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Early Operation on Patients with a Hip Fracture Improved the Ability to Return to Independent LivingA Prospective Study of 850 Patients
Amer N. Al-Ani, MD1; Bodil Samuelsson, RN2; Jan Tidermark, MD, PhD3; Åsa Norling, RN1; Wilhelmina Ekström, MD4; Tommy Cederholm, MD, PhD5; Margareta Hedström, MD, PhD1
1 Karolinska Institutet, Department of Clinical Science, Intervention and Technology (CLINTEC), Department of Orthopaedics, Karolinska University Hospital Huddinge, SE-141 86 Stockholm, Sweden. E-mail address for A.N. Al-Ani: amer.al-ani@karolinska.se
2 Karolinska Institutet, Department of Orthopaedics, Danderyd Hospital, SE-182 88, Stockholm, Sweden
3 Karolinska Institutet, Department of Clinical Science and Education and Department of Orthopaedics, Capio S:t Göran Hospital, SE-112 81 Stockholm, Sweden
4 Karolinska Institutet, Department of Molecular Medicine and Surgery, Section of Orthopaedics and Sports Medicine, Karolinska University Hospital Solna, SE-171 76 Stockholm, Sweden
5 Department of Public Health and Geriatrics, Clinical Nutrition and Metabolism Unit, Uppsala University Hospital, SE-751 85, Uppsala, Sweden
View Disclosures and Other Information
Disclosure: In support of their research for or preparation of this work, one or more of the authors received, in any one year, outside funding or grants in excess of $10,000 from the Stockholm County Council Research Fund for clinical studies (EXPO 1999). 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. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.
Investigation performed at the Department of Orthopaedics, Karolinska University Hospital, Huddinge, and the Department of Orthopaedics, Danderyd University Hospital, Danderyd, Sweden

The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2008 Jul 01;90(7):1436-1442. doi: 10.2106/JBJS.G.00890
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Abstract

Background: The outcome for many patients with a hip fracture remains poor. The aim of the present study was to investigate whether the timing of surgery in such patients could influence the short-term clinical outcome.

Methods: We included 850 consecutive patients with a hip fracture who were admitted to the hospital during one year in a prospective study. Three cutoff limits for a comparison of early and late operation were defined. The outcome (the ability to return to independent living, risk for the development of pressure ulcers, length of the hospital stay, and mortality rate) for patients who had an operation within twenty-four, thirty-six, and forty-eight hours was compared with the outcome for those who had an operation at a later time.

Results: Patients who had the operation more than thirty-six and forty-eight hours after admission were less likely to return to independent living within four months (odds ratio, 0.44 and 0.33, respectively), whereas there was no significant difference with use of the twenty-four-hour cutoff limit. The incidence of pressure ulcers in the groups that had the operation later was increased at all three cutoff limits (a delay of more than twenty-four hours, more than thirty-six hours, and more than forty-eight hours) (odds ratio, 2.19, 3.42, and 4.34, respectively). The length of hospitalization was also increased in the groups that had the later operation (median, fourteen compared with eighteen days, fifteen compared with nineteen days, and fifteen compared with twenty-one days, respectively) (p < 0.001 for all comparisons). The importance of surgical timing remained significant after adjusting for several possible confounders (p < 0.05).

Conclusions: Early compared with late operative treatment of patients with a hip fracture is associated with an improved ability to return to independent living, a reduced risk for the development of pressure ulcers, and a shortened hospital stay.

Level of Evidence: Therapeutic Level II. See Instructions to Authors for a complete description of levels of evidence.

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    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.
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    Amer N. Al-Ani
    Posted on August 12, 2008
    Dr. Al-Ani and Colleagues respond to Dr. Bidwai
    Karolinska University Hospital, Huddinge

    We thank Dr Bidwai for his interest in our article (1). As pointed out in his letter, the results of our study contribute to the growing evidence that early operative treatment is beneficial for patients with hip fractures. However, none of the questions raised by Dr Bidwai can be given an answer based on our paper and we are not aware of any other paper that can support an evidence based answer.

    If you ask us for our opinion, we do believe that the time taken to medically optimize patients most often is justified provided that this process is performed in close collaboration with the attending anesthesiologist and that the indication for potentially time-consuming preoperative medical investigations are balanced against the negative effect of the prolonged waiting time.

    Our present goal is to perform surgery on hip fracture patients as soon as possible and always within 24 hours. Prior to the surgical procedure, we believe that pain should be minimized and that the fasting time be as short as possible in order to reduce the metabolic response to stress. Moreover, our aim is to allocate our resources so we can avoid being forced to perform hip fracture surgery during the night.

    References: 1.Amer N. Al-Ani, Bodil Samuelsson, Jan Tidermark, Åsa Norling, Wilhelmina Ekström, Tommy Cederholm, and Margareta Hedström Early Operation on Patients with a Hip Fracture Improved the Ability to Return to Independent Living. A Prospective Study of 850 Patients J Bone Joint Surg Am 2008; 90: 1436-1442

    Amit S Bidwai
    Posted on July 28, 2008
    Role of delay for medical optimisation of hip fracture patients
    Wrightington and Wigan Hospitals

    To the Editor:

    The article by Al-Ani et al.(1) has stimulated much debate in our institution about the optimal treatment protocol for patients with hip fractures. This paper adds to the growing body of evidence that seems to indicate that timing of surgery is the most important predictor of outcome for these patients,and that the stress response of the patient to trauma is critical.

    We are particularly interested in the 31% of patients who had surgery delayed because they required time for medical optimisation. Since there is mounting evidence in the literature favoring early surgical intervention as the most important factor in outcome, we would ask the authors to comment on whether the time taken to medically optimize patients is justified and secondly, should we be operating on these patients as soon as possible, including during the night?

    We recognize the difficulties of answering these questions in the absence of evidence based studies. As the authors rightly point out, randomized controlled trials for these patients are not always appropriate and certainly we would struggle to achieve ethical approval for a randomized controlled trial which compared a cohort patients who underwent surgery within 24 hours despite having potentially reversible medical conditions with a cohort that included patients who were medically optimized pre-operatively.

    Are we to conclude from the present study that whatever the medical status of the patient, the more important variable in outcome is time to surgery due to the nature of the catabolic stress response to trauma? Time delays for medical optimisation may actually be detrimental to patient outcome.

    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. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

    References:

    1.Amer N. Al-Ani, Bodil Samuelsson, Jan Tidermark, Åsa Norling, Wilhelmina Ekström, Tommy Cederholm, and Margareta Hedström Early Operation on Patients with a Hip Fracture Improved the Ability to Return to Independent Living. A Prospective Study of 850 Patients J Bone Joint Surg Am 2008; 90: 1436-1442

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