Complications
Total hip arthroplasty and open reduction and internal fixation of hip fractures, and surgery due to major trauma, are among the orthopedic procedures with the highest deep vein thrombosis (DVT) risk.[70] 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 pharmacologic prophylaxis.[71] The most critical period for VTE development is within the first month after orthopedic surgery, but the risk of VTE may persist for longer.[70]
Patients with lower leg trauma and lower leg immobility with a plaster cast or brace are at increased risk of developing DVT. One Cochrane review of eight randomized controlled trials showed a lower rate of DVT in outpatients with lower leg immobility with low molecular weight heparins compared with those without prophylaxis or with placebo.[144] However, because the primary outcome of these studies included asymptomatic DVT confirmed by screening venography or ultrasonography, routine thromboprophylaxis in patients with lower leg immobility is not recommended.[67]
Another Cochrane review of 16 randomized 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.[145]
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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.
Guidelines from the American Academy of Orthopaedic Surgeons strongly recommend VTE prophylaxis in all patients ages 65 years or older. There are significant established risk factors for VTE in these patients, including age, presence of hip fracture, major surgery, delays to surgery, and the potential serious consequences of failure to provide prophylaxis.[17] This recommendation was based on data from six moderate-quality studies and four low-quality studies that showed the risk of DVT was significantly less with VTE prophylaxis than with control. Most general complications were not significantly different between treatment groups and there was some evidence that mortality was less with prophylaxis when compared with control groups.[17]
The National Institute for Health and Care Excellence in the UK recommends venous thromboembolism prophylaxis for 1 month after surgery to 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.[69]
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 femoral neck fractures can range from 5% to 18%, and is uncommon following intertrochanteric fractures.[9]
If suspected, pelvic magnetic resonance imaging or technetium bone scanning may aid diagnosis.
If symptomatic, requires referral to an orthopedic surgeon.
Nonunion and failure of fixation are the two most common reasons for reoperation and are significantly higher in neck of femur fractures in older patients treated with internal fixation.[9][85]
Occurs as a result of osteopenic condition of bone or poor fixation technique.
Referral should be made to an orthopedic surgeon.
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