Review Question - QID 219454

This 82-year-old female sustained a left stable intertrochanteric hip fracture. Delaying operative intervention greater than 48 hours has been demonstrated to increase patient mortality following surgery.

Hip fractures are ubiquitous injuries treated by orthopedic surgeons, and are only expected to increase in incidence secondary to an aging United States population. Hip fractures in general tend to be a harbinger of poor outcomes, with an estimated 30% mortality rate at one year post-operatively. As such, clinicians continually attempt to devise ways to reduce said mortality. Factors that have been found to improve mortality include prompt medical optimization, interdisciplinary patient management, and operative intervention within 48 hours. A host of patient-related factors have been demonstrated to alter mortality negatively, particularly those with ASA designations of III or greater, age over 85, male gender, and 2 or more pre-existing conditions. Notably, the type of intraoperative anesthesia administered (spinal vs. general) does not impact mortality following surgery, as evidenced by the recent REGAIN trial. Furthermore, the length of the cephalomedullary nail used in stable intertrochanteric hip fractures has no bearing on mortality.

Bennett et al. performed an institutional retrospective review of 841 hip fracture patients, finding a delay to surgical fixation surpassing 48 hours was associated with increased initial hospital length of stay and the overall increase in postoperative complication rates. Furthermore, in-hospital mortality was found to be increased (5.7%) compared to those who were operated on within 24-48 hours (1.0%). The authors conclude early operative fixation within 48 hours is one of the most significant modifiable risk factors in reducing mortality.

Neuman et al. REGAIN trial investigators performed a pragmatic, randomized control trial of over 1,600 hip fracture patients randomized to receive either general or spinal anesthesia at a 1:1 ratio. The study's endpoints were death, inability to walk approximately 10 feet independently or with a walker or cane at 60 days following surgery, and delirium. The authors found no difference in mortality, function, and delirium rates and concluded that neither type of anesthesia was superior to the other.

Parker and Griffiths performed a randomized controlled trial involving 322 hip fracture patients being randomized to receive either general or spinal anesthesia. The authors found no differences in hospital stay, blood transfusions, or postoperative complications. Mortality was found to be similar at 30 days but reduced for those receiving general anesthesia at one year. The authors concluded no clinically significant differences were found, and noted larger studies need to be performed to better delineate differences between the two techniques.

Figures 1 & 2 demonstrate an AP pelvis and cross-table lateral of the left hip exhibiting a stable two-part intertrochanteric hip fracture.

Answer 1: There is no difference in mortality between general and spinal anesthesia in hip fracture patients
Answer 3: Taking an interdisciplinary approach to patient management reduces mortality
Answer 4: The male gender is at increased risk for mortality compared to females
Answer 5: The length of cephalomedullary nail in both intertrochanteric hip fractures is highly debatable and has not reliably modified mortality risk