Hip Fracture

Hip Fracture

Neal Biddick, MD

Staci Saunders, MD

Zahir Kanjee, MD, MPH

Is there a benefit to early (<24 hours) compared to late (>24 hours) surgery after hip fracture?

Complications and mortality are more common when patients wait >24 hours for surgery.

This question was evaluated by a 2017 analysis of administrative data for 42,230 patients undergoing hip fracture surgery performed by 522 orthopedic surgeons in Ontario, Canada.1 Patients with previous hip fracture, lacking data on hospital arrival time, <45 years old, or receiving surgery by nonorthopedic surgeons were excluded. The primary exposure was time from initial presentation to any ED until surgery (in hours). Covariates included characteristics of patients (demographics, comorbidity [based on previously validated models]), orthopedic-specific conditions (osteomyelitis, bone cancer, other fracture, recent hip arthroplasty, and trauma), procedure (type, duration, and time of day/week), operating
surgeons (seniority, volume), and hospital (surgical volume, size, and academic or community status). The primary outcome was 30-day mortality from time of admission. Secondary outcomes included 90-day and 1-year mortality as well as medical complications (including myocardial infarction, venous thromboembolism, and pneumonia).

After controlling for covariates, 30-day mortality was first analyzed using time as a continuous variable. A graphic depiction of this analysis permitted the selection of an inflection point in the primary exposure at which to dichotomize patients into early versus late surgery groups. A logistic regression with propensity-score matching was subsequently performed. Authors conducted multiple sensitivity analyses including one limited to patients without comorbidity, another among those >65 years of age who had received blood thinners within a year prior to surgery, and a post hoc analysis limited to patients undergoing surgery within 36 hours.

The mean time to surgery was 38.8 hours. An inflection point was notable at 24 hours (Figure 27.1), so this time point was chosen as the demarcation between the early and late surgery groups in further analyses. The primary outcome was lower in the early surgery group (5.8% vs. 6.5%, absolute risk reduction 0.79%, 95% CI 0.23%-1.35%; P = .006). The early surgery group also had reductions in 90-day (absolute risk reduction 1.35%, 95% CI 0.61%-2.10%; P < .001) and 1-year (absolute risk reduction 2.31%, 95% CI 1.47%-3.25%; P < .001) mortality, along with numerous outcomes at 30 days such as pulmonary embolism (absolute risk reduction 0.51%, 95% CI 0.28%-0.74%; P < .001), pneumonia (absolute risk reduction 0.95%, 95% CI 0.48-1.43; P < .001), and myocardial infarction (absolute risk reduction 0.39, 95% CI 0.15%-0.62%; P = .001). These results were robust to sensitivity analyses limited to patients without comorbidity, who underwent surgery within 36 hours, and >65 years of age who received blood thinner prescriptions in the previous year. Caveats include the retrospective design and use of administrative data.

National Institute for Health and Care Excellence (NICE) guidelines2 recommend surgery on the same day or 1 day following admission.

Figure 27.1 The relationship between hours from hospital arrival to surgery and 30-day mortality, adjusted for multiple covariates. (Reprinted from Pincus D, et al. Association between wait time and 30-day mortality in adults undergoing hip fracture surgery. J Am Med Assoc. 2017;318(20):1994-2003, with permission.)

Do intravenous bisphosphonates prevent adverse outcomes after an osteoporotic hip fracture?

Intravenous zoledronic acid prevents recurrent fractures and decreases mortality in patients with osteoporotic hip fractures.

HORIZON-RFT3 was a multinational, randomized, double-blind, placebo-controlled trial of zoledronic acid, a once-yearly intravenous bisphosphonate, among 2127 patients with recent hip fracture. Previously ambulatory patients ≥50 years of age were included within 90 days from surgical hip fracture repair after low-intensity trauma (such as a fall from standing) if they refused or could not tolerate an oral bisphosphonate. Exclusion criteria included CrCl <30 mL/min, corrected Ca <8.0 mg/dL or >11.0 mg/dL, active cancer, or non-osteoporotic metabolic bone disease. Patients received zoledronic acid 5 mg IV annually or placebo within 90 days of surgical repair and were followed for up to 5 years. Initially, vitamin D2 or D3 loading doses 2 weeks prior to the study drug were reserved for those whose 25-hydroxyvitamin D was either ≤15 ng/mL
or not available, but after the authors noted very high prevalence of vitamin D deficiency, the protocol was changed and all subsequent patients received loading doses routinely. All patients received routine oral daily supplementation of Ca and vitamin D. Patients underwent annual dual-energy x-ray absorptiometry scans.

The initial primary outcome was time to first fracture, but due to a low event rate, this plan was altered slightly during the course of the study. The subsequent primary outcome was new clinical fracture (outside of facial/digital fractures or those in abnormal, such as metastatic, bone). Secondary outcomes included rates of vertebral and non-vertebral fractures, changes in bone mineral density (BMD), delayed healing of the index fracture, osteonecrosis of the jaw, other adverse events, and mortality.

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Feb 5, 2020 | Posted by in CRITICAL CARE | Comments Off on Hip Fracture
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