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Delays in Surgery for Hip Fracture Cause Problems

Posted on: 10/15/2009
For older adults with osteoporosis (brittle bones), it's not bad enough when there's a hip fracture that needs repair. But added complications from poor health, from being in the hospital, and from the surgery can be deadly. Pneumonia, heart failure, infections, and pressure ulcers (bed sores) head the list of problems that some seniors face when a hip fracture occurs. And according to this report from the Washington University School of Medicine, a delay in surgery increases the risk of complications even in healthy patients.

When it comes to osteoporosis-related fractures, surgeons and other health care professionals are trying to prepare for what's ahead. With over 100 million seniors by the year 2025 (that's only 15 years away), the number of fractures is expected to rise from two million every year now to over four million then. And that translates into billions of dollars in health care costs.

What can be done to reduce the number and severity of complications related to surgery for hip fracture? That's the focus of this article. First, it's clear from other studies that a delay in surgery can make things worse. Even a 24-hour delay increases the risk of death. The longer the delay, the greater the risk of pressure ulcers.

What's causing the delays? One of the significant factors contributing to delays in surgery is the insistence on cardiac testing before surgery. In an effort to prevent heart attacks and other cardiac complications, this practice is actually increasing the risk of such problems. Treating the heart conditions before having surgery seems like it makes good sense. But, in fact, studies show that testing doesn't really change how these patients are treated -- it just delays the surgery they were admitted for in the first place. And now we know those delays can be deadly.

A second, important risk factor for poor outcome after surgery for hip fracture is malnutrition. Decreased bone mass is often linked with poor nutrition. And with an inadequate diet comes weight loss and no fat to protect the bones when a fall occurs. Not only that, but malnutrition also leads to poor wound healing and an increased risk of those pressure ulcers already mentioned.

What can be done when the patient comes in to the hospital with osteoporosis and a hip fracture? Isn't it already too late to make a difference? Evidently not, according to several studies that showed using intravenous nutritional supplementation followed by vitamins taken by mouth can really make a difference. Nutritional consultation with a specialist is also advised. A nutritional expert can help with the immediate concerns about malnutrition as a risk factor for complications but also set up a plan for home once the patient is discharged. This step is essential in preventing future health problems of all kinds.

Another important risk factor for complications associated with hip fracture surgery is low hemoglobin. Hemoglobin helps carry the oxygen you need in every cell of the body. Without enough hemoglobin, anemia develops. This particular risk factor has many causes to watch out for. Besides the obvious loss of blood from the surgery, there can be internal bleeding from the GI tract.

Many older adults have bleeding ulcers from taking antiinflammatory drugs for their arthritis. Smoking adds to the risk of GI bleeding. One-third of all patients having hip fracture surgery end up needing a blood transfusion. What can be done to prevent bleeding problems? The research supports using a drug called proton pump inhibitor (PPI) right after surgery for anyone with risk factors for GI bleeding. Surgeons are also advised to do everything possible to avoid/reduce bleeding during the operation. This is possible now more than ever before with today's minimally invasive surgical techniques.

There are other measures that can be taken to decrease postoperative problems after hip fracture repair. These include protective padding over bony prominences to prevent pressure ulcers, antibiotics to prevent infections, and proper pain management to prevent stress-induced heart problems. Preventing blood clots through the use of medications, compression stockings, and pneumatic pumps applied to the lower legs for at least the first 24 hours is standard practice.

Research is underway to find other ways to reduce surgical risks through the use of better anesthesia and improved methods of fracture fixation (brittle bones are difficult to hold together). But the danger isn't over once the patient leaves the hospital. Now they face a 2.5-fold risk of another fracture. That's why it's important to carry through with a postoperative program to address the problem of the osteoporosis through medications and exercise. The authors suggest developing specialized osteoporosis clinics where patients can receive proper education about this condition. Every effort should be made to reduce risk factors for both osteoporosis and for falls.

Philipp N. Streubel, MD, et al. Fragility Fractures: Preoperative, Perioperative and Postoperative Management. In Current Orthopedic Practice. September/October 2009. Vol. 20. No. 5. Pp. 482-489.

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