Inequalities in use of total hip arthroplasty for hip fracture: population based study
BMJ 2016; 353 doi: https://doi.org/10.1136/bmj.i2021 (Published 27 April 2016) Cite this as: BMJ 2016;353:i2021
All rapid responses
Rapid responses are electronic comments to the editor. They enable our users to debate issues raised in articles published on bmj.com. A rapid response is first posted online. If you need the URL (web address) of an individual response, simply click on the response headline and copy the URL from the browser window. A proportion of responses will, after editing, be published online and in the print journal as letters, which are indexed in PubMed. Rapid responses are not indexed in PubMed and they are not journal articles. The BMJ reserves the right to remove responses which are being wilfully misrepresented as published articles or when it is brought to our attention that a response spreads misinformation.
From March 2022, the word limit for rapid responses will be 600 words not including references and author details. We will no longer post responses that exceed this limit.
The word limit for letters selected from posted responses remains 300 words.
I read the recent articles relating to the ‘adherence’ to the NICE hip fracture guidance with great interest(1,2). It appears that much of the variation is simply as a result of a sensible interpretation of the available evidence and that full ‘adherence’ with the NICE guidance would be extremely poor practice. The NICE guidelines states that one should: “Offer total hip replacements to patients with a displaced intracapsular fracture who were able to walk independently out of doors with no more than the use of a stick and are not cognitively impaired and are medically fit for anaesthesia and the procedure.”
Surely ‘offer’ in the context of the Montgomery v Lanarkshire Health Board ruling means that surgeons must ensure patients are aware of any “material risks” involved in a proposed treatment, and of reasonable alternatives. In this context the editorial stating “The degree of non-adherence to this guidance was remarkable” is both sensationalist and misleading. The biggest reason for ‘non-adherence’ may well be sensible shared decision making based on the limited available evidence. The concept of being ‘medically fit for surgery’ is an inherently grey area, and arguably one which can only be determined reliably for the individual in retrospect.
The evidence in this area is far from conclusive. The functional benefits of total hip arthroplasty have been demonstrated but they are not particularly large, for example the Baker et al study demonstrated a functional gain that was less than the minimal clinically important difference(3). The evidence demonstrates clear disadvantages of total hip arthroplasty including a significantly higher dislocation rate and overall complication rate(4,5). Notably several of the trials cited by NICE excluded patients who meet the NICE criteria to be ‘offered’ total hip arthroplasty. For example Baker et al excluded patients with a walking distance of less than half a mile(3), Keating et al excluded patients with serious concomitant disease6, while several of the studies excluded patients with advanced arthritis changes in the affected hip(3,7-9). It is very possible that a reason for 42% of those undergoing total hip arthroplasty not meeting the NICE eligibility criteria is that the NICE guidance ignores a common reason for trial exclusion, that being advanced arthritic change of the affected hip joint. Perry et al identified several variables that increased the odds of receipt of total hip arthroplasty after fracture, including younger age, fewer co-morbid conditions, and better mobility before fracture(2); again this appears to represent a sensible interpretation of the evidence by surgeons in a way that demonstrates the critical flaws in the NICE guidance. Finally it is worth considering what NICE’s ‘guidance’ means:
“The recommendations in this guideline represent the view of NICE, arrived at after careful consideration of the evidence available. When exercising their judgement, professionals are expected to take this guideline fully into account, alongside the individual needs, preferences and values of their patients or service users. The application of the recommendations in this guideline is not mandatory and the guideline does not override the responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or their carer or guardian.”
When the evidence is extremely limited and inconclusive, it is better to have open ended guidance which allows the clinician to communicate the uncertainty to patients and thus reach a sensible shared decision. The NICE guidance should be seen as just ‘guidance’, while seeing 100% ‘compliance’ or ‘adherence’ as a target appears remarkably flawed in this context.
1. Chaudhry H. Total hip arthroplasty after hip fracture. BMJ (Clinical research ed.). 2016;353.
2. Perry DC, Metcalfe D, Griffin XL, Costa ML. Inequalities in use of total hip arthroplasty for hip fracture: population based study. BMJ (Clinical research ed.). 2016;353.
3. Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial. The Journal of bone and joint surgery. American volume. Dec 2006;88(12):2583-2589.
4. Hopley C, Stengel D, Ekkernkamp A, Wich M. Primary total hip arthroplasty versus hemiarthroplasty for displaced intracapsular hip fractures in older patients: systematic review. BMJ (Clinical research ed.). 2010;340:c2332.
5. Burgers PT, Van Geene AR, Van den Bekerom MP, et al. Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fractures in the healthy elderly: a meta-analysis and systematic review of randomized trials. International orthopaedics. May 24 2012.
6. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. The Journal of bone and joint surgery. American volume. Feb 2006;88(2):249-260.
7. van den Bekerom MP, Hilverdink EF, Sierevelt IN, et al. A comparison of hemiarthroplasty with total hip replacement for displaced intracapsular fracture of the femoral neck: a randomised controlled multicentre trial in patients aged 70 years and over. The Journal of bone and joint surgery. British volume. Oct 2010;92(10):1422-1428.
8. Blomfeldt R, Tornkvist H, Eriksson K, Soderqvist A, Ponzer S, Tidermark J. A randomised controlled trial comparing bipolar hemiarthroplasty with total hip replacement for displaced intracapsular fractures of the femoral neck in elderly patients. The Journal of bone and joint surgery. British volume. Feb 2007;89(2):160-165.
9. Macaulay W, Nellans KW, Garvin KL, Iorio R, Healy WL, Rosenwasser MP. Prospective randomized clinical trial comparing hemiarthroplasty to total hip arthroplasty in the treatment of displaced femoral neck fractures: winner of the Dorr Award. The Journal of arthroplasty. Sep 2008;23(6 Suppl 1):2-8.
Competing interests: No competing interests
As a patient advocate and an engineer, I spent a considerable time in research to tease out the hypothesis that I have held since 2009; that the chances or otherwise of receiving a THA rather than a HA seemed to be down to no more than random chance, influenced by day of admission; budget of the hospital (HA is cheaper); and/or the personal preference of the Orthopod involved. This seems now to be borne out by this well researched and documented study.
It seemed to me that the HA was a poorly thought out treatment for intracapsular fracture in and of itself. Surely anyone with even a rudimentary understanding of tribology (the wear between surfaces) would realise that a metal ball, in a bone socket (acetabulum) is without any doubt, going to erode that bone and cartilage at a higher rate than would the femoral head. And of course the rate of that wear would be proportional to use. THA introduces a wearing surface similar, but far from equal to, that of the native acetabulum. So, without any need to consult any engineering algorithm we can deduce that THA good; HA bad, if viewed purely from an engineering standpoint. So if one is given a HA it is obvious that you will succumb to 'engineered' osteoarthritis; probably within a quite short time window, if you are active. That possibility is diminished considerably with a THA, although cannot be entirely eliminated and will be dependent on the choice of materials used in the implant.
This study shows that there are huge shortcomings to treatment that could, and no doubt have brought about immense suffering; risk to life due to revision, that always increases in proportion to age, and a loss to society of active and useful people who have been consigned to pain; poor ambulation, often with sticks or crutches; wheelchairs, or worst, death in theatre. The selection criteria has to be made more transparent and consistent, but do we really need a guideline to inform that decision? Is it not implicit in training for a speciality that the best evidence is the basis for any protocol even if your hospital tells you to limit your THAs for trauma patients due to budget constraints? Does Orthopedics fall outside simple humanity or are some so deluded as to actually believe the often touted view that HA can last for twenty years.
Every hip trauma patient deserves the right to make an informed decision about their treatment with an informed clinician. Not to be told in the small hours on a Friday or Saturday night, in a fog of opiates, that they are on the list for a 'hemi', whilst not having a clue what the FY2 or duty registrar is talking about.
This study should be compulsory reading for surgical registrars and maybe all doctors.
Competing interests: No competing interests
Poorer people in difficult circumstances are not stupid . . . 'they' realise that they often get fobbed off with lesser quality treatment and also less access to information which might, just might, help the situation. But is this type of research likely to engender trust in the public's willingness to take part in research? Were the participants told that they would not be given the results? And given a reason for with-holding them? Or that the most useful information - that is, the names of specific hospitals - would be kept secret? Could those surgeons and hospitals who do give the most optimal treatment give that information via the BMJ and so, as it is likely, be picked up by the media and inform the public in ways those in deprived areas are more likely to be informed?
Many clinicians have known the situation for a long time obviously, so why is it kept secret? Is there any agreement entered into between clinicians and managers that information should not be disclosed? If not, there would be no breach of the type of highly unethical agreement made for this study to go forward surely. Does NICE have any real powers to deal with such a situation? Are people in deprived areas going to have the option of waiting longer to see a surgeon who will give them transparent information and the option of a better procedure? Are people in deprived areas less likely to have quick referrals to any surgeon anyway?
As the information in the study is now public, will individuals who suffer the consequences of poor treatment - and crucially somehow find out that they have received non transparent prior information or treatment non compliant with NICE guidance - have any way of dealing with that, for instance, by being offered another better treatment if they can cope with it; compensation to go private; or compensation to help deal with the possible adverse consequences which will probably be lifelong.
Finally what is the point of NICE and ethics committees whic can leave such loopholes that knowledge using NHS data can be withheld including from those who need it most to make decisions about their lives?
It may be that there are lists published to inform which surgeons give the best treatment - either privately or in the NHS?
Competing interests: No competing interests
Re: Inequalities in use of total hip arthroplasty for hip fracture: population based study
Response to Benjamin Dean...
Dear Mr Dean,
We read your response with interest. Importantly, our study [1] was not designed to test the quality of the hip fracture guidance, but to examine compliance with the guideline, and to explore why variation may exist.
It is certainly true that further evidence is necessary to determine which hip fracture patients gain the most from THA. However, we did find that compliance increased year-on-year throughout our study, which might suggest a drive amongst surgeons to support the guideline.
“Sensible shared decision making” does not readily explain the inter-hospital variation in compliance (ranging from 1% to 60%) or the systematic inequalities observed by socioeconomic status or day-of-the-week.
We agree that surgeons should have discretion to depart from guidelines when the evidence is uncertain, nevertheless national guidelines are clearly important in benchmarking and minimising healthcare inequalities. We hope that the arrival of further trial evidence [2] will inform future guidelines that are enthusiastically supported by individual surgeons.
Yours sincerely
Daniel Perry
David Metcalfe
Xavier Griffin
Matthew Costa
1. Perry DC, Metcalfe D, Griffin XL, Costa ML. Inequalities in use of total hip arthroplasty for hip fracture: population based study. BMJ 2016;353:i2021.
2. Bhandari M, Devereaux PJ, Einhorn TA, et al. HEALTH Investigators. Hip fracture evaluation with alternatives of total hip arthroplasty versus hemiarthroplasty (HEALTH): protocol for a multicentre randomised trial. BMJ Open 2015; 5:e006263. doi:10.1136/bmjopen-2014-006263.
Competing interests: No competing interests