Hip Fracture

Dr Janet Lippett

Consultant Orthogeriatrician

October 2011

Hip Fracture

Overview

Facts and Figures

Hip Fracture – The Royal Berkshire Way

Orthogeriatrics

Pre-operative Assessment

Falls Assessment

Osteoporosis Assessment

Post operative Care and Rehabilitation

Hip Fracture

Hip Fracture

Facts and Figures

90% of patients admitted with a hip fracture are over 65.

10% die in the first 30 days; 30% die within a year.

Its common – average 450/yr in the RBH.

<50% return back to their own home.

80% of older women say they would rather die than experience the loss of independence and QOL associated with a hip fracture.

Fragility Fractures cost the UK health economy £1.8 billion a year

More bed days than stroke and heart disease

Hip Fracture

Hip Fracture – The Royal Berkshire Way

Pre 2007 liaison service

New Orthogeriatric Service set up in 2007

– Full time Consultant Orthogeriatrician

Achieving high standards in National Audits

– Top 10 in 2010 National Hip Fracture Database Annual Report

– Reduction in length of stay from 42 to 17 days

– Nearly 100% falls and bone health assessments

– Reduction in pressure sores

Hip Fracture

Orthogeriatrics

Pre-op assessment/optimisation, peri-operative complications, rehabilitation, falls and bone health assessments.

A good service reduces mortality, complications, length of stay and improves functional outcomes such as mobility and return to independence.

1940s Lionel Cosin – rehabilitation of neck of femur fracture patients

1950s Michael Devas and Bobby Irvine

2000s Janet Lippett and Apu Chatterjee

Hip Fracture

Pre-operative Assessment

Orthogeriatric medical assessment

Aim to get to theatre within 36 hours

2007 2011

Pre-op Assessment

20% 78%

Theatre within 48 hours

69% 92%

Hip Fracture

Hip Fracture

Hip Fracture

Falls Assessment

History

Medication Review

Gait and Balance

Home Hazard Assessment

Multidisciplinary Involvement

– Occupational Therapist and Physiotherapy

NHFD results 2011 – 99% of patients assessed

Hip Fracture

Osteoporosis

Commonest bone disease in adults

Reduction in bone density with a subsequent increased risk of fracture.

Life time risk of fracture in women over 50 is 1 in 2.

Falls and fractures account for more inpatient bed days than stroke and cardiovascular disease.

Osteoporosis is a “silent illness”.

NHFD 2011 – 98% of patients assessed (cf 45% in 2007)

Hip Fracture

Hip Fracture

Risk Factors

Gender

– F>M

Parental history of hip fracture

Previous fracture

– 2-5 fold increased risk

Low BMI

– Esp. if <20 kg/m2

Low Bone Mineral Density (BMD)

Smoking

– Dose dependent

Alcohol

– Esp. >3 units/day

Drugs

– Steroids, anticonvulsants, heparin, hormone treatments for cancer

Hip Fracture

What can we do - guidelines

NICE guidance

– Treat over 75s without investigation

FRAX and NOGG

– DEXA vs lifestyle vs treat

National Osteoporosis Society

– Usual guidance on the internet and has a local group

Hip Fracture

Hip Fracture

Hip Fracture

DEXA scanning

Hip Fracture

Lifestyle

Exercise

– Weightbearing – dancing, walking, aerobics

Diet

– Fruit and veg, fish, dairy products

Sunlight

– 10-20 mins exposure on base arms a day

Alcohol

– Reduce intake to <3 units per day

Hip Fracture

Drug Treatment

Calcium and Vitamin D for all

Bisphosphonates

– Mainstay of treatment – Alendronate

– Main side effect is indigestion

– Must sit up for 30 mins after, drink with whole glass of water and avoid food

Strontium

– Daily but doesn’t have complicated administration instructions

– Main side effect is diarrhoea

Hip Fracture

Post-operative Care and Rehabilitation

Post-operative complications

Tailor made rehabilitation programme

Woodley Ward

Community Rehabilitation

Inpatient Community Rehabilitation

National Hip Fracture Database

Hip Fracture

The Future

Fracture Liaison Service

– Improved service for femur fractures

– Service for non hip fractures

– Improved compliance with medication

– Support for patients

Hip Fracture

Thanks

Apu Chatterjee

Andrew McAndrew and the Orthopaedic Surgeons

Karen Barnard – Trauma Nurse Practioner

Helen Slade and Helen Mallock – Ward Managers

Liz Scott and the Physio team

Moyra Pugh and the OT team