Editorials
Musculoskeletal diseases Statistics Health services administration
Volume 216 - Issue 8

Hip fracture surgery: the importance of evidence‐based practice

Author:  Peter FM Choong

Med J Aust 2022; 216 (8): 406-407. || doi: 10.5694/mja2.51493
Published online: 2 May 2022

Registries are invaluable assets that not only benefit medical research, but also health care for all

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Registries are invaluable assets that not only benefit medical research, but also health care for all

During 2015–16, almost 18700 hip fractures were recorded in Australia; the incidence rate was nearly 200 times as high among people aged 45years or more than among younger people, and 1.7 times as high for women as men.1 As longevity increases and the prevalence of osteoporosis, sarcopaenia, obesity, and dementia rise in Western countries,2 the numbers of people at risk of fractures will continue to climb.

The burden of hip fractures is high. In 2017–18, hip fracture was the second most frequent reason for emergency admissions involving surgery;3 the lifetime risk of hip fracture in women in England and Wales (2001) was equivalent to that of breast cancer (11%).4 In one study, only one‐third of people returned to their previous level of independence after a hip fracture; 50% required long term help, and as many as one‐quarter required full‐time nursing care.5 In Australia, risk of death within twelve months for people aged 65years or more is more than 3.5 times as high following a hip fracture as for other people their age.6 The cost of hip fractures can be devastating; it is estimated that direct medical expenses in Australia amounted to $1billion in 2016, not including the costs of lost productivity and workforce participation.1

In 1988, the first formal registry to track hip fracture care was established in Sweden,7 inspiring similar registries in Europe and elsewhere.8 There were calls in Australia from the early 2000s to improve prevention of fragility fractures through the strategic management of osteoporosis, and the development and promotion of guidelines for managing fractures in older people.9 This led to the establishment of the Australian and New Zealand Hip Fracture Registry (ANZFHR) in 2012,10 co‐curated by geriatric medicine specialists and orthopaedic surgeons. This response has brought us closer than ever before to better understanding how best practice strategies for treating people with osteoporotic fractures can be encouraged.

In this issue of the MJA, Harvey and her colleagues11 report a population‐based retrospective review of outcomes following 40744 index hospitalisations with hip fracture in New South Wales during 2011–2018. Eleven in twelve patients with hip fractures underwent surgery; most of the 3450 who did not were aged 95years or more (9%), had three comorbid medical conditions (23%), or had intertrochanteric type breaks (65%). The decision not to undertake surgery in such patients is not unusual, despite advances in peri‐operative optimisation, anaesthesia, and surgery. The authors partially attributed the decline in 30‐day and 12‐month mortality among people who underwent surgery during 2011–2018 to increased awareness of guidelines and benchmark care standards, hip fracture audits, and improved peri‐ and post‐operative care. The study by Harvey and colleagues raises questions that a high quality registry such as the ANZHFR can help answer, including whether outcome variations are related to the geographic location of surgery, the experience of the surgeons, the type of prostheses used, sex differences, and the impact of changing demographic characteristics.

The ANZFHR approach is an excellent example of how to improve patient care in three important ways. First, patient outcomes are improved by promoting evidence‐based guidelines in partnership with surgeons, peri‐operative clinicians, and geriatric medicine specialists.12,13 Second, the careful collection of longitudinal data provides evidence that enables clinicians to assess the impact of their work and changing paradigms of care, and to optimise what they are doing, how they are doing it, and their selection of patients.8 Third, integrating data on patient‐related and objective outcomes measures collected over time will give the best indication of treatment quality and consequently of its value.14

One must also mention the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) when discussing how systematic data collection has allowed careful post‐market surveillance of implants, and facilitated practices that have led to important recommendations with major implications for patient care and health system cost.15 This was particularly evident in the AOANJRR analysis of metal‐on‐metal articular surface replacement hip prostheses, which led to a dramatic downturn in their use.16 The AOANJRR has collated a near complete collection of all cases of joint replacement undertaken in Australian hospitals.14 This reflects practitioner confidence in the registry, the careful stewardship that ensures data integrity, and the high esteem in which patients and professionals hold it.

By building on the lessons learned during the establishment of the AOANJRR, other data‐centric registries, including the ANZHFR, will also become invaluable assets that will not only benefit medical research in Australia, but also health care for all Australians.

 

Author

  • Peter FM Choong1,2
  • 1. University of Melbourne, Melbourne, VIC
  • 2. St Vincent's Hospital, Melbourne, VIC

Correspondence: pchoong@unimelb.edu.au

Competing interests

I have received consultancy fees and support for travel to designer surgeon meetings related to tumour prostheses from Stryker and Johnson & Johnson.

Acknowledgements

I am supported by a National Health and Medical Research Council Practitioner Fellowship.

References

Linked content

  • MJA Research Letter: Improved survival rates after hip fracture surgery in New South Wales, 2011–2018

Provenance: Commissioned; externally peer reviewed.

View this article on Wiley Online Library