Musculoskeletal diseases

Arthritis self-management programs (ASMPs) are integrated into many clinical practice guidelines and policies, and are the core business of Arthritis Foundations. Australian Arthritis Foundations are embarking on a National Quality Assurance Program which should raise awareness and improve confidence in such programs. ASMPs aim to empower people, improve quality of life while living with chronic disease, increase healthy activities and improve self-monitoring — ...

Richard H Osborne DipApplBiol, BSc, PhD · Jean M Spinks BPharm, MPH · Ian P Wicks MB BS, FRACP, PhD

Joint replacement is the most effective healthcare measure in improving patient quality-of-life outcomes. More than 46 000 hip and knee replacements were performed in Australia between July 2000 and July 2001. The need for joint replacements will increase as the population ages. More than 90% of hip and/or knee replacements survive for 10–15 years. Prosthesis selection needs to be tailored to each patient, although rationalisation ...

John A L Hart FRACS, FAOrthA, FACSP(Hon)

In the financial year ending June 2002, 26 689 hip replacements and 26 089 knee replacements (total, 52 778) were performed in Australia. Hip and knee replacement procedures have increased between 5%–10% each year for the past 10 years, with a combined increase in hip and knee replacement of 13.4% in the past year. The revision rate for hip replacement surgery in Australia is unknown but is estimated to ...

Stephen E Graves MB BS, DPhil, FAOrth · David Davidson MB BS, FRCSEd, FRACS · Lisa Ingerson RN, MN · Philip Ryan MB BS, BSc, FAFPHM · Elizabeth C Griffith BA, GradDipPH · Brian F J McDermott BBus, MEnvSt, GradDipElecComp · Heather J McElroy BSC(Hons), DipStats · Nicole L Pratt BSc(Hons)

Tissue engineering involves the use of cells (either adult, mesenchymal or embryonic stem cells) coupled with biological or artificial matrices or scaffolds which guide the cells during repair or regeneration of the tissue. Recently discovered and isolated growth factors can promote either adult or stem-cell growth and differentiation along selected pathways to re-form and repair skeletal tissues in adults. Bone repair enhancement and ...

Barry W Oakes MB BS, MD

It is a pleasure to be able to add my thoughts to this Supplement. Even though I may not have as many qualifications as most of the other participants, I do have an intimate understanding of surgery and what it means to be a patient. In my 32 years, I have experienced a wide range of procedures, including two total hip replacements, a bilateral total knee ...

Benjamin A J Horgan

Treatment for chronic low back pain (pain persisting for over 3 months) falls into three broad categories: monotherapies, mulitidisciplinary therapy, and reductionism. Most monotherapies either do not work or have limited efficacy (eg, analgesics, non-steroidal anti-inflammatory drugs, muscle relaxants, antidepressants, physiotherapy, manipulative therapy and surgery). Multidisciplinary therapy based on intensive exercises improves physical function and has modest effects on pain. The reductionist approach (pursuit of a pathoanatomical diagnosis with the view to target-specific treatment) should be implemented when a specific diagnosis is needed. While conventional investigations do not reveal the cause of pain, joint blocks and discography can identify zygapophysial joint pain (in 15%–40%), sacroiliac joint pain (in about 20%) and internal disc disruption (in over 40%). Zygapophysial joint pain can be relieved by radiofrequency neurotomy; techniques are emerging for treating sacroiliac joint pain and internal disc disruption.

Nikolai Bogduk MD, DSc, FFPM (ANZCA)

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.

Michael N Chilov MB BS, BOptom · Ian D Cameron MB BS, PhD, FAFRM(RACP) · Lyn M March MB BS, PhD, FRACP

Acute anterior shoulder dislocations, when managed non-operatively, have traditionally been treated by placing the arm in a sling. There is no formal evidence that this treatment is of benefit. Three recently reported studies, one in cadavers and two in patients, suggest that the detachment of the structures in the front of the shoulder is made worse when the shoulder is placed in internal rotation, as when the arm is in a sling. By contrast, the structures are realigned when the arm is placed in external rotation. Shoulder dislocations, if managed non-operatively, should not be treated by placing arms in a sling. Rather, placing them in a splint or using a pillow so that the the arm is externally rotated should be considered.

George A C Murrell MBBS, DPhil

Two recent RCTs have clarified the benefits In Australia, about 12% of the population, and 34% of people over 50 years of age, suffer from osteoarthritis.1 The most commonly affected joint is the knee.2 For patients with knee osteoarthritis and symptoms that are refractory to drugs, arthroscopic surgery is often performed. Arthroscopy may be diagnostic or therapeutic, and potentially may delay more extensive surgery such as replacement arthroplasty.3 It allows for resection of meniscal tears and debridement of the articular surface, as well as joint lavage to remove debris and inflammatory factors (eg, interferon gamma), which are believed to be a major but remediable source of the pain of osteoarthritis. The procedure has a low incidence of morbidity and can be repeated.4 Although the number of arthroscopic procedures undertaken for knee osteoarthritis in Australia is not available, a considerable proportion of the 56 000 knee arthroscopies performed each year would be for knee osteoarthritis.2 The role of arthroscopy for osteoarthritis of the knee [is] now challenged. Evidence for the effectiveness of lavage and debridement for knee osteoarthritis comes largely from case series and cohort studies. These have shown that about 50% of patients report pain relief after the procedure.5 Predictors of poor outcomes from arthroscopy include marked malalignment, restricted range of motion, marked radiographic evidence of osteoarthritis, and prior surgery.6,7 Better outcomes are predicted by preoperative mechanical symptoms, such as those resulting from loose bodies or meniscal tears, or radiographic evidence of only mild articular degeneration.8-10 However, other studies have not been able to identify any predictive factors for outcome.11 Two recently reported randomised controlled trials have attempted to clarify the benefits of these forms of treatment. In one, 180 patients with knee osteoarthritis were randomly allocated to tidal needle irrigation or sham irrigation (in which the knee capsule was not punctured by the needle).12 After 12 months, the study found that patients in both groups had a 17% improvement in pain and physical function scores, with no statistically significant difference between the two groups. It was suggested that most, if not all, of the benefit of irrigation was a placebo effect. In a more recent randomised controlled trial, 180 patients were randomly allocated to three treatment groups — arthroscopic lavage and debridement, arthroscopic lavage alone, or sham surgery.5 Follow-up at 12 months found little improvement in patients in each of the three groups (as assessed by outcome measures such as the Knee Specific Pain Scale, the Arthritis Impact Measurement Scales and the SF-36 Health Survey), and no statistically significant difference between the groups. The inclusion of sham procedure groups and the adequate power of these randomised controlled trials allowed them to better address questions about comparative benefits and placebo effects raised in previous smaller randomised trials. However, although selection criteria for both studies were clearly stated, specific clinical indications for arthroscopy were not clearly defined. Such indications can vary considerably between practitioners. A recent study found that agreement between two groups of surgeons (research fellows and attending staff), independently predicting which patients undergoing arthroscopic debridement for knee osteoarthritis would improve, was only slightly better than chance, with neither group predicting the correct outcome more than 59% of the time.13 One indication for which arthroscopic treatment of knee osteoarthritis has been widely regarded as successful is the presence of meniscal tears. Unfortunately, neither of the recent randomised trials analysed patients with meniscal tears separately. Such an analysis would have been especially valuable in the light of a report that meniscal tears in patients with osteoarthritis were not associated with any increase in pain or impairment.14 Few studies specify treatment failure with alternative or less invasive therapies as a prerequisite to enrolment, although this may have a substantial impact on their overall success. An earlier randomised controlled trial found that, of 200 patients screened during the enrolment period, more than half improved sufficiently with conservative medical management (exercise and medication) such that no further medical or surgical treatment was warranted at the follow-up visit.8 The authors noted that “none of the studies of arthroscopy for this population in the orthopaedic surgery literature specified previous rehabilitation treatment . . . and many patients included in previous studies would have benefited from medical and rehabilitation therapy alone”. With the role of arthroscopy for osteoarthritis of the knee now challenged, but concerns about the enrolment criteria of recent studies persisting, there remains a need for further investigation. Randomised controlled trials of surgical interventions are notoriously difficult,15 but, compared with other surgery, there are features about arthroscopic surgery for knee osteoarthritis that would facilitate undertaking such trials. Equipoise over the benefits of the procedure is now well established in the medical literature, and the high prevalence of knee osteoarthritis means that, even if only a small percentage of patients are willing to be enrolled in trials, it is likely that sufficient power could still be achieved to test most clinical hypotheses. In addition to randomised controlled trials, population-based studies are needed. A Canadian evaluation of 14 391 arthroscopic knee debridement procedures for osteoarthritis found that almost 10% of patients required total knee replacement within 1 year after debridement. Rates of arthroplasty were particularly high in those aged 70 or older, and it was suggested that debridement may currently be overutilised in elderly patients.16 Given the increasing prevalence of knee osteoarthritis with an ageing population, it is important for clinicians to recommend options such as arthroscopy with good reason. At present, both the benefits of therapeutic arthroscopy and its role among alternative treatments for knee osteoarthritis remain unclear.

Adam B Chapman BA/BSc(Hons), MPH · Julian A Feller MB BS FRACS

Guides casebook. Cases to accompany Guides to the evaluation of permanent impairment, 5th edition. Christopher R Brigham, Leon H Ensalada, James B Talmange. Chicago: AMA Press, 2002 (xi + 384 pp). ISBN 1 57947 264 8. Impairment evaluation using the American Medical Association (AMA) Guides is an important requirement in the medico-legal arena, but correct application can be a daunting process given the Guides’ complexity. This casebook highlights the need for a good understanding of how to apply the Guides correctly and for a thorough objective assessment. For clinicians involved in impairment assessment, this book provides an insight into the methods of evaluation as well as some of the shortcomings of these methods. Sixty-eight cases are presented, most of them relating to musculoskeletal disorders. There is a broad spread of clinical cases; ranging from the more severe and catastrophic injuries, to more common conditions. The more controversial and ill-defined conditions, such as complex regional pain syndrome, fibromyalgia and the curiously termed "elusive cumulative trauma disorder", are discussed in detail. Each case is presented with a history and physical examination followed by a discussion of the rating according to the 4th and 5th edition of the Guides. After each case, there is a useful explanation of the differences between the ratings as well as relevant discussion on the difficulties of evaluating impairment. In most cases, there is little difference between the rating according to the 4th and 5th editions, one exception being impairment of the spine. The other differences are mostly with regard to musculoskeletal disorders. Given the current preponderance of claims for loss of sexual function following spinal injury, and cognitive loss following relatively mild traumatic head injury, the detailed discussion of these cases is particularly relevant. Problems associated with impairment evaluation in the presence of pain behaviour and in patients with poor credibility are also discussed. This book is topical, user friendly and essential for clinicians who carry out independent impairment evaluations. Although many insurance companies require clinicians to complete a certified course before undertaking evaluations, this casebook illustrates that being certified in the use of the Guides is not sufficient. Thorough and objective clinical examination remains a necessity for impairment evaluation, particularly in musculoskeletal injury. My experience in reading medico-legal reports is that while ratings according to the AMA Guides are frequently quoted, the clinical findings of the examiner often do not stand up to close scrutiny, and incorrect impairment ratings are sometimes provided. Hopefully, this casebook will assist both doctors and lawyers in their quest to provide objective and accurate evaluation of impairment. The book is value for money and essential reading for those who are called upon to provide an assessment of impairment. Seamus E DaltonOrthopaedic Surgeon Crows Nest, NSW Order this book See also:• Guides to the evaluation of permanent impairment (5th edition) • Special package prices

Seamus E Dalton

To the Editor: We applaud the efforts of Wasiak et al to apply the principles of evidence-based medicine to answer clinical questions.1 However, it is important to understand the historical context of clinical trials reported in the literature, and, when necessary (eg, when conducting a meta-analysis or when the results of trials appear to conflict), to seek additional information from the authors. One of us (H K G) designed the randomised-controlled trial (RCT) reported by Corry et al.2 It was a pilot study and not a definitive clinical trial. The primary outcome measure was resonant frequency, an objective measure of muscle stiffness. This trial was conducted before the introduction of validated outcome measures for assessing upper limb function in children with cerebral palsy, and it was not possible to perform any sample size calculation for functional outcomes. At 12 weeks in the group receiving injections of botulinum toxin A, there was a significant difference in grasp and release but not in the ability to pick up coins. It is not surprising therefore that this study found significant decreases in muscle stiffness, but the functional results were inconclusive. The other RCT identified by Wasiak et al also involved one of us (D F).3 It was designed specifically to investigate functional outcomes, a sample size calculation was performed from pilot work, and a specific functional outcome measure (QUEST) was used. This study reported significant functional improvements after the use of botulinum toxin combined with occupational therapy. These two studies, when understood in their historical sequence, should therefore be considered complementary and not contradictory. It is important to assess the quality of randomised clinical trials as well as their conclusions (eg, using the Physiotherapy Evidence database PEDRO scale <http://ptwww.fhs.usyd.edu.au/pedro>).4,5 The smaller study by Corry et al2 had insufficient power and inadequate methodology to investigate functional outcomes. On the other hand, the conclusions of the study by Fehlings et al3 should be taken as the current level of evidence. We therefore submit that the conclusion drawn by Wasiak et al is incorrect. We support further research to evaluate and strengthen the evidence relating to botulinum toxin A and upper-extremity function.6

H Kerr Graham · Roslyn N Boyd · Darcy Fehlings

In reply: We thank Graham et al for their response to our article.1 It is important to understand that the clinician who posed the question regarding botulinum toxin A injection wished to find the "best available medical evidence". We were not asked to take account of the historical context of previously published articles, nor were we asked to exclude specific types of RCTs. If we were to exclude specific RCTs based on the preference of an author, then the strong methodological principles that surround the evidence-based practice movement would be open to extreme forms of bias. We also disagree that our conclusions were incorrect. Our reading of the article by Corry et al2 differed from that of Graham et al. We do not consider that their study showed that botulinum toxin injection significantly improved the function of the hemiplegic upper limb. Together with the results of the study by Fehlings et al,3 indicating a significant improvement in weight-bearing at four weeks (part of the QUEST assessment), our conclusion — that we could not support or refute the efficacy of botulinum toxin injections for improving upper-limb function in cerebral palsy because of differing opinions — remains unchanged.

Jason Wasiak · Brian J Hoare

To the Editor: We were interested to read the recent supplement on preventing osteoporosis.1 We could find only one reference to cigarette smoking, on page S13, where it is noted that "the role of lifestyle changes (including specific exercise regimens, changes in diet and quitting smoking) has not been evaluated adequately". The orthopaedic literature is replete with information and evidence on the adverse effects of cigarette smoking on bone density, healing of fractures, incorporation of bone grafts, etc. A meta-analysis2 has suggested that smokers have greater bone loss over time than non-smokers. Granted, there may as yet be no direct evidence that quitting smoking reduces "the fracture burden". However, to discuss osteoporosis and management of fractures without discussing the major adverse effects of cigarette smoking is akin to discussing the prevention of melanoma and the outcomes of treatment without discussing unprotected exposure to sunlight (for example). Could the "writing group" tell us what steps are being taken to inform Australians of the adverse effects of cigarette smoking on their bones, quite apart from the other public health issues surrounding this extraordinarily harmful habit?

Roy PL Carey · Walter E Plehwe · Peter R Ebeling

In reply: On behalf of the writing group, I wish to thank Carey and Plehwe for their perceptive comment on the effects of cigarette smoking on bone health. The focus of our supplement was the prevention of fragility fractures, and unfortunately there is no evidence that smoking cessation reduces fracture rate. However, the authors are correct to emphasise the negative impact of cigarette smoking on fracture healing, bone graft incorporation and bone density, the last factor being a strong predictor of fragility fracture. The meta-analysis that Carey and Plehwe refer to1 showed that hip bone mineral density (BMD) in current smokers was one-third of a standard deviation below that of people who had never smoked. This meta-analysis and another recent study2 showed that these effects are greatest in men and are dose-dependent. Prospective studies also show that smokers have higher rates of bone loss than non-smokers. Extrapolations from these BMD data suggest smoking increases the lifetime risk of vertebral fracture by 13% in women and 32% in men, while hip fractures are increased by 31% and 40%, respectively. In response to the question of what steps are being taken to publicise the effects of smoking on bone health, we would like emphasise that further prospective studies are urgently required to assess the effect of smoking cessation on fracture risk, BMD and bone turnover; and the message that smoking has a negative impact on BMD should be incorporated into public education campaigns run by government and non-government organisations for both osteoporosis prevention and smoking cessation. This area of bone health is eminently suited to successful intervention.

Roy PL Carey FRACS · Walter E Plehwe MB BS FRACP PhD · Peter R Ebeling MD FRACP

1: Clinical records Case 1: A 46-year-old Indian man required lumbosacral (Steffee) fusion1 for chronic low-back pain after a successful laminectomy for disc herniation sciatica. Good pain relief was obtained for four weeks after the operation, and then his back pain recurred. After a brief period of symptomatic treatment, he was re-operated on at six weeks, and the metal screws and plates, which were found to be loose in the bone, were removed. The bone was noted to be softer than normal and the fusion was not sound. Swabs for infection were sterile. The patient gave a history of long-term adherence to a vegetarian diet, as well as continuous night-shift work for 10 years with minimal sunlight exposure. He had never smoked. His 25-hydroxyvitamin D (25OHD) concentration was < 12 nmol/L (reference range, 35–155 nmol/L). The results of laboratory tests were calcium, 2.27 mmol/L; albumin, 38 g/L; phosphate, 1.33 mmol/L; alkaline phosphatase, 179 U/L (reference, < 120 U/L); and γ-glutamyltransferase, 195 U/L (< 65 U/L). The patient was taking carbamazepine, which may account for the liver function abnormalities. Vitamin D supplementation (ergocalciferol, 2000 units daily) was commenced. Dietary calcium intake was assessed as at least 800 mg/day. Physiotherapy, initiated because of his back problems, was continued and his work was transferred to day-time shifts only. After eight weeks of treatment and sunlight exposure, the results of laboratory tests were calcium, 2.44 mmol/L; albumin, 45 g/L; alkaline phosphatase, 117 U/L; γ-glutamyltransferase, 102 U/L; and 25OHD, 125 nmol/L. Plain x-ray and computed tomography scan showed his fusion to be sound at 12 months and his symptoms to be much improved. Case 2: A 49-year-old white woman was admitted for elective removal of metal plates (Steffee) from L2–L3 fusion two years previously. Before x-ray films were obtained, it was hoped that her fusion was sound. However, imaging had suggested the pedicle screws had loosened, contributing to ongoing low-back pain and sciatica (Figure 1). Furthermore, x-ray of the lumbar spine in flexion showed narrowing of the angle between the end-plates of L2 and L3, indicating movement posteriorly (Figure 2). At operation, all screws were grossly loose, and a bone graft placed posterolaterally had not joined to the vertebral bodies. Further bone chips were inserted, and a bone biopsy was taken. Swabs for infection were sterile. Areas of woven bone were present and the appearance of the osteoid suggested a mineralisation defect, although undecalcified sections were not available. This patient had a four-year history of insulin-requiring diabetes mellitus, for which she also took metformin, glibenclamide and pioglitazone. Other medical problems included obesity (body mass index, 44 kg/m2), hypertension and bronchospasm, treated without long-term inhaled or systemic corticosteroids. She had never smoked. Her 25OHD concentration was < 12 nmol/L. Ergocalciferol 3000 units daily was commenced. The serum alkaline phosphatase level was normal (79 U/L). Dietary calcium intake was considered adequate. Specific questioning revealed a history of "hating the sun", and avoiding exposure to sunlight throughout her adult life. One month later, her 25OHD concentration was 27 nmol/L and the dose of ergocalciferol was increased to 4000 units daily. Six months after operation, imaging suggested that the new bone graft had become incorporated into the spine. Figure 1: Lateral x-ray of the lumbar spine in extension. Arrow denotes a radiolucent zone at the margin of the upper screw, indicating loosening. Figure 2: Lateral x-ray of the lumbar spine in flexion, showing significant narrowing of the angle between the endplates of lumbar vertebrae 2 and 3, compared with Figure 1. Recently, attention has again been drawn to the high prevalence of severe vitamin D deficiency in certain population groups in Australia, including veiled and dark-skinned women and their children.2,3 Another group at high risk are the elderly: 67% of older patients admitted to a short-stay geriatric rehabilitation unit were found to have vitamin D deficiency.4 A similar prevalence has been found in residents of nursing homes.5 However, it is not widely appreciated that moderate to severe vitamin D deficiency may also occur in middle-aged people. Our two patients were in their late 40s when severe vitamin D deficiency became apparent. In the first patient, recurrent pain a short time after surgery was of such severity that internal fixation plates had to be removed. The screws were loose, and, in the absence of infection, the profound vitamin D deficiency can be assumed to have resulted in failure of mineralisation of osteoid and hence failure of the surgical procedure, with resulting increased morbidity. This patient had multiple risk factors for vitamin D deficiency (pigmented skin, habitual night-shift work and a vegetarian diet). Although he now exercises regularly, including during daylight hours, and works day-time shifts, he has required ongoing vitamin D supplementation to maintain satisfactory 25-hydroxyvitamin D (25OHD) concentrations. The second patient's bone had an abnormal histological appearance, and, despite an omnivorous diet, her choice to avoid direct sunlight for many years had resulted in profound vitamin D deficiency. Vitamin D deficiency of the severity reported here is extremely uncommon in younger Australian adults. However, patients with long-standing orthopaedic or spinal disorders who become housebound may be particularly at risk, irrespective of their age. The functions of vitamin D in bone metabolism are well known and its deficiency may be reconciled with the failure of spinal fusion, as described in these patients. This report highlights the need for attending surgeons and physicians to be aware of the potential for vitamin D deficiency in their patients, since failure to recognise this easily reversible problem may result in complications of treatment, including failure of spinal fusion surgery, additional morbidity and the substantial costs of further surgery and hospitalisation. Lessons from practice Persistence or recurrence of low back pain and sciatica after spinal fusion surgery may indicate failure of the operation. Risk factors include infection, smoking and vitamin D deficiency. Patients at any age who actively avoid exposure to sunlight are at risk of vitamin D deficiency. Vitamin D deficiency is readily identified and corrected and should be considered in patients who may require spinal fusion surgery.

Walter E Plehwe FRACP, PhD · Roy PL Carey MB BS, FRACS

Joint arthroplasty is arguably the most successful operation in modern times. Orthopaedics of the future, however, will focus on new strategies for contemporary problems that integrate advancing technology and basic science with surgery. Figure: (a) MRI scan of a popliteal tumour gives excellent contrast to help plan surgical margins. (b) Increased metabolic activity on functional scanning (arrows) reflects either a high-grade tumour or a poor response to adjuvant therapy. (c) In future, growth factors may be used to enhance bone formation around prostheses (arrows) to increase their biological fixation and longevity. Diagnosis. Orthopaedics relies heavily on accurate anatomical imaging. Developments in soft-tissue contrast using magnetic resonance imaging (MRI) and the ability to demonstrate inflammation, hypervascularity and accurate anatomy has enhanced non-invasive diagnosis of such conditions as meniscal tears, labral tears in the hip, and occult fractures. MRI has been particularly valuable in assessing resectability of primary bone and soft-tissue malignancies when planning surgical margins and assessing the appropriateness of amputation or limb preservation. Future diagnostic modalities will combine anatomical with functional imaging, such as positron emission tomography, to improve the assessment of bone and soft-tissue lesions. Molecular biology and cytogenetics play increasing roles in the diagnosis of orthopaedic conditions, of which a substantial number have a genetic basis (eg, Marfan's syndrome, osteopetrosis and osteogenesis imperfecta). Identifying subcellular anomalies also clarifies aetiological mechanisms and helps to plan strategies for treatment and genetic counselling. Many sarcomas also display characteristic cytogenetic abnormalities1 with prognostic and tumorigenic significance. Future genetic studies of musculoskeletal tumours are likely to define subsets of patients who are good and poor responders to therapy, as well as identifying the genes responsible in many syndromes, dysplasias and cancers.2 Treatment. Delayed healing and non-union of fractures are responsible for protracted disability and pain. A variety of growth factors, such as the bone morphogenetic proteins (BMPs),3 are now known to be important in stimulating bone formation. Synthetic growth factors for treating problem fractures can now be mass produced using recombinant-DNA technology. Future strategies are likely to include coating prostheses with factors that stimulate bone formation to enhance the biological fixation of these devices. This would be particularly relevant for joint arthroplasty in young patients, for whom aseptic loosening of cementless prostheses is the commonest reason for revision surgery. Recently, factors that stimulate and inhibit osteoclast formation and function have been identified. Regulation of these factors by genetic manipulation or introduction of synthetic analogues may have important applications in treating conditions that have a genetic basis. Explantation of tissue, its manipulation and subsequent reimplantation into the body is a novel method for treating acquired musculoskeletal defects. Some articular cartilage defects can be treated by harvesting the patient's own articular cartilage cells, culturing them in vitro and then reimplanting them into the articular defects during surgery to obliterate the defect. Future strategies may include cloning explanted cells with genes that enhance their growth and production of cartilage matrix before reimplantation. Guided engineering of other tissues, such as muscle, ligaments and bone, is likely to extend the armamentarium of reconstructive surgeons for patients with post-traumatic or resection defects.4 Despite intensive chemotherapy, 30% of patients with osteosarcoma succumb to metastatic disease. The targets for future treatment are likely to be identified from studies of the metastatic cascade. For example, proteolysis is known to be important in tumour progression, and the expression of the urokinase plasminogen activator system during the growth of osteosarcoma has been identified.5 By genetically manipulating the expression of components of the urokinase plasminogen system in an animal model of osteosarcoma we have significantly inhibited the behaviour of osteosarcoma, paving the way for developing non-toxic strategies for treating this tumour. Prevention. In contrast to the advances in diagnosis, progress in improving prevention through genetic information has been slow. Conditions for which this has been successful include X-linked hypophosphataemic rickets and osteogenesis imperfecta. With over 40 000 joint replacements performed each year in Australia and a failure rate of 1% per year, techniques to reduce the failure rate from misalignment of the prosthesis are likely to have a major impact on clinical outcome and resource utilisation. Computer-assisted, image-guided surgery will improve the accuracy of surgical technique in the future, and may be extended to facilitate minimally invasive surgery. Important features of orthopaedics in the future will be multidisciplinary collaboration and reliance on high technology. The markedly increased safety in anaesthesia will allow more and bigger surgical procedures to be performed on an ageing population.

Peter FM Choong MD, FRACS, FAOrthA

Editorial Breaking the back of back pain Public policy initiatives directed towards managing the disability of back pain can be highly successful MJA 2001; 175: 456-457 Disability from low back pain is a growing public health problem in Australia and developed countries worldwide, and one of the major issues targeted in the Bone and Joint Decade (2000-2010).1 Most population-based surveys of back pain report a point prevalence of 15%-30%, a one-year prevalence of 50%, and a lifetime prevalence of 60%-80%.2 Although episodes of acute low back pain are mostly short-lived, back complaints still constitute the second most common symptom (after upper respiratory complaints) prompting general practice encounters.3 Furthermore, disability from back pain places a significant socioeconomic burden on the individual and the community. In Australia, back problems are the leading specific musculoskeletal cause of health system expenditure, with an estimated total cost of $700 million in 1993-1994.4 Moreover, these costs are rising: in Victoria alone, claims lodged for back injury with the workers' compensation scheme cost the community $510 million in the 1999-2000 financial year.5 Attempts to reduce the burden of disability associated with back pain have often been directed towards prevention of pain per se, particularly in an occupational setting. Although direct involvement of workplace management in primary prevention strategies has had positive effects, interventions such as education, training and exercise programs for the back, ergonomic interventions and screening potential employees for risk factors for the development of back pain or injury have had limited success.6 Paradoxically, interventions aimed at preventing chronicity, such as early exercise, physiotherapy, rehabilitation and education programs, when implemented early (ie, within the first few weeks of back pain), are largely ineffective for improving longer-term outcomes.7 Attitudes and beliefs, particularly fear-avoidance beliefs, pain-coping strategies and illness behaviours, are important issues to consider when treating patients with back pain.8 While psychosocial approaches that seek to remedy unfounded fears and poor coping methods have met with limited success in treating patients with established chronic back disability, these approaches may be effective when implemented early in the course of back pain and could even be of value when directed towards those who have yet to develop back complaints. Provision of positive messages, such as those designed to improve attitudes to back pain and diminish fear, reduce self-reported disability in patients presenting with low back pain in general practice.9 These interventions also reduce extended work absence in industrial settings.10,11 The Victorian WorkCover Authority's statewide media campaign "Back pain — don't take it lying down", which commenced in 1997 (Box 1), aimed to provide a new approach through prime-time television advertisements featuring health professionals, and sports and local television celebrities. The messages, all endorsed by the relevant professional healthcare organisations, were simple: back pain is not a serious medical problem; disability can be reduced and even prevented by positive attitudes; and treatment should consist of continuing to perform usual activities, not resting for prolonged periods, exercising and remaining at work. The campaign counselled individuals with low back pain, their doctors and employers to avoid excessive medicalisation of the problem, and unnecessary diagnostic testing and treatment. A three-part evaluation of this campaign (evaluating general population attitudes, general practitioners, and the WorkCover Authority claims database) suggests that there has been widespread adoption of these messages (Box 2).13,14 The campaign successfully managed to: "de-medicalise" a public health problem; ease the burden on general practitioners and specialists; empower workers to solve their own health challenges; and save workers' compensation payments. The success of the campaign has been attributed to many factors, including the simple, direct language used to convey the messages, and the evidence-based content, both pioneered by the authors of The back book.12 In addition, virtually every professional body with a stake in back pain in Australia supported the campaign. Before this campaign, there was limited empirical evidence that primary preventive interventions reduce the overall burden of illness associated with low back pain. Now, evaluation of the campaign has shown that a public policy initiative directed towards managing the disability of back pain can be highly successful. There are compelling arguments for this approach. These include, firstly, the impression that informative interventions may be of more value when initiated early, even before the onset of symptoms; and, secondly, predictive models of low back pain are not presently able to identify those at risk of disability. By targeting the entire population, this public health approach reaches those hard-to-identify high-risk groups. There is evidence that a population strategy of universal change has greater overall effect than targeted high-risk strategies. Finally, the population approach may be an effective way of modifying doctors' behaviour, both through direct influences as well as through a change in the attitudes of their patients. Media campaigns are an established strategy for delivering preventive health messages. They have been particularly successful in Australia in altering health-related behaviours, such as sunlight exposure through the Slip! Slop! Slap program and smoking through the Quit program. With good evidence that negative attitudes and beliefs are important predictors of disability related to back pain, altering societal views of back pain would seem a highly appropriate policy to adopt. The long-term impact of this campaign is not clear. Recent publicity by the Victorian WorkCover Authority has focused on ergonomic interventions in the workplace — strategies that the United States has controversially rejected. Clinical effectiveness is not the only influence on policy:15 policymakers' own interests and ideologies are often significant. We may have to look to other interested industrialised societies, such as Sweden, the Netherlands or Canada, for evidence of this novel campaign's long-term effectiveness. Competing interests We received funding from the Victorian WorkCover Authority to conduct an independent evaluation of the media campaign. Rachelle Buchbinder Director, Department of Clinical Epidemiology, Cabrini Hospital; and Associate Professor, Monash University Department of Epidemiology and Preventive Medicine, Melbourne, VIC Damien Jolley Associate Professor, School of Health Sciences Deakin University, Melbourne, VIC Mary Wyatt Occupational Physician, Melbourne, VIC Brooks PM, Hart JAL. The Bone and Joint Decade: 2000-2010. Med J Aust 2000; 172: 307-308. Nachemson A, Waddell G, Norlund A. Epidemiology of neck and back pain. In: Nachemson A, Jonsson E, editors. Neck and back pain: The scientific evidence of causes, diagnosis, and treatment. Philadelphia: Lippincott Williams & Wilkins, 2000: 165-188. Bridges-Webb C, Britt H, Miles DA, et al. Morbidity and treatment in general practice in Australia 1990-1991. Med J Aust 1992; 157(Suppl Oct 19): S1-S56. Mathers C, Penn R. Health system costs of injury, poisoning and musculo-skeletal disorders in Australia 1993-94. Canberra: Australian Institute of Health and Welfare, 1999. AIHW Catalogue No. HWE 12 (Health and Welfare Expenditure Series No. 6). Annual Report Victorian WorkCover Authority 1999/2000. Melbourne (VIC): Victorian WorkCover Authority, 2001. Frank JW, Kerr MS, Brooker A-S, et al. Disability resulting from occupational low back pain. Part I: What do we know about primary prevention? A review of the scientific evidence on prevention before disability begins. Spine 1996; 21: 2908-2917. Frank JW, Brooker A-S, DeMaio SE, et al. Disability resulting from occupational low back pain. Part II: What do we know about secondary prevention? A review of the scientific evidence on prevention after disability begins. Spine 1996; 21: 2918-2929. Waddell G, Newton M, Henderson I, Somerville D, Main CJ. A Fear-Avoidance Beliefs Questionnaire (FABQ) and the role of fear-avoidance beliefs in chronic low back pain and disability. Pain 1993; 52: 157-168. Burton A, Waddell G, Tillotson KM, Summerton N. Information and advice to patients with back pain can have a positive effect. A randomised controlled trial of a novel educational booklet in primary care. Spine 1999; 24: 1-8. Symonds TL, Burton AK, Tillotson KM, Main CJ. Absence resulting from low back trouble can be reduced by psychosocial intervention at the work place. Spine 1995; 20: 2738-2745. Indahl A, Velund L, Reikeraas O. Good prognosis for low back pain when left untampered. A randomized clinical trial. Spine 1995; 20: 473-477. Roland M, Waddell G, Moffat J, et al. The back book. London: The Stationery Office; 1996. Buchbinder R, Jolley D, Wyatt M. Population based intervention to change back pain beliefs and disability: three part evaluation. BMJ 2001; 322: 1516-1520. Buchbinder R, Jolley D, Wyatt M. Effects of a media campaign on back pain beliefs and its potential influence on management of low back pain in general practice. Spine 2001. In press. Black N. Evidence based policy: proceed with care. BMJ 2001; 323: 275-278. Make a comment 1: Victorian WorkCover Authority back pain campaign (1997-2000): "Back pain — don't take it lying down" The campaign was based on the messages outlined in The back book, an evidence-based patient educational booklet.12 Messages Positive advice to stay active and exercise, not to rest for prolonged periods, and to remain at work; Encouragement for patients to take responsibility for getting better and coping; Advice that physical activity and work won't cause harm, that investigations may not be helpful, and surgery may not be the answer. Campaign Concentrated campaign for 3 months initially, followed by a low-key maintenance campaign, with a top-up 3-month concentrated campaign 2 years later; Television commercials, aired in prime-time slots; radio and printed advertisements; outdoor billboards, posters, seminars; workplace visits and publicity articles; Promotion by recognised international and national medical experts, Australian sporting and television personalities, and endorsement by the relevant national professional bodies; The back book, translated into 16 languages, made widely available; and Management guidelines for compensable back pain provided to all Victorian doctors. Target audience The general community, health professionals, and employers. Back to text 2: Evaluation of the Victorian WorkCover Authority back pain campaign Study design Quasi-experimental, non-randomised, non-equivalent, before-after telephone surveys of the general population in Victoria, with New South Wales as the control group; Similar before-after postal surveys of general practitioners in both States; and Descriptive analysis of Victorian WorkCover Authority claims database Results Attitudes of the general population to back pain and its treatment in Victoria changed by more than 10%, while in NSW they remained essentially static. Doctors in Victoria, in contrast to those in NSW, reported much lower probabilities of instigating medical interventions for patients presenting with low back pain. There was an immediate and significant impact of the campaign on the patterns of workers' compensation back claims in Victoria. The rate of medical payments for back claims fell by more than 25% during the period October 1997 - October 2000, and the rate of compensated days for back claims dropped from 75 days per 1000 claim-days to 55 days per 1000 claim-days during the same period. Back to text

Rachelle Buchbinder · Damien Jolly · Mary Wyatt

Editorial Clinical pathways and fractured neck of femur The generalisability and cost effectiveness of clinical pathways need further research MJA 2000; 172: 415-416 The proportion of Australians aged 65 and over is projected to continue increasing for the next 50 years.1 Fractures of the neck of femur are common in this age group and are associated with increased risk of morbidity and mortality, long-term institutionalisation and costly management. Their impact on a public healthcare system funded by an ever-diminishing number of tax-paying workers is a major concern. Increasing attention is being given to improving management of these fractures and rehabilitation of patients.2-5 Morbidity and mortality rates have been reduced through increased surveillance for and treatment of complications, such as wound and other infections, pressure sores and deep venous thrombosis. Early involvement of multidisciplinary teams in patient rehabilitation and early mobilisation have been used in large hospitals to reduce delays and optimise treatment for previously ambulatory patients. These programs result in fewer perioperative complications and enable patients to return home and resume functional independence earlier, reducing the number who need long term residential aged care.2,3 However, these improvements come at a cost -- direct costs, such as salaries of additional staff for multidisciplinary teams,6 and indirect costs, such as when patients are sent home early, and postdischarge care is assumed by family and community.7 Pressure on hospital administrations to contain or reduce costs may result in outcomes of little, if any, benefit to the patient, but which may have a substantial impact on others living with or looking after the patient. Little is known about the nature and extent of this potential impact. Implementation of these efforts needs to be both preceded and accompanied by careful evaluation and assessment. Among strategies that attempt to achieve savings is the development and use of clinical pathways, as outlined by Choong and colleagues8 in this issue of the Journal. A clinical pathway is a type of management plan formulated for a specified condition, which defines expected daily activities, identifies lines of responsibility for those activities, and indicates goals for the patient to achieve along the way.9 These pathways are based on a multidisciplinary perspective and collaboration. Introduction of a clinical pathway requires considerable commitment and investment of time from many departments within the hospital, as well as substantial changes to the medical record. It also raises concerns about the medicolegal implications of non-compliance with the pathway in the event of an adverse outcome. All these issues require further study.10,11 Clinical pathways have been successfully implemented for a variety of conditions and settings, overseas and in Australia. However, patient groups have been relatively homogeneous, such as those having elective hip, knee or other surgery. In contrast, hip-fracture patients are very heterogeneous, ranging from the fit, active (albeit osteoporotic) "young" elderly, to the very frail, bedridden 90-years-plus residents of nursing homes. A clinical pathway developed from evidence-based practices may be the most efficient way to restore the mobility of elderly patients and ensure their discharge back to their pre-admission residence. However, because of the high level of comorbidities in these patients, the potential for variation from the pathway is high.2 Choong and colleagues describe a controlled trial of a clinical pathway for patients with proximal femoral fracture in a major teaching hospital.8 Modest benefits were found for the hospital budget, and clinical outcomes for patients on the pathway appeared no worse than for patients who received standard hospital treatment. Use of the pathway seemed to have little real effect on shortening stay in comparison with the control group; the major difference in stay was found for patients who required review by the Aged Care Assessment Team and were therefore likely to be frailer. The frail elderly have not usually been seen as a target group for clinical pathways, but future studies of this group may show that they benefit from this approach without adverse outcomes on complications or discharge destinations. This study illustrates the problems of assessing the usefulness of clinical pathways, which should be addressed in the design of future studies. The clinical relevance of short reductions in length of hospital stay (1.4 days in this instance) is open to question. Economic aspects need to be documented as part of study design to allow analysis of cost effectiveness. The real effectiveness of the pathway for the community, rather than just the hospital, remains unclear, and future studies need to include strategies to assess that effect. The overall economic benefit to the community should take into account the increased use of community services, use of interim or permanent residential care, and extra costs and stress for families who provide a large proportion of the care after discharge from hospital.3 Clinical pathways have developed primarily in large metropolitan hospitals with resources to research and implement the process, while proximal femoral fractures are treated in a wide range of hospitals with varying levels of funding and allied health support. These pathways may have the potential to improve clinical outcomes and costs in hospitals where the number of femoral fracture patients is too small to warrant an orthogeriatric unit or where there is no access to a designated rehabilitation unit. Ultimately, the generalisability of this approach will become evident as more research in this area is reported. Recent reports in the Journal highlight the difficulties in transforming evidence into practice.12,13 Despite these difficulties, compliance with evidence-based best practice in the management of fractured neck of femur, together with preventive measures such as early management of osteoporosis and falls prevention programs, should help lessen the current and future economic and personal burden of hip fracture in Australia. Cheryl E Swanson Research Scientist, Division of Orthopaedic Surgery Catherine E Yelland Director, Geriatric Assessment and Rehabilitation Unit Gregory A Day Senior Lecturer, Division of Orthopaedic Surgery University of Queensland and Royal Brisbane Hospital Brisbane, QLD Cooper C, Campion G, Melton IJ III. Hip fractures in the elderly: a world-wide projection. Osteoporosis Int 1992; 2: 285-289. March LM, Chamberlain AC, Cameron ID, et al. How best to fix a broken hip. Med J Aust 1999; 170: 489-494. Swanson CE, Day GA, Yelland CE, et al. The management of elderly patients with femoral fractures. A randomized controlled trial of early intervention versus standard care. Med J Aust 1998; 169: 515-518. Dowsey M, Kilgour M, Santamaria N, Choong PFM. A prospective study of clinical pathways in hip and knee arthroplasty. Med J Aust 1999; 170: 59-62. Sanders KM, Nicholson GC, Ugoni AM, et al. Health burden of hip and other fractures in Australia beyond 2000. Med J Aust 1999; 170: 467-470. Farnsworth MG, Kenny P, Shiell A. The costs and effects of early discharge in the management of fractured hip. Age Aging 1994; 23: 190-194. Caplan G, Board N, Paten A, et al. Decreasing lengths of stay: the cost to the community. Aust N Z J Surg 1998; 68: 433-437. Choong PFM, Langford AK, Dowsey MM, Santamaria NM. Clinical pathway for fractured neck of femur: a prospective controlled study. Med J Aust 2000; 172: 423-427. Tallis G, Balla JI. Critical path analysis for the management of fractured neck of femur. Aust J Pub Heath 1995; 19: 155-159. Kitchiner DJ, Bundred PE. Clinical pathways: a practical tool for specifying, evaluating and improving the quality of clinical practice. Med J Aust 1999; 170: 54-55. Dwyer P. Legal implications of clinical practice guidelines. Med J Aust 1998; 169: 292-293. Doust JA, Silagy CA. Applying the results of a systematic review in general practice. Med J Aust 2000; 172: 153-156. Rubin GL, Frommer MS, Vincent NC, et al. Getting new evidence into medicine. Med J Aust 2000; 172: 180-183. Make a comment Choong

Cheryl E Swanson · Catherine E Yelland · Gregory A Day

Healthcare Clinical pathway for fractured neck of femur: a prospective, controlled study Peter F M Choong, Anna K Langford, Michelle M Dowsey and Nick M Santamaria MJA 2000 172: 423-426 For editorial comment, see Swanson et al Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Orthopaedic surgery Abstract Objective: To assess outcomes of using a clinical pathway for managing patients with fractured neck of femur. Design: Prospective, pseudorandomised, controlled trial. Setting: St Vincent's Hospital, Melbourne, Victoria (a tertiary referral, university teaching hospital), 1 October 1997 to 30 November 1998. Participants: 111 patients (80 women and 31 men; mean age, 81 years) admitted via the emergency department with a primary diagnosis of fractured neck of femur. Interventions: Management guided by a clinical pathway (55 patients) or established standard of care (control group, 56 patients). Main outcome measures: Timing of referrals and discharge planning; total length of stay; and complication and readmission rates within 28 days of discharge. Results: Patients managed according to the clinical pathway had a shorter total stay (6.6 versus 8.0 days; P = 0.03), even if assessment for placement by the Aged Care Assessment Service was required (9.5 versus 13.6 days; P = 0.03). There were no significant differences in complication and readmission rates between pathway and control patients (complication rates, 24% versus 36%; P = 0.40; readmission rates, 4% versus 11%; P = 0.28). Conclusion: Coordinated multidisciplinary care of patients with fractured neck of femur reduces length of stay without increasing complications. By 2050, a quarter of Australia's population will be aged over 65 years, and the incidence of hip fractures is consequently expected to increase fourfold.1 The logistic challenge posed by this increasing incidence and the fourfold greater resources needed by patients over 65 years compared with the average patient2 will be compounded by the expected continuing decline in bed availability. Improving the efficiency of health service delivery to patients with hip fractures may help improve overall availability of acute hospital beds for other elective surgery. Clinical pathways are proposed as a means of providing high quality care in a timely and cost-effective manner. These pathways consist of treatment protocols that aim to streamline and standardise management with multidisciplinary input from medical, nursing, paramedical and administrative staff. They have been used successfully to improve outcomes after elective hip and knee joint replacement.3 This led us to examine the impact of such a coordinated approach on acute and unpredictable admissions such as in patients with femoral-neck fractures. However, surgery for acute hip fracture differs significantly from hip joint replacement as it is non-elective and patient needs and clinical course are more variable. We conducted a prospective, controlled study to assess the effectiveness of clinical pathways for improving outcomes of patients undergoing surgery for acute fracture of the neck of femur. Specifically, we examined time to mobilisation, length of hospital stay, and complication and readmission rates as indices of outcome. Methods We used a pseudorandomised, controlled study design to compare the outcomes of patients whose management was guided by a clinical pathway with those who received the established standard of care in our orthopaedic unit. As the preparation and implementation of the clinical pathway was a quality improvement initiative, ethics committee approval was deemed unnecessary. Setting and participants The study was conducted at St Vincent's Hospital, Melbourne, Victoria (a tertiary referral hospital affiliated with the University of Melbourne). Participants were all patients who underwent standard surgical treatment for acute fracture of the neck of femur (by internal fixation using compression hip screw and plate or hemiarthroplasty) at the hospital between 1 October 1997 and 30 November 1998. In this period, 126 patients were admitted with a diagnosis of fractured neck of femur. Fifteen were excluded from the study, five because they were transferred to another institution for treatment, eight because of associated medical conditions that precluded surgical intervention, and two because of a decision to undertake non-standard surgery. One hundred and eleven patients were allocated to one of two groups (control or clinical pathway) by an administrative clerk, who was independent of the study and unaware of the study hypothesis. Patients were allocated on the basis of their unit record number -- even numbers to the control group (56 patients), and odd numbers to the clinical pathway group (55 patients). A retrospective analysis of a historical treatment group (n = 118) showed a mean length of stay of 11.8 days (range, 2.6-40.0 days; SD, 7.3). To detect a reduction in length of stay of a third at a significance level of 0.05 with a power of 0.8 would require two groups, each with a minimum of 55 participants. Management regimens Management regimens for the clinical pathway and control groups are compared in Box 1. Options for discharge destinations for all patients comprised rehabilitation in an in-patient rehabilitation facility attached to the hospital or in another hospital, patients' own home (with or without domiciliary care services), hostel or nursing home. Patients were deemed suitable for fast-stream rehabilitation in the on-site rehabilitation facility if they had the potential to regain or improve on their prefracture status, were able to achieve this outcome in less than a month, and had a high probability of returning to their previous living environment. Patients who were not expected to regain their prefracture functional level, were not expected to achieve this level in less than two months or were expected to need a higher level of care than before the fracture were referred to the Aged-Care Assessment Service (ACAS) for placement in slow-stream rehabilitation, nursing home, hostel or special accommodation, depending on patient medical conditions and limitations. This service was mediated by a social worker who, together with a medical registrar, prepared the patient for thrice-weekly assessment by a consultant geriatrician which could take place on three occasions per week. Outcome measures Duration of stay: Times in the various stages of the admission were recorded prospectively. Definitions of times were: To surgery: time between admission and theatre; To mobilisation: time between surgery and the patient first walking with the use of aids; To ACAS assessment: time between submission of the referral to ACAS and first assessment by the geriatrician; and Total length of stay: time from admission to discharge from hospital. Inpatient complications: Patients were assessed daily for confusion (disorientation in time, place or person). Wound infection was defined as all wound erythema lasting longer than 24 hours. Deep vein thrombosis was diagnosed clinically and confirmed by ultrasonography, and urinary tract infection was confirmed microbiologically. Postdischarge complications and readmissions: All patients' medical records were examined 28 days after discharge to identify postdischarge complications or readmissions related to the fracture. This time was chosen as we expected the patient to have recovered significantly from their surgery by then. Statistical analyses Results were analysed using SPSS version 8.0.4 Continuous and normally distributed data were compared with t tests for independent groups. Data that were not normally distributed, such as length of stay, were transformed logarithmically before this analysis; consequently, geometric means are reported for these data. Multiple linear regression with a general linear model was used to test for interactions between groups and the variables age, sex, referral to ACAS and premorbid status. Proportions were compared between groups using the z test. P values < 0.05 were regarded as significant. Results The 111 patients comprised 80 women and 31 men, with mean age 81 years. Control and pathway patients did not differ significantly in median age (82 versus 84 years; P = 0.1), number with premorbid conditions (19 versus 18; P = 0.94), number who did not speak English (16 versus 13; P = 0.6) or were confused on admission (24 versus 22; P = 0.98). Outcomes Durations of stay Durations at various stages of the admission for pathway and control patients are compared in Box 2. No significant differences were found between the groups in mean time in the emergency department or mean time from admission to surgery. Pathway patients walked significantly earlier than control patients, but the difference (1.6 versus 2.0 days) was not clinically important. However, the pathway group had a significantly shorter total length of stay than the control group (mean, 6.6 versus 8.0 days; P = 0.03). This meant that control patients stayed 21% longer than pathway patients. After adjusting the log-transformed length-of-stay values for the possible confounding variables of age, sex, aged-care assessment and premorbid status with multiple linear regression, we found that none of these variables produced significant between-group interactions. Group (pathway versus control) remained the most significant factor influencing total length of stay. Referral for aged-care assessment Fifteen of the 55 pathway patients and 18 of the 56 control patients were referred for ACAS assessment. This referral was preoperative for three pathway and two control patients. Time from referral to first assessment by a geriatrician differed only slightly between pathway and control patients: mean times were 2.5 days for pathway patients (range, 1-8 days) and 2.8 days for control patients (range, 0-8 days). Patients who were referred to ACAS had significantly longer total stays than those who were not referred (11.7 versus 6.5 days; P < 0.001; difference, 5.2 days; 95% CI, 3.0-7.5 days). This difference remained significant when the control and pathway groups were analysed separately. However, mean length of stay was significantly shorter for pathway patients referred to ACAS than for control patients referred to ACAS (9.5 versus 13.6 days; Box 2). We explored the possibility of confounding variables for patients referred to ACAS and found that there were none, suggesting that group membership (pathway or control) was the most influential factor affecting length of stay. Postdischarge destinations were similar in pathway and control groups referred to ACAS: 12/15 pathway patients and 16/18 control patients proceeded to slow-stream rehabilitation. Discharge destinations Discharge destinations are shown in Box 2. Patients in each group were most often discharged into fast-stream rehabilitation, followed in frequency by slow-stream rehabilitation or nursing homes. Complications and readmissions There were no significant differences between pathway and control patients in numbers who were confused postoperatively (23/55 versus 31/56) and in rates of other inpatient complications (10/55 versus 14/56 patients), postdischarge complications (3/55 versus 6/56), or readmission rates (2/55 versus 6/56). Discussion We found that use of a clinical pathway for management of fractured neck of femur reduced mean length of hospital stay from 8.0 to 6.6 days, suggesting that a proactive, multidisciplinary approach can reduce hospital stay for this condition. To date, only a few studies5-7 have reported results of a coordinated, multidisciplinary approach to management of fractured neck of femur in Australia. They found, similarly to our study, that these early-intervention programs reduced the length of stay of elderly patients with this condition compared with standard care.5-7 However, actual length of stay varied greatly between studies (from 11.38 days to 32.55 days). This variation highlights the limitations in management inherent in individual institutions because of variation in local factors such as availability of ACAS and support services and patient characteristics. Length of stay in the pathway group at our hospital, which was two to four times shorter than at other hospitals,5-7 may have benefited from our on-site rehabilitation unit. Although we found that use of a clinical pathway reduced total length of stay, the change (1.4 days) was not dramatic. This may be because the strong culture of continued refinement of care in our orthopaedic department had already reduced length of stay for many classes of orthopaedic conditions, including fractured neck of femur. Nevertheless, the reduction of 1.4 days in the clinical pathway group was encouraging. Unlike a previous study,5 our study included patients with language and cognitive difficulties. This choice was made to minimise any selection bias, as patients susceptible to osteoporotic fractures are in an age group which commonly has cognitive difficulties and as our patient population includes a large proportion of non-English-speaking people. We believed that their inclusion would test the efficacy of clinical pathways in the delivery of multidisciplinary care. We observed no difficulties applying the pathway to patients who had cognitive difficulties or did not speak English. Importantly, while use of clinical pathways reduced total length of stay, we found no significant clinical difference in time to mobilisation or complication or readmission rates between the two groups. This contrasted with our earlier findings on the effect of clinical pathways in elective joint replacement surgery.3 Possible explanations for the difference include the frequent existence of unstable and often untreated premorbid conditions in patients with fractured neck of femur, which require attention during their acute admission. In contrast, patients undergoing elective joint replacement have the benefit of preadmission assessment clinics which may resolve expected medical, allied health or discharge issues before admission. Up to a third of our patients with fractured neck of femur were referred for ACAS assessment for placement. Patients who required this assessment stayed significantly longer than patients who did not, possibly reflecting their respective comorbidities and the shortage of aged-care beds in the community. While the time between ACAS referral and consultation was similar for pathway and control patients, total length of stay was four days shorter for pathway than for control patients. It is likely that the daily review of patients' health status promoted by the clinical pathway optimised their readiness for discharge and prompted more regular reviews of discharge plans by the ACAS team. Interestingly, time between ACAS referral and consultation ranged up to eight days in both pathway and control groups. Reasons for this large range were not recorded and warrant further investigation. Some authors have identified that acute care, convalescence, rehabilitation and surgery accounted for more than 90% of total costs for fractured neck of femur, and that the main factors explaining cost variation were the number of days spent in acute care and convalescence or rehabilitation.9,10 However, our study was not designed to evaluate cost-effectiveness of clinical pathways, and, although use of the clinical pathway reduced length of stay by 1.4 days, we did not quantify costs involved in administering the pathway compared with control care. The net cost-effectiveness of our pathway is therefore unknown. Despite the weakness of a limited study, we showed that a multidisciplinary approach using clinical pathways for fractured neck of femur can reduce length of stay without increasing patient morbidity. Acknowledgements We wish to acknowledge the assistance of a special grant from the Victorian Centre for Ambulatory Care Innovation and Michael Bailey, statistical consultant, Alfred Hospital, Melbourne, Victoria. References Sanders KM, Nicholson GC, Ugoni AM, et al. Health burden of hip and other fractures in Australia beyond 2000. Med J Aust 1999; 170: 467-470. Day RO, Henry DA, Muirden KD, et al. Non-steroidal anti-inflammatory drug induced upper gastrointestinal haemorrhage and bleeding. Med J Aust 1992; 157: 810-812. Dowsey MM, Kilgour ML, Santamaria NM, Choong PF. Clinical pathways in hip and knee arthroplasty: a prospective, randomised controlled study. Med J Aust 1999; 170: 59-62. SPSS Inc. SPSS Base 8.0 for Windows. Chicago, (Ill): SPSS Inc, 1998. Swanson CE, Day GA, Yelland CE, et al. The management of elderly patients with femoral fractures. A randomised controlled trial of early intervention versus standard care. Med J Aust 1998; 169: 515-518. Tallis G, Balla JI. Critical path analysis for the management of fractured neck of femur. Aust J Public Health 1995; 19: 155-159. Cameron I, Lyle D, Quine S. Accelerated rehabilitation after proximal femoral fracture: a randomised controlled trial. Disabil Rehabil 1993; 15: 29-34. Lavernia CJ. Hemiarthroplasty in hip fracture care: effects of surgical volume on short-term outcome. J Arthroplasty 1998; 13: 774-778. French FH, Torgerson DJ, Porter RW. Cost analysis of fracture of the neck of femur. Age Ageing 1995; 24: 185-189. Hollingworth W, Todd C, Parker M, et al. Cost analysis of early discharge after hip fracture. BMJ 1993; 307: 903-906. (Received 2 Aug 1999, accepted 25 Jan 2000) Authors' details Department of Orthopaedics, St Vincent's Hospital, Melbourne, VIC. Peter F M Choong, MD, FRACS, Director of Orthopaedics, Professor of Orthopaedics; Anna K Langford, RN, BN, Clinical Nurse Specialist; Michelle M Dowsey, RN, BN, Clinical Nurse Specialist. University of Melbourne, Melbourne, VIC. Nick M Santamaria, MEdSt, PhD, Senior Research Fellow. Reprints: Professor P F M Choong, Department of Orthopaedics, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC 3065. PeterChoongATc031.aone.net.au Make a comment 1: Treatment regimens for control and clinical pathway patients with fractures of the femoral neck Control groupClinical pathway groupEmergency departmentAssessment X-rays Orthopaedic referral Orthopaedic consultation Transfer to wardAssessment Information checklist (prefracture placement, health status, carer) Preoperative investigations (including x-ray) Orthopaedic referral Transfer to wardWard (preoperative)Schedule surgery Preoperative tests ordered Anaesthetic assessmentOrthopaedic consultation Schedule surgery Anaesthetic assessmentWard (postoperative)Strict bedrest X-ray within 48 hours Physiotherapy referral after x-ray MobiliseX-ray within 24 hours Mobilise day after surgeryDocumentationAd hoc patient progress notesSpecific pathway documentation specifying responsibilities by discipline and time frame, to be signed on task completion Coded data collection sheetMedicationProphylactic antibiotics 24h Thromboprophylaxis until discharge (low molecular weight heparin, thigh length stockings)Prophylactic antibiotics 24h Thromboprophylaxis until discharge (low molecular weight heparin, thigh length stockings)Discharge planningBegun postoperatively Depends on patient progress Discharge phone call and summary to discharge destinationBegun on admission Depends on premorbid independence level Discharge package with information on wound care, expected milestones, contact details, simple exercises, equipment for staple removal. Back to text Back to text

Anna K Langford · Michelle M Dowsey · Nick M Santamaria

Editorial Measuring the success of joint replacement surgery Patients need measures that help them make informed choices MJA 1999; 171: 229-230 The United Nations General Assembly designated 1999 as the International Year of Older Persons. Population ageing is a major focus of social and economic planners and policymakers in Australia. One particular concern is to provide equitable, affordable and appropriate health care services to older people.1 In 1998, in Australia, there were 2.3 million people aged 65 years and over, including 976 500 who were aged 75 years and over. The proportion of the population aged 65 and over is projected to increase from 12% to 21% between now and 2031.2 Osteoarthritis, of which the principal symptoms are pain and restricted joint movement, affects about 25% of people over 65 years and contributes to restricted mobility, the most common form of disability among older men and women.3 North American studies have shown that total hip replacement and total knee replacement effectively reduce pain and improve function in patients with advanced osteoarthritis.4,5 Such surgery is associated with significant improvements in health status and quality of life. However, surprisingly little is known about the epidemiology and outcomes of joint replacement surgery for osteoarthritis in Australia. To define the national practice and outcomes of joint replacement surgery, the Australian Orthopaedic Association established the National Joint Replacement Registry in 1998. The Registry has received significant federal funding, is supported by industry and has been defined as a Federal Quality Assurance Activity. Data collected by the Registry from State and Territory health departments indicated that, in 1997-1998, 13 545 primary total hip replacements and 15 599 primary total knee replacements were performed in Australia. Data from a Registry pilot study of 260 patients undergoing these procedures indicated that about 90% were performed for osteoarthritis and about 80% were in people aged 60 years and over (Dr S Graves, Project Director, Australian Orthopaedic Association National Joint Replacement Registry, personal communication). In this issue of the Journal, March and colleagues6 have investigated whether hip and knee replacement restore health-related quality of life (as measured with the Medical Outcomes Study Short-Form 36 [SF-36]) to that of the age-matched general population. They found that total hip replacement reduced pain and improved physical function in those undergoing surgery to that of the age-matched population. Social function and overall vitality were also restored. Although total knee replacement reduced pain and improved physical function somewhat, postoperative scores, particularly among younger patients, were still significantly less than the population norm or scores for patients undergoing total hip replacement. Similar findings have been reported elsewhere7-9March and colleagues have suggested that these findings might be related to factors such as unrealistic expectations or the presence of comorbidities. Others have been unable to explain the apparent difference in outcome between hip replacement and knee replacement as measured by the SF-36. Although it is possible that knee replacement is less effective than hip replacement in improving quality of life, it is also possible that the SF-36 is less responsive to change following knee replacement. Perhaps restoration of hip function allows patients to perform the activities defined on the SF-36 better than restoration of knee function. March et al noted that the general health of the younger patients undergoing knee replacement declined in the year after surgery. It is not clear to what extent the decline in health status was a contributor to or a consequence of the poorer functional outcomes of surgery in this age group. The effect of comorbidities on long-term outcomes after joint replacement surgery requires further investigation. Debate continues over the best way to assess the outcomes of joint replacement surgery. Currently, radiological, functional, health status, quality-of-life and global satisfaction instruments are being used to provide comprehensive assessment. Yet, it appears that the more generic the instrument, the less responsive it is to change following joint replacement surgery.4 There is no clear correlation between improvements in health status and health perceptions after joint replacement surgery.10 Should we use disease-specific or more global quality-of-life measures when trying to assess the value of therapy, particularly in the elderly? Disease-specific measures may provide more relevant information to patients and clinicians than global measures. Patients can be told that, after hip replacement, it is likely they will have less pain and be able to better perform activities of daily living such as dressing, sitting, walking or climbing stairs. The patient can then weigh these benefits against the risks and complications of surgery and make an informed decision. Patients may have more difficulty in making such decisions if outcomes are expressed in terms of improved vitality or sense of well-being, particularly if it is known that such outcomes can be influenced by comorbidities. On the other hand, global measures allow comparisons between hip replacement surgery and treatments of other conditions, which might help a patient to determine treatment priorities. The best instrument is the one that measures the outcome of greatest relevance. Our challenge, in the International Year of Older Persons, must be to define the outcomes of greatest relevance to the elderly. Owen D Williamson Orthopaedic Surgeon Alfred Hospital, Melbourne VIC email: owen.williamsonATbigpond.com Commonwealth Department of Health and Family Services Conference for Older Australians Interim Report. Canberra: The Department, 1998 (Publication No. 2325). Australian Bureau of Statistics. Australian Social Trends 1999. Catalogue No. 4102.1, 1999. Australian Bureau of Statistics. National Health Survey: Summary of Results. Canberra, ABS: 1995 (Catalogue No. 4364.0). Kreibich DN, Vaz M, Bourne RB, et al. What is the best way of assessing outcome after total knee replacement? Clin Orthop 1996; 331: 221-225. Laupacis A, Bourne R, Rorabeck C, et al. The effect of elective total hip replacement on health-related quality of life. J Bone Joint Surg [Am] 1993; 75-A: 1619-1626. March LM, Cross MJ, Lapsley H, et al. Outcomes after hip or knee replacement surgery for osteoarthritis. Med J Aust 1999; 171: 235-238. Hozack WJ, Rothman RH, Albert TJ, et al. Relationship of total hip arthroplasty outcomes to other orthopaedic procedures. Clin Orthop 1997; 344: 88-93. Van Essen GL, Chipchase LS, O'Connor D, Krishnan J. Primary total knee replacement: short-term outcomes in an Australian population. J Qual Clin Practice 1998; 18: 135-142. Birdsall PD, Hayes JH, Cleary R, et al. Health outcome after total knee replacement in the very elderly. J Bone Joint Surgery [Br] 1999; 81-B: 660-662. McGuigan FX, Hozack WJ, Moriarty L, et al. Predicting quality-of-life outcomes following total joint arthroplasty. Limitations of the SF-36 health status questionnaire. J Arthroplasty 1995; 10: 742-747.

Owen D Williamson

Research Outcomes after hip or knee replacement surgery for osteoarthritis A prospective cohort study comparing patients' quality of life before and after surgery with age-related population norms Lyn M March, Marita J Cross, Helen Lapsley, Alan J M Brnabic Katherine L Tribe, Clarissa J M Bachmeier, Brett G Courtenay and Peter M Brooks* MJA 1999; 171: 235-238 For editorial comment, see Williamson Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Orthopaedic surgery Abstract Objective: To compare the health-related quality of life of people with osteoarthritis before and after primary total hip and knee replacement surgery with that of the general Australian population. Design: A prospective cohort study. Setting: Three Sydney hospitals, public and private. Participants: Patients with osteoarthritis undergoing primary total hip (n = 59) and knee (n = 92) joint replacement surgery. Main outcome measure: Medical Outcomes Study Short Form (SF-36) scores before and 12 months after joint replacement surgery (compared with population norms). Results: Patients in each age group showed a significant improvement in health-related quality of life after joint replacement surgery in most scales of the SF-36, particularly physical function, role physical and bodily pain. SF-36 scores for the 42 hip-replacement patients aged 55-74 years improved to equal or exceed the population norm on all scales. SF-36 scores of the 52 knee replacement patients aged 55-74 years improved, but physical function and bodily pain scores remained significantly worse than the population norm. SF-36 scores for both hip (n = 17) and knee (n = 40) replacement patients aged 75 years and over improved significantly, becoming similar to population norms for this age group. Conclusions: Total hip or knee replacement for osteoarthritis significantly improves patient health and well-being at 12 months after surgery. Age alone should not be a barrier to surgery. Introduction Osteoarthritis is one of the leading causes of pain and disability in the Australian population.1,2 Total joint replacement is the most common treatment for advanced osteoarthritis of the hip or knee, with the primary goal of the procedure being to improve the patient's quality of life.3In Australia, in the financial year 1997/98, Medicare benefits of $13 500 000 were paid for 17 000 hip and knee replacements. This number represents only some of the total surgery performed, as the number of operations on Veterans' Affairs patients and on public patients in public hospitals are not available. Despite joint replacement surgery being one of the most common operations performed in this country, very limited Australian outcomes data have been published.4 The Medical Outcomes Study Short-Form 36 (SF-36) has been used extensively to assess the effect on quality of life of several procedures, including total joint replacement,5,6 and it has been suggested that it should be the focus of preoperative and postoperative outcome evaluation for total hip arthroplasty.7 As a generic measure of health-related quality of life with standardised scoring, it enables comparisons between diseases, treatments and published population norms. It measures health on eight 100-point scales: physical function, role physical (ie, role limitations due to physical problems), bodily pain, general health, vitality, social function, role emotional (ie, role limitations due to emotional problems), and mental health. It is one of the most widely used health-related quality-of-life instruments and has been shown to be reliable and valid. Studies in the US have shown that the SF-36 detects a significant improvement in health-related quality of life in patients undergoing total hip or knee replacement when preoperative scores are compared with postoperative scores.8-11 The SF-36 also demonstrates a difference in outcome between total hip and total knee replacement patients,8,10 with patients undergoing total hip replacement achieving significantly better outcomes than the knee replacement patients. We aimed to compare the health-related quality of life (as measured by the SF-36) of people with osteoarthritis undergoing primary total hip and knee replacement surgery with that of the normal Australian population.2 Putting changes in the health-related quality of life of these patients in the context of population norms for the same age group gives us a meaningful measure of the effectiveness of this surgery. It also provides information in a way that allows comparisons with other diseases and treatments, assisting rational choices to be made about the use of the limited healthcare dollar. Methods The information on the patients undergoing total joint replacement collected for this analysis was part of a long-term follow-up of patients in a cohort study aiming to assess the costs of arthritis and the effectiveness of its treatment. The cohort includes patients from both public and private hospitals and surgeons operating in both sectors are involved. Patients with osteoarthritis booked for primary total hip or knee replacement surgery at three Sydney hospitals (St Vincent's public and private hospitals and the Centre for Bone and Joint Diseases, North Ryde) between March 1994 and December 1995 were approached to participate in the study. Recruitment was through regular contact with the orthopaedic surgeons and their practice staff. Baseline information was collected from patients through a series of questionnaires, including the SF-36. Questionnaires were administered between one week and three months before surgery. After surgery, patients completed the SF-36 questionnaire at the end of each three months for their first postoperative year. Most questionnaires were self-administered, with less than 10% requiring face-to-face interview. This is consistent with the Australian Bureau of Statistics methodology for collecting general population data.2 Annual follow-up of these patients by mail is continuing. This article presents SF-36 information from patients at baseline and 12 months after surgery. Ethics committee and Medical Board approval was obtained from the St Vincent's campus of the University of New South Wales Medical School, the Centre for Bone and Joint Diseases and the Royal North Shore Hospital. All patients in the study gave written informed consent. Analysis Mean scores for each of the SF-36 dimensions were calculated for patients in the age groups 55-64, 65-74 and 75 years and over. Scores for men and women were combined, as, apart from older males undergoing joint replacement having lower preoperative scores for role emotional, there was no significant difference in scores between the sexes. Scores for each dimension were transformed according to the SF-36 user's guide12 to a scale of 0-100 (100 = best possible score). We used one-sample t tests to compare the transformed scores with general population norms derived by the Australian Bureau of Statistics from the 1995 National Health Survey. The t test was chosen on the assumption that the population value was the real value (given that published standard errors were so low) and that we were observing the variance of the study data from the population value. A P value of 0.05 was considered to be significant and no adjustment was made for multiple comparisons. SF-36 on the web More information about the SF-36 health survey can be found on the SF-36 website: http://www.sf-36.com An online demonstration of the SF-36 survey (score yourself and read an explanation of the result in comparison with US population norms) is available at: http://www.qmetric.com/demo/sf-36v1.shtml Results Two-thirds of the eligible patients were recruited (226 of 343). Reasons for exclusion included being unable to be contacted before surgery (50% of those who did not participate in the study), being non-English-speaking (10%) and refusal or inability to complete the questionnaires (40%). Eligible patients who did not participate in the study did not differ significantly from the cohort in terms of age, sex or type of joint replacement (ie, hip or knee) (data not shown). At the time of analysis, we had complete information for 151 patients at 12 months' follow-up (59 with hip replacement and 92 knee replacement; 52% female; median age, 72 years). An additional 75 patients (60% female; median age, 74 years) had incomplete follow-up information. Their last recorded SF-36 scores showed no significant differences from scores at the same stage of follow-up among those with complete information (data not shown). Patients' SF-36 scores before and 12 months after surgery are shown in the Figure, in comparison with scores for the general population. Knee replacements 55-64 years age group: Eight patients undergoing knee replacement were recruited. Six of these patients reported having other illnesses, most commonly cardiovascular disease (reported by five patients). At 12 months' follow-up, these eight patients showed improvement from baseline according to mean SF-36 scores for physical function, role physical, bodily pain and vitality, but these scores remained significantly lower than the population norms. The power to detect the observed difference to be statistically significant at the 5% level ranged from 83% to 100% for these four comparisons. Their scores on the other four scales (general health, social function, role emotional, mental health) remained lower than population norms, but this difference was not statistically significant (power to detect a significant difference ranged from 7% to 55%). 65-74 years age group: Twenty-eight of the 44 patients (64%) reported having a comorbid illness, with the most commonly reported again being cardiovascular disease (61% of those with comorbidity). Mean SF-36 scores improved significantly on all scales except general health. The mean general health score was significantly higher than the population norm at 12 months' follow-up, but had been higher to begin with at baseline. Mean physical function, role physical and bodily pain scores remained significantly lower than the population norms at 12 months' follow-up. The power to detect these differences ranged from 85% to 99%. Mean vitality, social function, role emotional and mental health scores improved from baseline to be similar to population norms. The power to detect the significance of these differences ranged from 8% to 36%. 75 years and over: Thirty-two of the 40 patients (80%) reported suffering from another illness, most commonly cardiovascular disease (60% of those with comorbidities). Mean SF-36 scores improved significantly on most scales (particularly role physical, physical function and bodily pain), but not on general health and mental health, which were fairly high before surgery. The mean general health score was significantly higher than the population norm at 12 months' follow-up; the other scores improved to population levels. Given the small difference seen between patient and population scores, large numbers would be required to show statistically significant differences (power ranged from 7% to 33%). Hip replacements 55-64 years age group: Comorbidities were reported by 5 of the 14 patients (36%). All five had cardiovascular disease among other comorbidities. Mean scores for vitality and social function improved to become significantly higher than the population norms (power to detect significant difference, 90% and 96%, respectively), while the other scores improved to be similar to the population norms, with particular improvement in physical function, role physical and bodily pain. 65-74 years age group: Thirteen of the 28 patients reported suffering from a comorbid illness, most commonly cardiovascular disease (46% of patients with comorbidities). Mean SF-36 scores improved on all scales except general health, which had a baseline value above the population norm. Mean scores for general health and mental health were significantly higher than the population norms at 12 months' follow-up (power to detect difference, 85% and 75%, respectively) and the other scores improved to be similar to the population norms (power to detect difference ranged from 7% to 58%). The improvement from baseline was particularly evident in role physical, physical function and bodily pain scores. 75 years and over: Comorbidities were reported by 12 of the 17 patients (71%), most commonly cardiovascular disease (reported by 58% of those with comorbidities). Mean SF-36 scores improved on all scales except general health and mental health. At 12 months' follow-up, mean scores on none of the scales were significantly different from the population norms, possibly due to the small numbers in this group (power to detect a difference less than 30% for most scales). Again, there was improvement to population norms in role physical, physical function and bodily pain. Discussion We found that knee or hip replacement surgery significantly improved the health-related quality of life of patients with osteoarthritis. Before surgery, the patients had poor SF-36 scores for bodily pain, physical function and role physical, a clear reflection of the impact of chronic osteoarthritis on health-related quality of life. After surgery, the biggest improvements were in these scores. Improvement in these physical dimensions of health is likely to lead to improvements in social function, mental health and vitality. We found no improvement in general health despite gains in the other scales. This has been shown in other studies,11 and has been suggested to be due to the patients' previous medical history and pre-existing and general health-related conditions. In our study it was apparent that the general health of patients was already higher at baseline than the population norm, suggesting that relatively healthy patients are being selected for total joint replacement. A US study that compared patients undergoing total hip replacement with age-matched and sex-matched population norms found that age and sex made important differences in SF-36 scores.9 Men younger than 65 years had scores lower than the norms in the physical scales, but were comparable in the mental scales, and women scored lower than the norm in all scales. No sex differences were found in our study, but similar age differences were observed, particularly for patients undergoing total knee replacement, among whom the youngest age group had the poorest outcome relative to the age-matched population. We hypothesise that this may be related to the higher population norms for this age group, unrealistic expectations for outcomes among patients, and the presence of existing comorbidities in younger patients requiring knee replacement. One implication of these findings is that older age should not be a barrier to joint replacement surgery, as the outcome is likely to be relatively successful for older patients. Potential limitations that need to be considered when interpreting these results include the non-randomised cohort design, the power of the analysis given the small sample size of the subgroups, and the overall response rate. However, the inclusion of several groups of surgeons operating at different sites and across the public and private sectors contributed significantly to the generalisability of the results. This study showed the improvement of SF-36 scores of patients undergoing total hip or knee replacement up to and in some cases beyond population norms. Whether these statistically significant differences are clinically important remains to be seen. Longer follow-up is required to determine whether the dramatic improvement from baseline is maintained. Nonetheless, at one year follow-up, it would appear that total knee or hip joint replacements are successful at restoring health and well-being, and that older age alone should not be a barrier to surgery. Acknowledgements This study was funded by grants from the National Health and Medical Research Council. We are grateful to the secretarial staff of the orthopaedic surgeons for their assistance with recruitment to this study and to the patients who have been so cooperative. References Australian Bureau of Statistics. Disability and handicap, Australia 1988. Canberra: ABS, 1996 (Catalogue No. 4120.0). Australian Bureau of Statistics National Health Survey: SF-36 population norms, Australia, 1995. Canberra: ABS, 1997 (Catalogue No. 4399.0). Bombardier C, Melfi CA, Paul J, et al. Comparison of a generic and a disease-specific measure of pain and physical function after knee replacement surgery. Med Care 1995; 33 Suppl 4: AS131-AS144. Van Essen GJ, Chipchase LS, O'Connor D, Krishnan J. Primary total knee replacement: short-term outcomes in an Australian population. J Quality Clin Practice 1998; 18: 135-142. Bayley KB, London MR, Grunkemeier GL, Lansky DJ, Measuring the success of treatment in patient terms. Med Care 1995; 33 Suppl 4: AS226-AS235. Stucki G, Liang MH, Phillips C, Katz JN. The Short-Form 36 is preferable to the SIP as a generic health status measure in patients undergoing elective total hip arthroplasty. Arthritis Care Res 1995; 8: 174-181. Ritter MA, Albohm MJ, Overview: maintaining outcomes for total hip arthroplasty. The past, present and future. Clin Orthop 1997; 344: 81-87. Hozack J, Rothman RH, Albert TJ, et al. Relationship of total hip arthroplasty outcomes to other orthopaedic procedures. Clinical Orthop 1997; 344: 88-93. Lieberman JR, Dorey F, Shekelle P, et al. Outcome after total hip arthroplasty. Comparison of a traditional disease-specific and a quality of life measurement of outcome. J Arthroplasty 1997; 12: 639-645. Kiebzak GM, Vain PA, Gregory AM, et al. SF-36 general health status survey to determine patient satisfaction at short-term follow-up after total hip and knee arthroplasty. J Southern Orthop Assoc 1997; 6: 169-172. Ritter MA, Albohm MJ, Keating EM, et al. Comparative outcomes of total joint arthroplasty. J Arthroplasty 1995; 10: 737-741. Medical Outcomes Trust. How to score the SF-36 health survey. Boston: The Trust, 1994. (Received 16 Oct 1998, accepted 12 Jun 1999) Authors' details University of Sydney, Department of Rheumatology, Royal North Shore Hospital, Sydney, NSW. Lyn M March, MB BS, PhD, FRACP, FAFPHM, Associate Professor. Department of Medicine, University of New South Wales, Sydney, NSW. Marita J Cross, BSc(Hons), Research Assistant; Katherine L Tribe, BSc(Hons), Research Assistant; Clarissa J M Bachmeier, MD, MMed(ClinEpidem), Research Fellow. School of Health Services Management, University of New South Wales. Helen Lapsley, BA, MEc, Senior Lecturer. Northern Sydney Public Health Unit, Hornsby Ku-ring-gai Hospital, Sydney, NSW. Alan J M Brnabic, MSc, Statistician. Department of Orthopaedics, St Vincent's Hospital, Sydney, NSW. Brett G Courtenay, MB BS, FRACS, Orthopaedic Surgeon. Faculty of Health Sciences, University of Queensland, Brisbane, Qld. Peter M Brooks, MB BS, FRACP, FAFPHM, Executive Dean. No reprints will be available from the authors. Correspondence: Associate Professor L M March, Department of Rheumatology, Royal North Shore Hospital, St Leonards, NSW 2065. Email: lmarcATdoh.health.nsw.gov.au Click in figure for a larger version Back to text

Lyn M March · Marita J Cross · Helen Lapsley · Katherine L Tribe · Brett G Courtenay · Peter M Brooks

For Debate The potential effect on hip fracture incidence of mass screening for osteoporosis Nicholas A Pocock, Nicole L Culton and Neil D Harris MJA 1999; 170: 486-488 For editorial comment, see Morris et al; see also Sanders et al. With ageing of the Australian population, treatment of osteoporosis-related hip fractures will impose an increasing burden on the healthcare system. Based on current age-adjusted hip fracture incidence and population projections for New South Wales, we estimated a 90% increase in hip fractures by the year 2021. Contributing significantly to this increase will be the number of men reaching the high risk age group for osteoporotic hip fractures. A suggested solution -- screening and appropriate therapy for individuals at high risk of osteoporosis -- may have only a modest impact. Our calculations show that, even with optimistic screening and therapy compliance rates, hip fractures could still increase by over 50%. Other approaches need to be further explored. Introduction - Discussion - References - Authors' details - - More articles on Public and environmental health Introduction Osteoporosis-related hip fractures are a high-cost item in the Australian healthcare budget, and place considerable demands upon the limited resources of the public health system. This burden will increase in the first quarter of the next century as the projected Australian population over 65 years of age increases from the current level of 2.25 million to between 4.02 and 4.05 million by 2021.1 To avoid this impending healthcare crisis, several reports have suggested a screening program to identify individuals at high risk of osteoporosis, followed by appropriate intervention to reduce the number of hip fractures.2-6The possible introduction of a mass-screening program for osteoporosis raises a number of issues. Cost effectiveness is of major importance, and there are reports to indicate that screening for osteoporosis may well be cost effective.3,5,6 However, few data exist on the impact of a screening program on the healthcare system, and, in particular, on the demand for acute-care hospital beds, which has important implications for healthcare planning. To assess the impact of screening on the demand for hospital beds for hip fracture treatment, we have used available population projections for New South Wales (NSW) to calculate the likely number of hip fractures in people aged 65 years or older by the year 2021. We then assessed the potential of a screening program, coupled with effective therapy, to reduce hip fracture incidence using available data on population capture rates of current large screening programs, and data on therapy compliance and drug-efficacy rates. Our methods and the results we obtained are shown in the Box. Discussion Current costs of osteoporotic hip fractures in Australia exceed $400 million annually,15 and hip fracture treatment is making great demands on an already overstretched hospital infrastructure.2,7,16,17In 1994-95, there were 52017 admissions to NSW hospitals of patients over 65 years of age with major hip fractures. Without further intervention, our calculations show that, even with a low population growth model, this figure may rise by the year 2021 to 9800 hip fracture admissions annually in this age group, an increase of about 89%. A major cause will be the increase in the number of men reaching the high risk age group for osteoporotic hip fractures. In 1997, the population of men in NSW over 80 years of age numbered about 60 300.1 This is projected to increase to about 123 900 by 2021,1 an increase of 106%. A 65% increase in the number of women over 80 years of age is expected in the same interval. Our calculations show the limited preventive effect on increasing hip fracture incidence of an active interventional screening and therapy program for osteoporosis. Even with a relatively optimistic 60% screening and therapy compliance rate, hip fractures may still increase by about 55% compared with 1994-95. In view of the age of the target population (the average age of hip fracture patients in NSW is 82 years7), 40% capture and therapy compliance rates may be more realistic, suggesting that hip fractures may increase by 74% compared with 1994-95. It is also possible that capture and therapy compliance rates in the target population might not even achieve these levels. We also used the lowest of a number of population growth models.1 If faster population growth occurs, the increase in hip fractures will exceed our predictions, with correspondingly more serious implications for the healthcare system. We assumed the screening technique would identify all patients at increased risk of hip fracture and all would be offered therapy. This optimistic assumption is almost certainly incorrect and thus our calculations overestimate the benefits of a screening program. On the other hand, compared with current drug regimens, advances in therapy may decrease fracture risk. Moreover, therapies with minimal toxicity and which have demonstrated benefit, such as vitamin D and calcium, could be applied widely to high risk patients in nursing homes and other institutions.2,13 However, the potential benefit of such an approach is limited, as, at present, only 29% of hip fracture patients are admitted from nursing homes and an additional 9% from hostels.7 Our analysis does not address the cost efficacy of a screening program for osteoporosis. Nor does it address the possible role of population education in preventing osteoporosis. Recent raised community awareness of osteoporosis may translate in the future into consumer-driven demand for preventive action from healthcare providers and more self- initiated prevention. The recent increased demand for acute-care hospital beds in NSW has been partly met by reducing the average length of stay in hospital and increasing the number of day-only procedures. However, there is a limit to how much of the demand for hospital services can be met by these means. The average length of stay for hip fracture treatment in NSW has already been reduced from 31.5 days in 198018 to 11 days in 1995,7 and there is likely to be only limited additional gain from future efforts to reduce hospital stay for these patients.7 The increased number of hip fractures by 2021 will require considerable additional hospital resources, and, in view of the seasonal variation in hip fracture incidence,18 may impose an extreme burden on hospital services at certain times of the year. To cope with this, health service providers need to address the issue of future hospital bed availability for hip fractures. Failure to plan adequately may result in delay in treating other, less urgent, patients. In conclusion, Australia, like other Western countries, must cope with the health problems of an ageing population in the early part of the next century, with osteoporotic hip fractures likely to be a major component of the expected increased demand for acute-care hospital services. A preventive program based on mass screening for osteoporosis and treatment of high risk individuals may have only a limited impact. While potentially of benefit, this approach would be insufficient by itself, and additional or alternative approaches to this problem, such as education of the community, need to be further explored. References Australian Bureau of Statistics. Population projections for New South Wales 1997 to 2051. Canberra: ABS, 1998. (Catalogue No. 3222.0.) Wark JD. Osteoporosis: the emerging epidemic. Med J Aust 1996; 164: 327-328. Garton MJ, Cooper C, Reid D. Perimenopausal bone density screening -- will it help prevent osteoporosis? Maturitas 1997; 26: 35-43. Kanis JA. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis: synopsis of a WHO report. Osteoporos Int 1994; 4: 368-381. Tosteson AN, Rosenthal DI, Melton LJ, Weinstein MC. Cost effectiveness of screening perimenopausal white women for osteoporosis: bone densitometry and hormone replacement therapy. Ann Intern Med 1990; 113: 594-603. Black DM. Why elderly women should be screened and treated to prevent osteoporosis [review]. Am J Med 1995; 98 Suppl 2A: 67S-75S. March L, Chamberlain A, Cameron I, et al. Prevention, treatment and rehabilitation of fractured neck of femur. Health Outcomes Project 1996. Sydney: Public Health Unit, Northern Sydney Area Health Service, 1996 (ISBN 07310 9633 9). Updated information provided by personal communication. Also on the internet <http://www.mja.com.au/public/issues/iprs2/march/fnof.pdf> Barratt AL, Cockburn J, Redman S, et al. Mammographic screening: results from the 1996 National Breast Health Survey. Med J Aust 1997; 167: 521-524. Salzman C. Medication compliance in the elderly. J Clin Psychol 1995; 56 Suppl 1: 18-22. McElnay JC, McCallion CR, al-Deagi F, Scott M. Self-reported medication non-compliance in the elderly. Eur J Clin Pharmacol 1997; 53: 171-178. Wren BG, Brown L. Compliance with hormonal replacement therapy. Maturitas 1991; 13: 17-21. Rozenberg S, Vandromme J, Kroll M, et al. Compliance to hormone replacement therapy [review]. Int J Fertil Menopausal Stud 1995; 40 Suppl 1: 23-32. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of alendronate on risk of fracture in women with existing vertebral fractures. Lancet 1996; 348: 1535-1541. Seeman E. Osteoporosis: trials and tribulations [review]. Am J Med 1997; 103 Suppl 2A: 74S-87S. Randell A, Sambrook PN, Nguyen TV, et al. Direct clinical and welfare costs of osteoporotic fractures in elderly men and women. Osteoporos Int 1995; 5: 427-432. Lord SR. Femoral neck fractures: admissions, bed use, outcomes and projections. Med J Aust 1996; 145: 493-496. Lord SR. Hip fractures: changing patterns in hospital bed use in NSW between 1979 and 1990. Aust N Z J Surg 1993; 63: 352-355. Lau EM, Gillespie BG, Valenti L, O'Connell D. The seasonality of hip fracture and its relationship with weather conditions in New South Wales. Aust J Public Health 1995; 19: 76-80. (Received 13 Nov 1998, accepted 13 Mar 1999) Authors' details Department of Nuclear Medicine and Bone Densitometry, St Vincent's Hospital, Sydney, NSW. Nicholas A Pocock, MD, FRACP, Senior Staff Specialist. Nicole L Culton, BAppSc, Research Officer. Neil D Harris, BA(Comm), RN, Research Officer. Reprints will not be available from the authors. Correspondence: Associate Professor N A Pocock, Department of Nuclear Medicine and Bone Densitometry, St Vincent's Hospital, Sydney, NSW 2010. Email: n.pocockATunsw.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> How many hip fractures can we prevent in New South Wales Methods To determine the predicted NSW population of those aged 65 years and over in 2021, we used the most recent Australian Bureau of Statistics population projections (low population growth model).1 To calculate the likely absolute numbers of hip fractures in 2021, we assumed similar age-adjusted hip fracture rates to those currently found in NSW.7 In women, the annual incidence of hip fractures in NSW (based on figures for 1995-96) ranges from 1.77/1000 in the 65 to 69 years age group, to 33.21/1000 in the over-85 group.7 In men, the respective rates are 1.01/1000 and 18.45/1000.7 These hip fracture incidences were applied to the NSW population predictions to derive the expected number of hip fractures in 2021 for the low population growth model. It is difficult to estimate the likely capture rate of an osteoporosis screening program (ie, the proportion of the target population using the service), as the population at risk of osteoporotic fractures is generally older than those targeted by current screening programs (eg, mammographic screening for breast cancer). In addition, an osteoporosis screening program would need to include men, and no comparable screening programs for men currently exist in Australia. In the absence of a more suitable model, a recent study of the data from the 1996 National Breast Health Survey reported that about 50% of the target population have participated in the Program within the past two years.8 For our analysis we have made projections using 10%, 20%, 40%, 60% and 80% population capture rates. There is no current consensus on the best osteoporosis screening program. For our study, however, we assumed a hypothetical best-case scenario in which the screening technique would identify all patients at increased risk of fracture, and therapy would be offered to all at-risk subjects. Reported compliance rates for long term medical therapy vary widely.9 While figures of up to 80% have been reported,10 particularly with medications which have few side effects, lower compliance rates are more common for medications with adverse or unpleasant side effects (eg, hormone replacement therapy).11,12 There are few data available on long term compliance with therapy for osteoporosis, such as bisphosphonates, calcitriol or the latest generation of selective oestrogen receptor modulators. The possible efficacy of a screening and treatment program was calculated separately for compliance rates of 20%, 40%, 60% and 80%. The efficacy of a treatment program targeted at high risk individuals depends not only on compliance with therapy, but also on drug efficacy. Available data suggest that current therapies for osteoporosis may have about 50% efficacy in reducing fractures.13,14 While it is possible that more effective therapeutic regimens will become available in the future, we used a value of 50% drug efficacy. Results In 2021, the projected age-specific NSW population for men and women over the age of 65 years (low population growth model) is shown in Table 1.1 Based on these population figures, and on recent data on age-specific admission rates for hip fractures,7 by 2021 we predict there will be about 9800 hip fracture admissions annually in NSW in subjects aged 65 years and older (Table 2). This is an increase of about 89% above current levels and compares with an expected 14% to 22% increase in the entire NSW population during the same period.1 In Table 3 the impact of an osteoporosis screening program and effective therapy in 2021 is shown for NSW men and women over 65 years at different capture rates and therapy compliance levels. The potential efficacy of a screening program would vary widely depending on population capture rates and therapy compliance. With an optimistic 60% population capture rate and 60% long term therapy compliance, with the low population growth model, a screening program might potentially prevent 1767 admissions for hip fractures. In this situation, hip fracture admissions in NSW in 2021 would still be 55% higher than in 1994-95. Back to text

Nicholas A Pocock · Nicole L Culton · Neil D Harris

Lynette M March, Anne C Chamberlain, Ian D Cameron, Robert G Cumming, Alan J M Brnabic, Terrence P Finnegan, Susan E Kurrle, Jennifer M Schwarz, Sydney M L Nade, Tom K F Taylor, and members of the Fractured Neck of Femur Health Outcomes Project Team* MJA 1999; 170: 489-494 Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Authors' details This article was first published in an unedited form after internet peer review. Click here to read the unedited version and the transcript of the review process. - - More articles on Orthopaedic surgery Abstract Objectives: To develop evidence-based guidelines for the treatment of proximal femoral fractures to optimise functional outcome while minimising length of stay in hospital. Data sources: Systematic literature search of MEDLINE and CINAHL computer databases, bibliographies, and current contents of key journals for 1966-1995. Study selection: English-language randomised controlled trials of all aspects of acute-care hospital treatment of proximal femoral fracture among subjects aged 50 years and over with proximal femoral fractures not due to metastatic disease. Data extraction: Two independent reviewers, blinded to authors, institution and study results, followed a standard Cochrane Collaboration protocol and assessed study quality and treatment conclusions. When necessary, a third review was performed to reach consensus. Results: Of the 120 articles published between 1966 and December 1995, 97 met the inclusion criteria. Fifteen clinical interventions were reviewed. Five were supported by National Health and Medical Research Council (NHMRC) level I evidence (prophylactic anticoagulants, prophylactic antibiotics, regional anaesthesia, pressure-relieving mattresses, and internal surgical fixation), two had no supporting randomised controlled trial evidence (time to surgery, time to mobilisation after surgery) and the remainder were classified as having Level II evidence. A review of current practice (1993-94) identified wide variability in these interventions across five acute-care hospitals in the Northern Sydney Area Health Service. Conclusions: Randomised controlled trial evidence (NHMRC Levels I and II) exists for many, but not all, aspects of hip fracture treatment. There is a need for changes to be made to some aspects of practice in accordance with evidence-based guidelines. Introduction Each year, fractures of the proximal femur (hip fracture) affect 4% of women and 2% of men aged 85 years or more. In 1995, this led to about 15 000 hospital admissions across Australia. Given current age-specific hip fracture rates1 and the expected ageing of the population,2 we calculated that by the year 2021 admissions for hip fracture will more than double. Conservative estimates of the current costs of acute inpatient care for these patients are $7.8 million in the Northern Sydney Area Health Service and $46.3 million for the whole of New South Wales (NSW).1 This does not include other costs, such as rehabilitation, support services, residential care, family assistance and changes in quality of life. The death rate in the 12 months after hip fracture is about 25%, four times greater than for community-living age-matched controls.3 Most survivors do not return to their prefracture level of independence and physical abilities.4The 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. Methods 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. Results 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). Discussion Our study reports the completion of a project which followed a structured approach to health-outcomes research, as advocated by the NSW Health Department.5 We developed evidence-based guidelines for the management of proximal femoral fractures. The method we used adhered closely to the guidelines for the development of guidelines published by the NHMRC.7 To our knowledge, this is the first time evidence-based guideline development has been performed within the context of clinical practice, ensuring that the recommendations for best-practice interventions are realistic. The levels of evidence for each recommendation were made explicit, with all the supporting evidence available for discussion. Clinical staff were involved throughout the process, and each step was systematically developed and evaluated. Thus, the support for our conclusions is robust. 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. Acknowledgements We acknowledge the support and assistance of the NSW Health Department's Health Outcomes Program Grants Scheme, the Cochrane Musculoskeletal Injuries Group, the staff and administration of the five acute-care public hospitals, the Northern Sydney Public Health and Health Service Development Units and the Swedish Hip Fracture Group. This study would not have been possible without the help of the other members of the Project team: Dr Don Holt, Mr Wayne Salvage, Mr John Skinner, Dr Krishna Hort, Mr Peter Whitecross, Mrs Barbara Carfrae, Ms Bronwyn Christiansen, Ms Loray Dudley, Ms Catherine Ferry, Ms Jill Makaroff, Ms Sarah Michael, Ms Melanie Saunders, Ms Katherine Scott, Ms Julia Sweeney, Ms Lorraine Heaslett, Mrs Carolyn Cole, Mr Terry Black. References 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> Australian Bureau of Statistics. Projections of the populations of Australia, States and Territories, 1984-2021 (Catalogue No. 3222.0) ISSN: 0816-3391. Katelaris AG, Cumming RG. Health status before and mortality after hip fracture. Am J Public Health 1996; 86: 557-560. 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. Irwig L. An approach to evaluating health outcomes. NSW Public Health Bulletin 4 (12). Sydney: NSW Department of Health, 1993. 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>) 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.) 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. Dolk T. Operation in hip fracture patients -- analysis of the time factor. Injury 1990; 21: 369-372. 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. Parker MJ, Pryor GA. The timing of surgery for proximal femoral fractures. J Bone Joint Surg Br 1992; 74: 203-205. Villar RN, Allen SM, Barnes SJ. Hip fractures in healthy patients: operative delay versus prognosis. BMJ 1986; 293: 1203-1204. 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. Finsen V, Borset M, Buvik GE, Hauke I. Pre-operative traction in patients with hip fracture. Injury 1992; 23: 242-244. Needoff M, Radford P, Langstaff R. Pre-operative traction for hip fractures in the elderly: a clinical trial. Injury 1993; 24: 317-318. Hofman A, Geelkerken RH, Wille J, et al. Pressure sores and pressure-decreasing mattresses: controlled clinical trial. Lancet 1994; 343: 568-571. 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. 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. 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. 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. 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. 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. 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. Bergqvist D. Orgaran in hip fracture surgery. Haemostasis 1992; 22: 104-108. 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. 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. Imperiale TF, Speroff T. A meta-analysis of methods to prevent venous thrombo-embolism following total hip replacement. JAMA 1994; 271: 1780-1785. Consensus Statement. Prevention of venous thrombo-embolism (Chairman, Nicolaides AN). Int Angiol 1997; 16: 3-38.. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Sorenson RM, Pace NL. Anesthetic techniques during surgical repair of femoral neck fractures: a meta-analysis. Anesthesiology 1992; 77: 1095-1104. 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. Hood G. Post-operative analgesia after triple nerve block for fractured neck of femur. Anaesthesia 1991; 46: 138-140. 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. 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. Buckley R, Hughes GN, Snodgrass T, Huchcroft SA. Perioperative cefazolin prophylaxis in hip fracture surgery. Can J Surg 1990; 33: 122-127. 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. 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. Gatell JM, Garcia S, Lozano L, et al. Perioperative cefamandole prophylaxis against infections. J Bone Joint Surg Am 1987; 69: 1189-1193. Hedstrom SA, Lidgren L, Sernbo I, et al. Cefuroxime prophylaxis in trochanteric hip fracture operations. Acta Orthop Scand 1987; 58: 361-364. Hjortrup A, Sorensen C, Mejdahl S, et al. Antibiotic prophylaxis in surgery for hip fractures. Acta Orthop Scand 1990; 61: 152-153. 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. McQueen MM, Littlejohn MA, Miles RS, Hughes SP. Antibiotic prophylaxis in proximal femoral fracture. Injury 1990; 21: 104-116. 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. Tengve B, Kjellander J. Antibiotic prophylaxis in operations on trochanteric femoral fractures. J Bone Joint Surg Am 1978; 60: 97-99. Aune AK, Ekeland A, Odegaard B, et al. Gamma nail vs compression screw for trochanteric femoral fractures. Acta Orthop Scand 1994; 65: 127-130. 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. 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. 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. 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. 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. 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. 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. Gargan MF, Gundle R, Simpson AH. How effective are osteotomies for unstable intertrochanteric fractures? J Bone Joint Surg 1994; 76: 789-792. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Olerud C, Rehnberg L, Hellquist E. Internal fixation of femoral neck fractures: two methods compared. J Bone Joint Surg Br 1991; 73: 16-19. 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. Rehnberg L, Olerud C. Fixation of femoral neck fractures: comparison of the Uppsala and von Bahr screws. Acta Orthop Scand 1989; 60: 579-584. 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. 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. 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. 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. 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. 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. Cobb JP. Why use drains? J Bone Joint Surg Br 1990; 72: 993-995. 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. 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. 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. 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. Delmi M, Rapin CH, Bengoa JM, et al. Dietary supplementation in elderly patients with fractured neck of femur. Lancet 1990; 335: 1013-1016. 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. 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. 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. 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. Cameron ID, Lyle DM, Quine S. Accelerated rehabilitation after proximal femoral fracture. Disabil Rehabil 1993; 15: 29-34. 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. Gilchrist WJ, Newman RJ, Hamblen DL, Williams BO. Prospective randomised study of an orthopaedic-geriatric inpatient service. BMJ 1988; 297: 1116-1118. 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. Oyewole MF, Moloney A. A randomised, controlled trial of a high-support hospital discharge team for elderly people. Age Ageing 1994; 23: 228-234. 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. Todd CJ, Freeman DJ, Camilleri C, et al. Differences in mortality after hip fracture: The East Anglia audit. BMJ; 1995; 310: 904-908. Tallis G, Balla JJ. Critical path analysis for the management of fractured neck of femur. Aust J Public Health 1995; 19: 155-159. 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. 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) Authors' details Northern Sydney Area Health Service Public Health Unit, Hornsby Ku-ring-gai Hospital, Sydney, NSW. Lynette M March, Associate Professor; and Senior Staff Specialist in Clinical Epidemiology. Alan J M Brnabic, Statistician. Fractured Neck of Femur Health Outcomes Project, Health Services Development, Royal North Shore Hospital, Sydney, NSW. Anne C Chamberlain, Project Officer; Jennifer M Schwarz, Research Assistant. University of Sydney Rehabilitation Studies Unit, Royal Rehabilitation Centre, NSW. Ian D Cameron, Associate Professor; and Director. Department of Public Health and Community Medicine, University of Sydney, NSW. Robert G Cumming, Associate Professor. Department of Aged Care and Rehabilitation, Royal North Shore Hospital, Sydney, NSW. Terrence P Finnegan, Senior Staff Specialist. Rehabilitation and Aged Care Services, Hornsby Ku-ring-gai Hospital, Sydney, NSW. Susan E Kurrle, Staff Specialist. Department of Surgery, University of Sydney, NSW. Sydney M L Nade, Emeritus Clinical Professor of Orthopaedics. Department of Orthopaedics and Traumatic Surgery, University of Sydney, Royal North Shore Hospital, Sydney, NSW. Tom K F Taylor, Professor; and Head. Reprints: Associate Professor L M March, Department of Rheumatology, The Royal North Shore Hospital, St Leonards, NSW 2065. Email: lmarcATdoh.health.nsw.gov.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> 1: Systematic literature review of 15 aspects of treatment of proximal femoral fracture--conclusions and evidence level1. Time to surgery (Level III)8-12 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 medical assessment has been made and the patient's condition 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)13-15 Routine use of preoperative skin and tibial pin traction should be abandoned. Pain should be adequately controlled with narcotic analgesia and/or nerve block. 3. Prevention of pressure sores (Level I)16,17 Patients should be nursed on one of a range of foam-based low pressure mattresses rather than standard hospital mattresses. Patients at very high risk of pressure sores should ideally be nursed on a large-cell, alternating-pressure air mattress or similar pressure-decreasing bed. 4. Oxygen therapy (Level II)18,19 Some evidence supports its routine use 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. Prophylactic anticoagulants (Level I)20-39 Unless there is a specific contraindication, patients should receive unfractionated low dose heparin (LDH) or low molecular weight heparin (LMWH), with a preference for the latter. This should commence as soon as possible after admission. 6. Pressure gradient stockings (Level II)40 Patients should be wearing these as soon as possible after admission. 7. Type of anaesthesia (Level I)41 Regional anaesthesia (spinal or epidural) appears to be associated with reduced short-term mortality and morbidity (confusion and thromboembolism) when compared with general anaesthesia and is recommended for most patients. 8. Type of analgesia (Level II)42,43 Pain should be adequately controlled with narcotic analgesia before and immediately after surgery. Femoral nerve blocks are useful in selected cases. 9. Prophylactic antibiotics (Level I)44-55 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)56-74 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)75-88 should have internal fixation with a widely used method that is familiar to the surgeon (cancellous screws or compression screw and plate). Displaced intracapsular fractures (Level II)75-88 have no clearly superior surgical treatment. The options for surgical treatment of this fracture are internal fixation or arthroplasty. Internal fixation is associated with a 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). 11. Surgical wound drains (Level II)89-91 May not be required as often as currently used and early removal is advised (around 24 hours after insertion). 12. Urinary catheterisation (Level II)92 Avoid indwelling catheters (where possible). Intermittent catheterisation is preferable and has been shown not to increase the incidence of urinary tract infections. 13. Nutritional status (Level II)93-97 All patients should have a nutritional assessment so that protein supplementation can be given as indicated. 14. Mobilisation (Level III)56-88,98 No randomised controlled trial evidence was available. A review of studies related to types of surgery1 concluded that almost all patients should be mobilised on the first or second day, taking as much weight on the fractured leg as the patient can tolerate. 15. Rehabilitation (Level II)99-104 Early assessment by a specialist team (within three days of admission) and active rehabilitation as soon as patient is mobile on a support frame is recommended for those who were independent before their fracture. Back to text 2: Evidence-based guidelines for acute management of proximal femoral fractureAverageRecommendation1993-94 practiceClinical intervention(level of evidence)(min-max)*1. Time to surgery8-12Within 24 hours of admission (Level III-3)15% (6%-24%)2. Preoperative traction13-15Not necessary -- adequate analgesiashould be given (Level II)57% (41%-64%)3. Prevention of pressure sores16,17Pressure care mattress to be used assoon as possible after admission (Level I) Not routine4. Oxygen therapy18,19O2 saturation monitored from timeof admission (Level II)Not routineO2 administered for 48 hours after surgery and if O2 saturation < 95% (Level II)Not routine5. Prophylactic anticoagulants20-39To commence as soon as possibleafter admission (Level I)87% (82%-98%)6. Pressure-gradient stockings40To be worn as soon as possible afteradmission (Level II)40% (16%-70%)7. Type of anaesthesia41Regional anaesthesia recommendedfor most patients (Level I)54% (14%-75%)8. Type of analgesia42,43Femoral nerve block in selected cases(Level II)Not routine9. Prophylactic IV antibiotics44-55At induction of anaesthesia (Level I)95% (86%-98%)10. Type of surgeryExtracapsular and undisplacedintracapsular fractures: compression screw device (Level I)56-7494% (83%-100%)Displaced intracapsular fractures:hemiarthroplasty (Level II)75-8861% (52%-67%)11. Surgical wound drains89-91Remove as soon as possible -- consider from 24 hours (Level II) Not recorded12. Urinary catheterisation92If possible, avoid indwelling catheters(Level II)66% (40%-90%)13. Nutritional status93-97Routine assessment -- provision of protein supplements as needed (Level II) Not routine14. Mobilisation56-88,98Early assisted ambulation -- by 48 hoursMedian Day 3after surgery (Level III)(Days 2-5)15. Rehabilitation99-104Early assessment by specialist team(Level II)Not routine16. Acute hospital length of stayEarly discharge to nursing home (Day 5)Median Day 6(Level IV)(Days 5-9)Early transfer to rehabilitation unit (Day 7)Median Day 11(Level II)(Days 8-16)Level of evidence -- National Health and Medical Research Council (Australia) 7I:Evidence obtained from a systematic review of all relevant randomised controlled trials (RCTs). II:Evidence obtained from at least one properly designed RCT. III - 1:Evidence obtained from well-designed controlled trials without randomisation. III - 2:Evidence obtained from well-designed cohort or case-control analytic studies, preferably from more than one centre or research group. III - 3:Evidence obtained from multiple time series with or without the intervention. Dramatic results in uncontrolled experiments could also be regarded as this type of evidence. IV:Opinions of respected authorities, based on clinical experience, descriptive studies, or reports of expert committees.* Unweighted average across all five acute-care hospitals of the frequency of adherence to evidence-based best practice in 1993-94. (min-max) = range of values from lowest rate (min) to highest rate (max). Back to text

Lynette M March · Anne C Chamberlain · Ian D Cameron · Robert G Cumming · Terrence P Finnegan · Susan E Kurrle · Jennifer M Schwarz

Research Health burden of hip and other fractures in Australia beyond 2000 Projections based on the Geelong Osteoporosis Study Kerrie M Sanders, Geoffrey C Nicholson, Antony M Ugoni, Julie A Pasco, Ego Seeman, and Mark A Kotowicz MJA 1999; 170: 467-470 For editorial comment, see Morris et al; see also Pocock et al. Abstract - Introduction - Methods - Results - Discussion - Acknowledgements - References - Author's Detials - - More articles on Public and environmental health Abstract Objective: To calculate the expected increase in the number of fractures in adults attributable to the predicted increase in the number of elderly Australians. Data sources: All fractures in adult residents (> 35 years) of the Barwon Statistical Division (total population, 218 000) were identified from radiological reports from February 1994 to February 1996. The Australian Bureau of Statistics supplied predictions of Australia's population (1996 to 2051). Main outcome measure: The projected annual number of fractures in Australian adults up to 2051 (based on stable rates of fracture in each age group). Results: The number of fractures per year is projected to increase 25% from 1996 to 2006 (from 83 000 fractures to 104 000). Hip fractures are projected to increase 36% (from 15 000 to 21 000) because of a substantial rise in the number of elderly aged 85 years and over. Hip fractures are expected to double by 2026 and increase fourfold by 2051. Conclusions: In contrast to Europe and North America, where numbers of hip fractures are expected to double by 2026 and then stabilise, in Australia hip fractures will continue to place a growing demand on healthcare resources for many decades. These projections can be used for setting goals and evaluating the costs and benefits of interventions in Australia. Introduction Australia's population is ageing. Thus, diseases such as osteoporosis are affecting a greater proportion of the population. Cost-effective prevention and treatment of fractures will become increasingly important, as the proportion of the "prime working" population (aged 15 to 64 years) is expected to decrease by 7% between 1996 and 2051.1 Estimations of the annual number of fractures will facilitate effective allocation of limited healthcare resources. Previously, fracture rates in Australia have been extrapolated from rates in Dubbo and Busselton,2,3 populations that may not be representative of the national population as they are both fairly isolated towns with small numbers of men and women in the oldest age groups. Lord et al investigated changes in hip fracture admissions in New South Wales between 1979 and 1990 using International Classification of Diseases hospital discharge codes.4 Although frequently used for ascertaining hip fractures, the limitations of this method are well documented.5,6 The Geelong Osteoporosis Study is a population-based study of age-, sex- and site-specific fracture rate(s) within a well-defined geographic region sufficiently large to establish reliable rates of fracture. It is the largest Australian epidemiological study of adult fractures, identifying 2184 fractures over two years in people aged 35 years and over. Data from the 1996 national census confirm the findings of an earlier study7 that the regional population is typical of the nation in age distribution and socioeconomic range. The Australian Bureau of Statistics publishes projections of the size, structure and distribution of Australia's population into the next century.1 Assuming stable age- and sex-specific rates of fracture, we have projected annual numbers of fractures by anatomical site in adults over the next 50 years. Methods Population The Barwon Statistical Division is a region of southern Victoria7 defined by the Australian Bureau of Statistics which includes urban, semi-urban and rural residents and has a population of 218 000 (109 923 aged 35 years and over). Fracture ascertainment Using radiological reports from the two medical imaging practices in the region, we identified all fractures in adults (aged 35 years and over) residing within the Barwon Statistical Division over the two-year ascertainment period (17 February 1994 to 16 February 1996). Fractures were identified by a weekly computerised keyword search of all radiological reports. Although radiological services are available at several sites throughout the region, these sites are under the auspices of two medical imaging practices. Only reports of definite fractures were included as "cases". Reports referring to "likely" or "possible" fracture were not included unless radiologically confirmed at a later date. Vertebral fractures were included in the study on the basis of the radiological report, provided there was no previous record of a fracture at that level. The initial x-ray demonstrating each fracture was sought and the date of fracture was the date of the radiological diagnosis. As the region is well provided with medical facilities, few fractures would not have been assessed or followed up by services within the region. The standing orders for the ambulance service are to transport patients from residences within the study region to The Geelong Hospital. The study was well advertised and adults who may have sustained fracture(s) while outside the region were asked to contact study coordinators. Non-residents and patients with pathological fractures (metastatic cancer, Paget's disease and multiple myeloma) were excluded. We have previously reported that the exclusion of high trauma fractures may underestimate the prevalence of bone-fragility fractures in the community,8 so we did not exclude fractures on the basis of trauma classification. The method of fracture ascertainment has been previously described9 and validated, using hip fracture as a model.10 The study was approved by The Geelong Hospital Human Research and Ethics Advisory Committee. Projections We calculated the predicted number of fractures in each five-year age group for men and women as: Predicted number of fractures = Number of fractures in the study region Study region population X Projected Australian population X 0.5 (2 year ascertainment) The study region population was determined from the 1996 Australian Bureau of Statistics census. Annual population projections were also provided by the Australian Bureau of Statistics.1 This method of projection assumes that the fracture rate in each age group will remain unchanged over time. Confidence intervals around the projections were calculated by the bootstrap method.11 Results The number of fractures identified in the study population is shown in Table 1. Projections for all fractures During the ascertainment period, 2184 adults sustained fractures, producing an age- and sex-adjusted incidence of 102 per 10 000 person-years. In 1996, we estimate that about 83 000 Australians aged 35 years and over sustained fractures. We predict that by 2006 the total number of fractures per year will increase by 25%, to 104 000 (Figure 1). Projections for hip fractures Over the two-year ascertainment period, 428 people sustained hip fractures, producing an age- and sex-adjusted incidence in people aged 35 years and over of 17.2. The number of hip fractures in Australian women is projected to increase from 11 300 per year in 1996 to 44 700 in 2051. In men, the number is projected to rise from 4 000 to 15 300. Figure 2 shows the projection for all people aged 35 years or over. The number of Australians sustaining hip fractures each year is projected to increase by 15% every five years until 2036, then by about 10% every five years until 2051. A fourfold increase in hip fractures is expected by 2051, when about 23% of Australia's projected population will be aged 65 years and over (compared with 12% in 1996) and over 8% of the population will be aged 85 years and over (compared with 2% in 1996). Hip fractures are likely to increase more than fractures at other sites because the greatest population growth is expected in the oldest age groups, where the hip is the most common site of fracture.9 Projections for fractures at sites other than the hip During the ascertainment period, 1756 adults aged 35 years and over sustained fractures at sites other than the hip, producing an age- and sex-adjusted incidence of 77 per 10 000 person-years. We estimate that in 1996 about 68 000 Australians aged 35 years and over sustained fractures at sites other than the hip, and that the number of non-hip fractures is likely to increase by 9% every five years until 2036, and then by 4% every five years until 2051 (to 147 645 non-hip fractures per year). Projections for vertebral, Colles, humeral and pelvic fractures (the most common sites of fracture after the hip) are shown in Figure 3. Fractures at these sites are likely to increase more than fractures at other sites where fracture rates do not increase substantially with age.9 Population projections suggest that vertebral, humeral and pelvic fractures will increase by 12% every five years to 2036, then by 6% every five years to 2051. Colles fracture rates increase with age in women, but not in men,8 and the overall number of adults sustaining a Colles fracture will increase by 10% every five years until 2036, then by 5% every five years until 2051. Fractures other than hip, vertebral, Colles, humeral and pelvic fractures are predicted to increase at about half the rate predicted for these sites (6% every five years until 2036, then 3% every five years until 2051). Projection of fracture numbers by age group The number of fractures in adults aged 35 to 59 years is not predicted to change substantially over the projection period, as only a small population increase in this age group is anticipated. By contrast, among those aged 60 years and over, the number of fractures is predicted to increase by at least 10% every five years, and by almost 20% every five years among those aged 85 years and over (Table 2). Figure 4 shows the projected distribution of hip fractures across age groups for selected years from 1996 to 2051. Discussion The ageing of the Australian population is increasing the demand for health resources. Health expenditure per person aged 65 years and over is nearly four times higher than for younger individuals ($4900 v $1300).12It is likely that hip fracture, which becomes increasingly common with advancing age, contributes significantly to this higher expenditure. Almost all people with a fractured hip are hospitalised, with an average length of stay of 13 days.13 Studies in other white populations suggest that 50% of patients who survive hip fracture are discharged to nursing homes, and 25% remain institutionalised one year later.14,15 Comparable Australian data are not available, although the increased mortality after hip fracture has been confirmed.16 We estimate that hip fractures accounted for 0.9% of total government health services expenditure for 1995/96.12 Based on the number of Australian salary earners in 1998 (Australian Bureau of Statistics) and an average cost of $16 000 per hip fracture,17 treatment alone costs salary earners an average of $28 per year. In current dollar terms, this may escalate to $120 per salary earner per year by 2051 if the projected increase is realised. The number of adults sustaining a hip fracture is likely to more than double from 15 000 in 1996 to 34 000 in 2026, then almost double again by 2051. Fractures at other sites are expected to increase by 70% from 1996 to 2026, then by a further 26% to 2051. These rates of increase are far above the expected growth in total healthcare costs due to the ageing of the Australian population, which is estimated to be 4% every five years for the next 30 to 40 years.18 For the number of hip fractures to remain stable, their incidence (per 10 000 population per year) would need to decline from 17.2 in 19969 to 15.6 in 2001, 14.3 in 2006 and 11.3 in 2026. In the United States, an 18% reduction in hip fracture rates between 1988 to 2000 has been targeted by public health strategists.19 Current therapies (such as hormone replacement therapy and bisphosphonates) may reduce fracture rates by 50%, but their cost-effectiveness remains controversial.20,21 In most white populations the number of hip fractures is predicted to double between 1990 and 2025, and then plateau as the growth in the aged population ceases.22 However, in contrast with Europe and North America, the aged population and the number of hip fractures in Australia and New Zealand are likely to continue to increase from 2025 to 2050.22 Current trends suggest that almost three times as many women as men will sustain a hip fracture (Table 1). Largely for this reason, efforts to prevent hip fracture have focused on osteoporosis in women. However, mortality and rate of institutionalisation after hip fracture is higher in men,23 and increasing hip fracture rates among men, but not women, have been reported.24,25 The projected increased longevity in men suggests that osteoporosis will affect a growing number of Australian men, yet there are no data concerning efficacy of any drug treatment to prevent hip or vertebral fractures in men.26 Our projected number of vertebral fractures is likely to be an underestimate because our ascertainment relied on clinical indications for medical imaging. Between 50% and 75% of vertebral fractures do not come to medical attention.27,28 However, our data are likely to include some previously undiagnosed vertebral fractures that occurred before the ascertainment period. Nevertheless, the predicted number of vertebral fractures represents the number likely to come to medical attention each year. Excluding vertebral fractures does not alter the projected rate increase of all fractures. The validity of these projections is dependent upon reliable and stable incidence rates and accurate population projections. The major strength of our study was the comprehensive ascertainment of all fractures among adult residents of a defined region representative of Australia.9 A decline in hip fracture rates has recently been reported,19 but other studies have pointed to stable age-specific rates in women and younger men and increasing rates in older men.24,25,29,30 These projections highlight the need to decrease fracture rates among the elderly and can be used for setting goals and evaluating the costs and benefits of interventions in Australia. Acknowledgements This study was supported by the Victorian Health Promotion Foundation. We acknowledge the invaluable contributions of the radiologists (D Barry, JM Cameron, PJ Carman, WP Holloway, V Mercuri, PM Motterdam and DB Robertson) and staff at the Geelong Radiological Clinic, as well as the radiologists (NJ Ferris, DO Lun, CB Styles) and staff of the Medical Imaging Department at the Geelong and Colac hospitals. We also wish to thank Biljana Skoric and Soheila Panahi. References McLennan W. Projections of the populations of Australia, States and Territories, 1995-2051. Canberra: Australian Bureau of Statistics, 1996: 128. (Catalogue no. 3222.0.) Jones G, Nguyen T, Sambrook PN, Kelly PJ, Gilbert C, Eisman JA. Symptomatic fracture incidence in elderly men and women: The Dubbo osteoporosis study (DOES). Osteoporos Int 1994; 4: 277-282. Prince RL, Knuiman MW, Gulland L. Fracture prevalence in an Australian population. Aust J Public Health 1993; 17: 124-128. Lord SR. Hip fractures: changing patterns in hospital bed use in NSW between 1979 and 1990. Aust N Z Surg 1993; 63: 352-355. Bacon W, Maggi S, Looker A, et al. International comparison of hip fracture rates in 1988-89. Osteoporos Int 1996; 6: 69-75. Maggi S, Kelsey JL, Litvak J, Heyse SP. Incidence of hip fractures in the elderly: a cross national analysis. Osteoporos Int 1991; 1: 232-241. Ross KN. The development of the 1984 "Indicator of Disadvantage" and its application to resource allocation decisions for the "Disadvantaged Schools Program" in Australia. Geelong: School of Education, Deakin University, 1984. Sanders K, Pasco J, Ugoni A, et al. The exclusion of high trauma fractures may underestimate the prevalence of bone fragility fractures in the community: The Geelong Osteoporosis Study. J Bone Mineral Res 1998; 13: 1337-1342. Sanders K, Seeman E, Ugoni A, et al. The age- and gender-specific rate of fractures in Australia: a population based study. Osteoporos Int 1999. In press. Pasco JA, Henry MJ, Gaudry TM, et al. Identification of incident fractures: Geelong Osteoporosis Study. Aust N Z J Med 1999; 29: 203-206. Efron B, Tibshirani R. The introduction to the bootstrap. New York: Chapman & Hall, 1993. Australia's health 1998: the sixth biennial health report of the Australian Institute of Health and Welfare. Canberra: AGPS, 1998. Abraham B, d'Espaignet E, Stevenson C. Australian health trends 1995. Canberra: Australian Institute of Health and Welfare, 1995. Orwoll ES. The special problem of hip fracture. In: Favus MJ, editor. Primer on the metabolic bone diseases and disorders of mineral metabolism. 3rd ed. Philadelphia: Lippincott-Raven, 1996: 272-282. Keene G, Parker M, Pryor G. Mortality and morbidity after hip fractures. BMJ 1993; 307: 1248-1250. Center J, Nguyen TV, Schneider D, et al. Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet 1999; 353: 878-882. Randell A, Sambrook P, Nguyen T, et al. Direct clinical and welfare costs of osteoporotic fractures in elderly men and women. Osteoporos Int 1995; 5: 427-432. Gray R. Insurance: the long term funding of aged care. National Healthcare 1998; 8(4): 32-33. Melton L, Atkinson EJ, Madhok R. Downturn in hip fracture incidence. Public Health Rep 1996; 111 (March/April): 146-150. Black DM, Cummings SR, Karpf DB, et al. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 1996; 348: 1535-1541. Jonsson B, Christiansen C, Johnell O, Hedbrandt J. Cost-effectiveness of fracture prevention in established osteoporosis. Osteoporos Int 1995; 5: 136-142. Cooper C, Campion G, Melton LJ III. Hip fractures in the elderly: A world-wide projection. Osteoporos Int 1992; 2: 285-289. Sernbo I, Johnell O. Consequences of a hip fracture: A prospective study over 1 year. Osteoporos Int 1993; 3: 148-153. Melton LJI, O'Fallon WM, Riggs BL. Secular trends in the incidence of hip fractures. Calcif Tissue Int 1987; 41: 57-64. Bacon W. Secular trends in hip fracture occurrence and survival: Age and sex differences. J Aging Health 1996; 8: 538-553. Seeman E. Osteoporosis: trials and tribulations. Am J Med 1997; 103 (2A): 74S-87S. Kanis JA, McCloskey EV. Epidemiology of vertebral osteoporosis. Bone 1992; 13 Suppl 2: S1-S10. Cooper C, Atkinson EJ, O'Fallon M, Melton L. Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985-1989. J Bone Min Res 1992; 7: 221-227. Falch JA, Kaastad TS, Bohler G, et al. Secular increase and geograpical differences in hip fracture incidence in Norway. Bone 1993; 14: 643-645. Agnusdei D, Camporeale A, Gerardi D, et al. Trends in the incidence of hip fracture in Siena, Italy, from 1980 to 1991. Bone 1993; 14: S31-S34. (Received 13 Nov 1998, accepted 13 Apr 1999) Author's Detials University of Melbourne Department of Medicine, Barwon Health-The Geelong Hospital, Geelong, VIC Kerrie M Sanders, MNutrition, PhD, Research Fellow; Geoffrey C Nicholson, PhD, FRACP, Professor of Medicine; Julie A Pasco, PhD, Study Coordinator; Mark A Kotowicz, FRACP, Senior Lecturer in Medicine. Department of General Practice and Public Health, The University of Melbourne, Melbourne, VIC. Antony M Ugoni, BSc(Hons), Lecturer in Biostatistics. Austin and Repatriation Medical Centre, Melbourne, VIC. Ego Seeman, MD, FRACP, Associate Professor of Medicine, The University of Melbourne. Reprints will not be available from the authors. Correspondence: Dr M A Kotowicz, University Department of Medicine, Barwon Health-Geelong Hospital, PO Box 281, Geelong, VIC 3220. Email: m.kotowiczATmedicine.unimelb.edu.au Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au>". <URL: http://www.mja.com.au/> Back to textBack to textBack to textBack to textBack to textBack to text

Kerrie M Sanders · Geoffrey C Nicholson · Antony M Ugoni · Julie A Pasco · Ego Seeman · Mark A Kotowicz

Abstract Objective: To ascertain the effectiveness of clinical pathways for improving patient outcomes and decreasing lengths of stay after hip and knee arthroplasty. Design and setting: Twelve-month randomised prospective trial comparing patients treated through a clinical pathway with those treated by an established standard of care at a single tertiary referral university hospital. Participants: 163 patients (56 men and 107 women; mean age, 66 years) undergoing primary hip or knee arthroplasty, and randomly allocated to the clinical pathway (92 patients) and the control group (71 patients). Main outcome measures: Time to sitting out of bed and walking; rates of complications and readmissions; match to planned discharge destination; and length of hospital stay. Results: Clinical pathway patients had a shorter mean length of stay (P = 0.011), earlier ambulation(P = 0.001), a lower readmission rate (P = 0.06) and closer matching of discharge destination. There were beneficial effects of attending patient seminars and preadmission clinics for both pathway and control patients. Conclusion: Clinical pathway is an effective method of improving patient outcomes and decreasing length of stay following hip and knee arthroplasty. Introduction The past two decades have seen an 85% rise in Australian health costs to 36.6 billion dollars, with the largest proportion of this expended in acute hospital care.1 Newer health policies now incorporate measures to rationalise and improve the efficiency of many services. Such policies, however, are economically driven and frequently fail to consider the optimum level of service required by the community.2 Treatment protocols, variously known as clinical pathways, critical pathways and care paths, that aim to streamline and standardise management through a systematic approach so that high quality care may be provided in a timely and cost effective manner3,4 have been developed. Clinical pathways describe the course of hospitalisation for patients with a specified illness and encompass a predetermined plan of treatment. The use of clinical pathways is now well established and their successes are widely reported.5-7 Joint arthroplasty is a common and costly procedure associated with high resource use that is frequently performed in the elderly who may have many coexisting morbidities. These characteristics suggest that joint arthroplasty may be a suitable procedure to incorporate into a clinical pathway.8 As part of a "best practice" initiative in line with quality assurance activities at St Vincent's Hospital, the hospital's Orthopaedic Service has developed clinical pathways for hip and knee joint arthroplasty for treating osteoarthritis which aim to maximise the use of all available resources and minimise negative patient outcomes, thereby improving patient care. To this end, we report the effects of introducing clinical pathways at our hospital on quality indicators such as mobilisation, complication rates, discharge planning and readmission rates while also exploring the impact on length of stay. Methods We used a prospective randomised control group design to compare the outcomes of patients who underwent hip or knee joint arthroplasty at St Vincent's Hospital, Melbourne (a tertiary referral hospital affiliated with the University of Melbourne), between 1 January 1996 and 30 December 1997. All such patients were randomly allocated to either the control or clinical pathway group by a clerical assistant who was blinded to their demographic and clinical profiles. Diagnostic category and comorbidities had no bearing on the allocation of patients to either the pathway or control groups, but patients were excluded from the study after randomisation if they were having revision arthroplasty, simultaneous bilateral joint arthroplasty, arthroplasty for acute trauma or complex tumour surgery. The management of patients undergoing joint arthroplasty at St Vincent's Hospital, Melbourne, is outlined in Box 1. Outcome measures Length of stay (calculated from the time of the patient's admission to the time of discharge and expressed in days); Time to sitting out of bed and ambulation (time between surgery and the patient's first day of sitting out of bed or walking with assistance); Complications (wound infections, including all wound erythema lasting more than 24 hours, chest infections, deep vein thrombosis [DVT] as diagnosed by clinical features and confirmed by ultrasonography, joint dislocation, decubitus pressure areas, failure to cope at home and a decreased range of motion after discharge); Readmission (for complications during a follow-up period of three months from discharge); and Discharge matching (between the presumptive discharge destination given at the preadmission clinic and the patient's postdischarge destination). Clinical pathway and control patients Patients randomly allocated to the clinical pathway received proactive treatment whereby specific goals were set each day for the patient and treating team. Their hospital records included a special written protocol which listed milestones to be achieved, identified tests that should be ordered, set daily tasks for patients and members of the treating team, and provided space for documenting any variation in treatment or patient response. Each intervention was signed by the treating health professional and the discharge plan was re-evaluated daily to ensure it remained realistic and appropriate to the patient's needs. The clinical pathway formalised in writing the participation of the various members of the treating team. Patients not allocated to the pathway received "reactive" treatment whereby the treating team responded to the will and condition of the patient in providing postoperative care. Statistical analysis Results were analysed with SigmaStat V2 software.9 Data were compared using t tests for independent groups and multiple linear regression where appropriate. We used the z test for comparisons of proportions between groups. As the data for length of stay (LOS), time to sitting out of bed and time to ambulation were not normally distributed, these data were transformed using a logarithmic transformation before analysis with t tests. We calculated the sample size for this study after reviewing all hip and knee arthroplasty patient data for 1995, which showed a mean LOS of 13 days (range, 5.8-43.3; SD, 5.3). We believed that a 20% reduction in LOS (2.6 days) would represent a clinically significant outcome. Therefore, we calculated that to detect a reduction of 2.6 days in LOS at a significance level of 0.05 with a power of 0.8 would require two groups with a minimum of 65 subjects in each group. Results During the study period 175 patients underwent hip or knee joint arthroplasty and were randomly allocated to the pathway (94 patients) and control (81 patients) groups. Twelve patients were then excluded by the crtiteria listed in the methods, leaving 163 patients -- 92 in the clinical pathway group and 71 in the control group. The sample comprised 56 men and 107 women, with a mean age of 66 years (range, 67-93 years). All patients were followed for a minimum of three months and none were lost to follow-up. Our findings are summarised in Box 2. There was no significant difference between control and pathway patients in terms of age or weight. Although the clinical pathway group included more patients with premorbid conditions than the control group, this difference was not statistically significant (95% CI, - 0.03 to 0.21). Length of stay (LOS) was significantly shorter for the pathway group than for the control group (t = 2.585; P = 0.011). When LOS was analysed for the subgroups of patients in each group with premorbid conditions, this was still significantly shorter for the pathway group than the control group (t = 3.152; P = 0.001) despite the larger number of patients with premorbid conditions in the pathway group. Patients in the clinical pathway group sat out of bed and walked earlier after surgery than control patients. Multiple linear regression for each group showed that time to ambulation was the only significant contributor to reduction in log LOS in the clinical pathway group (time to ambulation -- coeff = 19.6, standard error [SE] = 9.6, P = 0.04; time to sitting out of bed -- coeff = - 4.35, SE = 9.3, P = 0.64, R2 = 0.127). Neither time to ambulation nor time to sit out of bed was significantly associated with reduced log LOS in the control group (time to ambulation -- coeff = 21.05; SE = 26.28, P = 0.42; time to sit out of bed -- coeff = - 4.13, SE = 28.54, P = 0.88, R2 = 0.0251). Patients from both the clinical pathway and control groups who attended either the preadmission clinic (n = 122) or the patient information seminar (n = 61) had a shorter LOS (7.22 days and 6.84 days, respectively) than patients who attended neither (n = 36; LOS, 8.55 days). The 54 patients who attended both the clinic and seminar had the shortest LOS at 6.6 days, and t tests showed that the shorter LOS for these patients relative to those who attended neither the clinic nor seminar was significant (t = 2.66; P = 0.009). Post-hoc t tests showed that the shorter LOS for patients who had attended both preadmission clinics and information seminars relative to those who had attended neither was significant (t = 2.66; P = 0.009). Box 2 shows that a greater proportion of clinical pathway patients were discharged to their planned discharge destination than control patients (95% CI, - 0.05 to 0.23), and that there were fewer readmissions in clinical pathway patients (95% CI, 0.006-0.174), although neither result was statistically significant. However, there were significantly fewer complications in clinical pathway patients (95% CI, 0.036-0.27). Discussion We found that a clinical pathway for hip and knee joint arthroplasty had a beneficial impact on the duration of admission, with patients on the pathway having a 1.5-day shorter stay than control patients. The seven-day LOS for our pathway patients compared favourably with that of Gregor et al,10 who showed a reduction in LOS from 12 to nine days for pathway patients. Length of stay was significantly shorter for the pathway group than the control group despite the larger proportion of pathway patients with premorbid conditions. This result should be interpreted cautiously, as the small overall number of patients with premorbid conditions meant that the test had less than optimal power (0.45). However, we conclude that comorbidities per se should not exclude patients from clinical pathways. Patients with comorbid conditions may actually be better served because of the greater fastidiousness and vigilance imposed by the daily protocol. While our findings that there were fewer complications and readmissions in clinical pathway patients were not significant, we believe that given the appropriate number of subjects in future studies both of these areas may approach significance. We noted that reducing the length of stay did not increase the complication rate, a finding corroborated by others.11 In addition, the readmission rate for complications for pathway patients was one-third that of controls. This contrasts with some studies which have reported an inverse relationship between length of stay and readmission rates.11 We, like other authors,12 believe that it is a lower quality of care and not length of stay per se that increases the risk of unplanned readmission. Discharge planning is an important part of the clinical pathway which appears to be closely linked with the length of stay. Appropriate matching of predetermined discharge destinations is a correlate of shorter admissions. If we are able to improve on our destination matching rate of 70%, we may be able to further reduce our length of stay, thereby making more resources available for other patients. Education of patients and their relatives appeared to have a positive influence on the patients' recovery after joint arthroplasty, with earlier mobilisation and discharge from hospital. Attending information seminars and preadmission clinics assisted in reducing the length of stay by almost two days. Patients and their relatives who understand the disease and the necessary treatment may be in a better position to assist with care and rehabilitation. Attendances for our information seminar and preadmission clinic were 38% and 74%, respectively, and we are endeavouring to increase these. First introduced by the New England Medical Center, clinical pathways are now incorporated into the management philosophy of many hospitals worldwide.13,14 Pathways involve input from medical, nursing, paramedical and administrative staff, and reflect the expertise of all members of the healthcare team while highlighting the interdependent nature of these roles in achieving positive outcomes for patients.15 A valuable subsidiary purpose of pathways is in providing information from which the financial cost of care may also be derived.16 Accurate costing of treatment is fundamental to the operation of institutions where prospective payments are made in accordance with diagnosis-related groups (DRGs), standardised lengths of stay and fixed reimbursement for care. Clinical pathways thus provide an important tool for coordinating and managing clinical resources. However, the driving force behind clinical pathways must remain the need to improve the quality of care and patient outcomes, and not their utility as a tool to ensure that budgetary demands are met. We are encouraged by our findings, which indicate substantial improvements for patients on a clinical pathway. To our knowledge, no other study has investigated the effect of clinical pathways on joint arthroplasty using a contemporaneous control group. 1 Management of joint arthroplasty patients at St Vincent's Hospital, Melbourne Preadmission clinics Preoperative review for patients undergoing elective joint replacement involves a multidisciplinary approach and includes medical, nursing, physiotherapy and occupational therapy consultation and anaesthetic and social work screening. Preexisting conditions are identified and testing and treatment are undertaken to achieve an optimum level of preoperative health. A discharge destination is determined based on medical and projected rehabilitation needs. Appropriate referrals are initiated. Patient information seminars Groups of patients and their families are invited to attend an information seminar about the surgery. The surgeon explains the aetiology of the disease, principles of management, nature of potential risks and their prevention. The nursing staff discuss acute postoperative care, including pain relief, pressure and wound care, intravenous therapy, and prophylaxis for deep venous thrombosis. The physiotherapist discusses the regimen of postoperative exercises, cautions and mobilisation. The occupational therapist describes the availability and use of various personal aids which assist the patient in preventing complications such as falls, injury or dislocation. Patients are able to raise any questions related to their surgery. Patients and their families are encouraged to take an active role in the postoperative management, and are acquainted with their very important role in the postdischarge phase. All members of the team stress the philosophy that the primary intention is to return patients home in preference to a rehabilitation hospital after the surgery. Discharge Patients are discharged home or to a rehabilitation unit. For those discharged home, community nursing care is provided at regular intervals for the first three weeks after discharge. Community nurses pay special attention to the nature of the patient's wounds, their exercise regimen and general medical condition. Any concerns are immediately related to the medical staff for further attention. Patients are followed up on a regular basis in the outpatient department. 2 References MacIntyre CR, Brook CW, Chandraraj E, Plant AJ. Changes in bed resources and admission patterns in acute public hospitals in Victoria, 1987-95. Med J Aust 1997; 167: 186-189. Parry TG. Health expenditure in Australia -- the current dilemma. Med J Aust 1992; 156: 592-594. Wigfield A, Boon E. Critical care pathway development: the way forward. Br J Nursing 1996; 5: 732-735. Grudich G. The critical path system. AORN J 1991; 53: 705-714. Gouveia WA, Massaro FJ. Critical pathway experience at New England Medical Center. Am J Health-Syst Pharm 1995; 52: 1068-1070. Saltiel E. Critical pathway experience at Cedars-Sinai Medical Center. Am J Health-Syst Pharm 1995; 52: 1063-1068. Stevenson LL. Critical pathway experience at Saratosa Memorial Hospital. Am J Health-Syst Pharm 1995; 52: 1071-1073. Leininger SM. Tools for building a successful orthopaedic pathway. Orthop Nurs 1996; 15: 11-19. SigmaStat [computer program]. Version 2. San Rafael, CA: Jandel Scientific Software, 1995. Gregor C, Pope S, Werry D, Dodek P. Reduced length of stay and improved appropriateness of care with a clinical path for total knee or hip arthroplasty. Joint Commiss J Qual Improv 1996; 22: 617-628. Rushworth RL, Rob MI. Readmissions to hospital: the contribution of morbidity data to the evaluation of asthma management. Aust J Public Health 1995; 19: 363-367. Ashton CM, Kuykendall DH, Johnson ML, et al. The association between the quality of inpatient care and early readmission. Ann Intern Med 1995; 122: 415-421. Zander K. Managed care within acute care settings: design and implementation via nursing case management. Health Care Supervisor 1988; 6: 27-43. Bower KA. Managed care: controlling costs, guaranteeing outcomes. Definition 1988; 3: 14. Heacock D, Brobst RA. A multidisciplinary approach to critical path development: a valuable CQI tool. J Nurs Care Qual 1994; 8: 38-41. Weilitz PB, Potter PA. A managed care system. Financial and clinical evaluation. J Nurs Admin 1993; 23: 51-7. (Received 27 Jan, accepted 20 Aug, 1998) Authors' details Department of Orthopaedics, St Vincent's Hospital, Melbourne, VIC. Michelle M Dowsey, BN, GradCertOrth, Clinical Nurse Specialist; Meredith L Kilgour, BN, GradDipAdvClinPrac, Nurse Unit Manager; Nick M Santamaria, BAppSc, PhD, Director of Nursing Research; Peter F M Choong, MD, FRACS, Professor, and Director of Orthopaedics. Reprints: Professor P F M Choong, Department of Orthopaedics, St Vincent's Hospital, 41 Victoria Parade, Fitzroy, VIC 3065. Email: PeterChoongATc031.aone.net.au

Michelle M Dowsey · Meredith L Kilgour · Nick M Santamaria