Annals for Hospitalists Inpatient Notes - Timely Hip Fracture Surgery

Abstract

Hip fractures are common and affect millions of elderly patients annually (1). Surgery is the ideal treatment for hip fracture to control pain, recover mobility, and improve quality of life. Moreover, surgery can interrupt the cascade of related physiologic disturbances. Patients with hip fractures are exposed to pain, bleeding, inflammation, and immobilization as well as prothrombotic, catabolic, and stress states, which can precipitate significant clinical complications (for example, myocardial infarction, pneumonia, and venous thromboembolism). Often, patients with hip fractures are older, havemultiple medical comorbidities, and receive many medications at the same time. Some even present with acute comorbidities. Given the complexity of these patients, orthopedic surgeons commonly consult with hospitalists for medical clearance and optimization before surgery. The usual preoperative approach is to optimize any acute medical conditions in the hope of reducing perioperative complications. This results in additional investigations and treatments and prolongs the time that patients are exposed to those deleterious states caused by the hip fracture. Hospitalists need to balance the length of time needed to optimize underlying medical conditions against the consequences of delaying surgery. In clinical practice, there is substantial debate about the ideal timing of surgery for hip fractures. Observational studies suggest that early surgery reduces mortality (2, 3), and most guidelines recommend surgical treatment within 48 hours. However, these recommendations are based on observational studies that are at risk for residual confounding. We performed the first large (n = 2970) randomized controlled trial, the HIP ATTACK-1 (HIP Fracture Accelerated Surgical TreaTment And Care tracK) trial (4), at 69 sites in 17 countries to determine if accelerated surgerywould improve clinical outcomes in patients with hip fractures. The HIP ATTACK-1 trial showed no significant reduction in mortality (294 deaths; hazard ratio [HR], 0.91 [95%CI, 0.72 to 1.14]) or in a composite of major complications (652 events; HR, 0.97 [CI, 0.83 to 1.13]) for patients who had accelerated surgery (median of 6 hours from hip fracture diagnosis to surgery) versus those who had standard care (median of 24 hours from hip fracture diagnosis to surgery) within the 90-day follow-up period (4). However, compared with standard care, accelerated surgery did result in a lower risk for delirium (odds ratio, 0.72 [CI, 0.58 to 0.92]), urinary tract infection (HR, 0.78 [CI, 0.61 to 0.99]), andmoderate to severe pain on days 4 to 7 after randomization. Accelerated surgery also resulted in faster mobilization after randomization (absolute median difference, 21 hours [CI, 20 to 22 hours]) and a shorter time from randomization to hospital discharge (absolutemean difference, 1 day [CI, 1 to 2 days]). The HIP ATTACK-1 trial suggested that accelerated surgery may be safe, even in patients with acute medical conditions. Early surgery did not result in an increased rate of mortality or major complications in a subgroup of patients who presented with acute comorbidities, including acute myocardial infarction with a mechanical complication, ST-segment elevation myocardial infarction, cardiogenic shock, stroke, subarachnoid hemorrhage, pulmonary embolism, coronary artery revascularization, short-term need for dialysis, presumptive bacteremia, and respiratory failure requiring mechanical ventilation. However, cautious interpretation is required because severe acute medical conditions were extremely rare— only 9 of 2970 (0.3%) patients had one of these conditions. A larger subgroup (131 of 2970 [4.4%] patients) with a broader set of acute comorbidities had similar findings, showing no increase in mortality or severe complications with early surgery. This subgroup included patients with any of the severe medical conditions listed earlier or any of the following conditions: transient ischemic attack, acute myocardial infarction without mechanical complication, non–ST-segment elevation myocardial infarction, unstable angina, congestive heart failure, deep venous thrombosis, aortic stenosis, atrial fibrillation, pulmonary arterial hypertension, coagulopathy, significant thrombocytopenia, hyponatremia or hypernatremia, hypokalemia or hyperkalemia, pH level less than 7.15, Glasgow Coma Scale score less than 12, active cancer, infection, or fracture acquired during seizure. The small number and heterogeneity of the conditions in this subgroup require cautious interpretation. Moreover, data on the preoperative stabilization of these patients were not obtained, leaving questions about the optimal preoperative approach. A post hoc subgroup analysis found that patients with elevated baseline troponin levels (after hip fracture and before surgery) had lower risk for 90-day mortality with accelerated surgery (17 of 174 [9.8%] patients) than with standard care (42 of 175 [24%] patients) (HR, 0.38 [CI, 0.21 to 0.66]). This suggests that these patients may not tolerate the physiologic perturbations related to the hip fracture and thus benefit from earlier surgery. Results from the HIP ATTACK-1 trial introduce a new paradigm in perioperative medicine—that rapid surgical stabilization of the hip fracture may prove to be of more benefit than the evaluation or treatment of acute comorbidities. These data support a broader hypothesis that surgical delays may lead to more harm than good and that early surgery may be beneficial, even in the face of certain acute medical comorbidities. One of the remaining challenges is to discover which medical comorbidities should be definitively evaluated and treated before surgery and how best to stabilize patients with the most severe comorbidities. Additional research is needed to answer these questions. For example, the upcoming HIP ATTACK-2 trial will provide additional answers for patients with concomitant cardiac ischemia. Patients with hip fractures, who also have evidence of an acute myocardial