The Medical Consultant's Role in Caring for Patients with Hip Fracture

Hip fractures are an important cause of death and functional dependence. Approximately 250 000 hip fractures occur annually in the United States, and this number is expected to increase several fold in the coming decades [1]. The mortality rate for persons in the U.S. Medicare population who sustain a hip fracture is 7% at 1 month, 13% at 3 months, and 24% at 12 months [2]. For patients who survive to 6 months, 60% recover their prefracture walking ability, half recover their prefracture ability to perform activities of daily living, and about 25% recover their prefracture ability to perform instrumental activities of daily living [3]. However, after 1 year, only 54% of surviving patients can walk unaided and only 40% can perform independently all physical activities of daily living [3]. Although surgical repair of the fractured extremity is the cornerstone of therapy, available data suggest that the factors crucial to optimal functional recovery in hip fracture are independent of fracture repair and are instead related to prefracture conditions and postfracture complications [4]. Thus, successful care and outcome of patients with hip fracture require an active partnership between the orthopedic surgeon and others, including the medical consultant. The medical consultant's role includes medical evaluation and stabilization of the patient before surgery, prevention and management of postoperative complications (such as delirium), and follow-up after increasingly shorter hospital visits. Despite the involvement of medical consultants in the care of most patients with hip fracture (in one large series of patients with hip fracture, 81% had a presurgical medical consultation [Magaziner J. Personal communication]), many internists have no formal training in this condition and may be unfamiliar with the optimal management of its complications. We review the clinical evidence to support decisions that internists are often asked to make for patients with hip fracture, develop evidence-based recommendations, and identify areas requiring further research. Medical decisions include decisions about timing of surgery, infection prophylaxis, thromboembolic prophylaxis, postoperative nutritional management, urinary tract management, prevention and management of delirium, application and timing of rehabilitation services, and prevention of subsequent falls. We excluded preoperative risk assessment and fracture prevention because extensive literature on these subjects already exists. We also excluded topics not usually under the purview of the medical consultant, such as choice of anesthesia and type of surgical repair. Methods We did a systematic review of processes related to the medical care of patients with hip fracture, concentrating on processes that could lead to improved functional outcome (Table 1). We searched the MEDLINE database, using the MeSH terms femoral fractures, hip fractures, or femoral neck fractures and the keywords or text words given in Table 1, for English-language articles published from January 1966 through June 1997. If no studies were identified, we repeated the search with only the keywords or text words. Articles were reviewed to determine their relevance to patients with hip fracture (for example, elderly persons or patients undergoing lower-extremity orthopedic procedures, such as total hip arthroplasty). To identify additional studies, we searched the reference lists of the selected articles. Within each subject area, we included meta-analyses; randomized, controlled trials; or other controlled studies wherever possible. If no such trials were identified, we included the best available evidence from studies with other designs. Articles were reviewed independently by two of the authors, the evidence was summarized, and recommendations were drafted. If the reviewers disagreed about a recommendation, the underlying assumptions leading to the recommendation were discussed until consensus was reached. Summaries were subsequently reviewed by a panel of content experts in orthopedics, internal medicine, geriatrics, rehabilitation, nursing, and nutrition and were revised on the basis of the panel's recommendations. Final summaries were prepared, and the quality of evidence was rated by using ratings adapted from the U.S. Preventive Services Task Force [5]. Meta-analysis was beyond the scope of this paper given the multiple domains, the heterogeneity of study populations, and the wide variation in quality and design of the studies. Table 1. Key Words and Text Phrases Used in MEDLINE Search Summary of Evidence A summary of the studies and the strength of the evidence is given in Table 2. Table 2. Summary of Evidence Timing of Surgery The timing of surgical repair of hip fracture may affect patient outcomes in two ways. Delay in surgical repair, which causes delay in return to weight bearing, may affect functional recovery. Conversely, failure to stabilize medical problems before surgery may increase risk for perioperative complications. Although the orthopedist schedules surgery, the rate-limiting step in this process is often the internist's preoperative medical evaluation. We identified 9 cohort studies [6, 7, 9, 10, 54-58]; 1 randomized, controlled trial of anesthetic techniques that included surgical delay as an independent variable [8]; and 1 autopsy series [59] that examined the effects of operative timing on post-operative outcome. The results of these 11 studies suggest that early surgical repair (within 24 to 48 hours) is associated with a reduction in 1-year mortality. However, most of the studies either did not control for the presence and severity of comorbid conditions or excluded patients with complicating medical conditions; thus, these data are difficult to interpret. Of the 5 studies that attempted to control for comorbid conditions [6-10], 4 reported lower mortality rates and 1 [6] reported a lower incidence of confusion and pressure ulcers in patients who underwent surgical repair within 48 hours. Evidence from cohort studies indicates that for medically stable patients who do not have active comorbid illness (such as unstable angina), surgical repair of hip fracture within the first 24 to 48 hours of admission is associated with a decrease in 1-year mortality. Patients who would benefit from delay and further medical evaluation have not been well characterized. Prophylactic Antibiotics Prophylactic antimicrobial agents are often administered to prevent postoperative wound infections. We reviewed the literature to identify the benefit of antibiotic use for postoperative infections and to identify the optimal timing of administration and duration of use. Three meta-analyses examined prophylactic antibiotic use in patients with hip fracture [11] (Table 3). The first compared antibiotic use with placebo, the second compared single doses of antibiotics with multiple doses, and the third compared 3 doses of antibiotics with multiple doses. We found no randomized trials that examined the timing of antibiotic administration, but we found one large case series involving patients undergoing elective surgery [12] (Table 3). Table 3. Dose and Timing of Prophylactic Antibiotics Meta-analysis of seven studies [60-66] that compared antibiotic use with placebo showed a 44% risk reduction in postoperative infection for the antibiotic group. Four studies [64, 67-69] compared multiple doses (range, 2 to 10 doses) with a single dose of antibiotics given immediately before surgery. There was a trend toward a reduction in postoperative infection in the multiple-dose group. A third meta-analysis summarized two studies [68, 70] that compared 3 doses of antibiotics with multiple doses. No significant differences were seen in infection rates between the two groups. First- and second-generation cephalosporins were used in most of the studies. The only study that addressed optimal timing of antibiotic administration was a cohort study of 2847 elective procedures [12]. In this study, wound infection rates were lowest when antibiotics were administered 0 to 2 hours before surgery. Considerable evidence from 11 randomized trials [60-70] supports the use of prophylactic antibiotics (first- and second-generation cephalosporins) in patients with hip fracture. Antibiotics seem to reduce the risk for deep-wound infections by approximately 44%, and therapy should probably be continued for 24 hours (that is, about 3 doses should be given). Published data suggest that antibiotics should be administered 0 to 2 hours before surgery. Thromboembolic Prophylaxis Venous thromboembolism is a substantial cause of postoperative morbidity and mortality in patients with hip fracture. Despite a clear rationale for prophylaxis and clinical evidence of efficacy, use of prophylaxis is not universal, largely because of questions about which agent is the safest and most effective [71]. We identified three meta-analyses [13, 14, 23] in which patients with hip fracture were examined and an additional 10 randomized, controlled trials in which prophylactic thromboembolic agents in hip fracture were examined (Table 4). One of the meta-analyses compared low-dose heparin with placebo, one compared low-molecular-weight heparin with placebo or low-dose heparin, and the third compared aspirin with no treatment [23]. We found no data on the duration of prophylaxis. Table 4. Efficacy of Thromboembolic Prophylaxis on Prevention of Deep Venous Thrombosis* The studies reviewed strongly support the use of thromboembolic prophylaxis, but which agent is optimal is less clear. Low-dose heparin has been the agent most frequently studied in hip fracture and was associated with a reduction of about 60% in deep venous thromboses in one meta-analysis [13] (Table 4). Low-molecular-weight heparin has also been evaluated by meta-analysis and was shown to produce a similar reduction in deep venous thrombosis [14] (Table 4). The latter meta-analysis also pooled data