An audit of pre-operative delay in Hip Fractures

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An audit of pre-operative delay in Hip Fractures

• Presented by
• Dr Wasim Anwar
• Orthopedic B Unit
• HMC Peshawar

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Hip Fractures

• In USA
• 250.000 hip fractures/year
• 90 in patients gt50ys old
• Mortality related to hip fracture 25 at one
  year
• 80 of patients recover their walking ability,
• Only 70 recover their ability to perform ADLs
  (activities of daily living)

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Hip Fractures

• In the UK
• 70,000 hip fractures annually
• 120,000 cases per year by 2015
• 75 of patients are over 75 years of age
• 80 are female
• Hip fractures account for 20 all orthopedic bed
  occupancy

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Risk Factors

• Age incidence doubles for each decade after
  50ys
• Sex 2-3 times higher in women
• Race 2-3 times higher in white women than in
  nonwhite women
• Habits Excessive alcohol or caffeine

• Physical inactivity
• Low body weight
• Previous hip fracture
• Dementia
• Psychotropic meds
• Visual impairments

• Osteoporosis

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Clinical Assessment

• History
• Hx
• fall in a small percentage it occurs
  spontaneously
• C/o
• pain and inability to move the hip or put
  weight
• Hx other osteoporotic fractures Colle,s
  or vertebral fractures

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Clinical Assessment Physical Exam

• Leg externally rotated
• Shortening
• May show trochanteric ecchymosis
• Inability to lift the extended leg
• ROM is limited and painful
• Distal neurovascular exam
• Check the pelvis
• Move posterior to anterior at the level of iliac
  crests
• Lateral to medial through the iliac crests

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CLINICAL PICTURE

• SYMPTOMS
• History of trauma,
• Pain,
• Swelling,
• Limited movements.

SIGNS
LOCAL Swelling, Ecchymosis,
Tenderness, Limited movements
Deformity, Length discrepancy,
Abnormal movements, Crepitus
EXTERNAL ROTATION INABILITY TO LIFT EXTENDED LEG
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Diagnostic Imaging

• X rays
• AP and lateral.
• Check the neck shaft angle 120-130.
• No results but fracture still suspected AP
  rotated 10-12 - best visualization of femoral
  neck
• CT scan
• MRI
• most sensitive
• if X rays negative but fracture still suspected
• Bone scan

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Hip Fractures

• Femoral neck 45
• Intertrochanteric 45
• Subtrochanteric 10

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Trabecular Pattern
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Arterial supply
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Femoral Neck fracture

• Intracapsular,
• disruption of blood supply to femoral head,
• high incidence of healing complications
  (nonunion, osteonecrosis)
• Extracapsular

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Intertrochanteric fracture

• Intertrochanteric 45
• extracapsular,
• no interference with the blood supply of the
  femoral head,
• less complications
• Malunion

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Subtrochanteric Fracture

• Extacapular
• Higher rate of complications

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Treatment Principles

• Early surgery / 24-48h in patients who are
  medically stable
• May wait up to 72h to stabilize the pt.
• Assess cardiac risk
• Delay in surgery/prolonged bed rest means
• increased risk of DVT, UTI, pulmonary
  complications, skin breakdown,
• delayed functional recovery

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Scottish Intercollegiate Guidelines Network (SIGN)

• Assessment, within 1 hour of arrival in the
  Emergency Department (ED)
• Early diagnosis
• Adequate analgesia before transfer of the patient
  from the ED
• Rapid transfer to the ward - fast tracking
• Minimise the delay to definitive surgery
• A multidisciplinary team approach
• Postoperative care and rehabilitation

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Principles for fixation of NOF Fracture
Physiological Age (yr) Functional Status Treatment
lt65 Community ambulator CRIF
ORIF if necessary
65-75 Community ambulator CRIF
Cemented bipolar arthroplasty (if closed reduction unsuccessful)
gt75 Community ambulator Cemented bipolar arthroplasty
gt75 Minimal household ambulator Cemented unipolar arthroplasty
gt75 Household ambulator extremely ill Percutaneous CRIF ( local anesthesia with sedation)
NA Preexistent arthritis Total hip replacement
NA Nonambulator CRIF or nonoperative if extremely ill
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Treatment Recommendations Based on Russell-Taylor
Classification of Subtrochanteric Fractures

• IA - Standard ILN
• IB- Recon Nail
• IIA- DHS or Recon Nail
• IIB - DHS e BG or Recon Nail

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AO Screws Fixation

• Minimally displaced femoral neck fracture

• Internal fixation with multiple screws

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Cephalomedullary Nail
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Prosthetic replacement
TOTAL ARTHROPLASTY
Femoral neck fracture
HEMIARTHROPLASTY
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Dynamic Hip Screw
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Different types of fixations of Subtrochanteric
fracture
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Rehabilitation

• Goal independent living
• Rehabilitation should begin first day after
  surgery with transfer from bed to chair
• Progress as soon as possible to standing and
  walking (2nd day post op)
• Promote weight bearing with assistance
  walker

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SYSTEMIC COMPLICATIONS

• LONG RECOMBANCY IN BED
• DVT, PE,,,
• MORTALITY

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LOCAL COMPLICATIONS

• Loss of fixation
• Malunion COXA VARA
• Nonunion
• Avascular necrosis of femoral head
• Dislocation of the prosthesis
• Loosening of prosthesis years after surgery

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An audit of pre-operative delay in Hip
Fractures

• Objective
• To Minimize the waiting time of definitive Hip
  surgery and cost

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Materials and Methods

• Prospective audit, Jan 2011 to April 2011
• All Patients admitted to orthopedic B unit HMC
  with hip fracture who underwent surgery
• Patients of Total hip replacement were excluded
  from study

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Data collection procedure

• Data collected from clinical notes
• Admission and operation times
• Pre-op hospital stay, total hospital stay,
  postoperative hospital stay and total cost of
  surgery were calculated
• Date of discharge

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An audit of pre-operative delay in Hip Fractures
Results
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An audit of pre-operative delay in Hip Fractures
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An audit of pre-operative delay in Hip Fractures

• 51 patients
• Male 23 (45.1) Female 28 (54.9)
• Mean age 60.56 yrs (range 7 90yrs)
• In hospital mortality 5.88
• Type of surgical intervention

1
3
2
DHS (48.5)
Hemiarthroplasty (21.5)
AO screws fixation (17.4)
Recon Nail 12.6
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An audit of pre-operative delay in Hip Fractures
P-Value 0.0000
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An audit of pre-operative delay in Hip Fractures
P-value 0.000
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An audit of pre-operative delay in Hip Fractures

• Total in hospital mortality 5.88
• Patients who had surgery within 2-5 days had
  lower in-hospital mortality of 4.1 compared to
  those who waited for surgery gt6 days had in
  hospital mortality 7.4 (p value .001)

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An audit of pre-operative delay in Hip Fractures

• Medical conditions delaying surgery increase
  Morbidity and mortality
• Non-medical delay causes
• Distress to the patient
• Increased morbidity and mortality
• Reduced chance of successful fixation and
  rehabilitation
• Reduced functional recovery
• Increased risk of DVT and PE
• Prolonged hospital stay
• Increased surgical cost

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Does delay in surgery after hip fracture lead to
worse outcomes? A multicenter surveyVictor
Novack,Alan Jotkowitz,Ohad Etzion and Avi Porath

• Objective To estimate the impact of delays in
  surgery for hip fracture on short- and long-term
  outcomes.
• Setting Seven major tertiary hospitals.
• Study population- 4633 patients, older than 65
  years admitted with hip fracture during the years
  20012005.
• Patients who had surgery within 2 days had lower
  mortality (in-hospital, 1-month and 1-year)
  compared to those who waited for surgery gt4 days
  (2.9, 4.0, 17.4 vs. 4.6, 6.1, 26.2,
  respectively).

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Early Mortality After Hip Fracture Is Delay
Before Surgery Important? Department of Trauma
and Orthopaedics, University Hospital Nottingham,

• A prospective, observational study of 2660
  patients
• The mortality was 9 at 30 days, 19 at 90 days,
  and 30 at 1 year.
• Those operated on without delay had a 30-day
  mortality of 8.7 whom the surgery had been
  delayed b/w 1 4 days had a 30-day mortality of
  7.3. (p 0.51).
• The 30-day mortality for patients for whom the
  surgery had been delayed for more than four days
  was 10.7, and this small group had significantly
  increased mortality at 90 days (hazard ratio
  2.25 p 0.001) and one year (hazard ratio
  2.4 p 0.001).

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Conclusions

• A significant proportion (approx 52) of
  patients wait longer than 6 days before surgery
• In hospital mortality was 5.88
• Commonest reason for delay was lack of theatre
  time
• In our study, evidence suggests that delaying
  surgery increases length of hospital stay and
  cost of surgery
• Delay in surgery causes distress to the patient
  and impact on functional outcome

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Limitations Of Study

• Small sample size
• Fitter patients
• Lack of data on morbidity mortality
• No long term followup

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Suggestions and Recommendations

• Operate within 24 hours of admission
• Increase theater time days
• Provision of dedicated trauma list in the evening
• Increase technical and clinical resources
• Close attention to pre-op medical care to avoid
  delay in surgery
• More research needed to determine optimum
  management e.g. National Hip Fracture database

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• Thank you