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The main objective of this study was to answer two questions about treatment of proximal femoral fractures: "What is the right thing to do?" and "Are we doing the right thing?", and then to develop evidence-based clinical guidelines for hip-fracture treatment. A systematic approach was taken, with a focus on health outcomes;⁵ we aimed to make recommendations that would optimise functional outcome while minimising length of stay in hospital.

What is the right thing to do?
We performed a systematic review of randomised controlled trials (RCTs) and meta-analyses that included patients over 50 years with proximal femoral fractures. In the absence of an RCT (there were none published for "time to surgery" and "time to mobilisation after surgery"), we searched for observational studies.

The main literature source was English language articles identified from MEDLINE and CINAHL from 1966 to December 1995. Search words used were "hip fractures", "proximal femoral fractures", "fractured neck of femur", together with specific interventions and clinical indicators (Box 1). The searches were limited to English language, RCTs, meta-analyses, age 50 years or over, and proximal femoral fractures not due to metastatic disease.

In addition, manual searches were conducted of current issues of key specialty and general journals, our personal literature, libraries, bibliographies of the published articles and personal contact with those working in areas relevant to hip fracture, including the Cochrane Collaboration Musculoskeletal Injuries Group.

Articles were distributed randomly to the assessors by the use of a random numbers table. The assessors, who were all experienced in the critical appraisal of scientific literature, were blinded to the authors, institutions and journal of publication of the articles. Articles were read independently by two assessors. Disagreements were resolved by a third assessment and a consensus meeting.

Results and data on study quality were recorded according to Cochrane Collaboration guidelines for the assessment of study quality.⁶ Guidelines for ranking the level of evidence were those devised by the National Health and Medical Research Council (NHMRC).⁷

Are we doing the right thing?
The study population for the medical audit came from the five acute-care Northern Sydney Area Health Service public hospitals during the 1993-94 financial year. All admissions for proximal femoral fracture in the 12 months were included. Patients with multiple injuries or fractures due to metastatic cancer were excluded. Data were extracted by trained medical record reviewers. A second audit, conducted by an independent reviewer in a 10% random subsample, showed more than 90% agreement.

Patients were identified by ICD-9 code 820 (fracture of neck of femur) and by the following procedural codes:

79.15 Closed reduction of fracture with internal fixation -- femur

79.35 Open reduction of fracture with internal fixation -- femur

81.51 Total hip replacement

81.52 Partial hip replacement

81.53 Revision of hip replacement

Development of evidence-based guidelines
The key steps in the process of care for the acute management of hip fracture were identified by discussion with clinical staff and review of medical records (Box 1) and a specific clinical question was asked for each (eg, "Do low pressure mattresses reduce the number and severity of pressure sores?"). All supporting trial evidence was summarised in table format with author, year, interventions tested, number of subjects, ranking of bias (low, moderate, high), adequate concealment of allocation to groups (yes/no), summary of results of the individual articles with odds ratios and 95% confidence limits and, where possible, a calculation of the number needed to treat.⁶ Data were in a suitable format for meta-analysis for "prophylactic antibiotics" and "type of anaesthesia", but summary statistics were not generated for the other treatment modalities. Full details of all articles and these summaries are available from the authors and are on the Internet.¹

From these tables, a one-page summary was generated for each clinical intervention, together with recommendations for clinical practice and suggestions for future study. These were circulated among the review team and the orthopaedic clinical groups.

The results of the medical literature review and medical record audit were presented to medical and nursing staff in each hospital in oral and written form. Local practice was compared with practice in the other hospitals and to evidence-based best practice.

After all these steps, a single page of draft guidelines was developed with NHMRC levels of evidence listed for each clinical recommendation. These were circulated and presented for further discussion before being adopted.

The right thing to do
Of the 120 articles published between 1966 and December 1995, 97 met the inclusion criteria. Articles were excluded if they did not report randomised trials, if they had insufficient numbers of patients with hip fracture, or if they were judged to be of poor quality by two independent assessors.1 Our conclusions from the literature review addressed 15 issues, and what we found, on the basis of available evidence, is given in Box 1. Box 2 presents the evidence-based clinical guidelines and average practice (1993-94) for each of the clinical interventions (as well as for acute-care-hospital length of stay) among the five acute-care hospitals audited. Average practice is given as unweighted averages across all five hospitals of the frequency of adherence to evidence-based best practice, plus the range from lowest to highest frequency.

The guidelines can be applied to most, but not all, patients who sustain a proximal femoral fracture. Individual circumstances and comorbidities will always influence decision-making. These guidelines should be updated as new evidence becomes available.

What we are doing
In all, 729 consecutive admissions were audited and will be the subject of a more detailed report evaluating the implementation of the guidelines. No significant variation was shown among the five acute-care hospitals with respect to the patients' age (mean, 82.4 years; 18% were 90 years or older), sex (81% female), admissions from nursing homes (28.7%) and fracture type (51% intracapsular, 43% extracapsular, 6% unknown). All patients had at least one comorbidity, 71.7% had two or more and almost a third had five or more.

Mortality at 12 months was 18%¹ for non-nursing-home patients and 38% for nursing-home patients. At the four-month follow-up, 16% of patients required a new nursing-home admission.

There was considerable variation in the clinical interventions (Box 2), particularly evident for "time to surgery", "preoperative traction", "pressure gradient stockings", "type of anaesthesia" (spinal) and "urinary catheterisation".

• Prophylactic antibiotics (intravenous) were used in the majority of patients in all five hospitals, but most continued their use longer than evidence and basic principles require. Giving additional oral antibiotics, for which there is no supporting evidence, was also common practice (lowest hospital rate, 32%; highest hospital rate, 83%).

• Surgical wound drains were used almost universally, with most remaining in place beyond 24 hours.

• Delay in mobilisation after surgery was associated with an increased length of stay. The hospital with the longest time to mobilisation also had the longest acute-care stay (median, 13 days v. overall median, 9 days).

• Three-quarters of patients who were admitted from their own home were discharged to a rehabilitation facility. Acute-care stay for these patients (median, 11 days) was considerably longer than for those returning to a nursing home (median, 6 days).

• The day of the week on which a patient was admitted was also found to be associated with length of stay, and this effect occurred both between and within the five hospitals. Patients admitted on a Thursday were likely to spend an extra two days in the acute-care facility (median, 11 days) compared with those admitted on other days (median, 9 days).

Current practice, identified by medical record audit, was compared with evidence-based best practice and areas of care requiring modification were identified. A number of steps in patient treatment were supported by high level evidence, but wide variability in the routine use of these treatments was seen among the five participating hospitals.

There was little or no supporting evidence for some common practices, including preoperative traction and the extended use of wound drains. Although not measured systematically, we observed great variability in clinicians' response to this information, ranging from relief to frank disbelief, and many showed considerable reluctance to drop a "time-honoured practice".

Prevention strategies involving medical therapies, such as prophylactic anticoagulants and antibiotics, were in widespread use and compared favourably with other audits.^105,106 However, non-pharmaceutical prevention strategies, including pressure-decreasing mattresses, oxygen saturation monitoring and nutritional supplements, were not in routine use in any hospital.

Despite high level evidence for the use of prophylactic anticoagulants, the exact timing of initial administration of anticoagulation remained in doubt, with surgical and anaesthetic staff expressing concern about its use in combination with regional anaesthesia. There is an extremely small, but nevertheless serious, risk of spinal haematoma with this combination. On the balance of available evidence, the benefits appear to outweigh the risk of harm, but it remains a controversial area, suggesting that further trials on types and timing of anticoagulants are required.

The evidence that regional anaesthesia was associated with reduced mortality and morbidity compared with general anaesthesia also met with a mixed response, with anaesthetists being completely polarised in their views. The published meta-analysis on this topic⁴¹ did have flaws (duplication of patients, not all RCTs), but our review team reassessed the original articles according to the Cochrane Collaboration protocol and performed a repeat analysis, excluding studies which appeared to be duplicated, and reached the same conclusion, albeit with a more conservative estimate of benefit (summary odds ratio for mortality, 0.68; 95% CL, 0.49, 0.96).

The optimum time from admission to surgical operation has long been a vexed question. Only observational studies,^8-12 with their inherent biases and conflicting results, were available to guide recommendations. Longer time to surgery is likely to increase the risk of complications and the total length of stay, and early surgery on patients who are medically stable has not been shown to cause any harm. We found considerable variability in time to surgery, with up to 20% of patients waiting longer than 72 hours. This may reflect the lack of availability of out-of-hours surgical facilities and, to a lesser extent, the achievement of medical stability, but these patients continue to be "poor surgical relations" and are not given the priority they deserve.

Earlier mobilisation also has resource implications and is dependent, in part, on the availability of physiotherapy staff, but also on a patient's general condition. While there are no randomised controlled trials to indicate the optimal time for mobilisation, a review of all trials of surgical treatment showed that ambulation on the first or second day after surgery had no adverse effects,^56-88,98 and a cohort study has now reached the same conclusions.¹⁰⁷

The day of admission appeared to influence both delay to surgery and overall acute length of stay, suggesting that the practice of adding these patients to a routine list, rather than making special arrangements for them, may be a factor in prolonging length of stay.

Patients requiring transfer to rehabilitation facilities generally stayed several days longer in the acute-care ward compared with those discharged to nursing-home care. This suggests a need to address difficulties with the process of assessment for rehabilitation and/or the availability of rehabilitation beds. Costs could be reduced by earlier transfer to rehabilitation from the more expensive acute-care ward, but whether this would mean longer-term cost savings remains to be determined.

Our study identified considerable variation in current management of patients who have sustained hip fractures. It has some limitations, being restricted to English language articles and to evidence published up to January 1996. As a result, a few relevant references may have been missed. However, we recommend that these guidelines be applied to most elderly patients admitted with hip fracture, as we have shown that sufficient information now exists to challenge treatments based solely on tradition or individual perceptions. The current "epidemic" of proximal femoral fractures¹⁰⁸ makes it essential that the best possible use is made of scarce resources to achieve optimal outcomes.

1. March L, Chamberlain A, Cameron I, et al. Prevention, treatment and rehabilitation of fractured neck of femur. Report from the Northern Sydney Area Health Service Fractured Neck of Femur Health Outcomes Project, 1996. (ISBN 07310 9633 9.) Also on the internet: <http://www.mja.com.au/public/issues/iprs2/march/fnof.pdf>
2. Australian Bureau of Statistics. Projections of the populations of Australia, States and Territories, 1984-2021 (Catalogue No. 3222.0) ISSN: 0816-3391.
3. Katelaris AG, Cumming RG. Health status before and mortality after hip fracture. Am J Public Health 1996; 86: 557-560.
4. Cumming RG, Klineberg R, Katelaris A. Cohort study of risk of institutionalisation after hip fracture. Aust N Z J Public Health 1996; 20: 579-582.
5. Irwig L. An approach to evaluating health outcomes. NSW Public Health Bulletin 4 (12). Sydney: NSW Department of Health, 1993.
6. The Cochrane Collaboration Reviewers' Handbook 1994. Section VI: Preparing and maintaining systematic reviews. Cochrane Collaboration, 1994: 1-75. (Version 3.0.2 Sept 1997 on the internet <http://wwwsom.fmc.flinders.edu.au/fusa/cochrane/ cochrane/hbook.htm>)
7. National Health and Medical Research Council Quality of Care and Health Outcomes Committee. Guidelines for the development and implementation of clinical practice guidelines. Canberra: NHMRC/AGPS, 1995. (ISBN 0644 356766.)
8. Bredahl C, Nyholm B, Hindsholm KB, et al. Mortality after hip fracture: results of operation within 12 hours of admission. Injury 1992; 23: 83-86.
9. Dolk T. Operation in hip fracture patients -- analysis of the time factor. Injury 1990; 21: 369-372.
10. Hoerer D, Volpin G, Stein H. Results of early and delayed surgical fixation of hip fractures in the elderly: a comparative, retrospective study. Bull Hosp Jt Dis 1993; 53: 29-33.
11. Parker MJ, Pryor GA. The timing of surgery for proximal femoral fractures. J Bone Joint Surg Br 1992; 74: 203-205.
12. Villar RN, Allen SM, Barnes SJ. Hip fractures in healthy patients: operative delay versus prognosis. BMJ 1986; 293: 1203-1204.
13. Anderson GH, Harper WM, Connolly CD, et al. Preoperative skin traction for fractures of the proximal femur: a randomised, prospective trial. J Bone Joint Surg Br 1993; 75: 794-796.
14. Finsen V, Borset M, Buvik GE, Hauke I. Pre-operative traction in patients with hip fracture. Injury 1992; 23: 242-244.
15. Needoff M, Radford P, Langstaff R. Pre-operative traction for hip fractures in the elderly: a clinical trial. Injury 1993; 24: 317-318.
16. Hofman A, Geelkerken RH, Wille J, et al. Pressure sores and pressure-decreasing mattresses: controlled clinical trial. Lancet 1994; 343: 568-571.
17. Nuffield Institute of Health, University of Leeds and the NHS Centre for Reviews and Dissemination. How effective are pressure-relieving interventions for the prevention and treatment of pressure sores? Effective Health Care Bulletin 1995; 2(1). York: University of York, 1995.
18. Brown AG, Visram AR, Jones RD, et al. Pre-operative and post-operative oxygen saturation in the elderly following spinal or general anaesthesia -- an audit of current practice. Anaesth Intensive Care 1994; 22: 150-154.
19. Fugere F, Owen H, Ilsley A, et al. Changes in oxygen saturation in the 72 hours after hip surgery: the effect of oxygen therapy. Anaesth Intensive Care 1994; 22: 724-728.
20. Agnelli G, Cosmi B, Di Fillipo P, et al. A randomised, double blind placebo controlled trial of dermatan sulphate for prevention of DVT in hip fracture. Thromb Haemost 1992; 67: 203-208.
21. Antiplatelet Trialists' Collaboration. Collaborative overview of randomised trials of antiplatelet therapy III: Reduction in venous thrombosis and pulmonary embolism by antiplatelet prophylaxis among surgical and medical patients. BMJ 1994; 308: 235-296.
22. Barsotti J, Gruel Y, Rosset P, et al. Comparative, double-blind study of two dosage regimens of low-molecular-weight heparin in elderly patients with a fracture of the neck of the femur. J Orthop Trauma 1990; 4: 371-375.
23. Bergqvist D, Efsing HO, Hallbook T, Hedlund T. Thrombo-embolism after elective and post-traumatic hip surgery: a controlled, prophylactic trial with dextran 70 and low-dose heparin. Acta Chir Scand 1979; 145: 213-218.
24. Bergqvist D. Orgaran in hip fracture surgery. Haemostasis 1992; 22: 104-108.
25. Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by peri-operative administration of subcutaneous heparin: overview of results of randomized trials in general, orthopedic and urologic surgery. N Engl J Med 1988; 318: 1162-1173.
26. Gerhart TN, Yett HS, Robertson LK, et al. Low-molecular weight heparinoid compared with warfarin for prophylaxis of deep vein thrombosis in patients who are operated on for fracture of the hip. J Bone Joint Surg Am 1991; 73: 494-502.
27. Imperiale TF, Speroff T. A meta-analysis of methods to prevent venous thrombo-embolism following total hip replacement. JAMA 1994; 271: 1780-1785.
28. Consensus Statement. Prevention of venous thrombo-embolism (Chairman, Nicolaides AN). Int Angiol 1997; 16: 3-38..
29. Lahnborg G. Effect of low dose heparin and dihydroergotamine on frequency of post-operative deep vein thrombosis in patients undergoing post-traumatic hip surgery. Acta Chir Scand 1980; 146: 319-322.
30. Lassen MR, Borris LC, Christiansen HM, et al. Clinical trials with low-molecular weight heparins in the prevention of post-operative thrombo-embolic complications: a meta-analysis. Semin Thromb Hemost 1991; 17(Suppl 3): 284-290.
31. Morris GK, Mitchell JR. Warfarin sodium in the prevention of deep venous thrombosis and pulmonary embolism in patients with fractured neck of femur. Lancet 1976; 2: 869-872.
32. Morris GK, Mitchell JR. Preventing venous thrombo-embolism in elderly patients with hip fractures: studies of low-dose heparin, dipyridamole, aspirin and flurbiprofen. BMJ 1977; 1: 535-537.
33. Nurmohamed MT, Rosendaal FR, Buller HR, et al. Low molecular weight heparin versus standard heparin in general and orthopaedic surgery: a meta-analysis. Lancet 1992; 340: 152-156.
34. Oertli D, Hess P, Durig M, et al. Prevention of deep vein thrombosis in patients with hip fractures: low-molecular weight heparin versus dextran. World J Surg 1992; 16: 980-984.
35. Pini M, Spadini E, Carluccio L, et al. Dextran/aspirin versus heparin/dihydro-ergotamine in preventing thrombosis after hip fractures. J Bone Joint Surg Br 1985; 67: 305-309.
36. Powers PJ, Gent M, Jay RM, et al. A randomised trial of less intense post-operative warfarin or aspirin therapy in the prevention of venous thrombo-embolism after surgery for fractured hip. Arch Intern Med 1989; 149: 771-774.
37. Rogers PH, Walsh PN, Marder VJ, et al. Controlled trial of low-dose heparin and sulfinpyrazone to prevent venous thrombo-embolism after operation on the hip. J Bone Joint Surg Am 1978; 60: 758-762.
38. Stranks GJ, McKenzie NA, Grover ML, et al . The A-V Impulse System reduces deep-vein thrombosis and swelling after hemiarthroplasty for hip fracture. J Bone Joint Surg Br 1992; 74: 775-778.
39. Williams JW, Eikman EA, Greenberg SH, et al. Failure of low-dose heparin to prevent pulmonary embolism after hip surgery or above the knee amputation. Ann Surg 1978; 188: 468-474.
40. Fisher CG, Blachut PA, Salvian AJ, et al. Effectiveness of pneumatic leg compression devices for the prevention of thromboembolic disease in orthopaedic trauma patients: a prospective, randomised study of compression alone versus no prophylaxis. J Orthop Trauma 1995; 9: 1-7.
41. Sorenson RM, Pace NL. Anesthetic techniques during surgical repair of femoral neck fractures: a meta-analysis. Anesthesiology 1992; 77: 1095-1104.
42. Coad NR. Post-operative analgesia following femoral neck surgery: a comparison between 3-in-1 femoral nerve block and lateral cutaneous nerve block. Eur J Anaesthesiol 1991; 8: 287-290.
43. Hood G. Post-operative analgesia after triple nerve block for fractured neck of femur. Anaesthesia 1991; 46: 138-140.
44. Bodoky A, Neff U, Heberer M, Harder F. Antibiotic prophylaxis with two doses of cephalosporin in patients managed with internal fixation for a fracture of the hip. J Bone Joint Surg Am 1993; 75: 61-65.
45. Boyd RJ, Burke JF, Colton T. A double-blind, clinical trial of prophylactic antibiotics in hip fractures. J Bone Joint Surg Am 1973; 55: 1251-1258.
46. Buckley R, Hughes GN, Snodgrass T, Huchcroft SA. Perioperative cefazolin prophylaxis in hip fracture surgery. Can J Surg 1990; 33: 122-127.
47. Ericson C, Lindgren L, Lindberg L. Cloxacillin in the prophylaxis of post-operative infections of the hip. J Bone Joint Surg Am 1973; 55: 808-813, 843.
48. Garcia S, Lozano ML, Gatell JM, et al. Prophylaxis against infection: single dose cefonicid compared with multiple dose cefamandole. J Bone Joint Surg Am 1991; 73: 1044-1048.
49. Gatell JM, Garcia S, Lozano L, et al. Perioperative cefamandole prophylaxis against infections. J Bone Joint Surg Am 1987; 69: 1189-1193.
50. Hedstrom SA, Lidgren L, Sernbo I, et al. Cefuroxime prophylaxis in trochanteric hip fracture operations. Acta Orthop Scand 1987; 58: 361-364.
51. Hjortrup A, Sorensen C, Mejdahl S, et al. Antibiotic prophylaxis in surgery for hip fractures. Acta Orthop Scand 1990; 61: 152-153.
52. Karachalios T, Lyritis GP, Hatzopoulos E. Antibiotic prophylaxis in the surgical treatment of peri-trochanteric fractures: a comparative trial between two cephalosporins. Chemotherapy 1990; 36: 448-453.
53. McQueen MM, Littlejohn MA, Miles RS, Hughes SP. Antibiotic prophylaxis in proximal femoral fracture. Injury 1990; 21: 104-116.
54. Nungu KS, Larsson S, Wallinder L, Holm S. Bone and wound fluid concentrations of cephalosporins: oral cefadroxil and parenteral cefuroxime compared in 52 patients with a trochanteric fracture. Acta Orthop Scand 1995; 66: 161-165.
55. Tengve B, Kjellander J. Antibiotic prophylaxis in operations on trochanteric femoral fractures. J Bone Joint Surg Am 1978; 60: 97-99.
56. Aune AK, Ekeland A, Odegaard B, et al. Gamma nail vs compression screw for trochanteric femoral fractures. Acta Orthop Scand 1994; 65: 127-130.
57. Bannister GC, Gibson AG, Ackroyd CE, et al. The fixation and prognosis of trochanteric fractures: a randomised, controlled trial. Clin Orthop 1990; 254: 242-246.
58. Bridle SH. Fixation of intertrochanteric fractures of the femur: a randomised, prospective comparison of the gamma nail and the dynamic hip screw. J Bone Joint Surg Br 1991; 73: 330-334.
59. Chapman MW, Bowman WE, Csongradi JJ, et al. The use of Ender's pins in extra-capsular fractures of the hip. J Bone Joint Surg Am 1981; 63: 14-28.
60. Dalen N, Jacobsson B, Eriksson PA. A comparison of nail-plate fixation and Ender's nailing in pertrochanteric fractures. J Trauma 1988; 28: 405-406.
61. Davis TR, Sher JL, Checketts RG, Porter BB. Inter-trochanteric fractures of the femur: a prospective study comparing the use of the Kuntscher-Y nail and a sliding hip screw. Injury 1988; 19: 421-426.
62. Desjardins AL, Roy A, Paiement G, et al. Unstable inter-trochanteric fracture of the femur: a prospective, randomised study comparing anatomical reduction and medial displacement osteotomy. J Bone Joint Surg Br 1993; 75: 445-447.
63. Esser MP, Kassab JY, Jones DH. Trochanteric fractures of the femur: a randomised, prospective trial comparing the Jewett nail-plate with the dynamic hip screw. J Bone Joint Surg Br 1986; 68: 557-560.
64. Gargan MF, Gundle R, Simpson AH. How effective are osteotomies for unstable intertrochanteric fractures? J Bone Joint Surg 1994; 76: 789-792.
65. Goldhagen PR, O'Connor DR, Schwarze D, Schwartz E. A prospective, comparative study of the compression hip screw and the gamma nail. J Orthop Trauma 1994; 8: 367-372.
66. Hogh J, Lund B, Lucht U. Trochanteric and subtrochanteric fractures: the operative results in a prospective, comparative study of Ender nailing and McLaughlin osteosynthesis. Acta Orthop Scand 1981; 52: 639-643.
67. Hornby R, Evans JG, Vardon V. Operative or conservative treatment for trochanteric fractures of the femur: a randomised, epidemiological trial in elderly patients. J Bone Joint Surg Br 1989; 71: 619-623.
68. Leung KS, So WS, Shen WY, Hui PW. Gamma nails and dynamic hip screws for peri-trochanteric fractures: a randomised, prospective study in elderly patients. J Bone and Joint Surg Br 1992; 74: 345-351.
69. Lund B, Hogh J, Lucht U. Trochanteric and sub-trochanteric fractures. One year follow-up of a prospective study of Ender and McLaughlin osteosynthesis. Acta Orthop Scand 1981; 52: 645-648.
70. Nungu S, Olerud C, Rehnberg L. Treatment of intertrochanteric fractures: comparison of Ender nails and sliding screw plates. J Orthop Trauma 1991; 5: 452-457.
71. Pitsaer E, Samuel AW. Functional outcome after intertrochanteric fractures of the femur: does the implant matter? A prospective study of 100 consecutive cases. Injury 1993; 24: 35-36.
72. Sernbo I, Johnell O, Gardsell A. Locking and compression of the lag screw in trochanteric fractures is not beneficial. A prospective, randomised study of 153 cases. Acta Orthop Scand 1994; 65: 24-26.
73. Sernbo I, Johnell O, Gentz CF, Nilsson JA. Unstable inter-trochanteric fractures of the hip: treatment with Ender pins compared with a compression hip-screw. J Bone Joint Surg Am 1988; 70: 1297-1303.
74. Stark A, Brostrom LA, Barrios C, et al. A prospective, randomised study of the use of sliding hip screws and Ender nails for trochanteric fractures of the femur. Int Orthop 1992; 16: 359-362.
75. Emery RJ, Broughton NS, Desai K, et al. Bipolar hemiarthroplasty for sub-capital fracture of the femoral neck: a prospective, randomised trial of cemented Thompson and uncemented Moore stems. J Bone Joint Surg Br 1991; 73: 322-324.
76. Elmerson S, Andersson GB, Irstam L, Zetterberg C. Internal fixation of femoral neck fracture: no difference between the Rydell four-flanged nail and Gouffon's pins. Acta Orthop Scand 1988; 59: 372-376.
77. Lu-Yao GL, Keller RB, Litternberg B, Wenberg JE. Outcomes after displaced fractures of the femoral neck: a meta-analysis of one hundred and six published reports. J Bone Joint Surg Am 1994; 76: 15-25.
78. Madsen F, Linde F, Andersen E, et al. Fixation of displaced femoral neck fractures: a comparison between sliding screw plate and four cancellous bone screws. Acta Orthop Scand 1987; 58: 212-216.
79. Kuokkanen H, Korkala O, Antii-Poika I, et al. Three cancellous bone screws versus a screw angle plate in the treatment of Garden I and II fractures of the femoral neck. Acta Orthop Belg 1991; 57: 3-57.
80. Olerud C, Rehnberg L, Hellquist E. Internal fixation of femoral neck fractures: two methods compared. J Bone Joint Surg Br 1991; 73: 16-19.
81. Radford PJ, Needoff M, Webb JK. A prospective, randomised comparison of the dynamic hip screw and the gamma locking nail. J Bone Joint Surg Br 1993; 7: 789-793.
82. Rehnberg L, Olerud C. Fixation of femoral neck fractures: comparison of the Uppsala and von Bahr screws. Acta Orthop Scand 1989; 60: 579-584.
83. Sernbo I, Johnell O, Baath L, Nilsson JA. Internal fixation of 410 cervical hip fractures: a randomised comparison of a single nail versus two hook-pins. Acta Orthop Scand 1990; 61: 411-414.
84. Sikorski JM, Barrington R. Internal fixation versus hemiarthroplasty for the displaced subcapital fracture of the femur: a prospective, randomised study. J Bone Joint Surg Br 1981; 63: 357-361.
85. Skinner P, Riley D, Ellery J, et al. Displaced subcapital fractures of the femur: a prospective, randomized comparison of internal fixation, hemiarthroplasty and total hip replacement. Injury 1989; 20: 291-293.
86. Sorensen JL, Varmarken JE, Bomler J. Internal fixation of femoral neck fractures. Dynamic Hip and Gouffon screws compared in 73 patients. Acta Orthop Scand 1992; 63: 288-292.
87. Svenningsen S, Benum P, Nesse O, Furset OI. Internal fixation of femoral neck fractures: compression screw compared with nail plate fixation. Acta Orthop Scand 1984; 55: 423-429.
88. van Vugt AB, Oosterwijk WM, Goris RJ. Osteosynthesis versus endoprosthesis in the treatment of unstable intra-capsular hip fractures in the elderly: a randomised, clinical trial. Arch Orthop Trauma Surg 1993; 113: 39-45.
89. Cobb JP. Why use drains? J Bone Joint Surg Br 1990; 72: 993-995.
90. Varley GW, Milner SA, Turner GM, et al. Ultrasound assessment of the efficacy of wound drains. J R Coll Surg Edinb 1994; 39: 97-99.
91. Varley GW, Milner SA. Wound drains in proximal femoral fracture surgery: a randomised, prospective trial of 177 patients. J R Coll Surg Edinb 1995; 40: 416-418.
92. Skelly JM, Guyatt GH, Kalbfleisch R, et al. Management of urinary retention after surgical repair of hip fracture. Can Med Assoc J 1992; 146: 1185-1189.
93. Bastow MD, Rawlings J, Allison SP. Benefits of supplementary tube feeding after fractured neck of femur: a randomised controlled trial. BMJ 1983; 287: 1589-1591.
94. Delmi M, Rapin CH, Bengoa JM, et al. Dietary supplementation in elderly patients with fractured neck of femur. Lancet 1990; 335: 1013-1016.
95. Sloan JP, Wing P, Dian L, Meneilly GS. A pilot study of anabolic steroids in elderly patients with hip fractures. J Am Geriatr Soc 1992; 40: 1105-1111.
96. Tkatch L, Rapin CH, Rizzoli R, et al. Benefits of oral protein supplementation in elderly patients with fracture of the proximal femur. J Am Coll Nutr 1992; 11: 519-525.
97. Zauber NP, Zauber AG, Gordon FJ, et al. Iron supplementation after femoral head replacement for patients with normal iron stores. JAMA 1992; 267: 525-527.
98. Brostrom LA, Barrios C, Kronberg M, et al. Clinical features and walking ability treatment of trochanteric hip fractures in the early post-operative period after hip fracture. Ann Chir Gynaecol 1992; 81: 66-71.
99. Cameron ID, Lyle DM, Quine S. Accelerated rehabilitation after proximal femoral fracture. Disabil Rehabil 1993; 15: 29-34.
100. 100. Fordham R, Thompson R, Holmes J, et al. A cost-benefit study of geriatric-orthopaedic management of patients with fractured neck of femur. Discussion paper. York: Centre for Health Economics, University of York, 1986.
101. Gilchrist WJ, Newman RJ, Hamblen DL, Williams BO. Prospective randomised study of an orthopaedic-geriatric inpatient service. BMJ 1988; 297: 1116-1118.
102. Kennie DC, Reid J, Richardson IR, et al. Effectiveness of geriatric rehabilitative care after fractures of the proximal femur in elderly women: a randomised clinical trial. BMJ 1988; 297: 1083-1086.
103. Oyewole MF, Moloney A. A randomised, controlled trial of a high-support hospital discharge team for elderly people. Age Ageing 1994; 23: 228-234.
104. Reid J, Kennie DC. Geriatric rehabilitative care after fractures of the proximal femur: one year follow-up of a randomised, clinical trial. BMJ 1989; 299: 25-26.
105. Todd CJ, Freeman DJ, Camilleri C, et al. Differences in mortality after hip fracture: The East Anglia audit. BMJ; 1995; 310: 904-908.
106. Tallis G, Balla JJ. Critical path analysis for the management of fractured neck of femur. Aust J Public Health 1995; 19: 155-159.
107. Koval KJ, Friend KD, Aharonoff GB, et al. Weightbearing after hip fracture: a prospective series of 596 geriatric hip fracture patients. J Orthop Trauma 1996; 10: 526-530.
108. Cooper C, Campion G, Melton LJ. Hip fracture in the elderly: a word-wide projection. Osteoporos Int 1992; 2: 285-289.

(Received 28 Jul 1998, accepted 19 Mar 1999)

Reprints: Associate Professor L M March, Department of Rheumatology, The Royal North Shore Hospital, St Leonards, NSW 2065.
Email: lmarcATdoh.health.nsw.gov.au

©MJA 1999
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