One metric in the TQIP program that most U.S. trauma centers subscribe to measures time to hip fracture fixation. Why is this important? When someone (usually an older adult) falls and breaks their hip, their mobility immediately drops to a much more sedentary level. We know this has an immediate impact on pulmonary function and increases pulmonary risk from simple things like atelectasis to more critical issues like pneumonia.

Given this fairly reliable correlation, it seems reasonable that restoring mobility to baseline quickly would be important. But as we have learned, just because something seems reasonable or logical doesn’t mean that it really is. Where is the evidence?

A paper first presented at the American Association for the Surgery of Trauma meeting in 2020 provided some excellent insight into this question. It was a prospective, multicenter study that included 85 US trauma centers over a 3-year period. The study included elderly patients aged 65 to 100 with an intertrochanteric hip fracture (IHF). Only patients with an isolated hip fracture were included; the presence of any other injury excluded them.

All hospitals were part of a single healthcare system that had implemented a system-wide practice guideline for managing hip fractures before the study began. The primary outcome studied was inpatient mortality. Secondary outcomes included complication rates, individual complications, and hospital length of stay.

Here are the factoids:

• Over 24,000 patients were enrolled in the study and were divided into four hospital cohorts:
  • No IHF guideline
  • Individual hospital IHF guideline
  • Partial adoption of the system IHF guideline
  • Full adoption of the system guideline
• Overall mortality was 1.7% across all trauma centers and levels and was not impacted by the volume of repairs performed by a center
• Hospitals that used their own guideline or the system guideline had the lowest mortality (1.2%); Those using a partial guideline did not show any significant improvement (1.8%)
• Hospitals that used their own guideline or the system guideline saw improvement in their TQIP report, whereas the others did not.
• There were no differences in length of stay or complications across the cohorts
• The majority of patients (70%) did not require any preoperative clearance via medical consultation or additional testing
• The majority of patients who were deemed at moderate to high preoperative risk were still able to have their operations within 24 hours

Bottom line: Obviously, this is not a randomized controlled trial, which would be very difficult to perform with the high enrollments achieved here. But the solid design and large numbers give us important information about the association between early fixation and mortality. It shows that adherence to a practice guideline, either developed by the health system or the hospital, is associated with a significant reduction in hospital mortality.

This study demonstrates the huge importance of crafting a well-designed practice guideline that respects the resources available at the hospital. It also shows that only a minority of these patients require consultation or testing for more complex medical clearance, so the main barriers are the availability of the operating room and the orthopedic surgeon. 

There will always be a certain number of these patients who will undergo their repair after 24 hours. This is unavoidable because some patients will come in at a time of day when the 24-hour clock runs out in the middle of the night. For most hospitals, it is not feasible to staff an OR and have an orthopedic surgeon immediately available in the middle of the night. We should all learn from this paper and strive to implement such a guideline and pay close attention to the details so that we can expedite hip fracture fixation as much as humanly possible. 

Reference: A multicenter study on definitive surgery for isolated hip fracture within 24 hours. J Trauma Acute Care Surg. 2021 Jan 1;90(1):113-121. doi: 10.1097/TA.0000000000002951. PMID: 33003017.