A 91-year-old man with Alzheimer’s dementia presents with severe right hip pain after a fall at his nursing home. His family reports that he is dependent in most of his activities of daily living (ADLs) and can normally ambulate short distances with a walker. He is alert and oriented at baseline but has been more confused since his wife died a week earlier from pneumonia. His only new medication is lorazepam as needed for anxiety. On admission, the patient is diagnosed with a displaced femoral neck fracture, delirium, and healthcare-associated pneumonia, with a new oxygen requirement of 5 L/min. The orthopedic surgery service requests a medicine consult. How should this patient be managed perioperatively?
Hip fractures are a major health burden on the United States’ geriatric population. The lifetime risk of hip fracture is approximately 17% for Caucasian women and 6% for Caucasian men.1 In 2010, an estimated 258,000 people aged 65 years and older were hospitalized with hip fractures.2 This number is expected to climb to 289,000 by 2030.
In total, hip fractures directly cost the healthcare system about $18 billion per year.1
Hip fractures, like most other geriatric syndromes, are almost invariably multifactorial in etiology. They occur at the intersection of general frailty, bone fragility, and fall risk. Hip fractures too often trigger a further downward spiral in elderly patients, as deconditioning and acute complications compound chronic comorbidities and compromise any remaining physiologic reserve. Mortality after a hip fracture approaches 25% at one year.3 An excess mortality risk persists for at least 10 years.4 Of the patients who survive six months, only 50% can perform their ADLs, and only 25% can perform their instrumental ADLs as well as they could prior to their fracture.5,6
Unsurprisingly, older adults with hip fractures are five times more likely to require nursing home placement at one year.5
Hospitalists frequently encounter patients with hip fractures in the perioperative setting. Given their close collaboration with orthopedic surgeons and emphasis on transitions of care, hospitalists can play an important role in reversing the trajectory of death and disability following hip fractures. Key aspects of inpatient management are outlined below.
Hip Fracture Repair
Hip fractures can be divided into intracapsular (femoral neck) or extracapsular (intratrochanteric or subtrochanteric) fractures. Their relative frequencies are listed in Table 1.7
Surgery types. Femoral neck fractures typically are the most difficult to heal, given a limited regional blood supply.5,7 Displaced femoral neck fractures require either a hemiarthroplasty or total hip arthroplasty. Over time, hemiarthroplasties tend to cause hip pain from acetabular erosion, so they are better suited for less active, elderly patients. Nondisplaced femoral neck, intratrochanteric, and subtrochanteric fractures are usually managed with open reduction and internal fixation.
The overall goal of surgery is to return patients to their prior level of functioning. In the short term, surgery also provides pain relief and allows for early mobilization. Nonoperative management is generally reserved for patients with very high operative risk or limited life expectancies or those who are bedridden at baseline.
Timing of surgery. In general, hip fracture repair should be performed within 24-48 hours of admission in patients who are medically stable. Though early surgery may not improve functional outcomes or mortality, it has been associated with improved pain control, decreased length of stay, and fewer major complications.8 Patients with active medical conditions (e.g. pneumonia) should be medically optimized before proceeding with surgery. A 2011 study found that most of the excess in-hospital mortality associated with surgical delays beyond five days was attributable to the active medical issues rather than to the delay itself.9
Prevention of Perioperative Complications
The principles of geriatric medicine should be applied to the care of elderly patients with hip fractures. Emphasis should be placed on early recognition of treatable conditions and avoidance of iatrogenesis. Careful assessment of medical problems, social support, and functional status within an interdisciplinary framework is recommended. Such a multi-faceted approach has been shown to reduce overall complications in hip fracture patients.10 Specific complications are discussed in more detail below.
Delirium. Delirium is the most common complication after hip fracture surgery, with a prevalence of 35%-65%.7 Proper pain control, minimization of polypharmacy, removal of tethers, and frequent reorientation are among the many preventive measures that should be implemented.
Venous thromboembolism (VTE). VTE is a leading cause of morbidity and mortality for hip fracture patients.11 Without prophylaxis, about 1.8% will develop symptomatic deep venous thromboses, and 1% will develop symptomatic pulmonary emboli in the first seven to 14 days after surgery. An estimated 4.3% will develop symptomatic VTE in the first 35 days after surgery.
The American College of Chest Physicians recommends that patients undergoing hip fracture surgery receive VTE prophylaxis for a minimum of 10-14 days postoperatively.11 Extending prophylaxis out to 35 days is reasonable. Low molecular-weight heparin is preferred over low-dose unfractionated heparin, fondaparinux, warfarin, and aspirin. Patients should receive preoperative VTE prophylaxis if surgery is delayed.
Postoperative infections. Urinary tract infections (UTIs) are the most common infectious complication after hip fracture surgery.7 If not caught early, they can result in urosepsis, prosthetic joint infections, and death. After the first 48 hours of urinary catheterization, the risk of a UTI is 5%-10% per day.12
Therefore, catheters should be removed within 24-48 hours of surgery.
Acute blood loss anemia. Anemia is common in hip fracture patients. It may be present on admission or develop as a result of intraoperative blood loss, ongoing drain output, or fluid resuscitation.
The recent FOCUS trial, which helped to clarify the optimal transfusion threshold for patients after hip fracture surgery, compared a liberal versus restrictive transfusion strategy in patients with cardiovascular disease.13 Transfusing for a hemoglobin < 10 g/dL, as opposed to transfusing for symptoms or a hemoglobin < 8 g/dL, did not improve mortality, in-hospital morbidity (including myocardial infarction), or functional status at 60 days.
Pressure ulcers. Patients with hip fractures are at risk of developing decubitus ulcers. One study found the incidence of new pressure ulcers to be 16% at seven days and 36% at 32 days after initial hospitalization.14 Multicomponent interventions have been shown to successfully reduce the rate of hospital-acquired pressure ulcers.15
Medical Management of Osteoporosis
The World Heath Organization defines osteoporosis as a bone mineral density of at least 2.5 standard deviations below that of a “normal” young adult as measured on DEXA scan, or a T-score ≤ -2.5.16 However, it is important to recognize that bone strength depends not only on the quantity of bone but also on the quality. Any patient who sustains a hip fracture with minimal trauma (e.g. a fall from standing height) should be considered to have osteoporosis, regardless of T-score.
Patients with their first hip fracture are 2.5 times more likely to have a future fragility fracture.17 Hospitalists must therefore make secondary prevention a priority. Medical management focuses on maintaining bone strength, slowing further bone loss, and preventing future falls.
Evaluation. A directed history and physical examination should be completed to screen for secondary causes of osteoporosis. A basic laboratory workup is reasonable in the inpatient setting (see Table 2).17 Other tests, such as a serum and urine protein electrophoresis, can be obtained as clinically indicated.
Patients require counseling directed at lifestyle factors, including the importance of weight-bearing exercise, smoking cessation, and avoidance of excessive alcohol intake. A comprehensive falls assessment is also warranted.
Treatment. All patients with hip fractures should be discharged from the hospital on calcium and vitamin D supplementation, unless there is a specific contraindication.18 Guidelines vary by organization, but the National Osteoporosis Foundation’s recommendations are listed in Table 3.17,19,20 Dietary calcium is usually insufficient to meet the daily requirement.
Bisphosphonates are considered first-line therapy for osteoporosis.17 The HORIZON trial was a randomized, placebo-controlled study that evaluated annual zoledronic acid infusions in hip fracture patients who were intolerant of oral bisphosphonates.21 Zoledronic acid reduced the rate of new fractures by 35% after 1.9 years, with a number needed to treat (NNT) of 19. It also improved survival by 28%, for an NNT of 27. All subjects also received calcium and vitamin D supplementation.
Both hospitalists and orthopedists might worry about bisphosphonates adversely affecting bone healing in the acute setting. Subsequent analyses from the HORIZON trial suggest that bisphosphonates can be safely started as soon as two weeks after surgery.22,23
Transitions of care. Despite well-established guidelines for the treatment of osteoporosis, patients with hip fractures often are undertreated. A retrospective study of 420 acute hip fracture patients found that only 37% received calcium, 36% received vitamin D, and 31% received a bisphosphonate on discharge.24 A prospective study of 1,075 women with new osteoporotic fractures found that only 17% had started anti-osteoporosis medications at one year.25
Hospitalists should recognize and address potential barriers to appropriate medical therapy. Patient-related obstacles may include the cost of medications, concerns about side effects, and lack of a PCP.24,25 Hospitalists should document the diagnosis of osteoporosis in the medical record so subsequent providers are attuned to the issue.26 They should also clarify the ownership of osteoporosis across the continuum of care, because medicine consultants, orthopedists, primary care or rehabilitation physicians, and subspecialists may all be involved. Hospitalists can certainly take advantage of this window of opportunity by starting patients on osteoporosis treatment and ensuring smooth transitions of care on discharge.
Back to the Case
The patient was started on intravenous antibiotics for healthcare-associated pneumonia with improvement of his oxygen requirement to 3 L/min. He underwent a right hemiarthroplasty on hospital day five and tolerated the procedure well. His delirium resolved with treatment of his infection, pain control, discontinuation of lorazepam, and other conservative measures. He was given VTE prophylaxis pre- and postoperatively. His urinary catheter was discontinued on day one after surgery. He was started on calcium supplementation and vitamin D repletion after his 25-OH vitamin D level returned low at 14 ng/mL.
The patient progressed well with physical and occupational therapy and was discharged back to his skilled nursing facility, with plans to start a bisphosphonate in two weeks.
Hospitalists should be familiar with the best practices for the perioperative management of hip fracture patients.
Dr. Anderson and Dr. Wolfe are hospitalists at the University of Colorado Hospital in Aurora. Dr. Anderson directs the medicine consult service, and Dr. Wolfe serves as the associate director.
- The Joint Commission. Improving and measuring osteoporosis treatment 2008. Oakbrook Terrace, Il; 2008. Available at: http://www.jointcommission.org/improving_and_measuring_osteoporosis_management/. Accessed September 29, 2013.
- Stevens JA, Rudd RA. The impact of decreasing U.S. hip fracture rates on future hip fracture estimates. Osteoporos Int. 2013;24(10):2725-2728.
- Braithwaite RS, Col NF, Wong JB. Estimating hip fracture morbidity, mortality, and costs. J Am Geriatr Soc. 2003;51(3):364-370. Haentjens P, Magaziner J, Colón-Emeric CS, et al.
- Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med. 2010;152(6):380-390.
- Hung WW, Egol KA, Zuckerman JD, Siu AL. Hip fracture management: tailoring care for the older patient. JAMA. 2012;307(20):2185-2194.
- Magaziner J, Simonsick EM, Kashner TM, Hebel JR, Kenzora JE. Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol. 1990;45(3):M101-107.
- Bateman L, Vuppala S, Porada P, et al. Medical management in the acute hip fracture patient: a comprehensive review for the internist. Ochsner J. 2012;12(2):101-110.
- Orosz GM, Magaziner J, Hannan EL, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004;291(14):1738-1743.
- Vidán MT, Sánchez E, Gracia Y, Marañón E, Vaquero J, Serra JA. Causes and effects of surgical delay in patients with hip fracture: a cohort study. Ann Intern Med. 2011;155(4):226-233.
- Vidán M, Serra JA, Moreno C, Riquelme G, Ortiz J. Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc. 2005;53(9):1476-1482.
- Falck-Ytter Y, Francis CW, Johanson NA, et al. Prevention of VTE in orthopedic surgery patients: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines. Chest. 2012;141(2 Suppl):e278S-e325S.
- Wald H, Epstein A, Kramer A. Extended use of indwelling urinary catheters in postoperative hip fracture patients. Med Care. 2005;43(10):1009-1017.
- Carson JL, Terrin ML, Noveck H, et al. Liberal or restrictive transfusion in high-risk patients after hip surgery. N Engl J Med. 2011;365(26):2453-2462.
- Baumgarten M, Margolis DJ, Orwig DL, et al. Pressure ulcers in elderly patients with hip fracture across the continuum of care. J Am Geriatr Soc. 2009;57(5):863-870.
- Sullivan N, Schoelles KM. Preventing in-facility pressure ulcers as a patient safety strategy: a systematic review. Ann Intern Med. 2013;158(5 Pt 2):410-416.
- World Health Organization. Prevention and management of osteoporosis: Report of a WHO scientific group 2000. Geneva, Switzerland; 2000. WHO technical report series; 921. Available at: http://whqlibdoc.who.int/trs/who_trs_921.pdf. Accessed July 9, 2013.
- National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis 2013. Washington, D.C.; 2013. Available at: www.nof.org/files/nof/public/content/file/917/upload/481.pdf. Accessed September 29, 2013.
- Tang BM, Eslick GD, Nowson C, Smith C, Bensoussan A. Use of calcium or calcium in combination with vitamin D supplementation to prevent fractures and bone loss in people aged 50 years and older: a meta-analysis. Lancet. 2007;370(9588):657-666.
- Holick MF, Binkley NC, Bischoff-Ferrari HA, et al. Evaluation, treatment, and prevention of vitamin D deficiency: an Endocrine Society clinical practice guideline. J Clin Endocrinol Metab. 2011;96(7):1911-1930.
- Ross AC, Taylor CL, Yaktine AL, Del Valle HB, eds. Dietary reference intakes for calcium and vitamin D. Washington, D.C.: National Academies Press; 2011. Lyles KW, Colón-Emeric CS, Magaziner JS, et al.
- Zoledronic acid in reducing clinical fracture and mortality after hip fracture. N Engl J Med. 2007;357: nihpa40967.
- Colón-Emeric CS, Nordsletten L, Olson S, et al. Association between timing of zoledronic acid infusion and hip fracture healing. Osteoporos Int. 2011;22(8):2329-2336.
- Eriksen EF, Lyles KW, Colón-Emeric CS, et al. Antifracture efficacy and reduction of mortality in relation to timing of the first dose of zoledronic acid after hip fracture. J Bone Miner Res. 2009;24(7):1308-1313.
- Byszewski A, Lemay G, Molnar F, Azad N, McMartin SE. Closing the osteoporosis care gap in hip fracture patients: an opportunity to decrease recurrent fractures and hospital admissions. J Osteoporos. 2011;2011:404969.
- Greenspan SL, Wyman, A, Hoovan FH, et al. Predictors of treatment with osteoporosis medications after recent fragility fractures in a multinational cohort of postmenopausal women. J Am Geriatr Soc. 2012;60(3):455-461.
- Kamel HK, Hussain MS, Tariq S, Perry HM, Morley JE. Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med. 2000;109(4):326-328.