Original Research

Operative Intervention for Geriatric Hip Fracture: Does Type of Surgery Affect Hospital Length of Stay?

Am J Orthop. 2015 May;44(5):228-232

References

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Results

Our search identified 720 patients who were over age 60 years and underwent operative fixation for hip fracture at our level I trauma center between 2000 and 2009. Of these 720 patients, 105 who had incomplete charts or did not meet the age criteria were excluded, leaving 615 patients (with complete records of isolated low-energy hip fractures) for analysis.

Table 1 lists the demographics of our patient population. The majority of patients had undergone ORIF (30.24%) or HA/THA (45.69%). CRPP was the least common procedure (9.92%) after CMN (14.15%). Mean age was 78.4 years; the majority of patients were between 75 and 89 years of age. Mean hospital LOS was 6.91 days. The majority of patients (n = 414; 67.32%) were female. ASA scores had a narrow distribution, with most patients assigned a score of 3. The readmission rate was significantly higher for HA/THA (39.1%) than for ORIF (28.5%; P = .02) and CRPP (24.6%; P = .04).

Table 2 lists mean LOS and associated costs for each procedure compared with HA/THA. Mean LOS for all patients was 6.91 days, with associated hospitalization costs of $30,011.25. Patients who underwent HA/THA had the longest mean LOS (7.43 days) and highest mean hospitalization costs ($33,657.90). In comparison, patients who underwent ORIF had a mean LOS of 6.59 days with $29,852.70 in costs (P = .04). CRPP also had a significantly (P < .003) shorter LOS (5.59 days) and lower costs ($25,322.70). Although CMN had a mean LOS of 6.89 days and $31,211.70 in costs, the difference in LOS was not significantly different from that of HA/THA. The proportion of surgeries that were HA/THA, CMN, ORIF, and CRPP did not change significantly through the 9-year period (P = .19). Similarly, mean LOS did not change significantly for any of the types of surgery through this period (Table 3).

Figure 1 provides the distribution of LOS for all 4 procedures. The interquartile range (IQR) for patients who underwent HA/THA was 4 to 9 days (median, 6 days). Patients who underwent CMN also had a median LOS of 6 days and an IQR of 4 to 8 days. Both ORIF (IQR, 4-8 days) and CRPP (IQR, 3-6 days) were associated with a median LOS of 5 days.

Figure 2 shows mean hospitalization costs based on type of procedure. HA/THA had the highest mean cost, $33,657.90, or $8335.20 more than CRPP ($25,322.70). Patients who underwent CMN had a mean cost of $31,211.70, versus $29,852.70 for patients who underwent ORIF.

Table 4 summarizes the multivariate analysis results. After ASA score, sex, age, and comorbidities were controlled for, there was an overall significant relationship involving surgical treatment, LOS, and associated hospitalization costs for HA/THA, ORIF, and CRPP. Compared with HA/THA, ORIF had $3805.20 less in costs (P = .042) and 0.84 fewer hospital days. Patients who underwent CRPP were hospitalized for significantly fewer days (1.63) and associated costs ($7383.90) (P = .0076). There was no significant difference in LOS and costs between HA/THA and CMN. Of the controlled variables, only ASA score (P < .001) and male sex (P = .001) were significantly associated with changes in LOS and costs. There was no significant association with comorbidities, LOS, or costs.

Discussion

In this study of surgical intervention in patients with hip fractures, we determined that HA/THA was associated with significantly increased hospital LOS and costs than ORIF and CRPP. Although arthroplasty had an increased mean LOS compared with CMN, the difference was not statistically significant. In addition to type of procedure, both male sex (P = .001) and preoperative ASA score (P < .001) were significant predictors of LOS and costs. These findings are supported by other studies in which preoperative functioning was found to be a strong predictor of increased LOS and costs among hip fracture patients,¹⁸ most likely because of increased risk for complications.¹⁹

Although our study was the first to directly compare LOS and costs for HA/THA and CMN, other investigators have analyzed the effect of surgical complications on LOS for patients treated with THA, HA, and CMN. In a study on the effects of surgical complications on LOS after hip fracture surgery, Foss and colleagues¹⁷ reported that the proportion of CMN patients (31%) with complications was larger than that of HA patients (19%) and THA patients (0%). They also reported that surgical complications were associated with significantly increased LOS during primary admission. Similarly, Edwards and colleagues²⁰ found that the infection risk was higher with CMN (3.1%) than with THA (0%) and HA (0%-2.3%) and that infections were associated with increased LOS (P > .001). However, further statistical analysis revealed that the odds of developing an infection were not significantly higher with CMN than with other studies.²⁰ Similarly, other studies have reported low rates of complications, including nonunion, with CMN.^21,22 In our study, we found no significant difference in LOS and costs for CMN and HA/THA after controlling for ASA score, which is known to be associated with a higher risk for complications.^18,19