DALLAS — Surgical repair of hip fracture in the elderly is associated with an extremely high risk of postoperative MI or death—a reality not reflected in current American College of Cardiology/American Heart Association preoperative cardiovascular evaluation guidelines, Dr. Jeanne Huddleston said at the annual meeting of the Society of Hospital Medicine.
The ACC/AHA guidelines lump together all orthopedic surgical procedures into a single intermediate-risk category, meaning their combined risk of postoperative MI or death is expected to be less than 5%. While that's true of elective total hip arthroplasty, hip fracture repair is another matter entirely, according to Dr. Huddleston, a hospitalist at the Mayo Clinic, Rochester, Minn., and a former society president.
She presented a population-based retrospective study in 1,197 patients who underwent urgent repair of a fractured hip and 693 who had an elective hip replacement operation at the clinic.
During a mean hospital length of stay of 8.9 days, the incidence rates of postoperative MI, heart failure, and mortality were markedly lower in the elective hip arthroplasty group (see box).
Moreover, the combined 1-year rate of MI and all-cause mortality was 34.2% in patients undergoing hip fracture repair, compared with 7.5% in the arthroplasty group. After statistical adjustment for patient age, gender, and American Society of Anesthesiologists physical status classification, the hip fracture repair patients were 3.6-fold more likely to have an MI or die within a year following surgery.
“We recommend that future updates to the ACC/AHA guidelines for preoperative cardiovascular evaluation for noncardiac surgery establish elderly hip fracture patients as a special subgroup of orthopedic surgeries whose perioperative risk of death or MI is tremendous, and requires special consideration for optimizing pre- and postoperative medical care,” the physician said.
Hip fracture repair is typically done on an urgent basis, but it doesn't fall within the definition of “emergency” surgery described in the guidelines. Thus, physicians can take up to 48 hours postfracture to optimize cardiac status and other aspects of the patient's medical condition prior to surgery—and that's a sound strategy given the high cardiovascular risk associated with the surgery, according to Dr. Huddleston.
Hip surgery is the second most frequently performed type of surgery in patients older than 65, behind only coronary artery bypass graft surgery.
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