Operative or conservative treatment for trochanteric fractures of the femur. A randomised epidemiological trial in elderly patients. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture: randomised controlled trial. Intramedullary hip screw versus sliding hip screw for unstable intertrochanteric femoral fractures in the elderly. Hemiarthroplasty versus internal fixation for displaced intracapsular hip fractures in the elderly. A randomised trial of 455 patients. Treatment for displaced intracapsular fracture of the proximal femur. A prospective, randomised trial in patients aged 65 to 79 years. The management of elderly patients with femoral fractures. A randomised controlled trial of early intervention versus standard care. Accelerated rehabilitation after proximal femoral fracture: a randomized controlled trial. Improved performance in activities of daily living and mobility after a multidisciplinary postoperative rehabilitation in older people with femoral neck fracture: a randomized controlled trial with 1-year follow-up. Effectiveness of geriatric rehabilitative care after fractures of the proximal femur in elderly women: a randomised clinical trial.
All elderly patients with extracapsular hip fractures seen in hospitals in Newcastle upon Tyne over a 12-month period were studied and followed up for six months. At one of the hospitals, patients were randomised to treatment by AO dynamic hip-screw or by traction. Complications specific to the two treatments were low, and general complications, six-month mortality and prevalence of pain, leg swelling and unhealed sores, showed no difference between the two modes of treatment. Operative treatment gave better anatomical results and a shorter hospital stay, but significantly more of the patients treated by traction showed loss of independence six months after injury. To assess whether intraoperative intravascular volume optimisation improves outcome and shortens hospital stay after repair of proximal femoral fracture.
                Prospective, randomised controlled trial comparing conventional intraoperative fluid management with repeated colloid fluid challenges monitored by oesophageal Doppler ultrasonography to maintain maximal stroke volume throughout the operative period.
                Teaching hospital, London.
                40 patients undergoing repair of proximal femoral fracture under general anaesthesia.
                Patients were randomly assigned to receive either conventional intraoperative fluid management (control patients) or additional repeated colloid fluid challenges with oesophageal Doppler ultrasonography used to maintain maximal stroke volume throughout the operative period (protocol patients).
                Time declared medically fit for hospital discharge, duration of hospital stay (in acute bed; in acute plus long stay bed), mortality, perioperative haemodynamic changes.
                Intraoperative intravascular fluid loading produced significantly greater changes in stroke volume (median 15 ml (95% confidence interval 10 to 21 ml)) and cardiac output (1.2 l/min (0.1 to 2.3 l/min)) than in the conventionally managed group (-5 ml (-10 to 1 ml) and -0.4 l/min (-1.0 to 0.2 l/min)) (P < 0.001 and P < 0.05, respectively). One protocol patient and two control patients died in hospital. In the survivors, postoperative recovery was significantly faster in the protocol patients, with shorter times to being declared medically fit for discharge (median 10 (9 to 15) days v 15 (11 to 40) days, P < 0.05) and a 39% reduction in hospital stay (12 (8 to 13) days v 20 (10 to 61) days, P < 0.05).
                Proximal femoral fracture repair constitutes surgery in a high risk population. Intraoperative intravascular volume loading to optimal stroke volume resulted in a more rapid postoperative recovery and a significantly reduced hospital stay. We report a randomised, prospective study comparing a standard sliding hip screw and the intramedullary hip screw for the treatment of unstable intertrochanteric fractures in the elderly. One hundred and two patients were randomised on admission to two treatment groups. Fifty-two patients were treated with a compression hip screw (CHS), and fifty had intramedullary fixation with an intramedullary hip screw (IMHS). Patients were followed for 1 year and had a clinical and radiological review at 3, 6 and 12 months. The mean duration of operation and fluoroscopy screening time was significantly greater for insertion of the intramedullary hip screw. There was no difference between the groups with regard to transfusion requirements or time to mobilise after surgery. There were two technical complications in the CHS group and three in the IMHS group. There was no significant difference between the two groups in radiological or functional outcome at 12 months. It remains to be shown whether the theoretical advantages of intramedullary fixation of extracapsular hip fractures bring a significant improvement in eventual outcome. A total of 455 patients aged over 70 years with a displaced intracapsular fracture of the proximal femur was randomised to be treated either by hemiarthroplasty or internal fixation. The preoperative characteristics of the patients in both groups were similar. Internal fixation has a shorter length of anaesthesia (36 minutes versus 57 minutes, p < 0.0001), lower operative blood loss (28 ml versus 177 ml, p < 0.0001) and lower transfusion requirements (0.04 units versus 0.39 units, p < 0.0001). In the internal fixation group 90 patients required 111 additional surgical procedures while only 15 additional operations on the hip were needed in 12 patients in the arthroplasty group. There was no statistically significant difference in mortality between the groups at one year (61/226 versus 63/229, p = 0.91), but there was a tendency for an improved survival in the older less mobile patients treated by internal fixation. For the survivors assessed at one, two and three years from injury there were no differences with regard to the outcome for pain and mobility. Limb shortening was more common after internal fixation (7.0 mm versus 3.6 mm, p = 0.004). We recommend that displaced intracapsular fractures in the elderly should generally be treated by arthroplasty but that internal fixation may be appropriate for those who are very frail. We performed a prospective, randomised trial comparing three treatments for displaced intracapsular fractures of the hip in 280 patients aged 65 to 79 years. The mean patient survival was significantly higher in the group undergoing reduction and internal fixation (79 months) compared with that with a cemented Thompson hemiarthroplasty or a cemented Monk bipolar hemiarthroplasty (61 months and 68 months, respectively). After three years, 32 of 93 patients (34.4%) who had undergone fixation had local complications, necessitating further intervention in 28 (30%). There were no significant differences in the functional outcome in survivors, who were reviewed annually to five years. Either reduction and internal fixation or cemented hemiarthroplasty may be offered as alternative treatments for a displaced intracapsular fracture in a mobile and mentally competent patient under the age of 80 years. The choice of procedure by the patient and the surgeon should be determined by the realisation that the use of internal fixation is associated with a 30% risk of failure requiring further surgery. If this is accepted, however, hemiarthroplasty is avoided, which, in our study has a significantly shorter mean survival time. The use of a bipolar prosthesis has no significant advantage. To determine the effect of an early intervention program in an acute care setting on the length of stay in hospital of elderly patients with proximal femoral fractures.
                Acute orthopaedic ward of a large teaching hospital.
                A randomised controlled trial comparing 38 Intervention patients with 33 Standard Care patients.
                Early surgery, minimal narcotic analgesia, intense daily therapy and close monitoring of patient needs via a multidisciplinary approach versus routine hospital management.
                Length of stay (LOS); deaths; level of independent functioning.
                Mean LOS was shorter in the Intervention group than in the Standard Care group (21 days v. 32.5 days; P < 0.01). After adjusting for other factors that could affect LOS (eg, age, sex, pre-trauma functional levels, pre-trauma comorbidity and postsurgical complications), the Intervention program was significantly predictive of shorter LOS (P = 0.01). The Intervention group did not experience greater numbers of deaths, deterioration in function or need for social support than the Standard Care group.
                This early intervention program in an acute care setting results in significantly shorter length of hospital stay for elderly patients with femoral fractures. This randomized controlled trial compared accelerated rehabilitation after surgical treatment of proximal femoral fracture with conventional care and was conducted in a general hospital in an outer urban area. Participating were 261 sequentially admitted patients over the age of 50 years who met predetermined inclusion criteria and all were followed up until death or 4 months after fracture. Patients who were treated with the accelerated rehabilitation programme had a 20% reduction in length of hospital stay. Improved physical independence (as measured by Barthel Index) was observed after fracture in accelerated rehabilitation programme patients with limited pre-existing disability. Non-nursing-home patients receiving accelerated rehabilitation were also less likely to be discharged to nursing-home care or die in hospital. Accelerated rehabilitation led to a substantial reduction in length of hospital stay with a modest short-term improvement in level of physical independence and accommodation status after discharge. To investigate the short- and long-term effects of a multidisciplinary postoperative rehabilitation programme in patients with femoral neck fracture.
                A randomized controlled trial in patients (n = 199) with femoral neck fracture, aged >or= 70 years.
                The primary outcomes were: living conditions, walking ability and activities of daily living performance on discharge, 4 and 12 months postoperatively. The intervention consisted of staff education, individualized care planning and rehabilitation, active prevention, detection and treatment of postoperative complications. The staff worked in teams to apply comprehensive geriatric assessment, management and rehabilitation. A geriatric team assessed those in the intervention group 4 months postoperatively, in order to detect and treat any complications. The control group followed conventional postoperative routines.
                Despite shorter hospitalization, significantly more people from the intervention group had regained independence in personal activities of daily living performance at the 4- and 12-month follow-ups; odds ratios (95% confidence interval (CI) ) 2.51 (1.00-6.30) and 3.49 (1.31-9.23), respectively. More patients in the intervention group had also regained the ability to walk independently indoors without walking aids by the end of the study period, odds ratio (95% confidence interval) 3.01 (1.18-7.61).
                A multidisciplinary postoperative intervention programme enhances activities of daily living performance and mobility after hip fracture, from both a short-term and long-term perspective. To compare postoperative collaborative care between orthopaedic surgeons and physicians in geriatric medicine with routine orthopaedic care in elderly women with proximal femoral fracture.
                Exclusion of patients dying before fit enough to enter trial, those with pathological fractures, those likely to be discharged within seven days of entering the trial, and those remaining unfit for transfer to a peripheral hospital. Remainder allocated to two groups: treatment group and control group.
                District hospital acute admission ward and rehabilitation ward.
                144 sequentially admitted elderly women with proximal fracture of the femur; 36 excluded on above criteria and remainder entered into trial.
                Both treatment and control groups (n = 54 in each) received physiotherapy and other services. The treatment group also received thrice weekly supervision by a geriatrician.
                Physical independence, residence after discharge, and length of hospital stay.
                At discharge significantly more patients in treatment group were independent in terms of activities of daily living than controls (41 v 25) and their median stay was 24 days (range 8-197) compared with 41 (9-365) (95% confidence intervals for difference 2 to 25). Significantly fewer treatment patients were discharged to institutional care (10% v 32%; 95% confidence interval for difference 6% to 37%) and more to their own homes (63% v 38%; 95% confidence interval for difference 6% to 44%). These beneficial effects were consistent across a range of ages and mental state.
                Both hospital and patient benefited when postoperative rehabilitation was provided in a setting specialising in such care for elderly patients with trauma.
Although there is a lack of available evidence to inform practice for undisplaced intracapsular fractures, variation in practice has reduced and most fractures are treated surgically. The limited available evidence from randomised trials does not suggest major differences in outcome between conservative and operative management programmes for extracapsular femoral fractures, but operative treatment is associated with a reduced length of hospital stay and improved rehabilitation. Conservative treatment will be acceptable where modern surgical facilities are unavailable, and will result in a reduction in complications associated with surgery, but rehabilitation is likely to be slower and limb deformity more common. Currently, it is difficult to conceive circumstances in which future trials would be practical or viable.