Hip Fracture Surgery

The term ‘hip fracture’ is usually used to describe fractures (breaks) of the upper part of the femur. Fractures involving the socket side of the joint are referred to as acetabular fractures.

Another common term used for hip fracture is a ‘neck of femur’ fracture, commonly abbreviated to NOF.

Most commonly, hip fractures occur in elderly patients with reduced bone density after a ‘low energy’ fall, such as a fall from standing height. They may also occur in younger, more active people, however, usually as a result of ‘high energy’ trauma such as a car crash, fall from a height or fall off a moving bicycle.

These days, almost all hip fractures are treated with early surgery to relieve pain, restore function and prevent complications of prolonged bed rest such as blood clots, pressure sores and infections.

There are different subtypes of neck of femur fracture, named after the part of the bone that they involve.

Symptoms of a Hip Fracture

Common symptoms of a hip fracture include:

Severe pain in the groin and upper thigh
Inability to walk or put weight through the leg
Inability to lift the leg
The leg may appear shortened with the foot turned out (externally rotated)

Occasionally, a person with an impacted or ‘stable’ hip fracture may be able to walk, but there will typically be pain in the groin with every step and a marked limp.

Types of Hip Fractures

To understand the types of hip fractures, it is necessary to know the basics of the anatomy of the top of the femur (thigh bone).

Overview of Hip Anatomy

The ball of the hip joint is called the femoral head. It is covered by glistening white cartilage, which glides smoothly on the cartilage that lines the inside of the hip joint socket (acetabulum).

The femoral head attaches to the shaft of the femur by the femoral neck. The femoral neck is a weak point in elderly bone and is commonly the site of fractures.

The base of the neck is where the thick capsule of the hip joint attaches the femur to the pelvis. It is also where blood flow enters the hip bones. Whilst in most parts of the body, blood generally flows away from the heart, this is not possible in the hip joint, as the top of the ball is covered in cartilage and is constantly moving. Therefore, in the hip, the blood flow enters at the bottom of the neck and travels back up the neck to enter the femoral head. This is important when explaining why different types of hip fractures require different surgeries.

At the bottom of the neck on either side are the ‘trochanters’. These are bony prominences to which the strong muscles of the hip joint attach to allow movement of the hip. The greater trochanter is on the outside and is where the gluteal muscles, or ‘glutes’, and short external rotator muscles attach. The lesser trochanter is on the inside and is where the main hip flexor, the iliopsoas tendon, attaches.

The region between the two trochanters is known as the intertrochanteric region.

Below the trochanters is the beginning of the femoral shaft. The upper part of the femoral shaft is known as the subtrochanteric region.

Femoral Head Fractures

Fractures of the femoral head itself are rare and usually occur in high-energy mechanisms in young people, such as car crashes.

Subcapital Fractures

Sub- (below) capital (head) fractures occur at the top of the femoral neck, just below the head. This is a common type of fracture in elderly patients. Some of these fractures may be undisplaced or quite stable, whereas others are displaced, where the fracture fragments have separated or shifted from each other.

Transcervical Fractures

Trans- (across) cervical (neck) fractures occur in the middle of the femoral neck and are usually quite unstable.

Basicervical Fractures

Basi- (base) cervical (neck) fractures occur at the bottom of the neck of the femur.

Intertrochanteric Fractures

This is a very common site of hip fracture with a fracture line that runs between the lesser and greater trochanter. They are usually unstable and require fixation.

Subtrochanteric Fractures

These fractures occur just below the lesser trochanter and involve the upper part of the shaft of the femur.

Treatment for Hip Fractures

These days, surgery is recommended for most patients who are brought to the hospital with a hip fracture because it is recognised that early surgery leads to better outcomes with regards to pain, complications and long-term outcomes.

In days gone by, elderly patients with hip fractures were often treated with prolonged bed rest with the leg in traction, which led to quite high rates of hospital-acquired complications such as pressure sores, blood clots, severe deconditioning and infections.

Modern treatment of hip fractures in Australia is guided by the Australian and New Zealand Guidelines for Hip Fracture Care. The principles of this guideline include:

Good early pain management in the Emergency Department, including the use of nerve blocks.
Early medical assessment by the anaesthetic and orthogeriatric teams
Hip fracture surgery within 36 hours of presentation
Early full weight bearing commenced the day after surgery
Focus on the prevention of future fractures by addressing bone health
Hospital discharge planning with input from a multidisciplinary team including social workers, physiotherapists, nursing, surgeons and orthogeriatric physicians.

While the goals of surgery are the same - to relieve pain and allow early full weight bearing - the actual type of surgery performed differs depending on the type of fracture.

In his role as an on-call orthopaedic trauma surgeon, Dr Williams commonly performs all types of hip fracture surgery.

The types of surgery required can be broadly categorised into either hip replacement surgery or internal fixation surgery.

Hip Replacement for Hip Fractures

Fractures that have likely injured the blood supply to the hip due to their location and degree of fracture displacement are best treated with either a total hip replacement or a hip hemiarthroplasty. This is because injury to the blood flow is usually irreversible and leads to collapse of the ball of the head (known as avascular necrosis). It is therefore safer to remove the ball and replace it with an artificial one.

Subcapital and transcervical fractures are most commonly treated with replacement, though some may also be suitable for fixation.

Total hip replacement for hip fracture is generally performed in patients who are:

More active
Relatively independent
Mobile without walking aids
Predicted to live for another 5 years or more

In this surgery, Dr Williams replaces both the ball and socket sides of the joint with artificial components, much as is done when it is needed for arthritis. While this takes a little longer than a partial hip replacement (hemiarthroplasty), the long-term function is usually better, and complication rates are very low. Dr Williams usually uses a minimally invasive anterior approach to the hip for all hip replacements for fractures to minimise dislocation risk.

Hip hemiarthroplasty is the term used to describe the replacement of the ball side of the hip only. As this is a slightly quicker procedure and anaesthetic, it may be preferable in a medically unwell patient. Hemiarthroplasty provides excellent pain relief from the fracture and allows full early weightbearing and unrestricted range of motion, though the long-term functional results may not be as good as those of total hip replacement.

A hemiarthroplasty is most suitable for a patient who:

Walks shorter distances
Relies on an assistive device to get around
Lives in a care facility.

Internal Fixation for Hip Fractures

Hip fractures are ‘fixed’ rather than replaced when it is thought that the blood flow to the femoral head is likely intact due to the location of the fracture (below the level of entry of the blood vessels at the base of the neck) or minimal displacement of the fracture.

Types of hip fractures that may be suitable for internal fixation include:

Undisplaced or stable impacted subcapital fractures
Displaced subcapital fractures in young people in whom an anatomic reduction has been achieved (the risk of avascular necrosis is balanced against the desire to avoid total hip replacement in a young patient)
Basicervical fractures (some also suited to replacement)
Intertrochanteric fractures
Subtrochanteric fractures

There are different ways of ‘fixing’ hip fractures. The most common types of fixation that Dr Williams uses in practice are:

Femoral Nail Fixation

This is the most common method of fixation. In this technique, the fracture is reduced on a fracture table under general anaesthetic. X-ray guidance is used to make sure the fracture is well aligned. The bones are then stabilised by inserting a ‘rod’ into the top femur, a large screw through the rod into the femoral head and a smaller screw lower down to stabilise the rotation of the leg. Because the procedure is done under X-ray guidance, it can be performed ‘percutaneously’ through 3-4 small incisions. The length of the femoral nail (short or long) is chosen based on the fracture type and position.

The formal term for this device is a cephalomedullary nail. It is commonly referred to as a ‘gamma nail’, though this is a brand name for one nail type.

The nails are made of titanium and are designed to be strong enough for the patient to put full weight through the leg immediately after surgery. The compression of walking can actually aid fracture healing.

Plate Fixation

Some fractures are best fixed with a large screw inserted into the femoral head, which is stabilised by a plate that is attached to the side of the femoral shaft with smaller screws. In the past, this was the most common form of fixation, referred to as a ‘pin and plate’.

The main types of devices used in Dr Williams’ practice include either a Dynamic Hip Screw (DHS) or Femoral Neck System (FNS).

When to use a plate or nail comes down to the technicalities of fracture position, type, and surgeon preference, and remains a debated topic.

Screw Fixation

Certain fracture patterns, such as stable subcapital fractures, may be stabilised with screws alone, though this is becoming less common.

What to expect in the hospital after a hip fracture?

As hip fractures are common injuries, all Australian trauma hospitals have established and standardised pathways for hip fracture care.

Before Surgery

You will be seen by an Emergency Doctor who will make the diagnosis using x-ray and give pain relief, including performing a nerve block to numb the fracture.
The orthopaedic team will assess you, discuss the injury and treatment options, including the risks and benefits. In many cases, these discussions are mainly had with a patient’s loved ones. They will then coordinate surgery as quickly and safely as possible - aiming for within 36 hours.
The orthogeriatric doctors (non-surgeon specialists) will review you from a medical standpoint to optimise the safety of surgery.
The anaesthetic team may also review you before surgery to assess your suitability and the safety of surgery.
Fasting will be minimised to avoid stress on the body

During Surgery

A general or spinal anaesthetic or both may be administered
The type and duration of surgery depend on the complexity and fracture pattern

After Surgery

You will usually spend 45-60 minutes in the recovery area of theatres before being transferred back to the ward.
Some patients may need to go to the Intensive Care Unit
Physiotherapy will commence the day after surgery, with a goal to have most patients putting full weight through the injured hip
The orthogeriatric team and orthopaedic surgical team will review you daily
You may be seen by a social worker or occupational therapist, who also helps to plan discharge
Possible discharge destinations include an inpatient rehab hospital, respite care in a nursing home, a patient’s home, or an aged care facility.

What is the recovery like following hip fracture surgery?

No two patients or fractures are exactly the same, so it is difficult to paint a picture of the ‘typical’ recovery following a hip fracture.

The goals of hip fracture treatment are always to:

Relieve acute pain
Restore mobility
Return a patient to their pre-injury level of function.

Unfortunately, this is not always possible as the hip fracture may be a symptom of a more general decline in elderly patients. Statistically, the outcomes following hip fractures in the elderly follow the rule of thirds.

One third of patients return to their pre-injury level of function.

One third of patients recover, though require an increased level of support (e.g., a previously independent patient from their own home transitions to aged care)

Up to one-third of patients sadly pass away within 12 months. This is not usually a direct result of any surgical complications but rather due to worsening frailty, and other conditions such as dementia, infections and heart failure.

With modern, guideline-based care, about 95% of patients with hip fractures can be treated and discharged from the hospital.

Can hip fractures be managed non-operatively?

In some cases, non-surgical or less invasive alternatives may be considered. These options depend on the injury pattern and the patient’s overall condition.

Surgery is indicated in most patients. Even in very elderly patients, surgery is usually offered due to the significant pain relief resulting from fracture stabilisation.
Palliative or comfort-focused care: In very frail patients who may not survive an anaesthetic or who are actively dying from another cause, such as a severe lung infection, the focus may be on comfort and pain relief rather than surgical treatment. In these cases, care is mainly guided by the experts in comfort care, such as the orthogeriatric team, palliative care and the pain service. Patients can be kept very comfortable with multimodal analgesia and the selective use of nerve catheters.