I. Problem/Challenge.

Hospitalists are often asked to consult on or co-manage patients undergoing orthopedic procedures. The scope can be general, such as pre-operative risk stratification or management of chronic medical problems. More challenging, specific problems include management of perioperative anticoagulation, diagnosis and management of perioperative delirium, fever, hypoxia, or fluid and electrolyte derangement.

In the elderly, the most common orthopedic procedures for which medicine consultation is requested are hip fracture repair and spine surgery. The complication with greatest morbidity and mortality, for which the orthopedic patient population is at particularly high risk, is thromboembolic disease. The role in the prevention of such complications is pivotal.

II. Identify the Goal Behavior.

Our primary goal as consultants or co-managers is to help orthopedic patients return to their previous level of function. Medical optimization to enable the patient to get to the operating room as soon as possible can significantly impact functional outcome. While we should aim for surgery within 24-48 hours in medically stable patients without major comorbid illness, there is no evidence of significant harm in waiting up to 72 hours if needed to stabilize active conditions (e.g., decompensated CHF, exacerbation of COPD, acute infection, etc). In addition, we need to assess each individual patient’s risks for specific complications and not only recommend but, when possible, implement effective preventive measures.

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We need to be particularly vigilant about two post-op complications with significant morbidity, venous thromboembolic disease and delirium.

III. Describe a Step-by-Step approach/method to this problem.

I. Hip Fractures

Given that more than 90% of patients with hip fracture are older than 65, most have preexisting medical comorbidities. Despite the advances in both surgical and medical services, the morbidity and mortality associated with hip fractures remain elevated. Some complications are related to the surgery itself, and others are medical. Medical complications may affect 20% of patients with hip fracture, and hospitalists play a major role in minimizing these. Remember that complications can occur even if the fracture is managed non-operatively. The following are common complications and an approach to their prevention.

A. Cardiac events: The incidence of post-operative cardiac ischemia or heart failure has been estimated around 35-42%. While these are common post-operative medical complication of hip fractures, most are not serious.

1. Perform a thorough pre-operative risk stratification using the ACC/AHA 2014 guidelines. These guidelines have been shown to accurately predict cardiac risk in orthopedic surgery.

2. Continue beta-blockers in patients who have been on them chronically, as per the above guidelines.

B. Venous Thromboembolic Disease (VTE): Up to 7% of patients undergoing surgery for a hip fracture suffer fatal pulmonary embolism. Without VTE prophylaxis, the prevalence of venography-detected proximal DVT increases to 27% of patients.

1. Early prophylaxis with low molecular weight heparin (enoxaparin 40mg SC daily or 30mg SC BID) has been shown to significantly reduce the incidence of post-op deep venous thrombosis. The American College of Chest Physicians recommends initiation of prophylaxis within 8 hours of surgery.

2. Prophylaxis should be extended one month post-operatively, as the risk for VTE remains high after the patient is discharged from the hospital.

C. Bleeding

While VTE poses significant risk after orthopedic surgery as noted above, we must weigh this against the competing risk of post-operative bleeding or hemorrhage. Major perioperative bleeding increases the risk of reoperation, length of stay, and hospital costs. Procedure type, cancer, female sex, coronary artery disease, and chronic obstructive pulmonary disease have been found to be independent predictors of major bleeding. Similar to how we decide whether to use a heparin bridge for anticoagulation, we must take a patient-specific approach to the perioperative risk stratification for thrombotic and bleeding complications.

D. Anemia

The prevalence of perioperative anemia ranges from 24-44%, more prevalent after intra-operative blood loss with a range of 51-87% post-operatively. It is a strong negative prognostic marker in hip fracture patients as it is usually associated with underlying comorbid conditions and decreased physiologic reserve. Severe anemia (Hb < 8 mg/dL) is associated with increased postoperative mortality and poor functional recovery. Although patients with hip fractures are commonly given allogeneic red blood cell transfusion, there is no data to support this practice. A multicenter randomized controlled study comparing a liberal transfusion policy (Hb <10 mg/dL) with a restrictive policy (Hb<8 mg/dL) in hip fracture patients showed no difference in mortality, in-hospital morbidity or ability to walk independently after 60 days.

1. Follow a restrictive policy for red blood cell transfusion in older hip fracture patients.

2. Consider perioperative parenteral and oral iron therapy and erythropoietin in order to decrease the need for blood transfusions, though these modalities need more study before becoming standard of care.

E. Delirium

Delirium is the most common complication of hip fracture surgery, occurring in up to 60% of patients with hip fracture. Though essentially all elderly are at risk, it is more common in patients with underlying dementia. Heightened vigilance and early intervention can reduce prevalence by up to 50%.

1. Perform a preoperative assessment of delirium risk factors: age >65, cognitive impairment or dementia, poor vision or hearing, severe illness, functional dependence, urinary retention, fecal impaction, alcohol use, electrolyte abnormalities, infection, undertreated pain, immobility, altered sleep-wake cycle, many medications (especially psychotropic or anticholinergic drugs).

2. Identify delirium early. Incorporate the Confusion Assessment Method (CAM), one of the most widely used diagnostic tools for delirium, into your daily assessment of the patient.

3. Treat the underlying causes.

4. Strongly consider a Geriatrics consultation. This has been shown in a randomized trial to reduce the incidence by over one-third.

5. Use non-pharmacologic interventions as much as possible. Normalizing sleep-wake cycles, re-orienting the patient, minimizing tethers, and providing the patient’s glasses or hearing aids are some simple measures that can be effective.

6. If necessary, pharmacologic management may be the next step. Start with low doses and increase slowly if indicated. Although the use of high potency antipsychotic drugs like haloperidol has an increased risk of extrapyramidal side effects, the reported incidence is low. Atypical antipsychotics cause less sedation and fewer extrapyramidal effects. Haloperidol 0.5 mg, risperi-done 0.5mg, or olanzapine 2.5mg are appropriate.

F. Urinary Tract Complications

The most common postoperative urinary tract complications after hip surgery are urinary retention, urinary tract infection (UTI), and acute kidney injury (AKI). After hip fracture, the incidence of urinary tract infection is 23-25%. UTIs increase the risk for post-operative delirium as well as mortality and can increase length of stay an additional 2.5 days.

1. Remove Foley catheter as soon as possible, usually on post-operative day #1. This will often force the patient to get out of bed more frequently.

2. Intermittent catheterization for urinary retention is superior to indwelling catheterization in terms of risk of infection.

3. Ensure adequate hydration and monitor volume status closely.

4. Diagnose and treat AKI promptly in order to minimize the risk of permanent kidney damage.

G. Decubitus Ulcers

These can occur in 10-40% of patients with hip fractures, and they are the most dreaded result of limited mobility. Unrecognized or untreated, these can be further complicated by cellulitis, septic arthritis, osteomyelitis, or even sepsis. Decubitus ulcers are more easily prevented than treated.

1. It is important to reposition the patient at fixed time intervals, at least every 2 hours. Also be sure to examine the skin regularly.

2. Another preventive measure is to get the patient out of bed and working with Physical Therapy as soon as possible. If you’re not co-managing and entering orders yourself, a little communication with the nursing staff goes a long way.

3. Foam and alternating pressure mattresses have been shown to reduce the incidence of pressure sores compared with standard care in elderly orthopedic patients.

4. Malnutrition increases the risk of developing decubitus ulcers. In addition, poor nutritional status is common in patients with hip fracture and appears to be independently associated with increased morbidity and mortality. Protein/vitamin supplements have been shown to reduce long-term complications but not mortality.

H. Pneumonia

Incidence estimated ~7%. The risk for pulmonary infection is increased by atelectasis secondary to anesthesia as well as splinting due to pain or limited mobility.

1. Recommend incentive spirometry ten times per hour starting from the time of admission. Take a few minutes to show the patient how to use the device properly and explain why it is important.

2. Early ambulation, usually on post-operative day #1, is a major preventive measure in this regard.

3. Monitor oxygen saturation closely, as post-operative hypoxia may be mild and persistent.

I. Recurrent Hip Fracture

A patient presenting with hip fracture is presumed to have underlying osteoporosis, and they are at high risk for recurrent fracture. Although current osteoporosis management guidelines recommend pharmacologic treatment after hip fracture, our adherence rates to prescribing bisphosphonates for the secondary prevention of osteoporotic fracture has been low across the country and abroad.

There is good data that shows that an annual infusion of zolendronic acid within 90 days after repair of a low-trauma hip fracture is associated with a reduction in the rate of new fractures as well as improved survival. However, administration of bisphosphonate to a patient with a healing fracture could potentially affect the dynamics of bone mineral density response, antifracture efficacy, and mortality benefit, depending on when the dose is given. Thus, the optimal time and place for starting a bisphosphonate after hip fracture is subject to debate.

More recently, position papers have been issued by the International Osteoporosis Foundation and the American Society for Bone and Mineral Research, recommending implementation of fracture liaison services (FLS) as the most efficient way of addressing the low treatment rate of osteoporosis post-fracture. A FLS identifies patients who have had a first fracture, assesses their bone metabolic status, and institutes appropriate medical therapy for secondary prevention. One study comparing a tertiary hospital with a FLS to one without showed a ∼40 % reduction in 3-year risk of major bone and ∼30 % reduction of any bone re-fracture.

1. Prescribe calcium and vitamin D for presumed osteoporosis. Recommended doses are 1200 mg elemental calcium daily and 800 IU vitamin D daily.

2. Discuss initiation of a bisphosphonate for secondary prevention and communicate with the patient’s primary care provider about this often-overlooked intervention. Note, bisphosphonates should not be prescribed for patients with vitamin D deficiency (< 10 ng/mL), hypocalcemia, renal disease, or esophageal strictures.

3. Consider scheduling bone mineral densitometry and Endocrinology follow-up.

4. Routinely inquire about falls. Assess fall risk and address underlying modifiable risk factors, especially medications (e.g., antihypertensives, other cardiac meds, benzodiazepines, etc). Ask about alcohol use.

5. Recommend a home safety evaluation, usually addressed in the Physical Therapy assessment.

II. Neurosurgery

Any of the above complications (A-F) can occur after spine surgery, so the same recommendations apply. All patients who undergo neurosurgical procedures are in a potentially unstable cardiopulmonary state and at risk for secondary neuronal injury. Hemorrhage, ischemia and ischemic edema may also occur following neurosurgery, and these are the most frequent cause of neurological deterioration. Some key points to remember:

A. Complications are more common in thoracolumbar than cervical procedures.

1. Thoracolumbar complications are more often related to hardware than to the procedure performed. Examples include pseudarthrosis and hardware failures.

2. Other complications are post-operative radiculopathies, wound infections, and urinary tract infections.

B. Cervical complications are often related to the surgical approach and include dysphagia and dysphonia.

1. Post-operative hematomas, cervical nerve root palsies, and axial neck pain are also common.

IV. Common Pitfalls.

Sometimes, after we have performed the pre-operative evaluation or have answered the question for which consultation was requested, we may be too hasty to sign off the case. As hospitalists, we are very familiar with what can go wrong post-operatively, and we can often predict which patients will experience complications. By following the patient two or three more days post-operatively, we may identify an evolving complication and intervene to halt its progression.

In addition, because we are so busy, we may not take the time to communicate with the primary team as well as we can. Simply dropping a list of recommendations in the chart is not enough to ensure that they are carried out. At least for the recommendations with the greatest potential impact on the patient’s outcome, a phone call can go a long way.

V. National Standards, Core Indicators and Quality Measures.

Two of the Joint Commission’s core measure sets include:

I. Venous Thromboembolism (VTE)

Six VTE core measures were endorsed by the National Quality Forum, and the ones which hospitalists are poised to enforce for orthopedic surgery patients include:

1. Venous thromboembolism prophylaxis

2. Venous thromboembolism patients with anticoagulation overlap therapy

3. Venous thromboembolism patients receiving unfractionated heparin with dosages/ platelet count monitoring by protocol

4. Venous thromboembolism discharge instructions

II. Surgical Care Improvement Project (SCIP)

The specific core measures in which hospitalists can be instrumental in implementation include:

1. Removal of the urinary catheter on post-operative day #1 or #2

2. Administration of beta-blocker therapy during the perioperative period to surgical patients on beta-blocker therapy prior to admission

3. Ordering the recommended venous thromboembolism prophylaxis

VI. What's the evidence?

Salerno. “Impact of Perioperative Cardiac Assessment Guidelines on Management of Or-thopedic Surgery Patients”. Am J Med. vol. 120. 2007. pp. 185.e1-185.e6.

Orosz. “Association of Timing of Surgery for Hip Fracture and Patient Outcomes”. JAMA. vol. 291. 2004. pp. 1738-1743.

Kim. “Use of osteoporosis medications after hospitalization for hip fracture: a cross-national study”. Am J Med. vol. 128. 2015 May. pp. 519-26.

Lyles. “Zoledronic Acid in Reducing Clinical Fracture and Mortality after Hip Fracture”. N Engl J Med. vol. 357. 2007.

Moran. “Early Mortality After Hip Fracture: Is Delay Before Surgery Important”. J Bone Joint Surg Am. vol. 87. 2005. pp. 483-489.

Nakayama. “Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate”. Osteoporosis International. vol. 27. March 2016. pp. 873-879.

Robertson. “Postoperative delirium after hip fracture”. J Bone Joint Surg Am. vol. 88. 2006 Sep. pp. 2060-2068.

Beaupre. “Best Practices for Elderly Hip Fracture Patients: A Systematic Overview of the Evidence”. JGIM. vol. 20. 2005. pp. 1019-1025.

Brandon. “Thrombotic and Bleeding Complications After Orthopedic Surgery”. Am Heart J. vol. 165. 2013. pp. 427-433.e1.

Carson. “Liberal or restrictive transfusion in high-risk patients after hip surgery”. N Engl J Med.. vol. 365. 2011 Dec 29. pp. 2453-62.

Carpintero. “Complications of hip fractures: A review”. World J Orthop.. vol. 5. 2014 Sep 18. pp. 402-411.

Chong. “Medical problems in hip fracture patients”. Arch Orthop Trauma Surg.. vol. 130. 2010 Nov. pp. 1355-61.

Vera-Llonch. “Clinical and economic consequences of bleeding following major orthopedic surgery”. Thromb Res. vol. 117. 2006. pp. 569-77.