1. Hip Fracture Dr Janet Lippett Consultant Orthogeriatrician October 2011

2. Hip Fracture Overview  Facts and Figures  Hip Fracture – The Royal Berkshire Way  Orthogeriatrics  Pre-operative Assessment  Falls Assessment  Osteoporosis Assessment  Post operative Care and Rehabilitation

3. Hip Fracture

4. Facts and Figures  90% of patients admitted with a hip fracture are over 65.  10% die in the first 30 days; 30% die within a year.  Its common – average 450/yr in the RBH.  <50% return back to their own home.  80% of older women say they would rather die than experience the loss of independence and QOL associated with a hip fracture.  Fragility Fractures cost the UK health economy £1.8 billion a year  More bed days than stroke and heart disease

5. Hip Fracture Hip Fracture – The Royal Berkshire Way  Pre 2007 liaison service  New Orthogeriatric Service set up in 2007 –Full time Consultant Orthogeriatrician  Achieving high standards in National Audits –Top 10 in 2010 National Hip Fracture Database Annual Report –Reduction in length of stay from 42 to 17 days –Nearly 100% falls and bone health assessments –Reduction in pressure sores

6. Hip Fracture Orthogeriatrics  Pre-op assessment/optimisation, peri-operative complications, rehabilitation, falls and bone health assessments.  A good service reduces mortality, complications, length of stay and improves functional outcomes such as mobility and return to independence.  1940s Lionel Cosin – rehabilitation of neck of femur fracture patients  1950s Michael Devas and Bobby Irvine  2000s Janet Lippett and Apu Chatterjee

7. Hip Fracture Pre-operative Assessment  Orthogeriatric medical assessment  Aim to get to theatre within 36 hours 20072011 Pre-op Assessment 20%78% Theatre within 48 hours 69%92%

8. Hip Fracture

10. Falls Assessment  History  Medication Review  Gait and Balance  Home Hazard Assessment  Multidisciplinary Involvement –Occupational Therapist and Physiotherapy  NHFD results 2011 – 99% of patients assessed

11. Hip Fracture Osteoporosis  Commonest bone disease in adults  Reduction in bone density with a subsequent increased risk of fracture.  Life time risk of fracture in women over 50 is 1 in 2.  Falls and fractures account for more inpatient bed days than stroke and cardiovascular disease.  Osteoporosis is a “silent illness”.  NHFD 2011 – 98% of patients assessed (cf 45% in 2007)

12. Hip Fracture

13. Risk Factors  Gender –F>M  Parental history of hip fracture  Previous fracture –2-5 fold increased risk  Low BMI –Esp. if <20 kg/m2  Low Bone Mineral Density (BMD)  Smoking –Dose dependent  Alcohol –Esp. >3 units/day  Drugs –Steroids, anticonvulsants, heparin, hormone treatments for cancer

14. Hip Fracture What can we do - guidelines  NICE guidance –Treat over 75s without investigation  FRAX and NOGG –DEXA vs lifestyle vs treat  National Osteoporosis Society –Usual guidance on the internet and has a local group

15. Hip Fracture

17. DEXA scanning

18. Hip Fracture Lifestyle  Exercise –Weightbearing – dancing, walking, aerobics  Diet –Fruit and veg, fish, dairy products  Sunlight –10-20 mins exposure on base arms a day  Alcohol –Reduce intake to <3 units per day

19. Hip Fracture Drug Treatment  Calcium and Vitamin D for all  Bisphosphonates –Mainstay of treatment – Alendronate –Main side effect is indigestion –Must sit up for 30 mins after, drink with whole glass of water and avoid food  Strontium –Daily but doesn’t have complicated administration instructions –Main side effect is diarrhoea

20. Hip Fracture Post-operative Care and Rehabilitation  Post-operative complications  Tailor made rehabilitation programme  Woodley Ward  Community Rehabilitation  Inpatient Community Rehabilitation  National Hip Fracture Database

21. Hip Fracture The Future  Fracture Liaison Service –Improved service for femur fractures –Service for non hip fractures –Improved compliance with medication –Support for patients

22. Hip Fracture Thanks  Apu Chatterjee  Andrew McAndrew and the Orthopaedic Surgeons  Karen Barnard – Trauma Nurse Practioner  Helen Slade and Helen Mallock – Ward Managers  Liz Scott and the Physio team  Moyra Pugh and the OT team