Correspondence
Hip Fracture
N Engl J Med 1996; 335:1994-1996December 26, 1996
- Article
To the Editor:
A review article on hip fracture (June 6 issue)1 is certainly welcome. The diagnosis, prevention, and treatment of osteoporosis and the assessment of risk factors and prevention of falls are not only critical if we are to decrease the incidence of first hip fractures, but also important in patients who have already had a fracture. The risk of a second hip fracture is increased two- to threefold in these patients, and the risk of fractures at other sites is also increased.
There are many approaches to decreasing the likelihood of further fractures in such patients. Treatment with calcium and vitamin D can reduce the incidence of hip fractures.2 Although we do not yet know the precise efficacy of secondary prevention after a first hip fracture, treatment with estrogen, bisphosphonate, or calcitonin should be considered in patients with osteoporosis at any stage in their disease. Similarly, a careful review of risk factors for falls and an attempt to minimize them should be as important in the patient who has had one hip fracture as it is in the elderly patient who is at high risk but has not yet had a fracture. There are practical interventions that can reduce the risk of falling.3
3 ReferencesSteven R. Cummings, M.D.
University of California, San Francisco, San Francisco, CA 94143Lawrence G. raisz, M.D.
University of Connecticut Health Center, Farmington, CT 060301
Zuckerman JD . Hip fracture. N Engl J Med 1996;334:1519-1525
Full Text | Web of Science | Medline2
Chapuy MC ,Arlot ME ,Delmas PD ,Meunier PJ . Effect of calcium and cholecalciferol treatment for three years on hip fractures in elderly women. BMJ 1994;308:1081-1082
CrossRef | Web of Science | Medline3
Tinetti ME ,Baker DI ,McAvay G , et al. A multifactorial intervention to reduce the risk of falling among elderly people living in the community. N Engl J Med 1994;331:821-827
Full Text | Web of Science | Medline
To the Editor:
In his review of therapy for hip fractures, Dr. Zuckerman mentions that in patients with hip fractures and a recent or concurrent myocardial infarction, the risk of reinfarction is substantially increased and that reconstructive surgery should be delayed until the risk of reinfarction has diminished. He refers to a 37 percent rate of perioperative reinfarction with surgery within the first three months after the initial infarction, a 17 percent risk four to six months after infarction, and a 5 percent risk after six months. These figures, from 1972,1 greatly overestimate the actual risk of surgery and may adversely influence the decision regarding surgical intervention.
Recent studies have demonstrated a much lower risk of reinfarction in the perioperative period. Rao et al. reported a 6 percent risk of perioperative reinfarction in the first three months after infarction, a 2 percent risk after four to six months, and only a 1.5 percent risk more than six months after the initial infarction.2 Shah et al. reported similar rates of reinfarction in patients who underwent noncardiac surgery (4 percent, 0 percent, and 6 percent, respectively).3 These lower rates of reinfarction reflect the increasing use and availability of preoperative noninvasive cardiac testing and more intensive and aggressive perioperative and postoperative monitoring in these high-risk patients.
Aggressive preoperative and postoperative care, even in high-risk patients, can reduce the risk of surgery to less than that of nonoperative care, which exposes the patient to the greater risks of being bed-bound.
3 ReferencesSteven F. Reichert, M.D.
Mount Sinai Medical Center, New York, NY 100291
Tarhan S ,Moffitt EA ,Taylor WF ,Giuliani ER . Myocardial infarction after general anesthesia. JAMA 1972;22:1451-1454
CrossRef | Web of Science2
Rao TL ,Jacobs KH ,El-Etr AA . Reinfarction following anesthesia in patients with myocardial infarction. Anesthesiology 1983;59:499-505
CrossRef | Web of Science | Medline3
Shah KB ,Kleinman BS ,Sami H ,Patel J ,Rao TL . Reevaluation of perioperative myocardial infarction in patients with prior myocardial infarction undergoing noncardiac operations. Anesth Analg 1990;71:231-235
CrossRef | Web of Science | Medline
To the Editor:
Zuckerman's review suggests that surgery “should be performed as soon after the injury as possible, usually within 24 to 48 hours after admission.” If the operation aims to protect the femoral head — for example, with internal fixation by cannulated screws — surgery should be performed within six to eight hours after trauma. Arterial irrigation is due principally to the intracapsular medial femoral circumflex artery. The hematoma inside the joint increases the intracapsular pressure and must be evacuated. The reduction of the fracture relaxes the distended capsular vessels (“unkinking”) and reduces the subsequent risk of necrosis of the femoral head.1,2 Even with the proper surgical techniques (which may include a primary intertrochanteric osteotomy in steep fractures), the rates of necrosis of the femoral head range from 10 to 50 percent.2-4
4 ReferencesChristof Burger, M.D.
Axel Prokop, M.D.
K.E. Rehm, M.D.
University of Cologne, D-50924 Cologne, Germany1
Rüter A, Trentz O, Wagner M. Unfallchirurgie. Berlin, Germany: Urban & Schwarzenberg, 1995:660.
2
Swiontkowski MF . Intracapsular fractures of the hip. J Bone Joint Surg Am 1994;76:129-138
Web of Science | Medline3
David A ,Richter J ,Huffner T . Mediale Schenkelhalsfraktur -- kopferhaltende Therapiekonzepte. Zentralbl Chir 1995;120:841-849
Web of Science | Medline4
Forgon M . Pathophysiologie der Kopfdurchblutung nach Schenkelhalsfraktur und ihre klinischen Konsequenzen. Hefte Unfallchir 1993;230:354-356
To the Editor:
Dr. Zuckerman does not mention the nonoperative treatment of impacted — wrongly called nondisplaced — fractures of the femoral neck. There are many reports1-3 on this subject, and there are good results with nonoperative treatments. My colleague and I have now used this approach in 200 patients, with early mobilization and weight-bearing.4 Secondary instability led to operative treatment in only 19 percent of these patients. Therefore, those who perform primary — or, better, “prophylactic” — internal fixations of impacted fractures perform an unnecessary operation in 81 percent of their patients. In our series poor medical or mental condition and an age over 70 years were the main risk factors for secondary instability. With multiple risk factors the prognosis for union is poor and in these cases the rate of secondary instability can reach 60 percent. But even these patients lose little if we have to operate later. Secondary instability in healthy patients 70 years of age or younger is extremely rare. We have not seen an increased rate of avascular necrosis after delayed internal fixation because of secondary instability. We therefore strongly favor the nonoperative treatment of impacted femoral-neck fractures in all patients.
We understand that many orthopedic surgeons, especially in the United States, are skeptical of this approach. Nailing or fixation with screws is a short, minimally invasive procedure. However, secondary instability occurs in 6 percent of cases even after internal fixation, and avascular necrosis develops in 25 to 36 percent.
Prophylactic internal fixation gives the surgeon a feeling of efficiency because there is no concern about secondary instability, but it is a limited efficiency. Primary internal fixation can have complications, and most patients are happy to avoid an operation and instead wait to see how well their hip mends.
4 ReferencesErnst L.F.B. Raaymakers, M.D., Ph.D.
Academic Medical Center, 1105 AZ Amsterdam, the Netherlands1
Hilleboe JW ,Staple TW ,Lansche EW ,Reynolds FC . The nonoperative treatment of impacted fractures of the femoral neck. South Med J 1970;63:1103-1109
CrossRef | Web of Science | Medline2
Hansen BA ,Solgaard S . Impacted fractures of the femoral neck treated by early mobilization and weight-bearing. Acta Orthop Scand 1978;49:180-185
CrossRef | Medline3
van Vugt A. The unsolved fracture: a prospective study of 224 consecutive cases with an intracapsular hip fracture. (Thesis. Nijmegen, the Netherlands: University of Nijmegen, 1991.)
4
Raaymakers EL ,Marti RK . Non-operative treatment of impacted femoral neck fractures: a prospective study of 170 cases. J Bone Joint Surg Br 1991;73:950-954
Web of Science | Medline
Author/Editor Response
Dr. Zuckerman and a colleague reply:
To the Editor: We agree with Drs. Cummings and Raisz that the diagnosis, prevention, and treatment of osteoporosis, the assessment of risk factors, and the prevention of falls are critical to our efforts to decrease the incidence of first-time hip fractures, as well as fractures in patients who have already sustained a hip fracture. However, the goal of the review article focused specifically on the treatment of patients who have already sustained hip fractures.
Dr. Reichert accurately addresses the important issue of risk stratification in patients with recent myocardial infarction who are scheduled for hip-fracture surgery. Indeed, there is a tendency now to operate earlier in patients with recent myocardial infarction. However, each patient must be evaluated carefully, with consideration given to the extent of the myocardial infarction, the amount of myocardium at risk, postinfarction symptoms and ischemia, the presence of congestive heart failure, and left ventricular function. Risk stratification can be further defined with both noninvasive and invasive testing. Since hip-fracture surgery is not elective, the risk of operative intervention must be weighed against the serious risks associated with nonoperative management and prolonged recumbency, including thromboembolic complications, pneumonia, pain, and loss of the ability to walk.
Although Shah et al.1 report low rates of reinfarction, the rate tended to be higher in patients 65 years of age or older (5.5 percent vs. 3.2 percent) and in those undergoing emergency surgery (11.6 percent vs. 3.45 percent). These differences underscore the possible increased risk of reinfarction in the population of patients with hip fractures.
Burger et al. raise the issue of the timing of surgery after femoral-neck fractures. This is a controversial topic. Although some have suggested that reduction and internal fixation of displaced femoral-neck fractures should be performed within eight hours after the injury (in combination with decompression of the intracapsular hematoma), the literature remains contradictory.2 As a result, we do not think that the treatment approach suggested can be identified as the standard of care for these injuries.
The points raised by Dr. Raaymakers concerning the nonoperative management of impacted femoral-neck fractures are important. However, we do not share his enthusiasm for this approach. The issue is complicated. First, the diagnosis of an impacted femoral-neck fracture must be made with certainty, and the fracture must not be confused with nondisplaced or minimally displaced fractures.3 Second, in Dr. Raaymakers's reported series of 170 cases, 87 percent of patients required up to one week to be able to get out of bed, and all patients were limited to partial weight-bearing for up to eight weeks after fracture.4 We believe an important goal of operative management is to allow unrestricted weight-bearing. In our experience, this optimizes postoperative rehabilitation and overall functional recovery.
4 ReferencesJoseph D. Zuckerman, M.D.
Andrew D. Rosenberg, M.D.
Hospital for Joint Diseases, New York, NY 100031
Shah KB ,Kleinman BS ,Sami H ,Patel J ,Rao TL . Reevaluation of perioperative myocardial infarction in patients with prior myocardial infarction undergoing noncardiac operations. Anesth Analg 1990;71:231-235
CrossRef | Web of Science | Medline2
Barnes R ,Brown JT ,Garden RS ,Nicoll EA . Subcapital fractures of the femur: a prospective review. J Bone Joint Surg Br 1976;58:2-24
Web of Science | Medline3
Frandsen PA ,Andersen E ,Madsen F ,Skjodt T . Garden's classification of femoral neck fractures: an assessment of inter-observer variation. J Bone Joint Surg Br 1988;70:588-590
Web of Science | Medline4
Raaymakers EL ,Marti RK . Non-operative treatment of impacted femoral neck fractures: a prospective study of 170 cases. J Bone Joint Surg Br 1991;73:950-954
Web of Science | Medline
