Conservative versus operative treatment for hip fractures

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.

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

We searched the Cochrane Musculoskeletal Injuries Group trials register and bibliographies of published papers, and contacted trialists. Date of the most recent search: August 1999.

Randomised and quasi-randomised trials comparing these two treatment methods in adults with hip fracture. Outcomes sought fell into four categories: a) fracture fixation complications, b) post-operative or clinical complications, c) anatomical restoration and d) final outcome measures including mortality.

Two reviewers independently assessed trial quality, by use of an twelve item scale, and extracted data. Additional information was sought from trialists. After grouping by fracture type, comparable groups of trials were subgrouped by implant type and where appropriate, data were pooled using the fixed effects model.

The five randomised trials identified involved only 425 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 identified studies 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.

Given the lack of available evidence to inform practice and the continued variation in practice, good quality randomised trials of operative versus conservative treatment for undisplaced intracapsular fractures are warranted. 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 appears to be associated with a reduced length of hospital stay and improved rehabilitation. However these results are derived mainly from one study. 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. Although further randomised trials would provide more robust data, they may be difficult to mount.