0
Scientific Articles   |    
Use of Medical Comorbidities to Predict Complications After Hip Fracture Surgery in the Elderly
Derek J. Donegan, MD1; A. Nicolas Gay, MD1; Keith Baldwin, MD, MSPT, MPH1; Edwin E. Morales, MD1; John L. Esterhai, Jr., MD1; Samir Mehta, MD1
1 Department of Orthopaedic Surgery, Hospital of the University of Pennsylvania, 2 Silverstein, 3400 Spruce Street, Philadelphia, PA 19104. E-mail address for S. Mehta: samir.mehta@uphs.upenn.edu
View Disclosures and Other Information
Disclosure: The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

Investigation performed at the Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

Copyright ©2010 American Society for Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2010 Apr 01;92(4):807-813. doi: 10.2106/JBJS.I.00571
5 Recommendations (Recommend) | 3 Comments | Saved by 3 Users Save Case

Abstract

Background: 

Comorbidities before and complications following hip fracture surgery can impact the return of function. We hypothesized that the American Society of Anesthesiologists (ASA) classification of medical comorbidities is a useful surrogate variable for the patient's general medical condition and would be a strong predictor of perioperative medical complications following hip fracture surgery.

Methods: 

A retrospective review of the cases of 197 elderly patients who had undergone operative management of a hip fracture was performed. The ASA class, data regarding perioperative medical and surgical complications, and demographic data were obtained. Medical complications were defined as those requiring intervention by an internist or medical specialist. Differences in complication rates among the ASA classes were determined.

Results: 

Medical complications were more common in patients in ASA class 3 (p < 0.001) and those in class 4 (p = 0.001) than in those in class 2. Patients in ASA class 3 had a 3.78 times greater chance of having a medical complication than did those in class 2 (p < 0.001). Patients in ASA class 4 had a 7.39 times greater chance of having medical complications than did those in class 2 (p = 0.001). No significant relationship was identified between the ASA class and surgical complications.

Conclusions: 

The ASA class is strongly associated with medical problems in the perioperative period following hip fracture surgery in the elderly. Patients identified as being at higher risk (in ASA class 3 or 4) preoperatively should be closely managed medically so that perioperative medical complications can be managed and evolving medical issues can be addressed in a timely fashion.

Level of Evidence: 

Prognostic Level II. See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article
    Sign In to Your Personal ProfileSign In To Access Full Content
    Not a Subscriber?
    Get online access for 30 days for $35
    New to JBJS?
    Sign up for a full subscription to both the print and online editions
    Register for a FREE limited account to get full access to all CME activities, to comment on public articles, or to sign up for alerts.
    Register for a FREE limited account to get full access to all CME activities
    Have a subscription to the print edition?
    Current subscribers to The Journal of Bone & Joint Surgery in either the print or quarterly DVD formats receive free online access to JBJS.org.
    Forgot your password?
    Enter your username and email address. We'll send you a reminder to the email address on record.

     
    Forgot your username or need assistance? Please contact customer service at subs@jbjs.org. If your access is provided
    by your institution, please contact you librarian or administrator for username and password information. Institutional
    administrators, to reset your institution's master username or password, please contact subs@jbjs.org

    References

    Accreditation Statement
    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
    CME Activities Associated with This Article
    Submit a Comment
    Please read the other comments before you post yours. Contributors must reveal any conflict of interest.
    Comments are moderated and will appear on the site at the discretion of JBJS editorial staff.

    * = Required Field
    (if multiple authors, separate names by comma)
    Example: John Doe





    Samir Mehta, MD
    Posted on June 07, 2010
    Dr. Mehta and colleagues respond to Mr. Haldane
    Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania

    Dear Mr. Haldane,

    Thank you for your letter. We agree with you completely in that there needs to be a multidisciplinary approach in the assessment and management of our elderly patients with hip fractures.

    However, as with any multidisciplinary or team approach to patient care, one team or one member of the team needs to take a position of leadership to direct care and potentially resolve differences of opinion in management.

    One of the factors to consider when providing an ASA grade based on our manuscript is that we essentially converted a four-tier system to a binary system, thereby potentially improving interobserver reliability. In our algorithm, ASA 1 and ASA 2 patients would be admitted to orthopaedics with close medical management. ASA 3 and ASA 4 patients should be acutely managed by a medical service with orthopaedic input. This two-tiered system may simplify the grading system. The anesthesiologist’s review of the patient also provides an unbiased perspective on the overall health of the patient, which is critical in their progression to surgery and limitation of peri- and post-operative complications.

    We apologize if our manuscript left the reader with the impression that care for the elderly hip fracture patient was left to a single service-line in the hospital. On the contrary, we believe that optimal management of this difficult patient population can only happen with input of various service lines offering their experience and expertise to provide the greatest benefit to this fragile group of patients.

    Andrew G. Haldane, MBBS, FRCA
    Posted on May 21, 2010
    Use of Medical Comorbidities to Predict Complications After Hip Fracture Surgery in the Elderly
    Worcestershire Royal Hospital, Worcester, United Kingdom

    To the Editor:

    Dr. Donegan and colleagues must be congratulated on their efforts to further elucidate factors that predict complications after surgery in this particularly vulnerable group of patients (1).

    The intent of the original American Society of Anesthesiologists (ASA) classification was for the collection and comparison of anesthetic statistical data, indeed it was formulated specifically to replace the concept of “operative risk” (2). This study adds further evidence that it may be used as a means to assess anesthetic and surgical risk.

    However, there is strong evidence that there is significant inter-observer variability in the assignment of an ASA grade (3). Therefore we feel that it would be unwise to use only the ASA grade assigned by the “admitting anesthesiologist” to stream patients to different areas for care. We believe a multi-disciplinary approach very early in the admission would be of additional benefit.

    The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity.

    References

    1. Donegan DJ, Gay AN, Baldwin K, Morales EE, Esterhai JL Jr, Mehta S. Use of medical comorbidities to predict complications after hip fracture surgery in the elderly. J Bone Joint Surg Am. 2010;92:807-13.

    2. Saklad M. Grading of patients for surgical procedures. Anesthesiology. 1941;2:281-4.

    3. Davenport DL, Bowe EA, Henderson WG, Khuri SF, Mentzer RM Jr. National Surgical Quality Improvement Program (NSQIP) risk factors can be used to validate American Society of Anesthesiologists Physical Status Classification (ASA PS) levels. Ann Surg. 2006;243:636-41.

    Related Content
    The Journal of Bone & Joint Surgery
    JBJS Case Connector
    Topic Collections
    Related Audio and Videos
    PubMed Articles
    Clinical Trials
    Readers of This Also Read...
    JBJS Jobs
    11/15/2013
    Louisiana - Ochsner Health System
    05/03/2012
    California - UCLA/OH Department of Orthopaedic Surgery
    01/22/2014
    Pennsylvania - Penn State Milton S. Hershey Medical Center