Volume 180 - Issue 5
Evidence-based guidelines for fixing broken hips
Authors: Michael N Chilov, Ian D Cameron and Lynette M March
Med J Aust 2004; 180 (5): 254-255. || doi: 10.5694/j.1326-5377.2004.tb05902.x
Published online: 1 March 2004
Published online: 1 March 2004
Michael N Chilov,* Ian D Cameron,† Lynette M March‡
* Intern, Concord Hospital [corresponding author], 50 Mi Mi Street, Oatley, NSW 2223; † Chair, Rehabilitation Medicine, University of Sydney; and Director, Aged Care and Rehabilitation Services, Northern Sydney Area Health Services, Rehabilitation Studies Unit, Ryde, NSW; ‡ Senior Staff Specialist in Rheumatology and Clinical Epidemiology, Department of Rheumatology, Royal North Shore Hospital, St Leonards, NSW. mchilovATgmp.usyd.edu.au
In reply: We thank McCulloch for his comments regarding the use of regional anaesthesia in the surgical management of hip fracture. He makes the point that surgical and anaesthetic techniques have improved and implies that the advantage seen for regional anaesthesia in published studies may no longer be present. Given that controversy still exists, we would recommend that further randomised controlled trials be conducted. However, for the following reasons, we stand by our recommendation that the available evidence supports the use of regional anaesthesia for most patients with this condition.
Our current recommendation is unchanged from the earlier version of the guideline (published in the Journal in 1999),1 and is also consistent with at least one other published guideline.2 A number of the concerns raised by McCulloch were addressed in the response to a letter by another correspondent after the publication of the original guidelines.3
While we acknowledge that the review by Parker et al4 only found the reduction in mortality at 1 month to be of borderline significance, when our review team reassessed the original articles using the Cochrane Collaboration protocol we reached a summary odds ratio for mortality of 0.68 (95% CI, 0.49–0.96). With time and further studies we expect that this estimate of effect will become more precise as the power of the meta-analysis is increased. This view is supported by a systematic review of all randomised studies comparing regional anaesthesia with general anaesthesia across surgical specialties. The study of Rodgers et al found a statistically significant reduction in mortality (odds ratio, 0.70; 95% CI, 0.54–0.90) when regional anaesthesia was compared with general anaesthesia.5 This overall point estimate is very similar to that of Parker et al in their meta-analysis of patients with hip fracture. Although lack of power meant that statistical significance did not exist within individual surgical specialties, there was, in fact, little difference in the effect across surgical groups, with no significant heterogeneity between studies.
Serious complications of regional anaesthesia (eg, spinal haematoma) are extremely rare, as shown in the recent PEP study in Australia and New Zealand that reported no cases in 4603 patients undergoing regional blockade.6 This should be compared with the number needed to treat with regional anaesthesia to prevent one death of 38, according to the data of Parker et al.4
There is no doubt that our recommendation needs to be considered in the context of individual patient characteristics and, while the recommendation may not apply to all patients with hip fracture, we feel that the available evidence supports the use of regional anaesthesia.
References
- 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. <eMJA full text>
- Scottish Intercollegiate Guidelines Network. Prevention and management of hip fracture in older people. SIGN publication No. 56. Edinburgh: SIGN, Jan 2002. Available at: www.sign.ac.uk/guidelines/fulltext/56/index.html (accessed Jan 2004).
- March LM, Cameron ID, Cumming RG. How best to fix a broken hip [letter]. Med J Aust 1999; 171: 330-331. i1082929
- Parker MJ, Handoll HHG, Griffiths R, Urwin SC. Anaesthesia for hip fracture surgery in adults (Cochrane Review). The Cochrane Library, Issue 4, 2003. Chichester, UK: John Wiley & Sons, Ltd. i1082931
- Rodgers A, Walker N, Schug S, et al. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ 2000; 321: 1493-1497. i1082933
- Prevention of pulmonary embolism and deep vein thrombosis with low dose aspirin: Pulmonary Embolism Prevention (PEP) trial. Lancet 2000; 355: 1295-1302. i1082935