Management of Trochanteric Fractures: Are We NICE Compliant?

Abstract

Introduction: The National Institute for Health and Care Excellence (NICE) updated the 2011 hip fracture management guidelines on January 6, 2023, suggesting that clinicians offer sliding hip screws in preference to intramedullary nails for trochanteric fractures above and including the lesser trochanter except reverse oblique fractures. This study aims to assess the compliance of our hospital with the updated guidelines while comparing the results with our performance prior to the update together with the national average.

Materials and methods: A retrospective observational study was done to analyse if trochanteric fractures managed surgically were compliant with NICE guidelines. Pathological fractures secondary to tumours and AO/OTA 31A1.1 fractures were excluded. Fractures were classified using the 2018 AO/OTA classification system independently by two authors, with a review from a senior consultant if there was interobserver variation. Group A (n=60) included trochanteric fractures managed surgically three months prior to the update, while Group B (n=46) included patients managed operatively three months following the update.

Results: The compliance rates for Group A and Group B were similar at 88.33% and 89.13%, respectively, while the national average was about 67% over the course of six months.

Discussion: 31A2 fractures showed higher rates of non-compliance in both groups. Non-compliance was thought to be multifactorial: surgeon bias, inaccurate classification of fractures and a lack of awareness of guidelines.

Conclusions: While there is scope for improvement, district general hospitals can achieve high rates of compliance. Educating and training doctors could help improve compliance.

Keywords: extracapsular hip fracture; hip fracture; intramedullary nail; nice guidelines; sliding hip screw; trochanteric fractures.

Figure 1. A1 fractures have a simple fracture line extending from the greater trochanter to the medial femoral cortex, while A2 fractures are multifragmentary pertrochanteric fractures and always have a posteromedial fragment. A3 fractures have a fracture line running from the lesser trochanter to the lateral femoral cortex distal to the lesser trochanter and are further classified based on fracture orientation and comminution.

Source: Reproduced from Marsh et al. [8] with permission from the Journal of Orthopaedic Trauma.

Figure 2. The 2018 AO/OTA TF classification is based on fracture orientation, comminution and involvement of the lateral wall. The 31A1.1 fractures are isolated fractures of the greater or lesser trochanter, while 31A1.2 and 1.3 fractures are simple pertrochanteric fractures with a competent lateral wall, i.e., lateral wall thickness >20.5 mm. Fractures classified as 31A2 have an incompetent lateral wall (lateral wall thickness <20.5 mm) with varying levels of fracture comminution. The 31A3 fractures consist of fractures running from the lesser trochanter inferiorly to the lateral femoral cortex in an oblique or transverse orientation, with or without comminution.

TF: trochanteric fracture. Source: Reproduced from Meinberg et al. [6] with permission from the Journal of Orthopaedic Trauma.