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Reducing Complications After Surgery for Hip Fractures

Surgeons are faced with many decisions when approaching surgery for patients with a hip fracture. Is the patient in good health? If so, then there's a green light for going ahead with the procedure. Does he or she have a heart health history? If that's the case, the patient needs cardiac testing before going into surgery. Studies show that patients with pre-existing heart problems have an increased risk of heart attack and even death after hip surgery for a hip fracture.

But there's a new twist on that policy of obtaining medical clearance before surgery. Studies now show that taking the extra precaution to conduct a cardiac evaluation doesn't change the outcome and may even increase the risk of postoperative complications. Delays in surgery come with risks of their own. For every day that goes by without surgery, the risk of infections, pressure sores, and other serious complications of surgery goes up.

But surgeons certainly don't want to lose their at-risk patients to a heart attack. They are caught between a rock and a hard place as the saying goes. What should they do? Testing takes time and delays surgery but alerts the surgical team of the risk of possible life-threatening cardiac events. Not testing and proceeding full speed ahead gets the surgery done as soon as possible with fewer overall complications.

The results of two new studies suggest that a simple preoperative blood test might be the answer. Measuring blood levels of a biomarker called troponin may alert the surgeon of an increased risk of complications. Those complications mean added days in the hospital for the patient and even possible death. Troponin is a complex regulatory protein that helps produce muscle (heart) contraction. Elevated troponin levels in the blood can signal when a person has had a heart attack.

In fact, there's some evidence that many patients fall and break their hips because they were having a silent heart attack. This new information might help put to rest the age old question of which came first: the fall or the fracture? Patients with high levels of troponin are the ones who should be held back for cardiac stress testing before having surgery. Anyone with normal troponin levels can proceed ahead with the operation.

There's another significant problem surgeons must consider with this age group (usually over age 65). And that's anticoagulation therapy. Many older adults have been on these blood thinners for months to years before breaking the hip. But there's a risk of bleeding while on these medications. Surgery is not usually recommended until the patient stops taking the drug for at least three to five days. Once again, such a policy delays surgery, which then increases the risk of postoperative problems. There's no quick and easy answer to this dilemma. More studies are needed to help develop some safe standards in this area.

Taking a look at some of the other large, long-term studies of death rates after hip fracture surgery, it looks like older men (again, 65 years old or older) die more often in that first year after hip fracture surgery than anyone else. Patients dependent on a walker to get around before surgery are also more likely to die after surgery than those who can walk independently before they fracture their hip.

Osteoporosis is a major risk factor in this population, too. Anyone with osteoporosis has a much higher risk of a second fracture six to 12 months after the first fracture. Surprisingly, many patients admitted to the hospital for hip fracture surgery aren't even tested for osteoporosis. Or if they do test positive (low bone density), appropriate treatment isn't prescribed when they are discharged.

More and more evidence points to the need for osteoporosis prevention, diagnosis, and treatment. The use of calcium, vitamin D, anti-osteoporotic drugs and specific bone building exercises form a simple recipe for treatment. It has been suggested that having an osteoporosis case manager might be one way to begin turning around the problem of undertreating osteoporosis. There is plenty of data to suggest that the added cost of a osteoporosis case manager is far less than what could be saved by preventing even half a dozen osteoporosis-linked bone fractures.

Surgeons can't predict and prevent every problem faced by hip fracture patients in need of surgery to repair the problem. But by taking a few simple steps, patients can expect fewer problems and a better chance of going home and continuing to live independently. Those steps include testing preoperatively for troponin levels, reducing and eliminating as many surgical delays as possible, and assigning an osteoporosis case manager to every patient over the age of 50 (and especially those who are 65 and older) with a hip fracture.

References: Erik Severson, MD, et al. Hip Fractures in the Elderly: Timing When to Get On and Off the Operating Table. In Current Orthopaedic Practice. September/October 2009. Vol. 20. No. 5. Pp. 490-493.

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