108MEDICINE & HEALTH/RHODE ISLAND

Approximately 325,000 people will havea hip fracture each year in the UnitedStates.1 In elderly patients, they result in aone-year mortality rate of 18-33% and in-hospital mortality of 2.7%.1 Hip fracturesare more common in patients with pre-existing cardiac disease, chronic renal fail-ure, diabetes mellitus, stroke, malignancy,and chronic obstructive pulmonary dis-ease,2 which also are major factors in the recovery process. Many patients experi-ence a significant functional decline andinability to perform activities of daily liv-ing (ADLs).1 Therefore, rehabilitation isa vital component of the patient’s recov-ery in order to regain the previous func-tional level, whether as an independentcommunity ambulatory or a full-assistnursing home resident. Only 14% of hipfracture patients return home after theirhospital course;1 the rest require some levelof inpatient rehabilitation.

The population of individuals olderthan age 65 is expected to grow from 35million to 77 million between 2000 and2040.3 Although hip fracture rates aredeclining in this age group—due tobisphosphonates, calcium and Vitamin Dintake, weight-bearing exercises, and bet-ter prevention of falls4—the annual num-ber of hip fractures will undoubtedly risebased upon changing demographics.

CLINICAL PRESENTATION/WORK-UP

Hip fracture patients are typicallyolder than age 65, with a mean age of85.1 They usually present after a fall with

Hip Fracture Surgical Treatment andRehabilitation

Craig Lareau, MD, and Gregory Sawyer, MD

�complaints of pain on the affected sideand an inability to ambulate. The af-fected limb is often shortened and exter-nally rotated due to the muscular forceson the fracture fragments. Radiographsconfirm the diagnosis, with standardviews including an AP Pelvis and AP andlateral of the affected hip. Rarely is a CTor MRI needed to make the diagnosis. MRI can identify occult fractures in thepatient with persistent pain and inabilityto ambulate with normal radiographs.5

Once the diagnosis has been established,a discussion with the patient, family, andorthopedic surgeon should take place todetermine the course of action. Cur-rently, the vast majority of hip fracturesare treated operatively with surgical tech-niques depending upon the fracture pat-tern. Rarely, in an elderly patient with

multiple serious medical co-morbidities,non-operative treatment may provide thebest outcome.

NON-OPERATIVE MANAGEMENTAND REHABILITATION

Non-operative treatment involves ei-ther early mobilization or a period of bedrest and/or traction followed by progres-sive weight-bearing. This is usually re-served for two subsets of patients. First,for patients with severe co-morbidities, therisks of the procedure and anesthesia out-weigh the benefits. Second, for patientswho are non-ambulatory or bedridden atbaseline, fracture fixation will not improvetheir ambulatory status. Nevertheless,some centers prefer to operate on thispopulation for improved pain control. Because about 90% of hip fractures are

Christine Lourenco, SPT, is a studentin the physical therapy program at North-eastern University.

Jon Mukand, MD, PhD, is MedicalDirector, Southern New England Rehabili-tation Center, and Clinical Assistant Pro-fessor, Rehabilitation Medicine, The War-ren Alpert Medical School of Brown Uni-versity, Boston University Medical School,and Tufts University Medical School.

Disclosure of FinancialInterests

Patricia I. Wolfe, PT, MS,, andChristine Lourenco, SPT, and theirspouses/significant others have no finan-cial interests to disclose.

Jon Mukand. Speakers’ Bureau:GlaxoSmithKline.

CORRESPONDENCEPatricia I. Wolfe, PT, MSRhode Island Hospital593 Eddy St.Providence, RI 02903Phone: (401) 444-8613e-mail:Pwolfe1@lifespan.org

Figure 1. Figure 2.

109VOLUME 93 NO. 4 APRIL 2010

managed operatively,6 the literature re-garding the success of non-operative man-agement is limited. In a recent study,mortality was 2.5 times higher with bedrest compared to operative treatment.6

Since the non-operative cohort tends tohave a higher morbidity, an accurate com-parison is difficult; it is unclear whetherthe difference in mortality is due to pa-tient factors or choice of treatment. Mor-tality with non-operative treatment ishigher with bed rest, compared to earlymobilization, because of an increased in-cidence of complications such as venousthromboembolism. Interestingly, thisstudy showed no significant difference inmortality between patients treated withsurgery and those managed non-opera-tively, but with early mobilization.6

OPERATIVE MANAGEMENT ANDREHABILITATIONFemoral Neck Fractures

Approximately 50% of all hip frac-tures are at the femoral neck, typicallydue to a direct fall onto the greater tro-chanter.7 These fractures are classifiedbased on the degree of displacement (Fig-

ure 3), and this impacts the type of sur-gical fixation. The three major types ofsurgical fixation for this fracture patternare in situ fixation, hemi-arthroplasty, andtotal arthroplasty.

a) In Situ Fixation This technique is chosen for im-

pacted, minimally displaced fractures.The surgical technique consists of theplacement of three large cannulatedscrews across the fracture site into thefemoral head. (Figure 2) Weight-bear-ing status after this procedure is surgeon-dependent. Classically, patients were in-structed to be touch-down weight bear-ing with a walker for approximately 8-12 weeks. However, many older patientsare unable to comply with this and areallowed weight-bearing as tolerated witha walker.8 Rehabilitation should focus ongait training and strengthening, withoutrequiring any precautions.

b) Hemi-arthroplastyThis technique consists of surgical

replacement of the proximal femur (Fig-ure 4) and is chosen for displaced femo-

ral neck fractures in relatively low de-mand patients. The most common sur-gical approaches for a hemi-arthroplastyare lateral and posterior. The lateral ap-proach involves splitting the hip abduc-tors and precautions include no activeabduction against resistance, no adduc-tion past neutral, no external rotation andno extension. The posterior approachinvolves releasing the short external rota-tors of the hip and then repairing thesemuscles. Posterior precautions consist ofno hip flexion >90 degrees, no adduc-tion past neutral, and no internal rota-tion beyond neutral.9 Post-operatively,regardless of the surgical approach used,patients can bear weight as tolerated onthis stable prosthesis. The overall dislo-cation rate is approximately 3%, with anincreased risk with the posterior ap-proach.10 There was no significant dif-ference in the dislocation rate betweenunipolar and bipolar hemi-arthoplasties.10 Rehabilitation needs tofollow the set precautions to avoid dislo-cating while performing strengthening,gait training, range of motion exercisesand ADLs.

Figure 3. Figure 4.

110MEDICINE & HEALTH/RHODE ISLAND

c) Total Hip ArthroplastyThis technique is primarily used for

the elective replacement of hip joints af-fected by degenerative joint disease. However, it also plays a role in femoralneck fractures in active elderly patientswith pre-existing hip arthritis. The ap-proaches used are the same as previouslydescribed, with the same precautions. Classically, it was thought that total hiparthroplasty was associated with higherdislocation rates than hemi-arthroplasty,but recent studies have shown no signifi-cant difference.11, 12

INTERTROCHANTERIC HIPFRACTURES

This pattern makes up the other50% of hip fractures in the elderly popu-lation.7 The fracture line runs betweenthe greater and lesser trochanter (Figure5), a well-vascularized area of the hip,reducing the risk of non-union and os-teonecrosis compared to femoral neckfractures.7 As a result, this fracture canbe treated with internal fixation, opposedto the hip replacements for displacedfemoral neck fractures. The two main

surgical techniques for this fracture typeare cephallomedullary nailing and a slid-ing hip screw with side plating.

a) Cephallomedullary Nail This fixation technique consists of

placing an intramedullary rod down thefemoral shaft in combination with a slid-ing hip screw directed into the center ofthe femoral head. (Figure 6) The surgi-cal technique involves several small inci-sions along the lateral thigh and requiresno post-operative precautions. Patientsare typically permitted weight bearing astolerated, although difficult fracture pat-terns may warrant non-weight-bearing orpartial weight-bearing status. Rehabili-tation focuses on gait training, strength-ening, and range of motion.

b) Sliding hip screw with sideplate

This surgical technique consists of astabilizing side plate along the lateral as-pect of the proximal femur in conjunc-tion with a sliding hip screw into thefemoral head. This requires a small inci-sion along the lateral proximal femur, for

placement of the side plate. No post-op-erative precautions must be followed. Once again, patients are typically madeweight-bearing as tolerated, althoughdifficult fracture patterns may requirelimited weight-bearing initially. Reha-bilitation focuses on gait training,strengthening, and range of motion.

POST-OPERATIVE COMPLICATIONS

It is essential to consider the compli-cations associated with operative versusnon-operative treatment. These poten-tial complications in the context of pa-tient factors will determine whether op-erative fixation is appropriate. The goalof treatment, whether operative or non-operative, is to minimize the likelihoodof complications based on a patient’s un-derlying comorbidities. Complicationsassociated with surgical management ofhip fractures include, but are not limitedto, cardiopulmonary arrest, wound infec-tion, acute blood loss anemia, damage tosurrounding blood vessels or nerves,venous thromboembolism (VTE) andanesthetic complications such as aspira-tion and pneumonia. In general, hip

Figure 5. Figure 6.

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arthroplasty to treat fracture is associatedwith almost a ten-fold higher rate of peri-operative mortality compared to electivehip arthroplasty for degenerative jointdisease.13 Complications associated withnon-operative management and bed restinclude VTE, pneumonia, and decubi-tus ulcers.

Post-operative pain control is oftenchallenging in the elderly hip fracturepatient. These patients are often in mod-erate to severe pain and require narcoticpain medications to allow participationin post-operative rehabilitation pro-grams. Pain control also plays a role inthe prevention of complications. For ex-ample, a patient in significant discomfortwill often be tachycardic, putting an ad-ditional strain on the cardiac system. Narcotic pain medications have multipleside effects, especially with elderly pa-tients, including constipation, urinaryretention, respiratory depression, andacute delirium.9 Oral narcotics such asPercocet or Vicodin provide adequatepain control and may need to be sched-uled before therapy. In patients who aresensitive to narcotics, a combination ofToradol and Tylenol can be used, al-though these medications also have sideeffects in the elderly patient.

The timing of surgical fixation in hipfracture patients is a debated topic. Somestudies show an increase in mortalitywhen surgery is delayed greater than fourdays,14 while others show no significantdifference in mortality before 48 hoursand later.15 Surgical fixation should oc-cur when the patient is deemed medi-cally fit to undergo a procedure.

CONCLUSIONS

As the mean age of the world’s popu-lation rises, the prevalence of hip fractureswill increase. The elderly patient group,in which this injury most frequently oc-curs, typically has multiple medical co-morbidities, making their pre-operativeand post-operative (or non-operative)care both challenging and rewarding. Hip fracture care requires surgical andmedical teamwork to optimize outcomesand facilitate the return of the patient tohis or her pre-injury level of function.

REFERENCES1. Bentler SE, et al. The aftermath of hip fracture:.

Amer J Epidemiol 2009;170:1290-9.2. Marinella MA, Markert RJ. Clinical predictors of

prolonged hospitalization in patients with hipfractures. JCOM 2009;16: 453-8.

3. Leibson CL, et al. Mortality, disability, and nurs-ing home use for persons with and without hipfracture. J Amer Geriatrics Soc 2002; 50:1644-50.

4. Brauer CA, Coca-Perraillon M, et al. Incidenceand mortality of hip fractures in the United States. JAMA 2009;302:1573-9.

5. Brunner LC, Eshilian-Oates L. Hip fractures inadults. Amer Fam Physician 2003;67:537-42.

6. Jain R, Basinski A, Kreder HJ. Nonoperative treat-ment of hip fractures. Internat Orthopaedics2003;27:11-7.

7. Koval KJ, Zuckerman JD. Handbook of Fractures3rd Edition. Lippincott Williams &Williams;2002; 318-37.

8. Browner BD, Levin AM, et al. Skeletal Trauma 3rdEdition. Elsevier Publishing; 2003; 2: 1700-815.

9. Rasul AT, Wright J. Total joint replacement reha-bilitation. eMedicine 2009.

10. Varley J, Parker MJ. Stability of hiphemiarthroplasties. Internat Orthopaedics2004;28:274-7.

11. Blomfeldt R, et al. A randomized controlled trialcomparing bipolar hemiarthroplasty with total hipreplacement for displaced intracapsular fracturesof the femoral neck in elderly patients. J Bone JointSurgery-British Volume 2007; 89-B(2):160-5.

12. Baker RP, Squires B, et al. Total hip arthoplastyand hemiarthroplasty in mobile, independentpatients with a displaced intracapsular fracture ofthe femoral neck. JBJS 2006;88: 2583-9.

13. Parvizi J, Ereth MH, Lewallen DG. Thirty-daymortality following hip arthroplasty for acute frac-ture. JBJS 2004;86:1983-8.

14. Moran CG, et al. Early mortality after hip frac-ture:. JBJS 2005;87: 483-9.

15. Orosz GM, et al. Association of timing of surgeryfor hip fracture and patient outcomes. JAMA2004;291:1738-43. Craig Lareau, MD, is a resident in

orthopedic surgery.Gregory Sawyer, MD, is a resident in

orthopedic surgery.Both are at The Warren Alpert Medi-

cal School of Brown University/Rhode Is-land Hospital.

Disclosure of Financial InterestsThe authors and their spouses/sig-

nificant others have no financial intereststo disclose.

CORRESPONDENCECraig Lareau, MDDepartment of Orthopedic SurgeryRhode Island Hospital593 Eddy St.Providence, RI 02903e-mail: Craig_Lareau@brown.edu