What is the harm associated with delay to surgery?

Quality of the evidence

Question 5: What is the harm associated with delay to surgery?

Case clarification

The patient is admitted early Friday evening. Although she is medically stable, operating room time is limited over the weekend. On Monday, she is added to the surgical sched- ule at the end of the day, after more “urgent” cases are completed.

Relevance

Length of hospitalization for hip fracture repair varies tre- mendously depending on the healthcare system. The demand for urgent surgery often exceeds available resources. Guidance is needed to determine whether delays in surgery in medically stable patients will lead to poorer outcomes.

Current opinion

In many centers, surgical repair of a hip fracture is not viewed as urgent care.

Finding the evidence

• Cochrane Database (http://www.cochrane.org/

reviews): with search terms: “hip fracture” AND “surgical delay” or “time to surgery” or “surgery timing”

° Returned 21 results (0 related to topic)

• PubMed (www.ncbi.nlm.nih.gov/PubMed/): with search terms: “hip fracture” and “surgery timing,” limited to English

° Returned 84 references (19 relevant)

• A review of reference lists of relevant articles for addi- tional published trials

Quality of the evidence

Level I

• 1 systematic reviews or meta-analyses Level II

• 18 cohort studies

Findings

Because of the ethical nature of this question, a randomized trial to address it is not feasible. In a recent systematic review of 52 studies involving 291,413 patients,²⁹ 3 studies involving 6,954 patients were prospective, excluded unfit patients, and adjusted for confounders. In one of these studies,³⁰ a delay of 4 or more days in medically stable patients increased mortality at 90 days (HR 2.25, 95%

CI = 1.2–4.3, p = 0.01) and at 1 year (HR 2.4, 95% CI = 1.45–

3.99, p = 0.001). Patients who were delayed due to acute medical comorbidities on admission had a higher mortality at 30 days (HR = 2.3, 95% CI = 1.62–3.33), 90 days (HR = 2.1, 95% CI = 1.6–2.7, p < 0.001), and 1 year (HR 1.72, 95%

15. Liptzin B, Laki A, Garb JL, Fingeroth R, Krushell R. Donepezil in the prevention and treatment of post-surgical delirium. Am J Geriatr Psychiatry 2005;13(12):1100–6.

16. Diaz V, Rodriguez J, Barrientos P, Serra M, Salinas H, Toledo C, et al. [Use of procholinergics in the prevention of postoperative delirium in hip fracture surgery in the elderly. A randomized controlled trial]. Rev Neurol 2001;33(8):716–9.

17. Morrison RS, Magaziner J, Gilbert M, Koval KJ, McLaughlin MA, Orosz G, et al. Relationship between pain and opioid anal- gesics on the development of delirium following hip fracture. J Gerontol A Biol Sci Med Sci 2003;58(1):76–81.

18. Sharma G, Kuo YF, Freeman J, Zhang DD, Goodwin JS.

Comanagement of hospitalized surgical patients by medicine physicians in the United States. Arch Intern Med 2010;170(4):

363–8.

19. Auron-Gomez M, Michota F. Medical management of hip frac- ture. Clin Geriatr Med 2008;24(4):701–19, ix.

20. Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of a comanaged Geriatric Fracture Center on short-term hip fracture outcomes. Arch Intern Med 2009;169(18):1712–7.

21. Friedman SM, Mendelson DA, Kates SL, McCann RM.

Geriatric co-management of proximal femur fractures: total quality management and protocol-driven care result in better outcomes for a frail patient population. J Am Geriatr Soc 2008;

56(7):1349–56.

22. Yang H, Raymer K, Butler R, Parlow J, Roberts R. The effects of perioperative beta-blockade: results of the Metoprolol after Vascular Surgery (MaVS) study, a randomized controlled trial.

Am Heart J 2006;152(5):983–90.

23. Juul AB, Wetterslev J, Gluud C, Kofoed-Enevoldsen A, Jensen G, Callesen T, et al. Effect of perioperative beta blockade in patients with diabetes undergoing major non-cardiac surgery: ran- domised placebo controlled, blinded multicentre trial. BMJ 2006;332(7556):1482.

24. Brady AR, Gibbs JS, Greenhalgh RM, Powell JT, Sydes MR.

Perioperative beta-blockade (POBBLE) for patients undergoing infrarenal vascular surgery: results of a randomized double- blind controlled trial. J Vasc Surg 2005;41(4):602–9.

25. Bangalore S, Wetterslev J, Pranesh S, Sawhney S, Gluud C, Messerli FH. Perioperative beta blockers in patients having non- cardiac surgery: a meta-analysis. Lancet 2008;372(9654):

1962–76.

26. Devereaux PJ, Yang H, Yusuf S, Guyatt G, Leslie K, Villar JC, et al. Effects of extended-release metoprolol succinate in patients undergoing non-cardiac surgery (POISE trial): a randomised controlled trial. Lancet 2008;371(9627):1839–47.

27. Dunkelgrun M, Boersma E, Schouten O, Koopman-van Gemert AW, van Poorten F, Bax JJ, et al. Bisoprolol and fluvastatin for the reduction of perioperative cardiac mortality and myocardial infarction in intermediate-risk patients undergoing noncardio- vascular surgery: a randomized controlled trial (DECREASE- IV). Ann Surg 2009;249(6):921–6.

28. Fleischmann KE, Beckman JA, Buller CE, Calkins H, Fleisher LA, Freeman WK, et al. 2009 ACCF/AHA focused update on perioperative beta blockade: a report of the American college of cardiology foundation/American heart association task force on practice guidelines. Circulation 2009;120(21):

2123–51.

• Surgery within 24 hours lowers overall pain and dura- tion of severe pain

• Hip fracture patients who also have acute medical comorbidities are at increased risk of death due to those comorbidities, regardless of timing of surgery

References

1. Sandby-Thomas M, Sullivan G, Hall JE. A national survey into the peri-operative anaesthetic management of patients present- ing for surgical correction of a fractured neck of femur.

Anaesthesia 2008;63(3):250–8.

2. Ricci WM, Della Rocca GJ, Combs C, Borrelli J. The medical and economic impact of preoperative cardiac testing in elderly patients with hip fractures. Injury 2007;38 Suppl 3:

S49–52.

3. Robertson BD, Robertson TJ. Postoperative delirium after hip fracture. J Bone Joint Surg Am 2006;88(9):2060–8.

4. Bitsch M, Foss N, Kristensen B, Kehlet H. Pathogenesis of and management strategies for postoperative delirium after hip frac- ture: a review. Acta Orthop Scand 2004;75(4):378–89.

5. Rockwood K. Delays in the discharge of elderly patients. J Clin Epidemiol 1990;43(9):971–5.

6. Marcantonio ER, Flacker JM, Michaels M, Resnick NM. Delirium is independently associated with poor functional recovery after hip fracture. J Am Geriatr Soc. 2000;48(6):618–24.

7. Edelstein DM, Aharonoff GB, Karp A, Capla EL, Zuckerman JD, Koval KJ. Effect of postoperative delirium on outcome after hip fracture. Clin Orthop Relat Res 2004;422:195–200.

8. Olofsson B, Lundstrom M, Borssen B, Nyberg L, Gustafson Y.

Delirium is associated with poor rehabilitation outcome in elderly patients treated for femoral neck fractures. Scand J Caring Sci 2005;19(2):119–27.

9. Marcantonio ER, Kiely DK, Simon SE, John Orav E, Jones RN, Murphy KM, et al. Outcomes of older people admitted to postacute facilities with delirium. J Am Geriatr Soc 2005;53(6):

963–9.

10. Siddiqi N, Stockdale R, Britton AM, Holmes J. Interventions for preventing delirium in hospitalised patients. Cochrane Database Syst Rev 2007;2:CD005563.

11. Marcantonio ER, Flacker JM, Wright RJ, Resnick NM. Reducing delirium after hip fracture: a randomized trial. J Am Geriatr Soc 2001;49(5):516–22.

12. Gustafson Y, Brannstrom B, Berggren D, Ragnarsson JI, Sigaard J, Bucht G, et al. A geriatric-anesthesiologic program to reduce acute confusional states in elderly patients treated for femoral neck fractures. J Am Geriatr Soc 1991;39(7):655–62.

13. Milisen K, Foreman MD, Abraham IL, De Geest S, Godderis J, Vandermeulen E, et al. A nurse-led interdisciplinary interven- tion program for delirium in elderly hip-fracture patients. J Am Geriatr Soc 2001;49(5):523–32.

14. Kalisvaart KJ, de Jonghe JF, Bogaards MJ, Vreeswijk R, Egberts TC, Burger BJ, et al. Haloperidol prophylaxis for elderly hip-surgery patients at risk for delirium: a randomized placebo-controlled study. J Am Geriatr Soc 2005;53(10):

1658–66.

C H A P T E R 1 2 Perioperative Medical Management

29. Khan SK, Kalra S, Khanna A, Thiruvengada MM, Parker MJ.

Timing of surgery for hip fractures: a systematic review of 52 published studies involving 291,413 patients. Injury 2009;40(7):

692–7.

30. Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture: is delay before surgery important? J Bone Joint Surg Am 2005;87(3):483–9.

31. Orosz GM, Magaziner J, Hannan EL, Morrison RS, Koval K, Gilbert M, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA 2004;291(14):1738–43.

32. Siegmeth AW, Gurusamy K, Parker MJ. Delay to surgery pro- longs hospital stay in patients with fractures of the proximal femur. J Bone Joint Surg Br 2005;87(8):1123–6.

Orthobiologics

T. William Axelrad

¹

and Thomas A. Einhorn

²

1Lake Charles Memorial Hospital, Lake Charles, LA, USA

2Boston University Medical Center, Boston, MA, USA

Case scenarios

Case 1

A 64 year old man presents 2 years after sustaining a Gustilo–Anderson type II distal-third tibia fracture treated with a statically locked intramedullary nail. He has type 1 diabetes and has smoked a pack of cigarettes a day for over 40 years. The patient had a small residual gap at the frac- ture site, and did not develop significant bridging callus.

His fracture was treated with dynamization of the nail at 9 months with removal of the proximal interlocking screws, and then revision intramedullary nailing 6 months later for continued lack of healing. He continues to have pain at the fracture site and shows no evidence of cortical bridging on plain radiographs.

Case 2

A 55 year old woman is seen for debilitating low back and neck pain for over 8 months. She has failed 3 months of physical therapy as well as having had two epidural steroid injections approximately 2 months ago. MRI shows degen- erative disc disease at L3–4 and L4–5 as well as C5–6.

Relevant anatomy

Fracture healing is affected by a variety of conditions as well as the anatomic location of the injury. Smoking, comor-

bidities such as diabetes, open fractures, and advanced age all have negative effects on the healing of fractures. Several anatomic regions have a higher rate of nonunion, such as the proximal metaphysis of the 5th metatarsal, the scaphoid, the femoral neck, and the subtrochanteric region of the femur.^1–3 It is presumed that the tenuous nature of the local blood supply is largely responsible for the resistance to union at these sites.

Open tibia fractures have been the subject of intense research with regard to improving clinical outcomes related to bone healing and reducing the risk of infection. The blood supply to the tibia is predominately supplied by the posterior tibial artery.⁴ Fractures that have soft tissue strip- ping (which devitalizes the bone) or an associated vascular injury are at increased risk for delayed union and nonun- ion. Dickson et al. obtained angiograms in 114 patients treated for an open tibia fracture.⁵ They found that open fractures with documented arterial disruption had a rate of delayed and nonunion of 46% compared to a rate of 16%

in similar injuries with a normal angiographic study. Others have achieved union in both distal femur and tibial non- unions after revascularization procedures alone.^6,7 Anatomic studies of the vascular supply of the tibia have shown that the proximal tibia is richly vascularized, while the diaphy- sis contains few extraosseous vessels.⁸ Disruption of these vessels after fracture results in rapid revascularization.

Delayed union and nonunion are characterized by an avas- cular area at the fracture site; in these cases restoration of stability and possibly bone grafting can result in healing.⁹

Several bones, when fractured, are resistant to union because their intraosseous vascular supply is provided by

Evidence-Based Orthopedics, First Edition. Edited by Mohit Bhandari.

© 2012 Blackwell Publishing Ltd. Published 2012 by Blackwell Publishing Ltd.

13

C H A P T E R 1 3 Orthobiologics fails conservative management has been treated with decompression and fusion with or without instrumenta- tion. The risk of pseudoarthrosis in patients undergoing spine fusion with iliac crest bone graft is estimated to be as high as 12%, with advancing age being a risk factor for this complication.²⁴ Chronic pain at the operative site is another complication that has been found to occur in nearly 40% of patients,²⁵ with both major and minor complications occur- ring in 10% and 39% respectively.²⁶

Top five questions

Risk factors

1. What patient and injury-related factors negatively affect