Hip fracture

Hip fracture treatment

Fifty years ago a hip fracture often meant the end of independent living for the elderly. Today with improved surgical techniques and intensive rehabilitation, with direct mobilization and weight bearing on the operated leg, most patients rapidly can return to their own home and achieve the same level of function as before the fracture. Long time ago there were not any treatment for hip fracture until traction was introduced in the mid-1800s, but even with this the fracture healing often failed. In the late 1800s, attempts were made to nail the hip, but the results were bad, depending on both the materials and infections. In 1931, Smith-Petersen introduced the modern nailing of femoral neck fractures with a large open surgery. The following year, Sven Johansson in Gothenburg amended the technology by cannulated nails. In the 1960s, fluoroscopy during surgery was introduced, which revolutionized the surgical technique and resulted in much reduced operating times – from one hour to 10-20 minutes for femoral neck fractures. The technology has also been developed and optimized with fluoroscopy via biplane image intensifiers (frontal view and side view with the same frame), which gives even more reliable results and shorter operation times.

In the 1960s, a trend toward reduced length of stay in hospital began. Initially the patient was not allowed to put weight on the operated leg because it was believed that this would impair healing. In 1951 cervical fractures in Lund had a period of 118 days without weight bearing and an average length of stay of 139 days. Trochanteric fractures had a period of 99 days without weight bearing and an average length of stay of 125 days. The period without weight bearing and length of hospital stay was reduced slightly during the 1950s, but until 1970 there still was a period without weight bearing of 8 days for patients with cervical fractures and 7 days for patients with trochanteric fractures, resulting in average hospital stays of 32 days for patients with cervical fractures and 26 days for patients with trochanteric fractures.

In the mid 1970’s direct postoperative weight bearing was introduced, and the mean length of stay was decreased. The mean length of stay in the orthopaedic department has gradually decreased over several decades. In the late 1980s, the mean length of stay for patients with hip fracture was 19 days. Today, patients with hip fractures have a mean hospital stay of 9-10 days. This rationalization of the hip fracture care has largely been able to meet the huge increase in patients with hip fractures.

The waiting time from arrival to the hospital for surgery is now about 1 day. The goal in Sweden is that 80% of the patients should be operated on within 24 hours.  Despite shorter length of stay constantly around 50 % of the patients return directly to the housing they had before the fracture. Shorter hospital stays have otherwise been showed to be due to a greater proportion of patients sent to secondary rehabilitation. 

Hip fracture care includes the entire continuum of care, and therefore a close collaboration between hospitals, primary care and community care is essential for high quality care. After the introduction of the Ädelreform in 1992, major changes have taken place in the principal responsibility and resource allocation, which has had financial consequences. While the care of the individual hip fracture patient has been optimized, the implications for the health care system have become severe by the increased amount of patients with hip fractures and especially the increased number of people over 80 years with hip fracture (which often also have other diseases). Only the progressively optimized care has have been able to prevent a catastrophic acceleration of resource consumption