Getting Geriatric Hip Fractures to the OR within 24 Hours Is Critical to Reduce Risk of Complications, Mortality

Femoral neck and intertrochanteric hip fractures in patients aged 65 years or older are among the most common fractures encountered by orthopaedic surgeons. These cases are almost always treated operatively to reduce the cardiopulmonary and thromboembolic complications that are associated with prolonged recumbency if the patient is treated non-surgically. Even in non-ambulatory patients, these fractures are treated surgically to promote mobilization, facilitate nursing care, and minimize the risk of decubitus ulcers. However, the mortality associated with geriatric hip fractures even when surgically managed is substantial and can exceed 30 percent at 1 year. Certain steps, including reducing time to the OR, eliminating unnecessary preoperative testing, operating through anticoagulation, and improving postoperative management of medical comorbidities, may help to reduce mortality in this very vulnerable population.

Time to OR
AAOS, the Orthopaedic Trauma Association, and the American College of Surgeons all agree that operating on geriatric hip fracture patients within 24 to 48 hours of presentation to the emergency department (ED) reduces mortality. More recent data suggest that the timeline should be further shortened. A retrospective cohort study published in JAMA included 42,230 patients with hip fractures (mean age, 80.1 years) treated by 522 orthopaedic surgeons. Patients were stratified into two groups based on whether they had surgery within or after 24 hours of arrival to the ED. The study found that 30-day mortality was significantly lower in the under-24-hour group. Mortality increased proportionally after 24 hours. A study from Steffensmeier et al in the Journal of Orthopaedic Trauma observed that decreased time to the OR is associated with significant decreases in length of stay (LOS), case cancellations, and hospital costs, with no increases in complications, readmissions, or 1-year mortality rate. Both groups in that study were treated within 24 hours.

Preoperative clearance
Unnecessary preoperative medical workups, especially cardiology testing, can significantly delay time to the OR and increase complication and mortality rates. The 2014 American College of Cardiology/American Heart Association clinical practice guideline on perioperative cardiovascular evaluation of patients undergoing noncardiac surgery recommends that the following conditions may need further preoperative cardiac workup:

• unstable coronary syndromes
• decompensated heart failure
• significant arrhythmias
• severe valvular disease
• dyspnea of unknown origin

However, preoperative testing is recommended only if it will change the management of the patient.

Preoperative echocardiography has been associated with a significant increase in time to the OR, LOS, and total healthcare costs at 1 year. If it is medically indicated, echocardiography should be performed as an urgent test so as not to further delay surgery.

Preoperative anticoagulants
Many patients presenting with hip fractures are on oral anticoagulation (e.g., rivaroxaban, dabigatran, apixaban) for atrial fibrillation or coronary stents. A retrospective study from Kolodychuk et al evaluated 535 patients with a hip fracture who underwent either cephalomedullary nailing or arthroplasty. Forty-one of the patients were taking oral anticoagulants. Both the group on preoperative anticoagulation and the control group had similar times to the OR (20.1 and 18.7 hours, respectively). There were no differences in blood transfusion rates, acute blood loss, or 30-day mortality between groups.

Many patients with hip fractures are on dual antiplatelet therapy (such as aspirin and clopidogrel). Should these patients have their surgeries delayed to minimize operative bleeding? A retrospective study from Tarrant et al evaluated 122 elderly patients with hip fractures who were on dual antiplatelet therapy. Whether the patient had earlier or delayed surgery, the need for transfusion did not change. However, the authors found that surgical delay was associated with increased complications and 30-day mortality. The finding suggests that hip fracture surgery should probably not be delayed for patients on anticoagulants because the need for transfusion may not significantly change by waiting, but the risk of mortality may increase.

Co-management with medicine service
Increasing evidence suggests that co-management services can reduce complications associated with medical comorbidities. In this arrangement, the medicine team is actively caring for the patient postoperatively to manage the medical condition(s). Orthopaedic surgery is still involved in managing the wound, deep vein thrombosis prophylaxis, and surgical complications. Hip fractures are major injuries for elderly patients, who usually have multiple comorbidities, including cardiopulmonary disease, osteoporosis, and dementia. Placing a cephalomedullary nail or performing arthroplasty in these patients creates a second trauma to their bodies that can create a systemic inflammatory response, by which previously stable medical conditions may become decompensated.

A retrospective study from Rohatgi et al reviewed 2,252 patients with geriatric hip fractures, of whom 757 were treated before the implementation of a co-management service and 1,495 were treated after implementation. The authors observed a 32 percent decrease in medical complications among the patients treated after implementation of the co-management service. There was no change in LOS or inpatient mortality.

Challenges
Implementation of measures to improve time to surgery can be challenging. The availability of OR resources and cooperation from multiple services (i.e., anesthesia, orthopaedics, medicine) can influence how smoothly this process can be performed. Will anesthesia proceed with hip fracture surgery on a patient without an echocardiogram or cardiology clearance? Can an echocardiogram be done urgently? Is there an orthopaedic trauma room available to do these cases during the day when staff and expertise are more readily available? If these cases are done at night, are there trained staff and qualified assistants available to help perform the surgery expeditiously? Will the medicine team follow this patient postoperatively? The answers to these questions will differ based on whether the hip fracture surgery is performed at a major teaching hospital, an academic medical center with residents, or a small community hospital with a few physician assistants covering multiple services overnight.

As hip fractures present to every hospital, all institutions, regardless of available resources, have to be able to manage these common fractures in a timely manner to prevent complications, morbidity, mortality, longer LOS, and financial burden associated with delayed care.

Michael DeRogatis, MD, MS, is an orthopaedic surgery resident at St. Luke’s University Health Network in Bethlehem, Pennsylvania, and serves as a resident-at-large member on the AAOS Now Editorial Board.

Paul S. Issack, MD, PhD, FAAOS, FACS, is a clinical associate professor in the Department of Orthopaedic Surgery, Weill Cornell Medical College, and a trauma and adult reconstruction orthopaedic surgeon at New York–Presbyterian/Lower Manhattan Hospital. He is also a member of the AAOS Now Editorial Board.

References

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