utilization of the two devices was analyzed according to year and region, and the devices were compared in terms of complications and outcomes. A dramatic change in practice was demonstrated, with the intramedullary nail fixation rate increasing from 3% in 1999 to 67% in 2006. Regional variation was substantial. The highest rate of utilization of intramedullary nail fixation was recorded by candidates from the South, Southeast, and Southwest, who converted to the new technology faster than those in the Northeast, Northwest, and Midwest. Overall, patients managed with plate fixation had slightly less pain and deformity in comparison with those managed with intramedullary nailing, with no significant differences being identified in terms of function or satisfaction. Patients managed with intramedullary nailing had more procedure-related complications, particularly bone fracture. From 1999 to 2006, a dramatic change in surgeon preference for the fixation device used for the treatment of intertrochanteric fractures has occurred among young orthopaedic surgeons. This change has occurred despite a lack of evidence in the literature supporting the change and in the face of the potential for more complications.

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The effect of a pre- and postoperative orthogeriatric service on cognitive function in patients with hip fracture: randomized controlled trial (Oslo Orthogeriatric Trial)

Leiv Otto Watne, Anne Cathrine Torbergsen, Simon Conroy … (2014)

Background Delirium is a common complication in patients with hip fractures and is associated with an increased risk of subsequent dementia. The aim of this trial was to evaluate the effect of a pre- and postoperative orthogeriatric service on the prevention of delirium and longer-term cognitive decline. Methods This was a single-center, prospective, randomized controlled trial in which patients with hip fracture were randomized to treatment in an acute geriatric ward or standard orthopedic ward. Inclusion and randomization took place in the Emergency Department at Oslo University hospital. The key intervention in the acute geriatric ward was Comprehensive Geriatric Assessment including daily interdisciplinary meetings. Primary outcome was cognitive function four months after surgery measured using a composite outcome incorporating the Clinical Dementia Rating Scale (CDR) and the 10 words learning and recalls tasks from the Consortium to Establish a Registry for Alzheimer’s Disease battery (CERAD). Secondary outcomes were pre- and postoperative delirium, delirium severity and duration, mortality and mobility (measured by the Short Physical Performance Battery (SPPB)). Patients were assessed four and twelve months after surgery by evaluators blind to allocation. Results A total of 329 patients were included. There was no significant difference in cognitive function four months after surgery between patients treated in the acute geriatric and the orthopedic wards (mean 54.7 versus 52.9, 95% confidence interval for the difference -5.9 to 9.5; P = 0.65). There was also no significant difference in delirium rates (49% versus 53%, P = 0.51) or four month mortality (17% versus 15%, P = 0.50) between the intervention and the control group. In a pre-planned sub-group analysis, participants living in their own home at baseline who were randomized to orthogeriatric care had better mobility four months after surgery compared with patients randomized to the orthopedic ward, measured with SPPB (median 6 versus 4, 95% confidence interval for the median difference 0 to 2; P = 0.04). Conclusions Pre- and postoperative orthogeriatric care given in an acute geriatric ward was not effective in reducing delirium or long-term cognitive impairment in patients with hip fracture. The intervention had, however, a positive effect on mobility in patients not admitted from nursing homes. Trial registration ClinicalTrials.gov NCT01009268 Registered November 5, 2009

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Hemiarthroplasty or internal fixation for intracapsular displaced femoral neck fractures: randomised controlled trial.

Jan Erik Madsen, Frede Frihagen, Lars Nordsletten (2007)

To compare the functional results after displaced fractures of the femoral neck treated with internal fixation or hemiarthroplasty. Randomised trial with blinding of assessments of functional results. University hospital. 222 patients; 165 (74%) women, mean age 83 years. Inclusion criteria were age above 60, ability to walk before the fracture, and no major hip pathology, regardless of cognitive function. Closed reduction and two parallel screws (112 patients) and bipolar cemented hemiarthroplasty (110 patients). Follow-up at 4, 12, and 24 months. Hip function (Harris hip score), health related quality of life (Eq-5d), activities of daily living (Barthel index). In all cases high scores indicate better function. Mean Harris hip score in the hemiarthroplasty group was 8.2 points higher (95% confidence interval 2.8 to 13.5 points, P=0.003) at four months and 6.7 points (1.5 to 11.9 points, P=0.01) higher at 12 months. Mean Eq-5d index score at 24 months was 0.13 higher in the hemiarthroplasty group (0.01 to 0.25, P=0.03). The Eq-5d visual analogue scale was 8.7 points higher in the hemiarthroplasty group after 4 months (1.9 to 15.6, P=0.01). After 12 and 24 months the percentage scoring 95 or 100 on the Barthel index was higher in the hemiarthroplasty group (relative risk 0.67, 0.47 to 0.95, P=0.02. and 0.63, 0.42 to 0.94, P=0.02, respectively). Complications occurred in 56 (50%) patients in the internal fixation group and 16 (15%) in the hemiarthroplasty group (3.44, 2.11 to 5.60, P<0.001). In each group 39 patients (35%) died within 24 months (0.98, 0.69 to 1.40, P=0.92) Hemiarthroplasty is associated with better functional outcome than internal fixation in treatment of displaced fractures of the femoral neck in elderly patients. NCT00464230.

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Author and article information

Journal

Journal ID (nlm-ta): Acta Orthop

Journal ID (iso-abbrev): Acta Orthop

Journal ID (publisher-id): IORT

Title: Acta Orthopaedica

Publisher: Taylor & Francis

ISSN (Print): 1745-3674

ISSN (Electronic): 1745-3682

Publication date (Print): October 2017

Publication date (Electronic): 06 July 2017

Volume: 88

Issue: 5

Pages: 505-511

Affiliations

[1 ]Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen;

[2 ]Department of Clinical Medicine (K1), Faculty of Medicine and Dentistry, University of Bergen, Bergen, Norway

Author notes

Correspondence: jan-erik.gjertsen@ 123456helse-bergen.no

Article

Publisher ID: iort-88-505

DOI: 10.1080/17453674.2017.1344456

PMC ID: 5560213

PubMed ID: 28681677

SO-VID: 01c53756-a0e9-4f06-8026-73c72bdc36ec

License:

This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non-Commercial License ( https://creativecommons.org/licenses/by-nc/3.0)

Improved outcome after hip fracture surgery in Norway : 10-year results from the Norwegian Hip Fracture Register

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Abstract

Background and purpose

Patients and methods

Results

Interpretation

Related collections

Orthopedics

Most cited references 17

Nail or plate fixation of intertrochanteric hip fractures: changing pattern of practice. A review of the American Board of Orthopaedic Surgery Database.

The effect of a pre- and postoperative orthogeriatric service on cognitive function in patients with hip fracture: randomized controlled trial (Oslo Orthogeriatric Trial)

Hemiarthroplasty or internal fixation for intracapsular displaced femoral neck fractures: randomised controlled trial.

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