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#Post#: 100--------------------------------------------------
Do hip fractures need to be repaired within 24 hours of injury?
By: osmaniaortho Date: October 3, 2012, 10:25 am
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There is considerable debate about the optimal timing of hip
fracture repair and whether delaying it affects outcomes.
Postoperative rates of medical complications and death are high,
for many reasons.
Patients who are medically stable (ie, who do not have
hypovolemia, accelerated hypertension, untreated infection, or a
symptomatic arrhythmia) and have preserved cardiopulmonary
function should proceed to operative repair as soon as
practically possible.
However, many patients wait more than 24 hours after admission
to the hospital until their medical conditions are optimized
prior to surgery or until a surgeon or operating room becomes
available. If the patient's medical condition is unstable, then
operative repair should be delayed until the patient is at his
or her healthiest possible baseline level.
How long can surgery be delayed? Available evidence suggests
that waiting up to 72 hours to allow time to stabilize any
existing medical conditions does not adversely affect health or
functional outcomes in patients with hip fracture. Further study
is needed to identify specific groups of patients who would
benefit from operative delay for medical stabilization.
Hip Fractures are Not All the Same
The term "hip fracture" refers to a fracture of the proximal
femur, be it in the femoral neck, across the trochanters, or
below the trochanters.
Femoral neck fractures (especially if displaced) may compromise
the blood supply to the femoral head
and increase the risk for avascular necrosis and nonunion. 1
Earlier operation is preferred for optimal technical results if
the femoral head is to be preserved. Intertrochanteric and
subtrochanteric fractures occur in well-vascularized areas and
pose less risk of osteonecrosis.
There are several options for surgical repair. 1 Internal
fixation with multiple screws can be used for minimally
displaced femoral neck fractures; a sliding hip screw may be
used for intertrochanteric fractures. Prosthetic replacement of
the femoral head is done if significant displacement occurs.
However, compared with internal fixation, this procedure carries
a higher operative risk from blood loss and anesthesia time.
Why Operate Immediately?
Many experts advocate repairing hip fractures
expeditiously—within 8 to 24 hours from admission to the
hospital.
In published series, patients who underwent surgery earlier had
lower rates of nonunion, 2 avascular
necrosis of the femoral head, 3 urinary tract infections, 4
decubitus ulcers, 5,6 pneumonia, venous
thromboembolism, 7 and death, 7-9 and better long-term
functional status 7 than did those who underwent surgery later.
In addition, delaying surgery prolongs the patient's pain and
suffering. In a recent prospective cohort study of 1,206
patients, those who underwent surgery within 24 hours had
significantly fewer days of
severe and very severe pain and shorter lengths of hospital
stay. 10 Higher pain ratings in patients with hip
fracture are associated with longer postoperative lengths of
stay, delayed postoperative rehabilitation, 11
and increased risk of delirium, 12 which increases mortality and
complications in elderly hospitalized
patients. 13
However, the evidence in this area is flawed by the
heterogeneity and retrospective design of the studies. To date,
no randomized prospective study has compared delayed surgery
with expeditious surgery, so it is difficult to know whether
surgical delay adversely affects outcomes directly, or whether
delay in surgery is simply a reflection of underlying
morbidities that adversely affect outcomes.
Why Delay Repair?
The main reason to delay surgery is to optimize the patient's
medical conditions.
Many patients with hip fractures have preexisting chronic
diseases such as diabetes, congestive heart failure, coronary
artery disease, or anemia. These conditions produce neuropathy,
visual impairment, or weakness, which may have contributed to
the fall and hip fracture.
In addition, an elderly patient who is found on the floor at
home with a fractured hip may have been there a long time
without access to food or water, predisposing him or her to
dehydration, electrolyte disturbances, and rhabdomyolysis with
renal failure. Any of these conditions, if not assessed,
treated, or stabilized preoperatively, may lead to perioperative
complications such as myocardial ischemia and infarction,
delirium, and nutritional compromise.
These complications increase in-hospital and overall mortality
and also lead to a delay in weight-bearing
and rehabilitation. 5,14 Therefore, a delay in surgical
intervention of 24 to 48 hours after admission is advocated to
correct metabolic disturbances and to optimize chronic medical
conditions, which may improve overall outcomes.
In contrast to prior studies noting increased mortality with
operative delay, recent studies noted no significant difference
in mortality rates after immediate hip fracture repair vs
delayed repair after
controlling for the severity of medical conditions. 5,15-17
In a retrospective analysis of 406 patients with proximal
femoral fractures, Kenzora et al 18 noted a higher 1-year
mortality rate after operative repair on the first hospital day
compared with the second through fifth hospital days (34% vs
5.8%, P < .00001); this difference remained significant in the
subgroup with three or fewer medical problems. No explanations
for delays in surgery were given, but the authors postulated
that physiologic changes induced by a fractured hip, such as
immobilization, dehydration, and other metabolic disturbances,
coupled with the stress of surgery itself, contributed to the
increased mortality with early repair.
Harries and Eastwood 19 noted no difference in short-term
outcome if surgery was delayed to optimize the patient's medical
condition.
Zagrodnick and Kaufner 20 noted a lower in-hospital mortality
rate (18.9% vs 9.1%) with preoperative stabilization of medical
conditions.
The largest study to date regarding the timing of surgery was
done by Grimes et al, 6 who retrospectively evaluated 8,383
patients with hip fractures operatively repaired between 1983
and 1993. Delaying surgery more than 24 hours from admission was
associated with a higher long-term mortality rate in unadjusted
analyses compared with prompt surgery (ie, < 24 hours from
admission). However, when adjusted for demographic variables and
for severity of underlying medical problems, no significant
association was found. Mortality at 30 days and postoperative
morbidity measures were similar, although those who underwent
delayed surgery had twice the risk of developing decubitus
ulcers.
Preoperative Stress Testing Vs. Beta-Blocker
Delaying hip fracture repair for noninvasive cardiac testing is
controversial.
For example, imagine a patient has an uncomplicated
intertrochanteric fracture and diabetes that requires insulin
but has no prior congestive heart failure or cardiovascular
disease. The consultant orders a dipyridamolethallium test,
which reveals anterior wall ischemia. The patient then undergoes
catheterization, angioplasty, and stent placement in the left
anterior descending coronary artery. He is now committed to 4
weeks of aspirin and clopidogrel therapy, and after these agents
are stopped another week is needed before the bleeding risk is
acceptable. Surgery has now been delayed 5 to 6 weeks, during
which time the patient has limited mobility, becomes
deconditioned, and is at increased risk of venous
thromboembolism. In addition, operative repair may now be more
technically difficult.
Alternately, empiric beta-blocker therapy has been shown to
significantly reduce perioperative cardiac
complications, independent of stress test results, in lower-risk
patients. Boersma et al 21 evaluated 1,097 patients who
underwent dobutamine stress echocardiography before major
vascular surgery; 360 of these patients received beta-blockers.
Patients receiving beta-blockers who had fewer than three risk
factors from the Lee risk index (high-risk surgery, ischemic
heart disease, congestive heart failure, cerebrovascular
disease, preoperative treatment with insulin, and preoperative
serum creatinine concentration > 2.0 mg/dL) had a very low risk
of cardiac complications (0.8%). Dobutamine stress
echocardiography had minimal additional prognostic value in
these patients.
Hip fracture repair poses a lower risk than major vascular
procedures for perioperative cardiac complications. Empiric
beta-blocker therapy in lower-risk patients confers significant
cardiac protection that allows expeditious repair of a fractured
hip, avoids unnecessary testing, and minimizes complications
related to operative delay.
References
1. Zuckerman JD. Hip fracture. N Engl J Med 1996; 334:1519-1525.
2. Manninger J, Kazar G, Fekete G, et al. Significance of urgent
(within 6h) internal fixation in the management of fractures of
the neck of the femur. Injury 1989; 20:101-105.
3. Jain R, Koo M, Kreder HJ, Schemitsch EH, Davey JR, Mahomed
NN. Comparison of early and delayed fixation of subcapital hip
fractures in patients sixty years of age or less. J Bone Joint
Surg Am 2002; 84:1605-1612.
4. Johnstone DJ, Morgan NH, Wilkinson MC, Chissell HR. Urinary
tract infection and hip fracture. Injury 1995; 26:89-91.
5. Parker MJ, Pryor GA. The timing of surgery for proximal
femoral fractures. J Bone Joint Surg Br 1992; 74:203-205.
6. Grimes JP, Gregory PM, Noveck H, Butler MS, Carson JL. The
effects of time-to-surgery on mortality and morbidity in
patients following hip fracture. Am J Med 2002; 112:702-709.
7. Perez JV, Warwick DJ, Case CP, Bannister GC. Death after
proximal femoral fracture-an autopsy study. Injury 1995;
26:237-240.
8. Villar RN, Allen SM, Barnes SJ. Hip fractures in healthy
patients: operative delay versus prognosis. Br Med J (Clin Res
Ed) 1986; 293:1203-1204.
9. Rogers FB, Shackford SR, Keller MS. Early fixation reduces
morbidity and mortality in elderly patients with hip fractures
from low-impact falls. J Trauma 1995; 39:261-265.
10. Orosz GM, Magaziner J, Hannan EL, et al. Association of
timing of surgery for hip fracture and patient outcomes. JAMA
2004; 291:1738-1743.
11. Morrison RS, Magaziner J, McLaughlin MA, et al. The impact
of postoperative pain on outcomes following hip fracture. Pain
2003;103:303-311.
12. Morrison RS, Magaziner J, Gilbert M, et al. Relationship
between pain and opioid analgesics on the development of
delirium following hip fracture. J Gerontol A Biol Sci Med Sci
2003; 58:76-81.
13. Francis J, Kapoor WN. Prognosis after hospital discharge of
older medical patients with delirium. J Am Geriatr Soc 1992;
40:601-606.
14. Morrison RS. The medical consultant's role in caring for
patients with hip fracture. Ann Intern Med 1998; 128:1010-1020.
15. Holmberg S, Kalen R, Thorngren KG. Treatment and outcome of
femoral neck fractures. An analysis of 2,418 patients admitted
from their own homes. Clin Orthop 1987; 218:42-52.
16. Zuckerman JD. Postoperative complications and mortality
associated with operative delay in older patients who have a
fracture of the hip. J Bone Joint Surg Am 1995; 77:1551-1556.
17. Sexson SB, Lehner JT. Factors affecting hip fracture
mortality. J Orthop Trauma 1987; 1:298-305.
18. Kenzora JE, McCarthy RE, Lowell JD, Sledge CB. Hip fracture
mortality. Relation to age, treatment, preoperative illness,
time of surgery, and complications. Clin Orthop 1984; 186:45-56.
19. Harries DJ, Eastwood H. Proximal femoral fractures in the
elderly: Does operative delay for medical reasons affect
short-term outcome? Age Ageing 1991; 20:41-44.
20. Zagrodnick J, Kaufner HK. [Decreasing risk by individual
timing of surgery of para-articular femoral fractures of the hip
in the elderly.] Unfallchirurgie 1990; 16:139-143.
21. Boersma E, Poldermans D, Bax JJ, et al. Predictors of
cardiac events after major vascular surgery: role of clinical
characteristics, dobutamine echocardiography, and betablocker
therapy. JAMA 2001; 285:1865-1873.
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