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Hip fractures: Who should treat these and when?
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Several studies on hip fracture patients show association between surgical delay and both complications and increased risk of death. National guidelines from Europe and the United States state 24 hours to 48 hours to be the maximum waiting time. The focus on a specific number of hours may tempt us to disregard what these hours are spent on. Efficient preoperative care, with pain relief, diagnostics, prophylactic measures and planning of anesthesia and surgery will still take some hours. But waiting, due to lack of resources or excessive preoperative work-up, is of no value.
Before naming and shaming anesthesiologists and cardiologists regarding postponing surgery for investigations and optimization, we must remember that they are convinced this is best for the patient. Only by close collaboration between specialties and sharing of modern knowledge, can the preoperative care become efficient and rapid. True contraindications for early surgery are few, and many are characterized by being possible to reverse in a day or 2 days. This may be uncontrolled diabetes mellitus, correctable arrhythmia, severe electrolyte disturbances, acute uremia, which are conditions that affect less than 5% of the patients with hip fractures.
Chronic severe illness cannot be reversed, and is better dealt with after the fracture is fixed. Surgery should never be delayed due to administrative reasons or unnecessary medical tests. The risks with anticoagulants, new or old, can be handled with knowledge and cautions. Already, centers challenge the relatively long waiting time recommended for new oral anticoagulants, combined with analysis of whether early surgery leads to clinically important risks. This was the process with clopidogrel, when it was introduced.
Who should perform hip fracture surgery? There may be a conflict between shorter waiting time to surgery and availability of skilled team members in the OR. Either we need forgiving, robust procedures that are manageable for less-experienced surgeons, or theoretically better, but demanding procedures provided by a small number of experts. In addition, the experience of the anesthesiologist and OR nurse is obviously also of paramount importance. The worst alternative is the use of fancy and expensive methods based on individual preferences and without follow-up on outcome measures.
In the literature, we see single-surgeon series leading to good results, which may speak in favor of dedicated high-volume surgeons only. In contrast, one can argue the common hip fracture is suited for young surgeons in training. This is true if good supervision is provided, and if the complexity of some hip fracture types is recognized and met with adequate measures. Assumingly, the resources and organization of each clinic determines whether to restrict hip fracture surgery to experts only or to let less experienced surgeons do it supported by evidence based treatment algorithms and education. With a constant flow of patients, the organization must have the capacity to give everyone with a hip fracture efficient treatment and care 24/7.
- References:
- Association of Anaesthetists of Great Britain and Ireland, et al. Anaesthesia. 2012;doi:10.1111/j.1365-2044.2011.06957.x.
- Griffiths R, et al. Anaesthesia. 2015;doi:10.1111/anae.13036.
- Moja L, et al. PLoS One. 2012;doi:10.1371/journal.pone.0046175.
- Palm H, et al. Acta Orthop. 2012;doi:10.3109/17453674.2011.652887.
- Parker MJ. Injury. 2015;doi:10.1016/j.injury.2015.02.020.
- Shiga T, et al. Can J Anaesth. 2008;doi:10.1007/BF03016088.
- Uzoigwe CE, et al. Injury. 2013;doi:10.1016/j.injury.2012.08.025.
- For more information:
- Cecilia Rogmark, MD, PhD, is associate professor in the department of orthopedics at Skane University Hospital. She can be reached at SE-205 02 Malmö, Sweden; email: cecilia.rogmark@skane.se.
Disclosure: Rogmark reports no relevant financial disclosures.