Total hip replacement for displaced intracapsular neck of femur fracture. Are current guidelines appropriate for all patients? Five-year retrospective analysis of 315 cases

Abstract

BackgroundAccording to the National Hip Fracture Database (NHFD), in 2018 31.4% of patients with displaced intracapsular neck of femur (NOF) fracture who, National Institute for Health and Care Excellence (NICE) viewed eligible for total hip replacement (THR), received this operation.We aimed to identify the compliance of performing THR for those patients in our unit and identify the reasons for proceeding with the alternative type of surgery. MethodsA five-year retrospective review of eligible patients was conducted between January 2014 and Dec 2018. Statistical analysis was performed between groups who did or didn't receive THR. Reasons for not performing THR were identified from pre-operative ward rounds notes. ResultsIn 2018 our unit performed THR for 44% of eligible cases. This was the highest result over five-years and higher than the national average.Out of the 348 eligible cases, pathological or undisplaced intracapsular fractures were excluded. Reminder received THR (138), hip hemiarthroplasty (166) or internal fixation (11).The average age was 77. Younger patients were more likely to receive THR than 80 years or older (p<0.05). THR group scored 0.4 points higher on AMTS and 0.2 lower on ASA scale then non-THR group (9.8 vs. 9.4 and 2.7 vs. 2.5 respectively). Mean time to surgery was 1.24 days with no significant difference between THR and non-THR group (1.6 vs. 1.1) but a slight delay to surgery during the weekends was noted (1.3 vs 1.8 days).Reasons for not performing THR were well documented as a combination of mobility restrictions and serious medical comorbidities. Retrospectively we judged the surgical decision making to be correct in 95% of cases. ConclusionsAnnual NHFD report comments on poor national and individual hospital's compliance with NICE guidelines without allowing surgeons to justify their choice of the procedure undertaken.Surgical decisions are made in a highly specialised multi-disciplinary environment taking into consideration individual patient's frailty and potential morbidity. Details of those discussions should be collected in NHFD to allow further analysis of reasons why surgeons decide not to offer THR to a patient NHFD views as eligible for this procedure. This could help in understanding the complex factors impacting on decision making in those cases.Level of evidence:Level III