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 hip fracture.

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.

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 stated.

“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 all actions to reduce risks for these often frail and elderly patients and to maximise learning from incident reports and audit.”