Hip fracture: management

Why this is important

The Guideline Development Group's consensus decision to recommend CT over a radionuclide bone scan as an alternative to MRI to detect occult hip fractures reflects current NHS practice but assumes that advances in technology have made the reliability of CT comparable with that of MRI. If modern CT can be shown to have similar reliability and accuracy to MRI, then this has considerable implications because of its widespread availability out of hours and lower cost. It is therefore a high priority to confirm or refute this assumption by direct randomised comparison. The study design would need to retain MRI as the 'gold standard' for cases of uncertainty and to standardise the criteria, expertise and procedures for radiological assessment. Numbers required would depend on the degree of sensitivity and specificity (the key outcome criteria) set as target requirement for comparability, but need not necessarily be very large. [2011]

Why this is important

No recent randomised controlled trials were identified that fully address this question. The evidence is old and does not reflect current practice. In addition, in most of the studies the patients are sedated before regional anaesthesia is administered, and this is not taken into account when analysing the results. The study design for the proposed research would be best addressed by a randomised controlled trial. This would ideally be a multicentre trial including 3,000 participants in each arm. This is achievable given that there are about 70,000 to 75,000 hip fractures a year in the UK. The study should have 3 arms that look at spinal anaesthesia versus spinal anaesthesia plus sedation versus general anaesthesia; this would separate those with regional anaesthesia from those with regional anaesthesia plus sedation. The study would also need to control for surgery, especially type of fracture, prosthesis and grade of surgeon.

A qualitative research component would also be helpful to study patient preference for type of anaesthesia. [2011]

Why this is important

Between 5% and 15% of people with an intracapsular hip fracture will have an undisplaced fracture. There is variation in the UK in how undisplaced intracapsular hip fractures are recognised, resulting in some people not being offered the most appropriate treatment. Research is needed to help healthcare professionals understand the clinical characteristics of people who have undisplaced hip fracture (on anterior-posterior and lateral X‑rays) and how this relates to the effectiveness of different treatment strategies.

The committee also noted a paucity of evidence for 2 of the interventions (total hip replacement and hemiarthroplasty) that could potentially be useful for people with undisplaced intracapsular hip fracture. A randomised controlled trial comparing these interventions would be beneficial. [2017]

Why this is important

The rapid restoration of physical and self-care functions is critical to recovery from hip fracture, particularly where the goal is to return the person to preoperative levels of function and residence. Approaches that are worthy of future development and investigation include progressive resistance training, progressive balance and gait training, supported treadmill gait re‑training, dual task training and activities of daily living training. The optimal time point at which these interventions should be started requires clarification.

The ideal study design is a randomised controlled trial. Initial studies may have to focus on proof of concept and be mindful of costs. A phase 3 randomised controlled trial is required to determine clinical effectiveness and cost effectiveness. The ideal sample size will be around 400 to 500 patients, and the primary outcome should be physical function and health-related quality of life. Outcomes should also include falls. A formal sample size calculation will need to be undertaken. Outcomes should be followed over a minimum of 1 year, and compare if possible, either the recovery curve for restoration of function or time to attainment of functional goals. [2011]

Why this is important

Residents of care and nursing homes account for about 30% of all people with hip fracture admitted to hospital. Two-thirds of these come from care homes and the remainder from nursing homes. These people are frailer, more functionally dependent and have a higher prevalence of cognitive impairment than people admitted from their own homes. One-third of those admitted from a care home are discharged to a nursing home and one-fifth are readmitted to hospital within 3 months. There are no clinical trials to define the optimal rehabilitation pathway following hip fracture for these people and therefore represent a discrete cohort where the existing meta-analyses do not apply. As a consequence, many people are denied structured rehabilitation and are discharged back to their care home or nursing home with very little or no rehabilitation input.

Given the patient frailty and comorbidities, rehabilitation may have no effect on clinical outcomes for this group. However, the fact that they already live in a home where they are supported by trained care staff clearly provides an opportunity for a systematic approach to rehabilitation. Early multidisciplinary rehabilitation based in care homes or nursing homes would take advantage of the day-to-day care arrangements already in place and provide additional NHS support to deliver naturalistic rehabilitation, where problems are tackled in the person's residential setting.

Early supported multidisciplinary rehabilitation could reduce hospital stay, improve early return to function, and affect both readmission rates and the level of NHS‑funded nursing care required.

The research would follow a 2‑stage design: (1) an initial feasibility study to refine the selection criteria and process for reliable identification and characterisation of those considered most likely to benefit, together with the intervention package and measures for collaboration between the Hip Fracture Programme team, care-home staff and other community-based professionals and (2) a cluster randomised controlled comparison (for example, with 2 or more intervention units and matched control units) set against agreed outcome criteria. The latter should include those specified above, together with measures of the impact on care-home staff activity and cost, as well as qualitative data from patients on relevant quality-of-life variables. [2011]