To operate or not: alternatives to surgery for hip fractures—a well-kept secret

Townsend Letter for Doctors and Patients,  Dec, 2004  by Marion Weil

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Editor:

If a non-surgical solution to an impacted femur neck hip fracture exists, why is it that no one seems to know about it? Why are patients--particularly in today's cost-contained healthcare environment--rushed to surgery instead of being given the option to make an educated choice?

These were some of the disquieting questions I addressed last year, after tripping over the welcome mat at a friend's home and breaking my hip put me on the threshold of a critical medical decision: whether or not to follow the "standard practice" of surgery or to explore a non-operative treatment. Happily, I chose the latter and experienced a full recovery without the trauma or possible complications of surgery.

However, in the vast majority of cases of an "impacted femur neck fracture," which is the type of broken hip experienced by 100,000 people annually, treatment is surgery, often with metal pins or surgical screws implanted. Rarely will doctors even consider a non-operative option--that is, if they even know that this solution exists.

Time to get the word out. I am eager to share my experience with others because I have come to truly appreciate the proverb that knowledge is power. I believe many people would opt for natural healing as I did if they were privy to the "secret" information that unfortunately has been either withheld or overlooked by most doctors specializing in hip fractures.

This may come as a shock to some, but I did not even go to the emergency room the night I fell. Instead, my friend, Judith, who would later care for me during my 10-week convalescence, and another friend picked me up in a van and took me home to ice my hip. (I put an arm around each person's shoulder so there would be no weight on the injured leg.) The next morning, Judith took me to see her internist who advised me to go to the hospital immediately. "Get thee to surgery!" was the call I heard repeatedly from doctors as I continued my quest over the next few days to get opinions from six different physicians.

At the age of 60 at the time and as someone who has practiced yoga for 30 years, I have a high awareness of my own body. If there was a way to avoid surgery, I wanted to know about it. Finally, the fourth physician, Dr. Eric Johnson, Chief, Orthopaedic Trauma and Fracture Surgery and Professor of Orthopaedic Surgery at the UCLA School of Medicine, in Los Angeles--once he was convinced that I was serious about a non-operative option--informed me of research done by a colleague in Holland. He agreed to treat me if I opted for the non-operative route.

The Dutch study published in 1991 ("Non-operative Treatment of Impacted Femoral Neck Fractures," abstract published in J Bone Joint Surg Br (1991) Nov. 73 (6): 950-954 by Ernst L. Raaymakers & R.K. Marti) reports a 94% success rate for complete non-operative healing for an otherwise healthy person aged 70 or younger! The downside? The only risk if the non-operative treatment did not stabilize the bone was loss of time; if the leg did not heal on its own, I would have to undergo the surgery I hoped to avoid. This research was confirmed in the updated study "Non-Operative Treatment of Impacted Femor Neck Fractures" by Dr. Ernst LFB Raaymakers, December 2002 Injury Journal, JINJ 33, supplement 3, pp. 8-14.

In my mind, there was no debate: I would invest the time in order to avoid the trauma of an operation, the possibility of complications such as pain or discomfort, possible protrusion through the skin of the metal parts, and the possibility of future surgery to replace metal parts, etc.

Non-operative treatment had come a long way from the "old days" of immobilized bed rest, which put patients at risk for blood clots and bedsores. Today's non-operative treatment includes early mobilization. Within two days, I was on my feet and using a walker, although I had to keep my weight off the injured leg.

The first couple of days, when the pain was severe, I used ibuprofen, until I read that it could possibly interfere with healing. By this time, the pain had subsided, although I did have occasional discomfort, as well as moments of fear and anxiety. Throughout my recovery, I saw Dr. Johnson periodically for x-rays, which showed no deterioration or instability of the leg. I adhered strictly to the minimum requirements of staying off the injured leg, and I listened to my body when it came to my care, whether it meant taking extra calcium or eating healthily.

Based on my experience, there are four essential elements I strongly recommend to anyone considering a non-operative treatment:

1. A walker and/or crutches (and wheelchair for outdoor excursions). While a walker was more reassuring in the early days of getting around, I later learned to use the crutches.

2. A long scarf or terrycloth robe sash. Looping the scarf or sash under both knees allows one to lift the legs together, such as when moving from a lying to a sitting position, or when preparing to stand with walker or crutches. Lateral leg movement is to be avoided.