Title : Diagnosis and management of bone tumours of the lesser trochanter
Abstract:
Globally, neck of femur fractures (NOFF) are one of the most devastating injuries to the elderly population with a recognised 1 year mortality of 30% and 30 day mortality of 10%. In the UK alone, the reported annual health and social care cost is £2 billion and rising. The UK National Hip Fracture Database (NHFD) has reported annually since 2010, auditing practices within all national centres to improve on these outcomes. In collaboration with the British Orthopaedic Association (BOA), they have provided and updated national guidelines outlining a gold standard evidence based approach to managing all NOFF patients. This represents an exemplar of the effectiveness of NOFF care on a national scale by enabling clinical teams to monitor their performance against agreed clinical standards. Key changes included financial incentives for hospitals achieving best practice criteria including: surgery within 36 hours of triage, prompt orthogeriatric review peri-operatively within 72 hours, pre and post operative delirium assessment, nutrition optimisation and specialist falls assessment with view to bone protection medication. 2017 data indicates the UK achieved these criteria in 59.7% of all NOFF patients. A further review noted correlation between early geriatric review and increased median time per patient was associated with a relative reduction in mortality of 3.4%. This represents an absolute reduction of 0.3% since the programme’s inception. The National Institute for Clinical Excellence (NICE) also produced guidelines with key criteria and patient based indications for total hip replacement (THR) or hemiarthroplasty for intra-capsular fractures. This has streamlined the approach for such fracture patterns in the UK ensuring decisions are evidence based and that appropriate patients who would benefit from a THR are ascertained. Latest data from 2018 informs us that 31.4% of eligible patients are now having a THR. Current evidence base also suggests cemented arthroplasty to be superior to uncemented due to reduced risk of prosthetic complications including: peri-prosthetic fracture, aseptic loosening, dislocation as well as post op thigh pain. Improving data notes 89.2% to have had cemented arthroplasty. Overall the UK orthopaedic model provides an example that others can follow to audit and reduce varying practice in NOFF care with the goal of globally improving outcomes of mortality and morbidity within this vulnerable cohort of patients.
