Connect
MJA
MJA

Evidence-based guidelines for fixing broken hips: an update

Michael N Chilov, Ian D Cameron and Lyn M March
Med J Aust 2003; 179 (9): 489-493. || doi: 10.5694/j.1326-5377.2003.tb05653.x
Published online: 3 November 2003

Abstract

Objective: To update evidence-based guidelines for the treatment of proximal femoral fractures published in the Journal in 1999.

Data sources: Systematic literature search of MEDLINE, CINAHL and EMBASE from January 1996 to September 2001 and the Cochrane Database of Systematic Reviews (most recent issue searched — Issue 2, 2002).

Study selection: Randomised controlled trials and meta-analyses of all aspects of acute-care hospital treatment and rehabilitation of proximal femoral fractures among subjects aged 50 years and over with proximal femoral fractures not associated with metastatic disease or multiple trauma.

Data extraction: All studies were read independently by two reviewers. Reviewers recorded individual study results, and an assessment of study quality and treatment conclusions according to Cochrane Collaboration protocols. If necessary, a third review was performed to reach consensus.

Results: 93 new studies were identified and 82 met our inclusion criteria. Recommendations for thromboprophylaxis, anaesthesia, surgical fixation of fractures and nutritional status have been altered to incorporate new evidence. Recommendations have been added regarding postoperative blood transfusion, the management of subtrochanteric fractures, and the type of surgical swabs which should be used.

Conclusions: Although there have been few significant changes to the previous recommendations, updating the guidelines has required substantial effort. The common clinical problem of hip fracture should be treated according to the most up-to-date evidence to achieve the best possible outcomes and optimal utilisation of limited resources. Guideline updates also require resourcing.

Hip fracture is a commonly encountered clinical problem, with the prevalence of proximal femur fractures in Australia predicted to double between 1996 and 2026.1 Hip fractures are associated with a 12-month mortality rate of about 25%, and most patients who survive do not return to the level of mobility and independence they had before the fracture.2,3

Evidence-based clinical practice guidelines, based on the published literature up to December 1995, were published in the Journal in 1999.4 These guidelines were implemented and evaluated in a study utilising clinical pathway methodology.5 In brief, we were able to show that implementing the guidelines changed some processes of care, but that there was minimal impact on longer-term outcomes (4-month mortality and nursing home placement).

Here, we update the 1996 guidelines. Hip fractures should be treated according to the most up-to-date evidence to ensure the best possible outcomes and optimal utilisation of limited resources.

Methods

We identified randomised controlled trials (RCTs) and meta-analyses of interventions for hip fracture management by searching electronic databases (MEDLINE, EMBASE and CINAHL) from January 1996 to September 2001. The Cochrane Database of Systematic Reviews was searched up to Issue 2, 2002. Search terms were “hip fractures” together with specific interventions, which had been identified in the previous review.4 Searches were limited to RCTs, meta-analyses, subjects aged 50 years or over, and proximal hip fractures not related to metastatic disease. Primary studies which had already been included in Cochrane Collaboration reviews at the time of our literature searching were not re-reviewed.

All articles were read independently by two assessors. Results and data on study quality were recorded on a pro forma developed according to Cochrane Collaboration guidelines for assessment of study quality.6 Disagreements were resolved by a third, independent assessment and a consensus meeting.

Individual study results and an assessment of the quality of each study’s methods were summarised in a table format with author, year, number of subjects, interventions tested, ranking of bias (low, moderate, high), adequate concealment of allocation of patients to groups, and summary of results with relative risk, 95% confidence intervals and conclusions regarding treatment.

These tables were then used to generate a summary for each intervention, which included the previous recommendation, a summary of the evidence provided by the new studies and any new recommendations.

Evidence-based guidelines were then developed, with National Health and Medical Research Council (NHMRC) levels of evidence listed for each recommendation.7

Results

Ninety-three new studies were identified, of which 82 met our inclusion criteria. Eleven studies were excluded for one of the following reasons: the majority of patients were involved in high-impact trauma (1 study),8 they were not randomised trials (5 studies),9-13 and they were published in a language other than English and did not meet our other inclusion criteria (5 studies).14-18 Fifteen studies were not re-read, as they were included in Cochrane Collaboration reviews at the time of searching.19-33

No new RCTs or meta-analyses were found relating to the following interventions: time to surgery, oxygen therapy, pressure-gradient stockings, and urinary catheterisation.

Two new issues in hip fracture management — postoperative blood transfusion and surgical swabs — were included in our review, because studies addressing these issues are now avail-able.

The updated evidence-based guidelines are summarised in the Box (page 492).

Discussion

The NHMRC recommends regular review of established guidelines.7 Our study updates previously published guidelines for the treatment of proximal femoral fractures.4

Although we identified a number of new studies and Cochrane Collaboration reviews, there have been few changes to previous recommendations. Recommendations regarding nutritional status and surgical fixation of fractures have been altered to incorporate new evidence. We have also included new recommendations for postoperative blood transfusion and surgical swabs (Box).

Our recommendations are similar to those of the Scottish Intercollegiate Guidelines Network (SIGN), which updated its hip fracture management guidelines in 2002.120 One difference is in the recommendation for thromboprophylaxis. The SIGN guideline recommends that all patients receive aspirin unless contraindicated. Having found little evidence for the benefit of heparin for the clinically important outcomes of pulmonary embolism, mortality, and bleeding, and benefit over routine early mobilisation, mechanical prophylaxis and aspirin, the SIGN group concluded that heparin be reserved for patients at high risk of venous thromboembolism. Patients are considered high risk according to multiple risk factors or contraindications to routine mechanical thromboprophylaxis and/or aspirin.

Although we have reviewed the same evidence as the SIGN group, we would argue for the use of either low molecular weight heparin (LMWH) or unfractionated heparin in most patients. Patients undergoing surgery for hip fracture are known to be at high risk for venous thromboembolism, with comparatively high rates of deep venous thrombosis and pulmonary embolism.121,122 In the East Anglian audit, the use of pharmacological prophylaxis was associated with a reduced risk of fatal pulmonary embolism.123 A meta-analysis of heparin in hip-fracture surgery has shown that heparin is protective against deep venous thrombosis, with a relative risk reduction of almost 60%. While this did not extend to a significant protective effect against pulmonary embol-ism, we would expect that with larger trials there would be sufficient statistical power to demonstrate this. Indeed, meta-analysis of orthopaedic and surgery trials has shown that heparin reduces the risk of pulmonary embol-ism, with similar risk reductions across different surgical specialties.124 Extrapolating these data to hip-fracture patients, we would expect the benefit to be high in these patients, in whom the rates of pulmonary embolism are high.

According to the recommendations of SIGN, a significant number of patients would be receiving aspirin as their only pharmaceutical prophylaxis against pulmonary embolism, even though LMWH has been shown to be superior to aspirin in preventing deep venous thrombosis, the precursor to pulmonary embolism.52

Despite a number of studies investigating the use of heparin for thromboprophylaxis in hip-fracture patients, it is apparent that its role has not yet been clearly defined.

Regional anaesthesia is still recommended for most patients during proximal femoral fracture fixation. Potential complications which may have limited its use include hypotension and spinal haematoma. There is new evidence to support a number of interventions aiming to reduce the incidence of hypotension.62-66,68 In the recent Pulmonary Embolism Prevention trial,56 no occurrences of spinal haematoma were documented in the 4603 hip-fracture patients who received regional anaesthesia (including those with and without aspirin and other anticoagulant therapy).

Our study has some limitations. Guidelines date quickly. In developing wide-ranging systematic reviews and guidelines, it inevitably takes consider-able time to review the primary studies and formulate recommendations. Publishing in a peer-reviewed journal also adds to the time from literature search to date of publication. Summarising complex issues in a review, such as this, can also be difficult. Although guidelines provide a useful resource for clinicians, it is still unclear whether the use of evidence-based guidelines improves outcomes.

Our study has updated previously published guidelines for the management of proximal femoral fractures. Reviewing the evidence accumulated in the 6 years since the last guidelines were produced required substantial effort. Since the development of the original guidelines, the Cochrane Collaboration Musculoskeletal Injuries Group has published reviews or protocols for planned reviews addressing most areas covered by our guidelines. Future updates may be able to draw on the reviews of this group rather than review studies individually, making the future guideline development a more manageable task. Guideline updates also require adequate financial resourcing to identify and appraise all relevant material.

Guidelines (and the evidence levels* on which they are based) for 17 aspects of treatment of proximal femoral fracture (changes to the existing guidelines4 and new recommendations are given in italics)

1. Time to surgery (Level III-2)34-38

No randomised trial evidence is available and observational studies give a range of conclusions. Early surgery (within 24–36 hours) is recommended for most patients once a medical assessment has been made and the patient’s condition has been stabilised appropriately. Undue delay to surgery inevitably increases length of stay and may lead to more complications, including more pressure sores, pneumonia and confusion.

2. Preoperative traction (Level II)39-42

There is no evidence to support the routine use of preoperative traction. The routine use of preoperative skin and skeletal traction should be abandoned.

3. Prevention of pressure sores (Level I)43,44

All patients should be nursed on a pressure-relieving mattress rather than a standard hospital mattress. Patients at very high risk of pressure sores should ideally be nursed on a large-cell, alternating-pressure air mattress or similar device.

4. Oxygen therapy (Level II)45,46

Some evidence supports the routine use of oxygen therapy for the first 72 hours after surgery. All patients should have oximetry assessment from the time of emergency admission to 48 hours after surgery, and oxygen administered as necessary.

5. Thromboprophylaxis (Level I)47-56

The substantial majority of hip fracture patients should receive heparin, either low molecular weight heparin (LMWH) or unfractionated heparin. Patients being treated with thromboprophylactic regimens other than LMWH may benefit from additional low-dose aspirin. Mechanical devices should be used for patients in whom anticoagulants and antiplatelet agents are contraindicated.

6. Pressure gradient stockings (Level I)57,58

Patients should be wearing pressure gradient stockings as soon as possible after admission.

7. Type of anaesthesia (Level I)59-68

Regional anaesthesia is recommended for most patients. Incremental dosing or metaraminol infusions can be employed to reduce hypotensive episodes often seen with spinal anaesthetics (Level II).

8. Type of analgesia (Level II)69-73

Adequate analgesia should be administered before and immediately after surgery. Nerve blocks may be useful in some cases.

9. Prophylactic antibiotics (Level I)74

Prophylactic intravenous antibiotics should be given at induction of anaesthesia. Prolonged antibiotic use is of no proven benefit for prophylaxis of wound infection.

10. Type of surgery

Extracapsular (trochanteric) fractures (Level I)75-84 should be treated surgically. A compression hip screw and plate has less

chance of failure, leading to reoperation, compared with a fixed device and may prove to be more cost effective in the long term.

Undisplaced intracapsular fractures (Level I)85-87 should have internal fixation with a widely used method that is familiar to the surgeon (cancellous bone screws or compression screw and plate).

Displaced intracapsular fractures (Level II)85-95 have no clearly superior surgical treatment. The options for surgical treatment of this fracture are internal fixation or arthroplasty. Internal fixation is associated with higher risk of implant failure than hemiarthroplasty (femoral head replacement). At present the choice of treatment is best determined by patient factors (including age, presence of arthritis, availability and cost of the different types of treatment, surgeon experience and preference). No clear benefit of bipolar over conventional hemiarthroplasty has been demonstrated (Level II).

Subtrochanteric fractures (Level II)96 The Medoff sliding plate has been associated with fewer failures of fixation when compared with other screw plates and is recommended for fixation of this fracture.

11. Surgical wound drains (Level II)97-99

Surgical wound drains may not be required as often as currently used and early removal is advised (about 24 hours after insertion).

12. Postoperative blood transfusion (Level II)100

Routine transfusion in asymptomatic patients with a haemoglobin level 80 g/L may not be required.

13. Surgical swabs (Level II)101

Calcium alginate swabs should be considered in hip fracture surgery.

14. Urinary catheterisation (Level II)102

Avoid indwelling catheters (where possible). Intermittent catheterisation is preferable and has been shown not to increase the incidence of urinary tract infections.

15. Nutritional status (Level II)103-107

Some evidence supports oral protein supplementation for the 6 months after surgery. All patients should have a nutritional assessment, so that protein and energy supplements can be provided as needed. In very thin patients nasogastric tube feeding could be considered.

16. Mobilisation

Early assisted ambulation should begin within 48 hours postoperatively (Level III-3).108-111 No particular mobilisation strategies can be recommended over others (Level II).112

17. Rehabilitation (Level II)113-119

A coordinated rehabilitation program should be available to patients with hip fracture. It should commence early in the hospital admission and provide opportunities for early supported discharge for patients who can manage this. For more frail patients, a coordinated inpatient rehabilitation program should be provided that is followed by a period of continuing rehabilitation after discharge.


* Levels of evidence are those of the Australian National Health and Medical Research Council.7

Received 16 January 2003, accepted 29 July 2003

  • Michael N Chilov1
  • Ian D Cameron2
  • Lyn M March

  • 1 Concord Repatriation General Hospital, Concord, NSW.
  • 2 Rehabilitation Studies Unit, Northern Clinical School, Faculty of Medicine, University of Sydney, Ryde, NSW.
  • 3 Institute of Bone and Mineral Research, Northern Clinical School, Faculty of Medicine, University of Sydney, St Leonards, NSW.


Correspondence: 

Competing interests:

None identified.

  • 1. Sanders KM, Nicholson GC, Ugoni AM, et al. Health burden of hip and other fractures in Australia beyond 2000. Projections based on the Geelong Osteoporosis Study. Med J Aust 1999; 170: 467-470. <MJA full text>
  • 2. Heikkinen T, Parker M, Jalovaara P. Hip fractures in Finland and Great Britain — a comparison of patient characteristics and outcomes. Int Orthop 2001; 25: 349-354.
  • 3. Davidson CW, Merrilees MJ, Wilkinson TJ, et al. Hip fracture mortality and morbidity — can we do better? N Z Med J 2001; 114: 329-332.
  • 4. March LM, Chamberlain AC, Cameron ID, et al. How best to fix a broken hip. Fractured Neck of Femur Health Outcomes Project Team. Med J Aust 1999; 170: 489-494. <MJA full text>
  • 5. March LM, Cameron ID, Cumming RG, et al. Mortality and morbidity after hip fracture: can evidence based clinical pathways make a difference? J Rheumatol 2000; 27: 2227-2231.
  • 6. Clarke M, Oxman AD, editors. Cochrane Reviewers’ Handbook 4.2.0. In: The Cochrane Library, Issue 2 2003. Oxford: Update Software.
  • 7. National Health and Medical Research Council. Guide to the development implementation and evaluation of clinical practice guidelines. Canberra: NHMRC, 1999. Available at: www.health.gov.au/nhmrc/publications/pdf/cp30.pdf (accessed Sep 2003).
  • 8. DiCicco JD 3rd, Jenkins M, Ostrum RF. Retrograde nailing for subtrochanteric femur fractures. Am J Orthop 2000; 29 Suppl 9: 4-8.
  • 9. Morrison RS, Siu AL. A comparison of pain and its treatment in advanced dementia and cognitively intact patients with hip fracture. J Pain Symptom Manage 2000; 19: 240-248.
  • 10. Sors H, Meyer G. Place of aspirin in prophylaxis of venous thromboembolism. Lancet 2000; 355: 1288-1289.
  • 11. Calder S. The comparison of a unipolar with a bipolar prosthesis of similar stem design. Clin Orthop 1999; 359: 259.
  • 12. Buciuto R, Hammer R, Herder A. Spontaneous subcapital femoral neck fracture after healed trochanteric fracture. Clin Orthop 1997; 342: 156-163.
  • 13. Koval KJ. Preoperative skin traction was not useful for hip fractures. J Bone Joint Surg Am 2001; 83: 303.
  • 14. Duranthon LD, Grimberg J, Vandenbussche E, et al. [Effectiveness of postoperative drainage after bipolar sealed endoprosthetic arthroplasty for femur neck fracture. Results of a prospective randomized study of 86 cases]. [French]. Rev Chir Orthop Reparatrice Appar Mot 2000; 86: 370-372.
  • 15. Pelet S, Arlettaz Y, Chevalley F. [Osteosynthesis of per- and subtrochanteric fractures by blade plate versus gamma nail. A randomized prospective study]. [French]. Swiss Surg 2001; 7: 126-133.
  • 16. Hoffmann R, Schmidmaier G, Schulz R, et al. [Classic nail versus DHS. A prospective randomised study of fixation of trochanteric femur fractures]. [German]. Unfallchirurg 1999; 102: 182-190.
  • 17. Di Roio C, Vedrinne JM, Hoen JP, et al. [Prevention of arterial hypotension during spinal anesthesia using intramuscular ephedrine in older people]. [French]. Ann Fr Anesth Reanim 1997; 16: 483-487.
  • 18. Graupe F, Eyssel M, Stock W. [Slit drainage in hip endoprosthesis — also an alternative in trauma surgery? A prospective follow-up study]. [German]. Unfallchirurg 1996; 22: 223-227.
  • 19. Rosen JE, Chen FS, Hiebert R, Koval KJ. Efficacy of preoperative skin traction in hip fracture patients: a prospective, randomized study. J Orthop Trauma 2001; 15: 81-85.
  • 20. Luthje P, Nurmi I, Aho H, et al. Single-dose antibiotic prophylaxis in osteosynthesis for hip fractures. A clinical multicentre study in Finland. Ann Chir Gynaecol 2000; 89: 125-130.
  • 21. Alho A, Austdal S, Benterud JG, et al. Biases in a randomized comparison of three types of screw fixation in displaced femoral neck fractures. Acta Orthop Scand 1998; 69: 463-468.
  • 22. Jonsson B, Sernbo I, Carlsson A, et al. Social function after cervical hip fracture. A comparison of hook-pins and total hip replacement in 47 patients. Acta Orthop Scand 1996; 67: 431-434.
  • 23. Park SR, Kang JS, Kim HS, et al. Treatment of intertrochanteric fracture with the Gamma AP locking nail or by a compression hip screw — a randomised prospective trial. Int Orthop 1998; 22: 157-160.
  • 24. Hardy DC, Descamps PY, Krallis P, et al. Use of an intramedullary hip-screw compared with a compression hip-screw with a plate for intertrochanteric femoral fractures. A prospective, randomized study of one hundred patients. J Bone Joint Surg Am 1998; 80: 618-630.
  • 25. Madsen JE, Naess L, Aune AK, et al. Dynamic hip screw with trochanteric stabilizing plate in the treatment of unstable proximal femoral fractures: a comparative study with the Gamma nail and compression hip screw. J Orthop Trauma 1998; 12: 241-248.
  • 26. Baumgaertner MR, Curtin SL, Lindskog DM. Intramedullary versus extramedullary fixation for the treatment of intertrochanteric hip fractures. Clin Orthop 1998; 348: 87-94.
  • 27. Watson JT, Moed BR, Cramer KE, Karges DE. Comparison of the compression hip screw with the Medoff sliding plate for intertrochanteric fractures. Clin Orthop 1998; 348: 79-86.
  • 28. Alho A, Austdal S, Benterud JG, et al. Biases in a randomized comparison of three types of screw fixation in displaced femoral neck fractures. Acta Orthop Scand 1998; 69: 463-468.
  • 29. Buciuto R, Uhlin B, Hammerby S, Hammer R. RAB-plate vs Richards CHS plate for unstable trochanteric hip fractures. A randomized study of 233 patients with 1-year follow-up. Acta Orthop Scand 1998; 69: 25-28.
  • 30. Benterud JG, Husby T, Nordsletten L, Alho A. Fixation of displaced femoral neck fractures with a sliding screw plate and a cancellous screw or two Olmed screws. A prospective, randomized study of 225 elderly patients with a 3-year follow-up. Ann Chir Gynaecol 1997; 86: 338-342.
  • 31. Lamb SE, Grimley Evans J, Morse RE, Trundle H. A randomised placebo controlled and double blind study of neuromuscular stimulation to improve mobility in the first three months after surgical fixation for proximal femoral fracture. J Bone Joint Surg Br 1998; 80 Suppl II: 172.
  • 32. Hoffman CW, Lynskey TG. Intertrochanteric fractures of the femur: a randomized prospective comparison of the Gamma nail and the Ambi hip screw. Aust N Z J Surg 1996; 66: 151-155.
  • 33. Urwin SC, Parker MJ, Griffiths R. General versus regional anaesthesia for hip fracture surgery: a meta-analysis of randomized trials. Br J Anaesth 2000; 84: 450-455.
  • 34. 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.
  • 35. Dolk T. Operation in hip fracture patients — analysis of the time factor. Injury 1990; 21: 369-372.
  • 36. 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.
  • 37. Parker MJ, Pryor GA. The timing of surgery for proximal femoral fractures. J Bone Joint Surg Br 1992; 74: 203-205.
  • 38. Villar RN, Allen SM, Barnes SJ. Hip fractures in healthy patients: operative delay versus prognosis. BMJ 1986; 293: 1203-1204.
  • 39. Jerre R, Doshe A, Karlsson J. Preoperative skin traction in patients with hip fractures is not useful. Clin Orthop 2000; 378: 169-173.
  • 40. Resch S, Thorngren KG. Preoperative traction for hip fracture: a randomized comparison between skin and skeletal traction in 78 patients. Acta Orthop Scand 1998; 69: 277-279.
  • 41. Parker MJ, Handoll HH. Pre-operative traction for fractures of the proximal femur. Cochrane Database Syst Rev 2002; (2): CD000168.
  • 42. Finsen V, Borset M, Buvik GE, Hauke I. Preoperative traction in patients with hip fractures. Injury 1992; 23: 242-244.
  • 43. Cullum N, Deeks J, Sheldon TA, et al. Beds, mattresses and cushions for pressure sore prevention and treatment. Cochrane Database Syst Rev 2002; (2): CD001735.
  • 44. Hartgrink HH, Wille J, Konig P, et al. Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial. Clin Nutr 1998; 17: 287-292.
  • 45. 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.
  • 46. 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.
  • 47. Handoll HH, Farrar MJ, McBirnie J, et al. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev 2000; (2): CD000305.
  • 48. 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, randomized study of compression alone versus no prophylaxis. J Orthop Trauma 1995; 9: 1-7.
  • 49. Eskander MB, Limb D, Stone MH, et al. Sequential mechanical and pharmacological thromboprophylaxis in the surgery of hip fractures. A pilot study. Int Orthop 1997; 21: 259-261.
  • 50. Anglen JO, Goss K, Edwards J, Huckfeldt RE. Foot pump prophylaxis for deep venous thrombosis: the rate of effective usage in trauma patients. Am J Orthop 1998; 27: 580-582.
  • 51. Kennedy JG, Soffe KE, Rogers BW, et al. Deep vein thrombosis prophylaxis in hip fractures: a comparison of the arteriovenous impulse system and aspirin. J Trauma 2000; 48: 268-272.
  • 52. Gent M, Hirsh J, Ginsberg JS, et al. Low-molecular-weight heparinoid orgaran is more effective than aspirin in the prevention of venous thromboembolism after surgery for hip fracture. Circulation 1996; 93: 80-84.
  • 53. Haentjens P. Thromboembolic prophylaxis in orthopaedic trauma patients: a comparison between a fixed dose and an individually adjusted dose of a low molecular weight heparin (nadroparin calcium). Injury 1996; 27: 385-390.
  • 54. Kew J, Lee YL, Davey IC, et al. Deep vein thrombosis in elderly Hong Kong Chinese with hip fractures detected with compression ultrasound and Doppler imaging: incidence and effect of low molecular weight heparin. Arch Orthop Trauma Surg 1999; 119: 156-158.
  • 55. The TIFDED Study Group. Thromboprophylaxis in hip fracture surgery: a pilot study comparing danaparoid, enoxaparin and dalteparin. Haemostasis 1999; 29: 310-317.
  • 56. Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000; 355: 1295-1302.
  • 57. Agu O, Hamilton G, Baker D. Graduated compression stockings in the prevention of venous thromboembolism. Br J Surg 1999; 86: 992-1004.
  • 58. Amarigiri SV, Lees TA. Elastic compression stockings for prevention of deep venous thrombosis. Cochrane Database Syst Rev 2002; (2): CD001484.
  • 59. Parker MJ, Handoll HH, Griffiths R. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev 2002; (2): CD000521.
  • 60. Juelsgaard P, Sand NP, Felsby S, et al. Perioperative myocardial ischaemia in patients undergoing surgery for fractured hip randomized to incremental spinal, single-dose spinal or general anaesthesia. Eur J Anaesthesiol 1998; 15: 656-663.
  • 61. Dobrydnjov I, Samarutel J. Enhancement of intrathecal lidocaine by addition of local and systemic clonidine. Acta Anaesthesiol Scand 1999; 43: 556-562.
  • 62. Yap JC, Critchley LA, Yu SC, et al. A comparison of three fluid-vasopressor regimens used to prevent hypotension during subarachnoid anaesthesia in the elderly. Anaesth Intensive Care 1998; 26: 497-502.
  • 63. Buggy DJ, Power CK, Meeke R, et al. Prevention of spinal anaesthesia-induced hypotension in the elderly: i.m. methoxamine or combined hetastarch and crystalloid. Br J Anaesth 1998; 80: 199-203.
  • 64. Favarel-Garrigues JF, Sztark F, Petitjean ME, et al. Hemodynamic effects of spinal anesthesia in the elderly: single dose versus titration through a catheter. Anesth Anal 1996; 82: 312-316.
  • 65. Critchley LA, Conway F. Hypotension during subarachnoid anaesthesia: haemodynamic effects of colloid and metaraminol. Br J Anaesth 1996; 76: 734-736.
  • 66. Ben-David B, Frankel R, Arzumonov T, et al. Minidose bupivacaine-fentanyl spinal anesthesia for surgical repair of hip fracture in the aged. Anesthesiology 2000; 92: 6-10.
  • 67. de Visme V, Picart F, Le Jouan R, et al. Combined lumbar and sacral plexus block compared with plain bupivacaine spinal anesthesia for hip fractures in the elderly. Reg Anesth Pain Med 2000; 25: 158-162.
  • 68. Critchley LA, Yu SC. A comparative study of three different methods of administering metaraminol during spinal anaesthesia in the elderly. Anaesth Intensive Care 2001; 29: 141-148.
  • 69. Spansberg NL, Anker-Moller E, Dahl JB, et al. The value of continuous blockade of the lumbar plexus as an adjunct to acetylsalicylic acid for pain relief after surgery for femoral neck fractures. Eur J Anaesthesiol 1996; 13: 410-412.
  • 70. Kwan ASK, Lee BB, Brake T. Intrathecal morphine for post-operative analgesia in patients with fractured hips. Hong Kong Med J 1997; 3: 250-255.
  • 71. Chudinov A, Berkenstadt H, Salai M, et al. Continuous psoas compartment block for anesthesia and perioperative analgesia in patients with hip fractures. Reg Anesth Pain Med 1999; 24: 563-568.
  • 72. Scheini H, Virtanen T, Kentala E, et al. Epidural infusion of bupivacaine and fentanyl reduces perioperative myocardial ischaemia in elderly patients with hip fracture — a randomized controlled trial. Acta Anaesthesiol Scand 2000; 44: 1061-1070.
  • 73. Parker MJ, Griffiths R, Appadu BN. Nerve blocks (subcostal, lateral cutaneous, femoral, triple, psoas) for hip fractures. Cochrane Database Syst Rev 2002; (2): CD001159.
  • 74. Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev 2002; (2): CD000244.
  • 75. Parker MJ, Handoll HH, Bhonsle S, Gillespie WJ. Condylocephalic nails versus extramedullary implants for extracapsular hip fractures. Cochrane Database Syst Rev 2002; (2): CD000338.
  • 76. Parker MJ, Handoll HH, Chinoy MA. Extramedullary fixation implants for extracapsular hip fractures. Cochrane Database Syst Rev 2002; (2): CD000339.
  • 77. Parker MJ, Handoll HH. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures. Cochrane Database Syst Rev 2002; (2): CD000093.
  • 78. Parker MJ, Handoll HH. Replacement arthroplasty versus internal fixation for extracapsular hip fractures. Cochrane Database Syst Rev 2002; (2): CD000086.
  • 79. Fritz T, Hiersemann K, Krieglstein C, Friedl W. Prospective randomized comparison of gliding nail and gamma nail in the therapy of trochanteric fractures. Arch Orthop Trauma Surg 1999; 119: 1-6.
  • 80. Chinoy MA, Parker MJ. Fixed nail plates versus sliding hip systems for the treatment of trochanteric femoral fractures: a meta analysis of 14 studies. Injury 1999; 30: 157-163.
  • 81. Parker MJ, Pryor GA. Gamma versus DHS nailing for extracapsular femoral fractures. Meta-analysis of ten randomised trials. Int Orthop 1996; 20: 163-168.
  • 82. Buciuto R, Hammer R. RAB-plate versus sliding hip screw for unstable trochanteric hip fractures: stability of the fixation and modes of failure — radiographic analysis of 218 fractures. J Trauma 2001; 50: 545-550.
  • 83. Olsson O, Ceder L, Hauggaard A. Femoral shortening in intertrochanteric fractures. A comparison between the Medoff sliding plate and the compression hip screw. J Bone Joint Surg Br 2001; 83: 572-578.
  • 84. Lunsjo K, Ceder L, Thorngren KG, et al. Extramedullary fixation of 569 unstable intertrochanteric fractures: a randomized multicenter trial of the Medoff sliding plate versus three other screw-plate systems. Acta Orthop Scand 2001; 72: 133-140.
  • 85. Parker MJ, Stockton G. Internal fixation implants for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev 2002; (2): CD001467.
  • 86. Parker MJ, Blundell C. Choice of implant for internal fixation of femoral neck fractures. Meta-analysis of 25 randomised trials including 4,925 patients. Acta Orthop Scand 1998; 69: 138-143.
  • 87. Lagerby M, Asplund S, Ringqvist I. Cannulated screws for fixation of femoral neck fractures. No difference between Uppsala screws and Richards screws in a randomized prospective study of 268 cases. Acta Orthop Scand 1998; 69: 387-391.
  • 88. Parker MJ, Rajan D. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 2002; (2): CD001706.
  • 89. Calder SJ, Anderson GH, Jagger C, et al. Unipolar or bipolar prosthesis for displaced intracapsular hip fracture in octogenarians: a randomised prospective study. J Bone Joint Surg Br 1996; 78: 391-394.
  • 90. Cornell CN, Levine D, O'Doherty J, Lyden J. Unipolar versus bipolar hemiarthroplasty for the treatment of femoral neck fractures in the elderly. Clin Orthop 1998; 348: 67-71.
  • 91. Kligman M, Zecevic M, Roffman M. The effect of intramedullary corticocancellous bone plug for hip hemiarthroplasty. J Trauma 2001; 51: 84-87.
  • 92. Parker MJ, Pryor GA. Internal fixation or arthroplasty for displaced cervical hip fractures in the elderly: a randomised controlled trial of 208 patients. Acta Orthop Scand 2000; 71: 440-446.
  • 93. Johansson T, Jacobsson SA, Ivarsson I, et al. Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractures: a prospective randomized study of 100 hips. Acta Orthop Scand 2000; 71: 597-602.
  • 94. Ravikumar KJ, Marsh G. Internal fixation versus hemiarthroplasty versus total hip arthroplasty for displaced subcapital fractures of femur — 13 year results of a prospective randomised study. Injury 2000; 31: 793-797.
  • 95. van Dortmont LM, Douw CM, van Breukelen AM, et al. Cannulated screws versus hemiarthroplasty for displaced intracapsular femoral neck fractures in demented patients. Ann Chir Gynaecol 2000; 89: 132-137.
  • 96. Lunsjo K, Ceder L, Tidermark J, et al. Extramedullary fixation of 107 subtrochanteric fractures: a ran-domized multicenter trial of the Medoff sliding plate versus 3 other screw-plate systems. Acta Orthop Scand 1999; 70: 459-466.
  • 97. Parker MJ, Roberts C. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev 2002; (2): CD001825.
  • 98. Cobb JP. Why use drains? J Bone Joint Surg Br 1990; 72: 993-995.
  • 99. Varley GW, Milner SA. Wound drains in proximal femoral fracture surgery: a randomized prospective trial of 177 patients. J R Coll Surg Edinb 1995; 40: 416-418.
  • 100. Carson JL, Terrin ML, Barton FB, et al. A pilot randomized trial comparing symptomatic vs. hemoglobin-level-driven red blood cell transfusions following hip fracture. Transfusion 1998; 38: 522-529.
  • 101. Davies MS, Flannery MC, McCollum CN. Calcium alginate as haemostatic swabs in hip fracture surgery. J R Coll Surg Edinb 1997; 42: 31-32.
  • 102. Skelly JM, Guyatt GH, Kalbfleisch R, et al. Management of urinary retention after surgical repair of hip fracture. CMAJ 1992; 146: 1185-1189.
  • 103. Hartgrink HH, Wille J, Konig P, et al. Pressure sores and tube feeding in patients with a fracture of the hip: a randomized clinical trial. Clin Nutr 1998; 17: 287-292.
  • 104. Schurch MA, Rizzoli R, Slosman D, et al. Protein supplements increase serum insulin-like growth factor-I levels and attenuate proximal femur bone loss in patients with recent hip fracture. A randomized, double-blind, placebo-controlled trial. Ann Intern Med 1998; 128: 801-809.
  • 105. Sullivan DH, Nelson CL, Bopp MM, et al. Nightly enteral nutrition support of elderly fracture patients: a phase I trial. J Am Coll Nutr 1998; 17: 155-161.
  • 106. Espaulella J, Guyer H, Diaz-Escriu F, et al. Nutritional supplementation of elderly hip fracture patients. A randomized, double-blind, placebo-controlled trial. Age Ageing 2000; 29: 425-431.
  • 107. Avenell A, Handoll HH. Nutritional supplementation for hip fracture aftercare in the elderly. Cochrane Database Syst Rev 2002; (2): CD001880.
  • 108. 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.
  • 109. 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.
  • 110. 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.
  • 111. 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.
  • 112. Parker MJ, Handoll HH, Dynan Y. Mobilisation strat-egies after hip fracture surgery in adults. Cochrane Database Syst Rev 2002; (2): CD001704.
  • 113. Cameron ID, Handoll HH, Finnegan TP, et al. Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures. Cochrane Database Syst Rev 2002; (2): CD000106.
  • 114. Cameron I, Crotty M, Currie C, et al. Geriatric rehabilitation following fractures in older people: a systematic review. Health Technol Assess 2000; 4: i-iii, 1-102.
  • 115. Tinetti ME, Baker DI, Gottschalk M, et al. Home-based multicomponent rehabilitation program for older persons after hip fracture: a randomized trial. Arch Phys Med Rehabil 1999; 80: 916-922.
  • 116. Sherrington C, Lord SR. Home exercise to improve strength and walking velocity after hip fracture: a randomized controlled trial. Arch Phys Med Rehabil 1997; 78: 208-212.
  • 117. Stromberg L, Ohlen G, Nordin C, et al. Postoperative mental impairment in hip fracture patients. A ran-domized study of reorientation measures in 223 patients. Acta Orthop Scand 1999; 70: 250-255.
  • 118. Huusko TM, Karppi P, Avikainen V, et al. Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia. BMJ 2000; 321: 1107-1111.
  • 119. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a ran-domized trial. J Am Geriatr Soc 2001; 49: 516-522.
  • 120. Scottish Intercollegiate Guidelines Network. Prevention and management of hip fracture in older people. SIGN Publication No. 56. Edinburgh: SIGN, 2002. Available at: www.sign.ac.uk/guidelines/fulltext/56/index.html (accessed Sep 2003).
  • 121. Thromboembolic Risk Factors (THRIFT) Consensus Group. Risk of and prophylaxis for venous thromboembolism in hospital patients. BMJ 1992; 305: 567-574.
  • 122. Gillespie W, Murray D, Gregg PJ, Warwick D. Risks and benefits of prophylaxis against venous thromboembolism in orthopaedic surgery. J Bone Joint Surg Br 2000; 82: 475-479.
  • 123. Todd CJ, Freeman CJ, Camilleri-Ferrante C, et al. Differences in mortality after fracture of the hip: the East Anglian audit. BMJ 1995; 310: 904-908.
  • 124. Collins R, Scrimgeour A, Yusuf S, Peto R. Reduction in fatal pulmonary embolism and venous thrombosis by perioperative administration of subcutaneous heparin: an overview of results of randomized trials in general, orthopaedic and urological surgery. N Engl J Med 1988; 318: 1162-1173.

Author

remove_circle_outline Delete Author
add_circle_outline Add Author

Comment
Do you have any competing interests to declare? *

I/we agree to assign copyright to the Medical Journal of Australia and agree to the Conditions of publication *
I/we agree to the Terms of use of the Medical Journal of Australia *
Email me when people comment on this article

Online responses are no longer available. Please refer to our instructions for authors page for more information.