Outcomes/Effectiveness Research

Studies examine factors influencing postoperative complications and functioning among patients undergoing hip fracture repair

Older patients hospitalized for hip fracture repair surgery can suffer numerous postoperative complications, but they also must become mobile as soon as possible after surgery to improve their functioning. Two studies supported by the Agency for Healthcare Research and Quality examined these issues. The first study (HS09459) found that one-fifth of hip fracture patients are admitted to the hospital with a major clinical abnormality that can dramatically increase their risk for postoperative complications if not corrected prior to surgery. The second study (HS09459 and HS09973) revealed that delay in getting older hip fracture patients out of bed after surgery is associated with poor functioning and survival. Both studies are discussed here.

McLaughlin, M.A., Orosz, G.M., Magaziner, J., and others (2006, March). "Preoperative status and risk of complications in patients with hip fracture." Journal of General Internal Medicine 21, pp. 219-225.

Researchers found that one-fifth of patients with hip fractures are admitted to the hospital with a major clinical abnormality, such as serious electrolyte disturbances, heart failure, or respiratory failure. The presence of more than one major abnormality before surgery increased the risk of postoperative complications nearly tenfold. The presence of major abnormalities on hospital admission that were not corrected or stabilized prior to surgery increased the risk of postoperative complications nearly threefold. Minor abnormalities (for example, mildly abnormal electrolyte, blood pressure, or glucose levels, or mild anemia), while warranting correction, did not increase the risk of postoperative complications.

Most minor abnormalities among patients were corrected before surgery, but 15 percent of patients with major clinical abnormalities underwent hip surgery without correction of the abnormalities. Although the prolonged immobility associated with delaying surgery can create its own problems, major abnormalities should be corrected or stabilized prior to hip fracture repair surgery. However, the researchers suggest that patients with minor abnormalities could have surgery with attention to these medical problems afterwards.

The researchers correlated 11 categories of physical and laboratory findings (presurgical risk factors) classified as mild and severe abnormalities with in-hospital complications among 554 adults (mean age of 83 years) who underwent hip repair surgery at 4 hospitals. Having a minor abnormality on admission (34.3 percent) was more common than having a major abnormality (22.6 percent).

Seven percent of patients suffered complications. The most frequent type of postoperative complication was cardiopulmonary (5.8 percent of the complications) followed by thromboembolic (1.8 percent), infection (1.6 percent), miscellaneous (1.2 percent), and hematologic (0.4 percent).

Siu, A.L., Penrod, J.D., Boockvar, K.S., and others (2006, April). "Early ambulation after hip fracture: Effects on function and mortality." Archives of Internal Medicine 166, pp. 766-771.

Older patients with hip fractures are immobilized an average of 5.2 days during their hospital stay for hip repair surgery. Longer immobility is associated with higher mortality at 6 months and poorer function at 2 months, according to this study. Patients who were immobile for 8 days had 5.4 percent lower 6-month mortality and 1 point higher FIM (Functional Independence Measure) locomotion score than those who were immobile for 2 days. This 1-point FIM difference is the difference between needing minimal personal assistance or just needing personal supervision with no assistance in walking 150 feet or transferring, for example, from a bed to a chair. It can make the difference between being able to go home or not, depending on the availability of an able-bodied caregiver to provide the needed assistance, explain the authors of the study.

Patients who were immobile the least amount of time reported less pain (5.9 percent compared with 40 percent who reported having more than 3 days of moderate or severe pain), were less likely to receive general anesthesia (22.6 vs. 51 percent), and were less likely to have had postoperative transfusions (37.7 vs. 72 percent) or prolonged urinary catheterization (9.4 vs. 54.9 percent). However, functional differences related to time spent immobile abated by 6 months as patients recovered function. Immobility had the most severe impact on patients who already needed help with walking when they were admitted to the hospital (usually older patients with more coexisting medical conditions).

These findings indicate that immobility should be minimized in patients undergoing repair of hip fracture. This can be achieved, in part, by early surgery for patients with stable medical problems and timely efforts to stabilize other patients for surgery, suggest the researchers. They also recommend improved pain management, local instead of general anesthesia when possible, early removal of indwelling catheters, and minimizing the immobilizing effects of postoperative transfusions (for example, by use of heparin locks). These findings were based on analysis of functioning and survival of 532 patients 50 years and older 6 months after hip repair surgery at 4 New York hospitals.

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