Surgical treatment of hip fractures in Norway. The Norwegian Hip Fracture Register

Abstract

Each year in Norway, approximately 9,000 patients are hospitalised and operated on due to hip fractures (femoral neck fractures, trochanteric fractures, and subtrochanteric fractures). There are several treatment methods available for the different types of fractures. Despite the high number of patients, and extensive research on hip fractures, there has so far been no consensus on the treatment. To evaluate the results of different treatment methods for different types of hip fractures, and to investigate the epidemiology of these fractures, the Norwegian Hip Fracture Register (NHFR) was established, and a nation-wide registration initiated, in 2005. The findings of this thesis were based on data from this new hip fracture register and from the Norwegian Arthroplasty Register. The overall intention was to evaluate the treatment of hip fractures in Norway, with special emphasis on dislocated, intracapsular femoral neck fractures in elderly patients. In the first paper, the completeness of the registration in the NHFR was evaluated using data from the Norwegian Patient Registry. The completeness of operation form registration was 64 % in 2005 and 79 % in 2006. All hospitals performing hip fracture surgery reported to the register at the end of 2006. The response rate of the questionnaire sent to the patients 4 months postoperatively was 58 %. After 2 years of registration, the data in the register confirmed that disagreement on which treatment methods should be used for different hip fractures, and in particular for the dislocated femoral neck fractures, existed between orthopaedic surgeons. In the second paper, we investigated the outcome of dislocated femoral neck fractures in elderly patients. The results of internal fixation with 2 screws/pins and bipolar hemiarthroplasty (HA) were compared. The functional outcome was assessed from questionnaires sent to patients 4 months postoperatively. This study showed that the patients operated with a hemiarthroplasty had less pain, were more satisfied with the result of the operation, and had a higher health-related quality of life according to EQ-5D. In the next study, we used the data from the questionnaires sent to elderly patients operated due to dislocated femoral neck fractures 4 and 12 months postoperatively to compare the results of internal fixation with 2 screws/pins and bipolar HA. Statistically significant differences were found after both 4 and 12 months. HA provided less pain, higher patient satisfaction, higher quality of life, and fewer re-operations compared with internal fixation. The differences were present also in patients with cognitive impairment and in groups of patients with different walking abilities. In the last study, we used data from the Norwegian Arthroplasty Register to investigate the results of total hip replacement (THA) as treatment for acute femoral neck fractures and sequelae after femoral neck fractures. The results of these particular THAs were compared to the results of THA in patients with osteoarthritis (OA). The results showed that THA in fracture patients showed good results, but with an increased risk of revision, especially due to early infections, early dislocations, and of peri-prosthetic fractures, compared to OA patients. The overall conclusion of this thesis is that we have established a well-functioning national register for hip fractures. Our findings suggest that elderly patients with dislocated femoral neck fracture should be treated with hemiarthroplasty in preference to internal fixation irrespectively of cognitive function and walking ability. THAs have also showed good results concerning the number of revisions.