Use MIS for hip fractures if it is right for the patient, not to shorten hospital stays

In the literature, minimally invasive surgery for hip fractures has been shown to possibly reduce by several days the length of a patient’s hospital stay, as well as reduce blood loss and soft tissue damage vs. open procedures, but this topic is controversial and there are differences in opinion about when hip fractures should be treated with a minimally invasive technique.

Much controversy arose after Michael Ho, MD, and colleagues published a study in 2009 that showed minimally invasive surgery (MIS) with a dynamic hip screw to fix hip fractures had benefits over traditional open surgery. Among the areas the study focused on were the more favorable outcomes with MIS as it related to operating time, blood loss and hospital stay. This research also showed fixation with dynamic hip screws implanted via MIS surgery maintained fixation as well as the open procedures.

However, Cecilia Rogmark, MD, PhD, of Skane University Hospital, in Malmo, Sweden, said the long-term outcomes that a patient with a hip fracture experiences are affected by more than 1 hour in the OR or the type of surgical procedure.

Beyond rehabilitation

According to Rogmark, hospital stay duration is one of the most meaningless outcome measurements for patients after hip fracture surgery, because it varies among countries. In the United States, patients can leave the hospital 1 day or 2 days after the surgery, but in Japan it is said patients can be kept up to 50 days after the surgery, for example, she said.

If successful, the surgeon and surgical technique still have a limited impact on the overall outcomes at 1 year after hip fracture treatment. The rehabilitation phase and everything else that happens to the patient during the first year after surgery has more of an effect on the outcomes, Rogmark said.

“The rest of the treatment chain for hip fracture patients is equally important and much neglected in many countries. I can see it here, even in Scandinavia, where we have public health care. We have difficulties in providing long-term rehabilitation. We can be excellent surgeons, put in the latest most expensive implants, but if we do not provide patients with proper rehabilitation, it is of lesser use. We have to protect our investment in the patient,” she told Orthopaedics Today Europe.

Length of stay varies

A study by Rogmark and colleagues published in Injury in 2015 showed the factors associated with loss of function after hip fracture surgery were stroke, heart attack or another “major” adverse event.

Length of stay after hip fracture surgery varies widely among countries. Therefore, it should not be a consideration when comparing the benefits of MIS and standard open surgical techniques, Rogmark said.

“In Sweden, at my hospital, patients are released in about 9 [days] to 10 days. [In] other societies, it can be when the extended family is ready to take the patient home or what the insurance company is providing them. If you get the number of days from the insurance, of course, you would want to stay those amount of days, because you paid for them. That is why I do not think length of stay is important,” she said.

Reduced soft tissue damage

MIS may, however, offer some benefits for certain patients with hip fractures, Rogmark noted. For example, MIS techniques can be useful for the treatment of extracapsular fractures, to minimize dissection of the soft tissue and to diminish possible damage to any major blood vessels the surgeon encounters, she said.

For hemiarthroplasty or total hip replacement (THR) done for a femoral neck fracture, a simple open procedure may offer better outcomes compared with MIS, Rogmark noted.

“I think it is better to have a good view in order to put your implant in the proper position and not to make any injuries to the skin, which would lead to a higher infection risk. There again, you have to have a simple form for surgery in order for all of the young surgeons to [get] a good result,” she said.

MIS is typically more complicated and has a higher learning curve, according to Rogmark. “The surgeon should be confident in performing the technique. Feeling a pressure to do MIS for some vague gain of hospital days, when he or she is not skilled in it, may lead to more complications.

“Most important is that the two studies supporting MIS in hip fracture cases are small single-surgeon series. In contrast, a randomized trial on MIS in hemiarthroplasty cases by Roy and colleagues did not find any benefits of MIS. We do not have any good scientific evidence for the use of MIS in hip fracture patients,” Rogmark said.

MIS acceptable option

Thierry Bégué, MD, of Hôpital Antoine-Béclère, in Clamart, France, told Orthopaedics Today Europe MIS techniques should be used for hip fracture surgery whenever possible, despite the fact they are more complicated than standard open procedures.

MIS offers a patient better outcomes and spares the soft tissue at the surgical site, reduces muscle damage and helps the patient recover from the procedure quicker, he said.

“That is the reason why, in all of the Western countries, we are trying to lower as much as possible the duration of stay inside of the hospital [in] hip fractures, it helps us to be able to get to the recovery phase for the patients quicker than we have in the past 10 years,” Bégué said.

Displacement calls for open surgery

Patients who undergo MIS for a hip fracture can usually leave the hospital 2 days to 3 days after surgery, which is less than the average of stay of 1 week for a traditional open procedure, according to Bégué.

However, he noted, MIS is not appropriate for every type of hip fracture and may not be appropriate to use when the surgeon needs a good view of the fracture or the overall surgical site.

“I think, for example, in the subcategory of a displaced fracture with a huge displacement, the reduction of the fracture is difficult to do in a minimally invasive way. We can go directly to an open procedure, which would be easy to reduce the fracture and fix [it],” he said.

Other than those indications, Bégué would not recommend an open procedure over an MIS approach for any hip fractures.

Limited indications

Certain pre-existing conditions in patients with hip fractures may not make them ideal candidates for MIS, said David Seligson, MD, of the University of Louisville, in Louisville, Ky., USA, who is an Orthopaedics Today Europe Editorial Board member.

“Some patients are not suitable for a small incision-type surgery because they have a pre-existing condition. An obese patient, for example, or a patient with a dysplastic hip, prior hip surgery, some kind of previous fracture, large osteophytes, things we would need to see more of to get a screw or a cup into the right position — those are the types of patients who would not do well with a minimally invasive procedure,” Seligson told Orthopaedics Today Europe.

In patients without any of these pre-existing conditions, Seligson said MIS is typically a better option than an open procedure. At the University of Louisville, Seligson said he and his colleagues will use an MIS approach to treat femoral neck fractures, for THR, for intertrochanteric hip fractures or for elective hip surgery.

Patient selection is key

How appropriate MIS is for a hip fracture depends on smart patient selection, Seligson said.

“You have to pick your candidates. If the patient chosen is not one who is too big, has reasonable anatomy, is one who does not have some kind of intrinsic problem in the hip where we have to see more, then they are okay. If you choose patients carefully, you will have a lower complication rate because you are dealing with better patients. That is the problem with a lot of these. It is not an all-comer type of procedure,” he said.

MIS for hip fractures is highly effective in young, healthy patients, but is also an effective procedure in elderly patients, which is important as there is a high incidence of hip fractures in the elderly, Federica Rosso, MD, of University of Turin, in Turin, Italy, told Orthopaedics Today Europe.

Effective in the elderly

The mortality rate for elderly patients who have experienced hip fractures is 20% to 40%, Rosso said.

She noted that a study published in Injury in 2015, which was conducted by Jean-Christophe Bel, MD, and colleagues, showed MIS for elderly patients with hip fractures can reduce intraoperative bleeding and surgical trauma.

“Bel and colleagues recently reported their results using MIS in elderly patients with neck or femur fractures treated with either a total hip or bipolar arthroplasty. The authors reported on significantly reduced postoperative blood loss and analgesic use in the MIS group compared to the conventional group,” Rosso said.

Outcomes can be improved for elderly patients whose fractures are treated via MIS approaches if the surgeon operates within 48 hours of the injury, optimizes the patient’s hemoglobin levels and insists on early mobilization postoperatively, if possible, she said.

Fracture tables, computers advance MIS

Advancements in some of the technology used for MIS hip fracture procedures may further improve these surgeries for all potential candidates, according to Seligson.

“There are now computer systems that help you get the correct starting point and measure the length of the nail, get everything more accurate. For an anterior approach, there are improved instruments and more common use of the new fracture tables, which tends to make it all easier. I see big changes coming,” he said.

Furthermore, the new fracture table designs can make MIS procedures safer. These tables feature a design that is easier to use and lets the surgeon bring a patient’s leg all the way down to the floor when performing THR, Seligson said.

In addition, MIS and the use of more advanced technology for hip fracture surgery have improved the related mortality rates and get patients out of the hospital quicker compared with rates from 30 years ago, he said.

“I think there is big excitement. People with hip fractures, when I started maybe 30 years ago, maybe half of them would die a year after surgery. It is down now to 20%, I believe. We are starting to do better and we will do better yet,” Seligson said. – by Robert Linnehan

• References:
• Bel JC, et al. Injury. 2015;doi:10.1016/S0020-1383(15)70005-7.
• Hansson S, et al. Injury. 2015;doi:10.1016/j.injury.2015.07.024.
• Ho M, et al. Int Orthop. 2009;doi:10.1007/s00264-008-0565-4.
• Roy L, et al. Injury. 2010;doi:10.1016/j.injury.2009.10.002.

• For more information:
• Thierry Bégué, MD, can be reached at Antoine Hospital Béclère, Université Paris-Sud, 157 rue de la porte de Trivaux, 92140 Clamart, France; email: thierry.begue@aphp.fr.
• Cecilia Rogmark, MD, PhD, can be reached at Department of Orthopaedic Surgery, Skane University Hospital, Lund University, 205 02 Malmo, Sweden; email: cecilia.rogmark@skane.se.
• Federica Rosso, MD, can be reached at AO Mauriziano Umberto I, largo Turati 62, 10128 Torino, Italy; email: federica.rosso@yahoo.it.
• David Seligson, MD, can be reached at Orthopedics at University of Louisville, Physicians Outpatient Center, 401 E. Chestnut St., Suite 240, Louisville, KY 40202 USA; email: david.seligson@louisville.edu.

Disclosures: Seligson reports he is a consultant for Stryker. Bégué, Rogmark and Rosso report no relevant financial disclosures.

Is the safety profile for minimally invasive hip fracture repair considerably better than for other techniques?

Short-term results are superior

To improve the management of this frail population, focus has been given to optimizing the surgical procedure itself to minimize the surgical stress reaction and the development of postoperative complications. This would facilitate postoperative mobilization and return to pre-fracture functional status.

The principle of minimally invasive surgery (MIS) is not so much to reduce the length of the skin incision, but also to minimize dissection of the muscles and of the capsular ligaments, thus to allow faster functional stability and earlier recovery of the joint. This requires good technical skills and good knowledge of the anatomy to minimize the risk of intraoperative femoral fractures, muscles or skin lesions, and postoperative complications dominated by the malpositioning of implants leading to hip dislocation. Even if the dissection is more limited, it is more detailed. What is more, hemostasis must be rigorous, otherwise the bleeding obscures the operation view.

The short-term results are superior to those obtained by conventional means. The amount of analgesic consumption is reduced with MIS. These patients are able more easily to return home due to the reduction of bleeding and pain allowing early rehabilitation. This technique is reliable, reproducible and as safe as with conventional approaches, and the accuracy of the implant positioning is the same. At 3 months, however, functional recovery seems similar, but the aesthetic character of the scar is indisputable with MIS.

Jean-Christophe Bel, MD, is a consulting orthopaedic surgeon in the Department of Orthopaedic Surgery and Traumatology at E. Herriot University Hospital and associate lecturer at Claude Bernard Lyon 1 University, in Lyon, France.
Disclosure: Bel reports no relevant financial disclosures.

Be comfortable with selected approach

With more than 1.5 million fractures per year worldwide and associated costs of many billion dollars ($8 billion in the United States in 1995), hip fractures present a socioeconomic problem. In theory, minimal invasive techniques have many advantages, such as less surgical trauma, more rapid recovery and shorter length of hospital stay, and are becoming more popular in the area of hip arthroplasty. These advantages are more important for the treatment of hip fractures, as these patients are older and frailer.

However, the learning curve is steep and the visualization more demanding. This can result in an increased complication rate (perioperative femoral fractures, malposition of the implants, etc.) for the surgeon who is not familiar with these techniques or who is hesitant to perform a more extensile approach, if needed. Recent studies show no significant differences in the long-term results and complication rates between the different hip approaches if the implants are correctly positioned and the surgeon is experienced with the technique he or she is using.

Minimal invasiveness is not always automatically the best option. The surgeon should perform the technique he or she feels more confident with to avoid problems, and complications can be devastating for this group of frail, elderly patients. In summary, the surgeon should be as minimally invasive as possible and as invasive as necessary.

Emmanouil Liodakis, MD, is an assistant professor and consulting orthopaedic surgeon in the trauma department at Hannover Medical School, in Hannover, Germany.
Disclosure: Liodakis reports no relevant financial disclosures.

• References:
• Ray NF, et al. J Bone Miner Res. 1997;doi:10.1359/jbmr.1997.12.1.24.
• Sterling RS. Clin Orthop Relat Res. 2011;doi:10.1007/s11999-010-1736-3.