Testing new surgical method for hip fractures
If you break your hip at an older age, you can have much worse function – and a completely different life. For consultant and postdoctoral researcher Mads Sundet at Diakonhjemmet Hospital, this is the backdrop for the HIFSAT study he leads. This large research project is testing a new surgical method for hip fractures.
“Many vulnerable elderly people break their hips. That's why we need to be sure that we are actually using the best method,” says Sundet.
From Finnmark to Malawi – and back to hip fractures
The path to the REMEDY center began in the north. Sundet finished medical school in Tromsø in 2003 and worked for six years in orthopedics in Hammerfest afterwards. This was followed by further specialization at Ullevål Hospital and Martina Hansens Hospital. He has since subspecialized in foot and ankle surgery.
At the same time, research interest grew.
As a student, he was already involved in the work at the Tromsø Mineskadesenter, which ran research projects in many places around the world.
– The war surgeon Hans Husum was an important inspiration at that time, he says.
Later, the road went to Malawi, where road traffic injuries became the main topic. With the support of orthopedist Sven Young, who lives and works in Malawi, Sundet laid the foundation for his doctorate on road traffic injuries. It was completed in 2022.
Today, hip fractures and their treatment are the focus. And at Diakonhjemmet Hospital, Siri Lillegraven at the REMEDY Center has become a key person.
– In recent years, Siri has been my most important mentor, he says.
A workweek between the operating room and research data
As a senior consultant in orthopedics and a postdoctoral fellow, Sundet divides his week between clinical practice and research.
“I generally have two to three research days each week, and two to three clinical days where I operate or have outpatient clinics,” he says.
This gives him a lot of the clinical work in the department and at the same time time for research.
The combination is demanding, but also motivating. What he sees in the operating room and in his encounters with patients directly provides ideas for research questions. The research, in turn, provides a critical look at established practice. A good example is the HIFSAT study.
A new way into the hip
In HIFSAT, two methods of operating on femoral neck fractures are compared. The patient receives a hemiprosthesis. This means a hip prosthesis that only replaces the damaged part of the hip joint, not the entire hip.
Before the operation, a "surgical approach" must be chosen, i.e. a way into the hip joint. The most common is called the lateral approach and means that the procedure is performed from the side of the hip.
“The SPAIRE method was developed to spare the muscles around the hip as much as possible during the operation. The surgeon can leave the muscle attachments alone to a greater extent,” explains Sundet.
“Lateral access was developed in the 1960s and is well-proven and safe. It is currently recommended in both national and international guidelines for the treatment of hip fractures,” explains Sundet.
With the lateral method, the surgeon detaches a powerful muscle from the femur.
– In theory, SPAIRE may cause less pain and less weakness in the hip, compared to the standard approach. But this has never really been investigated using good scientific methods, he says.
It was when the department had already started using SPAIRE that the research question arose.
– We saw that the SPAIRE method had become very popular in Norway in a short time, almost without scientific evidence. We then believed that it was essential to document the results, with high scientific quality.
How patients join HIFSAT
HIFSAT includes patients over 50 years of age with femoral neck fractures, who require hemiprosthesis, at one of the three study hospitals. For the patient, everything happens in the middle of a dramatic phase.
– All patients who meet the criteria for participation will receive information about the study and can participate if they wish, explains Sundet.
Around a quarter of patients have dementia and cannot consent themselves.
– In these cases, relatives can consent on behalf of the patient, he says.
Patients are then randomly assigned to either the standard lateral approach or the SPAIRE approach. After surgery, they are followed up with both clinical checks and questionnaires.
Measures pain, limping and everyday function
The study uses, among other things, the Harris Hip Score, a tool that measures pain, function and limping. In addition, length of stay, quality of life and results on functional tests such as the Short Physical Performance Battery (SPPB) are recorded.
– Pain and limping are perhaps the most important things for patients, and this is included in the Harris Hip Score, says Sundet.
He is also excited about the results of the physical tests.
“We include functional tests that are interesting, including SPPB. It tests walking speed, balance and the ability to get up from a chair five times,” he says.
The goal is not just to see who has the best hip right after surgery, but who actually manages best in everyday life.
Collaboration with strong research environments
HIFSAT is a collaboration between Diakonhjemmet Hospital, Akershus University Hospital (Ahus) and Ullevål.
– Ullevål and Ahus have for many years been at a high international level when it comes to randomized studies on patients with hip fractures. We at Diakonhjemmet Hospital have been more of a "working hospital" with many patients with hip fractures and relatively little research on surgical interventions, says Sundet.
This is precisely why collaboration is seen as a strength.
– The collaboration is going very well, and it is inspiring for us to be part of this research environment, he says.
A vulnerable patient group – small differences can mean a lot
He explains that elderly people with hip fractures are at high risk of both functional decline and death.
– A quarter die within a year of the breakup, says Sundet.
He does not believe that a new surgical approach alone will revolutionize healthcare.
“There is little evidence that improved surgical access will make a big difference to the healthcare system as a whole. But for individual patients, who may be able to walk better and have less pain, it could make a big difference,” he says.
Therefore, he believes it is crucial to know whether SPAIRE actually produces better results, or whether the current standard is still just as good.
– In any case, it is important that the methods we use are well documented, and that we actually use the best method, he emphasizes.
REMEDY makes it possible
HIFSAT is part of the portfolio of the REMEDY center for research into musculoskeletal diseases. For Sundet, there is little doubt that the center has been crucial.
“REMEDY has the expertise, experience and infrastructure we need. Without this, we busy clinicians would not have been able to plan, apply for funding and conduct such a large study,” he says.
Diakonhjemmet Hospital also has a long tradition of research into hip fractures within several disciplines. Research has been conducted on this within geriatrics, physiotherapy, nutrition and nursing.
– That is why many people are interested in this type of study and are also participating in HIFSAT. The data collection that is done can be used in other projects and by other researchers at the hospital, says Sundet.
Two of the key people in the study are physiotherapist and researcher Sylvia Sunde and orthopedist and research fellow Maren Paus.
– They are key players in the national professional community for research on hip fractures and treatment, and we see that HIFSAT opens doors for us both nationally and internationally, he says.
Can influence policies worldwide
How does he hope that HIFSAT will influence the treatment of hip fractures, both in Norway and internationally?
– No matter what the study concludes, it will probably have consequences for the treatment of hip fractures, says Sundet.
Many hospitals are already considering changing the surgical approach, but are waiting because the documentation is lacking and because the guidelines still recommend lateral access.
“If the two methods prove to be equally good, it is not necessary to change the surgical method,” he says. In that case, one can continue to use the method one has traditionally used in the past.
But if SPAIRE proves to be better, the impact could be huge.
– Should SPAIRE prove to be better, it will probably lead to changes in international guidelines for the treatment of hip fractures and significantly increased use of this technique, says Mads Sundet.
