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Meta-Analysis
. 2008 Jul 16;2008(3):CD000337.
doi: 10.1002/14651858.CD000337.pub2.

Conservative versus operative treatment for hip fractures in adults

Helen H G Handoll  1 , Martyn J Parker
Affiliations
Meta-Analysis

Conservative versus operative treatment for hip fractures in adults

Helen H G Handoll et al. Cochrane Database Syst Rev. .

Abstract

Background: Until operative treatment involving the use of various implants was introduced in the 1950s, hip fractures were managed using conservative methods based on traction and bed rest.

Objectives: To compare conservative with operative treatment for fractures of the proximal femur (hip) in adults.

Search strategy: We searched the Cochrane Bone, Joint and Muscle Trauma Group Specialised Register (March 2008), the Cochrane Central Register of Controlled Trials (The Cochrane Library 2008, Issue 1), MEDLINE (1966 to 2008), EMBASE (1988 to 2008), Current Controlled Trials, orthopaedic journals, conference proceedings and reference lists of articles.

Selection criteria: Randomised and quasi-randomised trials comparing these two treatment methods in adults with hip fracture.

Data collection and analysis: Two review authors independently assessed trial quality and extracted data. Additional information was sought from trialists. After grouping by fracture type, comparable groups of trials were subgrouped by implant type and data were pooled where appropriate using the fixed-effect model.

Main results: The five randomised trials included in the review involved only 428 elderly patients. One small and potentially biased trial of 23 patients with undisplaced intracapsular fracture showed a reduced risk of non-union for those fractures treated operatively. The four trials on extracapsular fractures tested a variety of surgical techniques and implant devices and only one trial involving 106 patients can be considered to test current practice. In this trial, no differences were found in medical complications, mortality and long-term pain. However, operative treatment was more likely to result in the fracture healing without leg shortening, a shorter hospital stay and a statistically non-significant increase in the return of patients back to their original residence.

Authors' conclusions: Although there is a lack of available evidence to inform practice for undisplaced intracapsular fractures, variation in practice has reduced and most fractures are treated surgically. The limited available evidence from randomised trials does not suggest major differences in outcome between conservative and operative management programmes for extracapsular femoral fractures, but operative treatment is associated with a reduced length of hospital stay and improved rehabilitation. Conservative treatment will be acceptable where modern surgical facilities are unavailable, and will result in a reduction in complications associated with surgery, but rehabilitation is likely to be slower and limb deformity more common. Currently, it is difficult to conceive circumstances in which future trials would be practical or viable.

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Conflict of interest statement

None known.

Figures

1.1
1.1. Analysis
Comparison 1 Conservative treatment versus internal fixation for undisplaced intracapsular fractures, Outcome 1 Non‐union.
1.2
1.2. Analysis
Comparison 1 Conservative treatment versus internal fixation for undisplaced intracapsular fractures, Outcome 2 Avascular necrosis.
1.3
1.3. Analysis
Comparison 1 Conservative treatment versus internal fixation for undisplaced intracapsular fractures, Outcome 3 Subsequent operation/reoperation.
2.1
2.1. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 1 Non‐union.
2.2
2.2. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 2 Fracture fixation failure rate.
2.3
2.3. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 3 Wound infection.
2.4
2.4. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 4 Pin tract infection.
2.5
2.5. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 5 Pneumonia (chest infection).
2.6
2.6. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 6 Deep pressure sore (heel and sacral).
2.7
2.7. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 7 Deep vein thrombosis.
2.8
2.8. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 8 Pulmonary embolism.
2.9
2.9. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 9 Remaining in hospital at 4, 8 and 12 weeks.
2.10
2.10. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 10 Remaining in hospital at 6 month follow up.
2.11
2.11. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 11 Varus deformity.
2.12
2.12. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 12 Leg shortening.
2.13
2.13. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 13 Mortality.
2.14
2.14. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 14 Pain.
2.15
2.15. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 15 Loss of independence.
2.16
2.16. Analysis
Comparison 2 Conservative treatment versus internal fixation for extracapsular hip fractures, Outcome 16 Loss of independence or death.
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Update of

References

References to studies included in this review

Bong 1981 {published data only}
    1. Bong SC, Lau HK, Leong JC, Fang D, Lau MT. The treatment of unstable intertrochanteric fractures of the hip: a prospective trial of 150 cases. Injury 1981;13(2):139‐46. [MEDLINE: ] - PubMed
Hansen 1994 {published data only}
    1. Hansen FF. Conservative vs surgical treatment of impacted, subcapital fractures of the femoral neck [abstract]. Acta Orthopaedica Scandinavica. Supplementum 1994;256:9.
Hornby 1975 {published and unpublished data}
    1. Hornby R. Personal communication 1997.
    1. Stevens J. Proximal femoral fractures [abstract]. Orthopaedic Transactions 1980;4(1):92‐3.
Hornby 1989 {published data only}
    1. Hornby R, Evans JG, Vardon V. Operative or conservative treatment for trochanteric fractures of the femur. A randomised epidemiological trial in elderly patients. Journal of Bone and Joint Surgery ‐ British Volume 1989;71(4):619‐23. [MEDLINE: ] - PubMed
    1. Hornby R, Grimley Evans J, Vardon V. Trochanteric fractures in the elderly [abstract]. Journal of Bone and Joint Surgery ‐ British Volume 1986;68(1):157. - PubMed
Sher 1985 {published and unpublished data}
    1. Sher JL, Stevens J, Porter BB, Checketts RG. A comparison of operative and conservative treatment for unstable trochanteric fractures [abstract]. Journal of Bone and Joint Surgery ‐ British Volume 1985;67(3):495.

References to studies excluded from this review

Harper 1994 {published data only}
    1. Harper WM. Treatment of intracapsular proximal femoral fractures [thesis]. Leicester (UK): Univ. of Leicester, 1994.
    1. Harper WM, Gregg PJ. The treatment of intracapsular proximal femoral fractures: a randomized prospective trial [abstract]. Journal of Bone and Joint Surgery ‐ British Volume 1992;74 Suppl 3:282.

Additional references

Conn 2004
    1. Conn KS, Parker MJ. Undisplaced intracapsular hip fracture: results of internal fixation in 375 patients. Clinical Orthopaedics and Related Research 2004;(421):249‐54. - PubMed
Higgins 2003
    1. Higgins JPT, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analyses. BMJ 2003;327(7414):557‐60. - PMC - PubMed
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Parker 1992
    1. Parker MJ, Myles JW, Anand JK, Drewett R. Cost‐benefit analysis of hip fracture treatment. Journal of Bone and Joint Surgery ‐ British Volume 1992;74:261‐4. - PubMed
Parker 1999
    1. Parker MJ. Proximal femoral fractures. In: Pynsent PB, Fairbank JC, Carr AJ editor(s). Classification of musculoskeletal trauma. Oxford: Butterworth‐Heinemann, 1999:184‐209.
Parker 2002
    1. Parker MJ. Trochanteric and subtrochanteric fractures. In: Bulstrode C, Buckwalter J, Carr A, Marsh L, Fairbank J, Wilson‐MacDonald J, et al. editor(s). Oxford textbook of orthopaedics and trauma. 1st Edition. Oxford: Oxford University Press, 2002:2228‐39.
Parker 2006
    1. Parker MJ, Handoll HHG. Extramedullary fixation implants and external fixators for extracapsular hip fractures in adults. Cochrane Database of Systematic Reviews 2006, Issue 1. [DOI: 10.1002/14651858.CD000339.pub2] - DOI - PubMed
Parker 2008
    1. Parker MJ, Handoll HHG. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures in adults. Cochrane Database of Systematic Reviews 2008, Issue 3. [DOI: 10.1002/14651858.CD000093.pub3] - DOI - PubMed
Raaymakers 1991
    1. Raaymakers EL, Marti RK. Non‐operative treatment of impacted femoral neck fractures. A prospective study of 170 cases. Journal of Bone and Joint Surgery ‐ British Volume 1991;73(6):950‐4. - PubMed
Stevens 1980
    1. Stevens J. Proximal femoral fractures [abstract]. Orthopaedic Transactions 1980;4(1):92‐3.

References to other published versions of this review

Parker 2000a
    1. Parker MJ, Handoll HHG. Conservative versus operative treatment for extracapsular fractures (Cochrane Review). Cochrane Database of Systematic Reviews 2000, Issue 3. - PubMed
Parker 2000b
    1. Parker MJ. Conservative versus operative treatment for intracapsular fractures (Protocol for a Cochrane Review). Cochrane Database of Systematic Reviews 2000, Issue 2. - PubMed

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