Complications
Total hip arthroplasty and open reduction and internal fixation of hip fractures, and surgery due to major trauma are among the orthopaedic procedures with the highest deep vein thrombosis risk.[85] With contemporary surgical protocols the prevalence of venous thromboembolism (VTE) after total hip arthroplasty has been reported to be up to 22%, using venography as a diagnostic method, even with the use of pharmacological prophylaxis.[86] The most critical period for VTE development is within the first month after orthopaedic surgery, but the risk of VTE may persist for longer.[85] Patients with lower leg trauma and lower leg immobility with a plaster cast or brace are at increased risk of developing deep vein thrombosis. One Cochrane review of eight randomised controlled trials showed a lower rate of VTE in patients with lower leg immobility with daily prophylaxis compared with those without prophylaxis or with placebo.[115] However, because the primary outcome of these studies included asymptomatic deep vein thrombosis confirmed by screening venography or ultrasonography, routine thromboprophylaxis in patients with lower leg immobility is not recommended.[116]
Another Cochrane review of 16 randomised trials in patients undergoing hip or knee replacement surgery suggests that there is 'moderate quality evidence' for the use of postoperative anticoagulants in the prevention of VTE; however, this comes at the risk of minor bleeding.[117]
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Trials in this review included both hip and knee replacement as well as hip replacements for both elective patients and those with hip fractures. Furthermore, no trials assessed patients undergoing hip fracture fixation. Some would suggest that prophylaxis is indicated in all patients with hip fractures; however, minimal evidence is present for which agent, for how long, and the subsequent trade-off regarding complications.[118] The National Institute for Health and Care Excellence in the UK recommends VTE prophylaxis for 1 month after surgery for people with fragility fractures (i.e., a fracture sustained from a fall from a standing height) of the pelvis, hip, or proximal femur if the risk of VTE outweighs the risk of bleeding.[76]
Occurs as a result of damage to the blood supply of the femoral head.
Risk increases if the femoral neck fracture is displaced.
Incidence following internal fixation (as opposed to replacement) of intracapsular fractures can range from 5% to 18%, but is uncommon following trochanteric fractures.[12]
If suspected, pelvic magnetic resonance imaging or technetium bone scanning may aid diagnosis.
If symptomatic, requires referral to an orthopaedic surgeon.
Non-union and failure of fixation are the two most common reasons for re-operation and are significantly higher in hip fractures in older people treated with internal fixation.[12][114]
Occurs as a result of osteopenic condition of bone or poor fixation technique.
Referral should be made to an orthopaedic surgeon.
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