MANAGEMENT OF HIP FRACTURES IN THE ERA OF THE SUB SPECIALIST ORTHOPAEDIC SURGEON

MA Bhutta Specialist Registrar  |  M Mawdsley ST3 |  M Jones Clinical Fellow  |  M Jones Clinical Fellow | M Fehily Consultant Surgeon |Trauma and Orthopaedics, Royal Bolton Hospital

Introduction

Increased life expectancy throughout the world is producing an aging population. With an estimated lifetime incidence of hip fracture in women and men of 18% and 6%, respectively, this represents the most common cause of injury requiring hospitalisation in those over the age of 65.1 In the UK in 2007 70,000 people over the age of 60 sustained a hip fracture. With numbers expected to rise by 2% every year, by 2020 101,000 patients will require medical care for this injury (National Hip Fracture Database (NHFD) website: http://www.nhfd.co.uk/). There is significant morbidity and mortality associated with hip fracture and one-year mortality ranges from 14% to 36%, presenting a significant burden of disease both medically and socially.2–4

Ann R Coll Surg Engl (Suppl) 2010; 92

Resources have been allocated for primary and secondary prevention in the diagnosis and treatment of osteoporosis and falls prevention. Similarly, for those who sustain this injury the focus has been on the optimisation of patients prior to surgical intervention and post-operative physiotherapy and social care. However, it is well documented that delays in surgical intervention have a deleterious effect on patient outcome. This is evident with increased pressure sores, hospitalacquired infections, increased hospital stay, reduced post-operative mobility status, increased cost and rate of mortality at one year.2,3,5,6

There is conflicting evidence as to the benefit of early operative intervention and whether surgery after 24 or 48 hours constitutes a surgical delay. While the first set of guidelines produced by the British Orthopaedic Association advises surgery within 48 hours (NHFD website), there is an increasing body of evidence suggesting the benefits of surgical intervention within 24 hours for patients who are medically fit, which has been endorsed by the Royal College of Physicians and others.2,3,5,7 The benefits represented include reduced length of hospital stay and major complications,6 which has significant implications on healthcare costs, given that estimated cost of hospital stay ranges between £5,600 and £12,000 per patient.8,9 Early intervention also improves the ability of this patient group to return to independent living.2,3,5

The delivery of an effective and efficient healthcare system for this patient population requires an understanding of the factors delaying surgical intervention to allow the implementation of changes to reduce unnecessary delay. Within western countries the delivery of surgical intervention within 48 hours can range from 33% to 93%, highlighting the challenge posed for delivery of surgical intervention within 24 hours.3 Therefore, there is an increasing need to find modifiable factors that can make an impact. Active medical problems account for a large proportion of patients who suffer a delay to surgical intervention that some units, including ours, have addressed with dedicated orthogeriatricians.2 For the remaining patients, delays are the result of a lack of availability of resources including operating rooms, support services or personnel with expertise.6,10

Modern orthopaedics has seen the development of the subspecialist surgeon with increasingly pro-active management of trauma patients. This coupled with the potential to delay surgery in some cases for upper or lower-limb-specific trauma operating lists creates a biased operating practice on the days on which such surgery is performed. However, when attempting to deliver surgical intervention for hip fracture patients within 24 hours, days when a trauma session has an upperlimb bias may affect this deleteriously.

The aims of this study were to assess the effectiveness of our unit in the delivery of surgical intervention to hip fracture patients within 24 hours and the hypothesis that upper-limb-specific trauma lists adversely affect the delivery of care to this patient group.

Methods

Our institution is a 671-bed busy district general hospital located in the north west of England with a catchment population of 330,000 and ten consultant orthopaedic surgeons. Of these there are three upper limb specialists, two foot and ankle specialists, a paediatric surgeon and four lower limb specialists. There are two to three dedicated consultant-led weekday trauma sessions with upper limb trauma sessions falling on alternate Tuesdays and Fridays and every Wednesday. At the weekend there are two trauma sessions on Saturday and one on Sunday.

Prospectively collected data from the NFHD website was analysed retrospectively, from which a total of 218 patients were identified to have been admitted to our institution with a hip fracture over a 12-month period. Of these two were excluded with incomplete data. The data collected included the time in hours from admission to the emergency department to surgery. The patient cohort was categorised by the day of admission and their outcomes at 24 hours, for which there were three subgroups: those who had surgical intervention for their hip fracture, those who were medically unfit (as defined by the orthogeriatricians and/or anaesthetists) and those whose surgery was delayed due to inadequate institutional theatre capacity.

Statistical analysis was performed with SPSS® 13 (Chicago, Illinois, USA). The data did not follow a normal distribution when assessed using the Shapiro–Wilk test. Statistical analysis was performed using a Kruskal–Wallis test with Monte Carlo adjustment of results.

Results

A total of 216 patients were identified who underwent operative intervention for a hip fracture. Of these 216 patients, at 24 hours 68 (31.5%) were medically unfit for surgery, 67 (31%) were delayed to surgery and 81 (37.5%) were operated on. The same breakdown based on the day of admission was also performed and the mean time to surgery for all patients was measured (Table 1).

TABLE 1

ADMISSIONS NUMBERS ON EACH DAY OF THE WEEK AND OUTCOMES FOR PATIENTS

  Mean time to surgery: all patients (h) Number medically unfit Number operated on within 24 h Number delayed to surgery Percentage of total admissions
Monday 56.4 (n=36) 12 11 13 16.7
Tuesday 70.7 (n=33) 10 11 12 15.3
Wednesday 56.7 (n=27) 8 14 5 12.5
Thursday 41.4 (n=30) 11 16 3 13.9
Friday 42.7 (n=36) 10 14 12 16.7
Saturday 60.4 (n=27) 10 4 13 12.5
Sunday 44.0 (n=27) 7 11 9 12.5

The mean delay to surgery based on the day of admission ranged from 41.4 to 70.7 hours. However, Tuesday and Saturday appeared to have the greatest delay while Thursday was most efficient.

Further analysis confirmed a statistically significant difference in the time to surgery between days of admission using Kruskal–Wallis H(6) 11.98 p<0.05. To assess whether the variation remained significant for weekdays alone a further analysis was performed. This was also statistically significant, with Kruskal–Wallis H(4) 11.33 p<0.017. To identify a specific day of admission for the cause of the statistical difference a p value of 0.008 was applied using a Bonferroni correction. Thursday became the standard for comparison with the lowest mean time to surgery. Although all such comparisons were statistically significant at a 95% confidence interval, only Friday achieved significance at the stricter confidence interval value by demonstrating a smaller variation in the time to surgery compared to other days of the week.

In our unit Wednesday is a dedicated upper-limb-led trauma day but there is also an alternating trauma session on Tuesday. No statistical significance was identified as a consequence of an upperlimb- led surgeon on Tuesday or at the weekend delaying hip fracture surgery.

Of those delayed for surgery in the first 24 hours, 50% of the patients were likely to be operated on within the next 24 hours except for Friday, on which 83% were operated upon. Analysis of those that were deemed medically unfit in the first 24 hours showed that 0–60% became fit for surgery the following day, with Tuesday having the greatest conversion to becoming medically fit at 60%.

Discussion

An aging population has increased the pressure on healthcare resources, of which the management of hip fractures is one. This burden is further heightened by the need to deliver efficient care, with optimisation of patients pre-operatively, focused post-operative care preferably by orthogeriatricians and with early surgical intervention.

Early surgical intervention decreases mortality in the short term but potentially continues to have an effect at one year independent of the presence of co-morbidity or increasing age while also decreasing rates of infection and pressure sores.2,3,6 Another benefit for this patient group is a decreased hospital stay beyond that achieved purely by early surgery, with benefits in cost for the delivery of care to local healthcare economics – such patients are more likely to return to independent living conditions.5,6

A delay beyond 48 hours, excluding those medically unfit, has become the minimum standard in western countries. This has been difficult to achieve, with the success of orthopaedic units varying from 33% to 93%.3 However, increasing evidence of the improved benefits of surgery within 24 hours suggests this is in fact the gold standard.

In our study surgery was delayed for more than 24 hours in the medically fit in 31% of cases, which appears better than previous reports between 50% (NHFD website)11 and 69%.5 However, at 24 hours 31.5% of patients were deemed medically unfit and this large group may represent the previously reported bias of early surgery for fitter patients, compared with those with higher American Society of Anesthesiologists grades being deemed medically unfit. Yet it is within this subgroup of those for whom no further optimisation is possible that early surgery should still be performed.6 This is highlighted by up to a 60% conversion of those patients who were medically unfit at 24 hours becoming fit for surgery in the subsequent 24 hours.

To continue to meet the challenge of time to surgery for hip fracture patients, work has been done to address the time spent in emergency departments and the use of trauma coordinators to expedite the assessment for patients and preparation for surgery and the efficiency of operating theatres.11

However, another factor that may play a role is the development of the subspecialist orthopaedic surgeon, exemplified by the number of associated societies.13 The increasing recognition and understanding of pathology and the technological and operative techniques in management has accelerated subspecialisation and potentially placed further strain on operating lists. As a consequence modern orthopaedics has seen trauma care distributed on this basis, which has further driven subspecialisation as surgeons from other subspecialties have lost familiarity with such cases.

Upper limb trauma cases (excluding neurovascular emergencies) are generally able to wait longer for fixation due to the increased mobility and reduced risk of complications such as deep vein thrombosis and bedsores. This has meant the more complex upper limb trauma received by orthopaedic units is placed solely on upper-limb-led operating lists. In our unit this, in effect, leads to stacking of cases on to upper-limb-led trauma lists every Wednesday, alternate Tuesdays and some weekends, with a reduced capacity for fixation of hip fractures on such days.

This study has identified variability in the delays to surgical fixation of hip fractures based on days of admission in our unit, with the greatest delays for patients admitted on Saturday (48.1%), Tuesday (36.4%) and Monday (36.1%). The delays that occur for those admitted on Saturday are possibly a consequence of a single trauma session on Sundays compared to two or three on other days. This appears to have a knock-on effect, causing similar delays to patients on Monday, although on that day more patients are operated on, clearing the backlog of patients based on chronological order as well as medical status.

However, patients admitted on Tuesday are delayed at similar rates, with equal operating lists, representing a possible consequence of weeks in which there are two consecutive days of upper-limb-led trauma sessions. This variation was statistically significant throughout the week: H(6) 11.98 p<0.05. This statistical significance was maintained for weekdays (Monday to Friday) alone: H(4) 11.33 p<0.0017.

Also a further subanalysis of the rates of delay to surgery based on the combination of the subspecialty lead surgeon on Tuesdays and at the weekend reveals a marked delay when there is an upper limb lead surgeon for both compared to any other combination, although not achieving statistical significance. This further highlights the impact of subspecialisation on the delivery of modern trauma care.

This study is the first to attempt to assess the impact of modern orthopaedic practice and subspecialisation on the delivery of early surgical intervention for hip fractures. It is clear that in our unit the necessary demand for increased specialisation of trauma care and the creation of ‘dedicated’ upper limb trauma lists has led to the realisation of delays in provision of care to hip fracture patients. As a result of this study we are attempting to prevent the occurrence of upper-limb-led theatre sessions on Tuesday and and at the weekend of the same week.We are also assessing the feasibility of increasing theatre sessions on Sunday and creating a hip fracture operating list on Wednesday to address the delays from alternating upper–limbled theatre sessions on a Tuesday.

These changes, we believe, will make a significant impact on the care of hip fracture patients and will highlight the possible need for other orthopaedic units to perform similar analysis as part of clinical governance and to identify another modifiable factors to improve care to this vulnerable patient population.

References

  1. Pickett W, Hartling L, Brison RJ. A population-based study of hospitalized injuries in Kingston Ontario, identified via the Canadian Hospitals Injury Reporting and Prevention Program. Chronic Dis Can 1997; 18:61–69.
  2. Bergeron E, Lavoie A, Moore L et al. Is the delay to surgery for isolated hip fracture predictive of outcome in efficient systems? J Trauma 2006; 60: 753–57.
  3. Novack V, Jotkowitz A, Etzion O, Porath A. Does delay in surgery after hip fracture lead to worse outcomes? A multicenter survey. Int J Qual Health Care 2007; 19:170–76.
  4. Gullberg B, Johnell O, Kanis JA.World-wide projections for hip fracture. Osteoporos Int 1997; 7: 407–13.
  5. Al-Ani AN, Samuelsson B, Tidermark J et al. Early operation on patients with a hip fracture improved the ability to return to independent living. A prospective study of 850 patients. J Bone Joint Surg Am 2008; 90:1,436–42.
  6. Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery prolongs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br 2005; 87: 1,123–26.
  7. The Royal College of Physicians. Fractured neck of femur. Prevention and management. Summary and recommendations of a report of The Royal College of Physicians. J R Coll Physicians Lond 1989; 23: 8–12.
  8. Klotzbuecher CM, Ross PD, Landsman PB et al. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 2000; 15: 721–39.
  9. Sernbo I, Johnell O. Consequences of a hip fracture: a prospective study over 1 year. Osteoporos Int 1993; 3:148–53.
  10. Sund R, Liski A. Quality effects of operative delay on mortality in hip fracture treatment. Qual Saf Health Care 2005; 14: 371–77.
  11. Charalambous CP, Yarwood S, Paschalides C et al. Factors delaying surgical treatment of hip fractures in elderly patients. Ann R Coll Surg Engl 2003; 85: 117–19.
  12. Lankester BJ, Paterson MP, Capon G, Belcher J. Delays in orthopaedic trauma treatment: setting standards for the time interval between admission and operation. Ann R Coll Surg Engl 2000; 82: 322–26.
  13. Sarmiento A. Subspecialization in orthopaedics. Has it been all for the better? J Bone Joint Surg Am 2003; 85:369–73.

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