What steps can reduce morbidity and mortality caused by hip fractures?

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Clinical Inquiries

What steps can reduce morbidity and mortality caused by hip fractures?

J Fam Pract. 2007 November;56(11):944-946

By

Michael Grover, DO

Frederick Edwards, MD

Kristin Hitchcock, MSI

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References

1. Parker MJ, Handoll HH, Bhargara A. Conservative versus operative treatment for hip fractures. Cochrane Database Syst Rev. 2000;(4):CD000337.

2. Dorotka R, Schoechtner H, Buchinger W. The influence of immediate surgical treatment of proximal femoral fractures on mortality and quality of life. Operation within six hours of the fracture versus later than six hours. J Bone Joint Surg Br. 2003;85:1107-1113.

3. 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.

4. Bottle A, Aylin P. mortality associated with delay in operation after hip fracture: observational study. BMJ. 2006;332:947-951.

5. Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism: the seventh ACCP Conference on Antithrombotic and Thrombolytic Therapy. Chest. 2004;126(3 Suppl):S338-S400.

6. Handoll HH, Farrar MJ, Mcbirnie J, Tytherleighstrong G, Milne AA, Gillespie WJ. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev. 2002;(4):CD000305

7. Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev. 2001;(1):CD000244.

8. Classen DC, Evans RS, Pestotnik SL, Horn SD, Menlove RL, Burke JP. The timing of prophylactic administration of antibiotics and the risk of surgical wound infection. N Engl J Med. 1992;326:281-286.

9. March L, Chamberlain A, Cameron I, et al. Prevention, Treatment, and Rehabilitation of Fractured Neck of Femur. report from the Northern sydney Area Fractured Neck of Femur Health outcomes Project. St. Leonards, Australia: Public Health Unit, Northern Sydney Area Health Service; 1996. Available at: www.mja.com.au/public/issues/iprs2/march/fnof.pdf. Accessed on october 11, 2007.

10. Brauer C, Morrison RS, Silberzweig SB, Siu AL. The cause of delirium in patients with hip fracture. Arch Intern Med. 2000;160:1856-1860.

11. 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.

12. Edelstein DM, Aharonoff GB, Karp A, Capla EL, Zuckerman JD, Koval KJ. Effect of postoperative delirium on outcome after hip fracture. Clin Orthop Relat Res. 2004;422:195-200.

13. Day H. Postoperative delirium. PIER: Physician’s Information and education resource, American College of Physicians. July 2006. Available at: pier.acponline.org/index.html. Accessed on October 11, 2007.

14. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc. 2005;53:1658-1666.

15. Morrison RS, Magaziner J, Mclaughlin MA, et al. The impact of post-operative pain on outcomes following hip fracture. Pain. 2003;103:303-311.

16. Christmas C. Hip fracture. PIER: Physicians’ Information and Education Resource, American College of Physicians. updated July 2006. Available at: pier.acponline.org/index.html. october 11, 2007.

EVIDENCE-BASED ANSWER

Surgery within 24 hours of hip fracture is a critical step in reducing complications, and may decrease mortality compared with conservative care (strength of recommendation [sor]: B, cohort studies). Give patients heparin at the time of admission to prevent venous thromboembolism (VTE) (SOR: A, systematic reviews of RCTs). Anticoagulation should be continued in some form for 10 days or until the patient is fully ambulatory (SOR: A). Patients should also get prophylactic antibiotics in the 2 hours before surgery (SOR: A, meta-analysis of RCT). reduce the risk of postoperative delirium by avoiding certain medications, minimizing sleep disturbances, and providing adequate analgesia (SOR: B, systematic review of cohort studies). Aggressive pain control should also be top of mind—higher pain scores are associated with longer hospital stays, delayed ambulation, and long-term functional impairment (SOR: C, extrapolation from a single cohort study).

Clinical commentary

Ensure that proper treatment continues after discharge
Mary M. Stephens, MD, MPH
East Tennessee State University, Kingsport

As an FP working in a hospital, I am often asked to consult on cases of hip fracture. It’s important to maximize the patient’s condition quickly in order for the orthopedist to be able to proceed with surgical repair within the first 24 hours of the injury.

Many hospitals have anticoagulation protocols or standing orders for postop hip fracture management, which should make VTE prevention almost automatic. However, it’s important to ensure that these orders are initiated preoperatively if surgery is delayed, and that treatment gets continued for the appropriate length of time—even after the patient is discharged to their home or to a facility for rehabilitation.

As physicians, we worry about the short-term mortality from VTE and pulmonary embolism, but delirium can be devastating for family members to watch, and carries its own morbidities. I talk to the patient and family preoperatively or immediately postoperatively about this risk so they can be prepared.

Evidence summary

Although most patients undergo surgery for hip fracture, family physicians often serve as consultants for perioperative management and rehabilitation. Several interventions have been studied that influence outcomes for hip fracture patients.

Surgical interventions: Timing is critical

Most ambulatory, medically stable patients elect to have surgical repair of their fractures. A meta-analysis found few randomized trials comparing operative with nonoperative therapy; it concluded that surgical treatment seems to be associated with a reduced length of hospital stay and improved rehabilitation.¹

The timing of surgery appears to be an important variable, particularly whether patients should undergo surgery within 24 hours of the fracture. Some studies found decreased mortality with earlier surgical intervention,² while others have not.³ A 2006 observational study⁴ found that delay in operating was associated with an increased risk of death in the hospital, even after adjusting for comorbidities. For all deaths in the hospital, the odds ratio [OR] for delaying more than 1 day, relative to 1 day or less, was 1.27 (95% confidence interval [CI], 1.23–1.32). Despite the inconsistency regarding mortality rates, complication rates (such as decubitus ulcers) do increase with a delay in surgery.³

FAST TRACK

Delay in operating after hip fracture was associated with increased risk of death in the hospital

Unfractionated vs LMW heparin

After a hip fracture, patients are at very high risk for VTE. For untreated patients, the rate of deep vein thromboses (DVT) may be as high as 50%, with an associated fatal pulmonary embolism rate as high as 7.5%.⁵

The effectiveness of unfractionated and low-molecular-weight heparin was evaluated in a 2002 Cochrane systematic review.⁶ While evidence was insufficient to recommend 1 agent over another, both were found to significantly decrease the incidence of lower-extremity DVT over placebo (for unfractionated heparin, relative risk [RR]=0.59 [95% CI, 0.49–0.72]; for low-molecular-weight heparin, RR=0.60 [95% CI, 0.50–0.71]). Number needed to treat [NNT] with either agent was 7.

Reduce infections with antibiotic prophylaxis

Antibiotic prophylaxis has been supported by a Cochrane review, which concluded that single-dose antibiotic prophylaxis before surgery significantly reduced the risk of deep wound infections (RR=0.40; 95% CI, 0.24–0.67; NNT=55), as well as superficial wound, urinary, and respiratory tract infections.⁷

Patients should receive antibiotics less than 2 hours before surgery to reduce the risk of infection.⁸ Classen et al found that patients treated less than 2 hours before surgery had a 0.6% rate of infection (10/1208), compared with a 3.85% rate for those treated 2 to 24 hours ahead (14/369) (NNT=31).⁸ It is unclear whether multiple-dose therapy provides additional benefit when administered over the first 24 to 36 hours after surgery⁹ (OR=0.60; 95% CI, 0.18–2.02). First- or second-generation cephalosporins were used in most studies.

Delirium: A common but avoidable complication

FAST TRACK

Inadequate pain control is associated with longer hospital stays and delirium

Delirium is a common complication seen after hip fracture, affecting approximately 10% to 16% of patients.^10,11 Delirium may increase the duration of hospitalization, and may be associated with an increased mortality at 1 year.¹² Delirium can be avoided by looking at each patient’s risk factors.¹³ Studies suggest avoiding use of meperidine, benzodiazepines, and medications with anticholinergic side effects.^11,13 Sleep deprivation, delayed mobility, and inadequate pain control are also associated with the development of delirium.¹³

Evidence-based answers from the Family Physicians Inquiries Network