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National Patient Safety Agency

Guidance for hospitals to reduce risks for patients undergoing hip replacement for fractures of the hip joint

Wednesday 11 March 2009


Today (11 March) NHS and private hospitals are being alerted to ways of reducing risk for patients undergoing hip replacement surgery after a fracture at the hip joint.


Approximately 60,000 total hip replacements and 60,000 repairs of hip fractures are carried out each year in the UK.

NPSA Announcements

The death rate following partial hip replacement for fracture treatment is ten times higher than following a planned hip replacement mainly because the patients undergoing surgery after fracture are older, ill and are in need of an emergency operation. The death rate is also significantly higher when surgery is delayed more than 48 hours.


The most common cause of sudden intra-operative death during this surgery is the occurrence of venous embolisation of fat and bone marrow contents. This occurs during the instrumentation and reaming of any long bone or any manoeuvre that raises the pressure within that bone.


Twenty-six patient deaths and 6 cases of severe harm were reported to the National Patient Safety Agency (NPSA) between October 2003 and October 2008 in patients having a partial or total hip replacement where bone cement was used. The majority related to older patients undergoing emergency emergency hip replacement surgery after a fracture at the hip joint.


The NPSA is therefore advising local organisations to report all deaths and incidents in such cases and to adopt best practice techniques in surgery and anaesthesia. 


This includes identifying patients most at risk and stabilizing their medical condition before surgery. Skilled anaesthetic input and communication between surgeon and anaesthetist at critical points during the surgery is vital. Best surgical technique should be used, including methods to reduce the pressure in the intramedullary canal. Bone cement, if used, should be introduced from below upwards.


Dr Kevin Cleary, Medical Director of the NPSA said:


“All clinicians want to do the best thing for their patients.  For certain patients the short term risks of using cement in orthopaedic surgery need to be balanced against the long term benefits.  This NPSA report shares evidence of harm from hospitals across the country and indicates certain practical steps which can be taken by surgical and anaesthetic staff to reduce risks to patients.  


“By asking staff to report all serious incidents to the NPSA, we hope to improve learning and make this common procedure even safer for patients.”


Miss Clare Marx, President of the British Orthopaedic Association said:


"Hip surgery is a very common procedure and when performed following hip fracture enhances the lives of many elderly patients. It is generally considered safe and effective. However there are rare examples where patients have experienced severe harm or death immediately following these replacement operations.


“We welcome and support the actions specified in the Rapid Response Report to reduce the risks for these often frail and elderly patients and to maximise learning from incident reports and audits."


View the NPSA’s latest guidance, a Rapid Response Report on "Mitigating surgical risk in patients undergoing hip arthroplasty for fractures of the proximal femur"





Notes for editors:


Media enquiries to Paul Cooney in the NPSA Press Office on 020 7927 9351, paul.cooney@npsa.nhs.uk or 0788 411 5956 (out of hours).


As well as the incidents reported to the NPSA, the Medicines and Healthcare Products Regulatory Authority (MHRA) received reports of 19 patient deaths and 6 cases of severe harm between 2000 and 2008 in NHS and independent facilities in the UK where cement was used during hip surgery.


“Bone cement implantation syndrome” can occur after an internal prosthesis is implanted using bone cement. Cardiac arrest and death have been reported. It was originally thought that problems related to toxic effects of the cement itself, but now it appears that harm is caused by fat embolism as the prosthesis is inserted under pressure and this can also occur when cement is not used. The Chief Medical Officer’s Annual Report (2007) highlighted the need to find ways of reducing the incidence of sudden death during hip fracture surgery.


Rapid Response Reports are page-long notices which are based on evidence of harm to patients and identify clear actions for healthcare staff to reduce risks of recurrence. Since June 2007, 17 have been issued to NHS organisations in England and Wales.


The National Patient Safety Agency is an Arm’s Length Body of the Department of Health. It encompasses three divisions; the National Research Ethics Service, the National Reporting and Learning Service and the National Clinical Assessment Service. Each has its own sphere of expertise to improve patient outcomes. The NPSA’s vision is to lead and contribute to improved, safe patient care by informing, supporting and influencing healthcare individuals and organisations.