Rapid Responses to:
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Rapid Responses: Rapid Responses published:
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Type of Anaesthesia and Complications
- Diego Reverte-Cejudo (25 November 2005)
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Has the risk of general anaesthesia been grossly underestimated?
- Richard G Fiddian-Green (27 November 2005)
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Pulmonary Micro-Infarction causes Chest-Infection and Cardiac Failure.
- Friedrich Flachsbart (27 November 2005)
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Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people.
- Rosie J Snaith (10 December 2005)
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Confirmation rather than new finding
- Nick Black (11 December 2005)
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Hip fractures and comorbidities
- Elliot F Epstein (12 December 2005)
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Re: Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people.
- Sengwee Toh (13 December 2005)
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Hip fractures in the elderly: should all patients have formal specialist medical assessment?
- Usman A Abdulkadir (13 December 2005)
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The effect of therapeutic interventions on outcome
- Alexander J Butwick (16 December 2005)
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Statins for hip fracture? Not bio--logical
- Eddie Vos (16 December 2005)
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Re: Statins for hip fracture? Not bio--logical
- Sengwee Toh (17 December 2005)
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Re: Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people
- Gary Heyburn, Timothy RO Beringer (19 December 2005)
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Re: Re: Statins for hip fracture? Not bio--logical
- Eddie Vos (21 December 2005)
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Delirium as important postoperative complication after hip fracture in elderly patients.
- Barbara C. van Munster, Johanna C. Korevaar and Sophia E. de Rooij. (24 December 2005)
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A good article that needs to be looked at with a different view....
- Anand Kommuri (2 January 2006)
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Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people:prospective observational cohort study
- Christopher G Moran (3 January 2006)
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Inappropriate recommendations.
- Nevil P Hutchinson, Robert W Hearn (4 January 2006)
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How many co-morbidities should be considered?
- Shi-Min Chang (4 January 2006)
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Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study
- Christopher G Moran (6 January 2006)
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Interdisciplinary collaboration for the reduction of mortality after femoral neck fracture
- Andor Sebestyén, Imre Boncz, Ferenc Tóth, and József Nyárády. (9 January 2006)
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Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study
- Christopher G Moran (3 February 2006)
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complications also after discharge
- Romke van Balen (2 May 2006)
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Diego Reverte-Cejudo, Retired Head of Medicine Dept Hospital General de Segovia, Carretera de Ávila, s/n 40002 Segovia, Spain
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Roche, Wenn, Sahota and Moran, on their article published on the last on line issue of BMJ on the mortality of hip fracture in relationship to the patient’s comorbifity and the presence of complications (Roche JJW, Wenn RT, Sahota O, and Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. Brit Med J dol: 10.1136/bmj.38643.663843.55 [published 18 November 2005]), do not take into account the type of Anaesthesia that the patients received. They show that patients having a postoperative chest infection have a 30-day mortality of 43% (hazard ratio: 8.5 95% CI: 6.6 to 11.1 compared to those without this complication). They do not communicate the type of anaesthesia applied. It is quite possible that those having general anaesthesia have a higher risk of chest infection, and therefore, a higher mortality that those submitted to spinal anaesthesia. I suggest the authors should report and analyse this point in their paper. Competing interests: None declared |
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Richard G Fiddian-Green, FRCS, FACS None
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The answer to Diego Reverte-Cejudo's question should determine whether the immediate and late risks of outcome following surgery for fractured hips might have been a product of deficiencies in perioperative resuscitation, as previously considered (1), and/or of the anaesthetic agents per se. General anaesthesia would seem to be far more of an art than a science. The possibility that a general anaesthetic might increase the risk of fatal outcome as long as a year after surgery might be very real. If so there might be very simple perioperative solutions such as upregulating oxidative phosphorylation by inducing hypercapnia (2). 1. It is neither co-morbidity, frailty nor advanced age Richard G Fiddian-Green (18 October 2002) eLetter re: Michael J Goldacre, Stephen E Roberts, and David Yeates Mortality after admission to hospital with fractured neck of femur: database study BMJ 2002; 325: 868-869 2. Renal failure and ascites after remote laparoscopy Samiran Adhikary, Prasad Mathews, and Ganesh Gopalakrishnan CMAJ 2005 173: 1323 eLetter re: Does CO2 insufflation during laparoscopy improve outcome?: Richard G Fiddian-Green cmaj.ca, 23 Nov 2005 Competing interests: None declared |
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Friedrich Flachsbart, General Medicine Praxis 37085 Göttingen
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Dear Sir, twenty years ago I published a poster on microemboli in the early postoperative phase. We used a combination out of nine possible signs of pulmonary embolism: Tachypnoe Hypoxemia Fever Dystelectasis Rales Tachycardia Pleuritis ECG-Changes High diaphragm. If we discovered 3 or more of these signs, we treated with risk- adapted full-dose-heparin-therapy. There was not one chest-infection to be treated with antibiotics! So we decided: Post-operative pulmonary complication is in nearly all cases an ischemic problem, caused by hypercoagulability and microembolism. You should intervene with heparin, guided by D - Dimer (ELISA). (And long-term anticoagulation in praxis later on, risk-adapted with coumarin, guided by INR and D - Dimer (ELISA). A study is necessary to test this idea. Sincerely Yours Friedrich Flachsbart F. Flachsbart: Mikroembolien. Deutsches Ärzteblatt 1987;84:A-1314 Competing interests: None declared |
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Rosie J Snaith, SHO Anaesthetics Paisley
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Dear Ediditor, The research highlighting cardiovascular, cerebrovascular diesease and COPD as the major comorbidities for postoperative complications and mortality after hip fracture in elderly people was excellent. I would be interested to know how many of the patients had their medication withheld either pre or postoperatively for any reason compounding the risk of any such event. This is often the case due to sometimes unnecessarily prolonged periods of fasting when diuretics, aspirin, statins and antihypertensives are not given. Although it may not be possible for physicians to review all hip fractures there is definately a role for the hospital pharmacist to ensure all routine medication is prescribed and given. Recent research by P. Foex (Anaesthesia Nov 2005) showed reduced perioperative mortality in the short and long term with statin administration for patients under going all types of surgery. To prevent hip fractures in the future perhaps there is a case for the "polypill" also containg calcium supplementation too! Competing interests: None declared |
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Nick Black, Professor of Health Services Research London School of Hygiene & Tropical Medicine
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I was delighted to see that this study confirms the finding we reported 7 years ago, that comorbidity is associated with serious adverse outcomes (including death).(1) 1. Imamura K, Black NA. Does comorbidity affect the outcome of surgery? Total hip replacement in the UK and Japan. Int J Qual Health Care 1998;10:113-123. Competing interests: None declared |
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Elliot F Epstein, Consultant Physician Walsall Manor Hospital, WS2 9PS
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Roche JJW et al report that, for elderly people with hip fracture, the presence of multiple comorbidities predicts operative risk (1). I believe this conclusion is flawed, as important confounding variables were not included in the multivariate analysis. The authors do not mention pre- admission dependency and cognitive impairment both potential determinants of poor outcome following hip surgery (2,3). In particular the authors do not mention undernutrition, a potentially remedial cause of poor outcome (4). The data collected concerning comorbidities may not truly reflect the susceptibility of the patient to the hazards of surgery. As an example the authors list cardiovascular disease and stroke as comorbid diseases; however, operative risk depends upon the severity of these conditions. I agree that management of concomitant medical conditions potentially increases chances of survival, however attention to nutritional status should also be part of a comprehensive management strategy. 1 Roche J, Wenn R, Sahota O, Moran C. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ. 2005; 331:1374 2 Aharonoff G, Koval K, Skovron M, Zuckerman J. Hip fractures in the elderly: predictors of one year mortality. J Orthop Trauma.1997; 11(3): 162-5 3 Gruber-Baldini AL, Zimmerman S, Morrison R, Grattan L et al. Cognitive impairment in hip fracture patients: timing of detection and longitudinal follow-up. J Am Geriatr Soc. 2003; 51(9):1227-36. 4 Eneroth M, Oldsson U, Thorngren K. Insufficient fluid and energy intake in hospitalised patients with hip fracture. A prospective randomised study of 80 patients. Clin Nutr. 2005; 24(2): 297-303. Competing interests: None declared |
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Sengwee Toh, Doctoral student Harvard School of Public Health, 02115
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In an article by Roche et al (1), preoperative comorbidities are associated with higher risk of postoperative complications and mortality. Statin treatment has been suggested to lower fracture risk (2). It is possible that the patients included in the study had lower use of statins, either because of lower comorbidities or under-utilization of statins. It would be ideal to include information on prior statin use in the study. Snaith points out that use of statins reduces perioperative mortality. If future studies can further establish the beneficial effect of statins in preventing fractures, statin use in perioperative period or in the management of high risk patients may be considered. 1 Roche J, Wenn R, Sahota O, Moran C. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ. 2005; 331:1374 2 Hatzigeorgiou C, Jackson, J. Hydroxymethylglutaryl-coenzyme A reductase inhibitors and osteoporosis: a meta-analysis. Osteoporos Int. 2005; 16(8):990-8 Competing interests: None declared |
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Usman A Abdulkadir, Clinical Research Fellow in Orthopaedics Wrightington Hospital, Hall Lane, Appley Bridge, Nr Wigan, WN6 9EP
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Dear Editor In the Paper by Roche et al[1] I note that all patients admitted 8th May 1999 to 7th may 2003 were evaluated, with the follow-up ending 7th June 2003, however we have been given mortality figures upto one year from admission,there seems to be a descrepancy of 11 months between last patient(s) admitted 7th may 2003 and their one year data which should be 6th May 2004. However, as already alluded to by the authors there is no significant difference in early mortality in patients who were under joint orthopaedic and geriatric care. Among lots of less populated studies such as that by Clague et al.[2] it has been shown that there is higher mortality in patients with chronic cognitive impairment/dementia, cardiovascular and pulmonary complications and high ASA grade. With the reinforcement of these findings by a more populated study there could be a case for a more structured system where these group of patients have a formal specialist medical assessment within 48-72 hours of admission as a routine if not already warranted pre-operatively, this will put further strain on the physicians but could potentially improve the outcome. Thank you. 1 JJW Roche, RT Wenn, O Sahota, CG Moran. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 2005; 331: 1374-6 2 JE Clague, E Craddock, G Andrews, MA Horan, N Pendleton. Predictors of outcome following hip fracture. Admission time predicts length of stay and in-hospital mortality. Injury 2002; 33: 1-6 Competing interests: None declared |
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Alexander J Butwick, Spr in Anaesthesia Stanford Medical Center, California, USA
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Previous investigations studying the potential effects of different types of anaesthesia following surgery for fractured hips have been reviewed in a recent meta-analysis.(1) The authors suggest that regional anaesthesia may reduce short-term mortality, and has minimal effects on long-term mortality. However, the analysis incorporated studies which were relatively old, with small numbers of participants and ambiguous methodology. Foss et al (2) suggest that future studies aiming to assess the effect of any therapeutic intervention are unlikely to dramatically affect mortality outcome. The impact from multiple pathophysiological alterations in the perioperative period (haemostatic alterations, surgical stress response, nutritional intake, post-operative rehabilitation, sleep disturbance, postoperative analgesia regimens) suggest that measuring the effect of a single intervention would be challenging. In addition, observational studies investigating mortality after hip fracture in the elderly may need to address the previously stated perioperative changes, and should attempt to standardise the preoperative assessment and optimisation of these high—risk patients. The results from the study by Roche et al (3) need to interpreted with caution as the management of patients in the pre- and peri-operative periods was unlikely to have been consistent. 1. Parker MJ, Handoll HH, Griffiths R. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev 2004(4):CD000521. 2. Foss NB, Kehlet H. Mortality analysis in hip fracture patients: implications for design of future outcome trials. Br J Anaesth 2005;94(1):24-9. 3. Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 2005;331(7529):1374. Competing interests: None declared |
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Eddie Vos, maintains health-heart.org Sutton (Qc) Canada J0E 2K0
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In his rapid response, Sengwee Toh proposes statins
should be investigated regarding bone fractures but the study he submits as reference by Hatzigeorgiou
C and Jackson JL states that a beneficial association was only found in case control studies [i.e. selection
biased] and not in randomized controlled studies [with similar populations in both groups].
I quote from the abstract: "The statistically significant improvement in hip fracture risk was seen only in case-control trials, not in either the eight prospective trials or the two randomized controlled trials (RCTs)." [Medline 15744453] Clearly, statins pre-select high-cholesterol subjects amongst the elderly and where increased longevity is always found and conversely, the low-cholesterol and therefore relatively fewer statin users among the elderly are always in the less healthy, increased mortality group. There is no 'bio-logical' reason why the inhibition of the mevalonate pathways by statin would decrease bone fractures. Since it is now mathematical certainty that statins do not save women from any cause of death, [CMAJ Nov. 8 2005], or anyone in a group of over 70 year olds for that matter [the PROSPER trial], I submit that case-control studies should not be used to justify their use and that trials in the elderly would be unethical. vos{at}health-heart.org Competing interests: None declared |
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Sengwee Toh, Doctoral student Harvard School of Public Health, 02215
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In response to Mr. Vos' comments, at least two cohort studies in elderly (not included in the meta-analysis done by Hatzigeorgiou et al) have showed an association of statin use and reduced fracture risk (1, 2). The claim of statin use in reducing fracture risk is based on biological plausibility (3) and findings from in vitro studies (4). Failure of statins to reduce all-cause mortality does not necessary equal failure of statins to reduce fracture risk. I do agree with Vos that case-control studies alone, and other types of observational studies for that matter, are not sufficient to justify use of statins in preventing fracture, large -scale randomised control trials are needed. 1 Scranton RE, Young M, Lawler E et al. Statin use and fracture risk: study of a US veterans population. Arch Intern Med. 2005; 165:2007-2012. 2 Schoofs MW, Sturkenboom MC, van der Klift M et al. HMG-CoA reductase inhibitors and the risk of vertebral fracture. J Bone Miner Res. 2004; 19:1525-1530. 3 Cummings SR, Bauer DC. Do statins prevent both cardiovascular disease and fracture? JAMA. 2000; 283:3255-3257. 4 Mundy G, Garrett R, Harris S et al. Stimulation of bone formation in vitro and in rodents by statins. Science. 1999; 286:1946-1949. Competing interests: None declared |
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Gary Heyburn, Asociate Specialist Orthogeriatrician Trauma Unit, Royal Victoria Hospital, bt12 6ba, Timothy RO Beringer
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We read with interest the paper by Roche et al highlighting the effect of comorbidities on mortality after hip fracture1. However as the paper was primarily concerned with the effect of comorbidities we wonder why the American Society of Anaesthesiologists(ASA) scoring system was not mentioned2. This is a scoring system normally used by anaesthetists to grade comorbidities. It is only used on patients undergoing surgery and is scored on a scale of 1 to 5. The ASA score is one of the variables recorded by the standardised audit of hip fractures in Europe reportedly mentioned as a source on which the study proforma was based. Although far from perfect and subject to interuser variability , the score is relatively simple to use and interpret. In the paper it is quoted that 41% of patients had no comorbidities. In Belfast this is certainly not our experience as most of the patients are graded as ASA 3 ( a patient with severe systemic disease that limits activity, but is not incapacitating). The relative percentages from our ongoing prospective audit of hip fracture patients are as follows ASA 1=2.5%, ASA 2=23%,ASA 3= 59%, ASA 4=13.5%, ASA 5 =1% The other characteristics of the study patients are similar to our own. Either their patients are healthier than our own or it may be that the methodology used by the investigators leads to a underrecording of comorbidities. It would be interesting to see if the simultaneous ASA scores recorded by the anaesthetists , if available, correspond with the level of comorbidities reported in this study. References 1. Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 2005;331(7529):1374. 2. Anon. New classification of physical status. Anesthesiology 1963:24:11 Competing interests: None declared |
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Eddie Vos, maintains health-heart.org Sutton (Qc) Canada J0E 2K0
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Toh's initial reference states that there are already
2 randomised trials that show statins do not prevent bone fractures and his response to mine adds 2 more
selection biased case-control studies [A
and B]
supporting my earlier point that statins select the healthier populations in the elderly. From the first (A): ".. post hoc analyses of statin-randomized trials have failed to find a benefit."
Let me pull out that old statistic that 1 in 50 White and 1 in 100 Black U.S. females may break a hip between the ages 80 and 81 and what do we know from existing relevant randomized trials that should be implemented first? Well, that hip fractures were reduced by 43% in 18 months by 1.2 g/d calcium and 800 IU/d [20 mcg] vitamin D3, vs. placebo. Moreover, average 84 year old French women then built bone density at half the rate that the women on placebo lost bone density [Chapuy MC et al NEJM 1992.]. A similar result in over 65 year olds in the U.K. was found from D3 alone. Both blinded trials used amounts of D3 insufficient to optimize 25(OH)D3. It is here that trials with 'serum level targeted' higher doses of D3 are needed, while statin trials post PROSPER are unethical since pravastatin promoted cancer and did not save lives in the over 70 year olds. Finally Toh cites an in vitro and animal study by MG. Mundy et al. What differentiates both types of studies from the type of human trials called for is that the former are always done in nutritionally and micro-nutrient replete conditions, while the human trials continue in populations we know not to be. Optimizing bone health nutrients first would eliminate those confounders if not obviate the need for pharma approaches to bone health altogether. Competing interests: None declared |
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Barbara C. van Munster, PhD Student / Fellow in geraitric Medicin Academic Medical Centre, Clinical Epidemiology, P.O.Box 22660, 1100 DD Amsterdam, The Netherlands, Johanna C. Korevaar and Sophia E. de Rooij.
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Dear Editor, Roche et al. evaluate in their study comorbidity and postoperative complications after hip fracture and the association between these complications and mortality1. We would like to emphasize the importance of this subject, and furthermore to stress our amazement by the complete absence of delirium as postoperative complication. Postoperative delirium is one of the most frequent complications in elderly patients following operation for hip fracture, with frequencies varying between 16% and 62%. Delirious patients suffered from more postoperative complications than patients without a delirium2. These complications, such as urinary tract infection, can both cause and prolong delirium. Other complications such as heart failure and nutrition problems might be a consequence of a stressful delirium. Moreover, it has been suggested that the anaesthesia, administration of opioids, sleep deprivation and unrelieved pain may play a role in the development of postoperative delirium3. Patients with a postoperative delirium after operation for hip fracture have significantly higher rates of mortality4’5. The established association by Roche et al. between postoperative complications and increased mortality could have been influenced by the presence of delirium as confounding factor. Besides, we believe the total incidence of postoperative complications and order in occurrence could have been different, when delirium would have been taken in account. Reference List (1) Roche JJ, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 2005; 331(7529):1374. (2) 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):119-127. (3) Bitsch M, Foss N, Kristensen B, Kehlet H. Pathogenesis of and management strategies for postoperative delirium after hip fracture: a review. Acta Orthop Scand 2004; 75(4):378-389. (4) 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. (5) Nightingale S, Holmes J, Mason J, House A. Psychiatric illness and mortality after hip fracture. Lancet 2001; 357(9264):1264-1265. Competing interests: None declared |
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Anand Kommuri, Senior SHO- elderly care South Tyneside Hospital, South Shields,NE34 0PL
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This is a very good study on the subset of patients who wuld be under the care of geriatricians in association with the orthopedic team.However, i would like to know some aspects of the study which would be of help to geriatricians. 1.Were the patients in the study ever reviewed by a physician prior to the surgery and would that have made a difference on the postoperative outcome. 2.What was the average duration of hospital stay in the patients with associated co-morbidities postoperatively and was there any difference in recovery patterns between patients transferred to elderly care for rehab and those who were treated in an orthopedic ward. 3.Did chest physiotherapy make any difference to the outcome of postoperative chest infections As part of osteoporosis ward round, we review all elderly patients admitted to orthopedics with fractures and also come to note the high proportion of patients developing clostridium difficile associated diarrheas due to a wide usage of antibiotics and account for significant morbidity. Further studies should also be done to evaluate the functional status and the no of hospital readmissions in the patients who had completely recovered. Competing interests: None declared |
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Christopher G Moran, Professor Trauma & Orthopaedic Surgeon Queen's Medical Centre Nottingham NG7 2UH
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Type of Anaesthesia and Complications: D Reverte-Cejudo Many thanks for your interest in our Paper. We have analysed the type of anaesthesia and its affect on outcome. Of the group of patients included in our analysis, 1129 (46%) had a general anaesthetic (GA), 841 (34%) had a general anaesthetic plus nerve block (GA + NB) and 359 (15%) had a spinal anaesthetic (SA). 87 patients had other combinations and data was missing for 32 patients. The mortality at 30 days for GA was 9.4%, GA +NB was 9.5% and SA was 11.1%. The one year mortality for GA was 30.9%, GA + NB was 31.9% and SA was 30.6%. Obviously, there is no significant difference. We have also looked at the incidence of chest infection after the various types of anaesthetic. 9.5% of patients developed a chest infection after a GA, 5.8% after GA + NB and 12.8% after SA. Univariant Cox regression analysis showed that the incidence of post-operative chest infection was significantly associated with GA (P=0.03) with an odds ratio of 0.59 (95% CI 0.42-0.84). Multi-variant Cox regression analysis, adjusting for anaesthetic type, age and gender confirmed this association. In summary, analysis of the anaesthetic type indicates that general anaesthetic is associated with an increased risk of chest infection but the type of anaesthetic used, at our institution, did not have a significant effect on mortality at 30 days or one year. However, a word of caution is important. The type of anaesthesia was not dictated by protocol, but was chosen by the individual anaesthetist and a large variety of techniques were used. There is no control for selection bias and, in our large series, there is no clear association between the type of anaesthesia and mortality. However, this could be a Type II error and it is not possible (or valid or sensible) to give a recommendation on the type of anaesthesia to be used for hip fracture patients based on our data. Has the risk of general anaesthesia been grossly underestimated?: RG Fiddian-Green Thank you for your interest in our paper. I hope that your questions have been answered in my response to Dr Reverte-Cejudo’s question. The art of anaesthesia is difficult to decipher and makes precise scientific evaluation extremely difficult. There were certainly no major differences in mortality related to anaesthetic type within our institution but, again, I would urge caution in the interpretation of this data. Pulmonary micro-infarction causes chest infection and cardiac failure: F Flachsbart Thank you for your interest in our Paper. Your hypothesis about pulmonary microemboli is interesting. All of our patients received prophylactic doses with LMWH but no therapeutic doses. The treatment of emboli is difficult in the early post-operative period as systemic anticoagulation within five days of hip arthroplasty is associated with a major complication rate of up to 50% because of wound bleeding, etc. Our current policy is only to commence systemic anticoagulation if there is objective evidence of pulmonary embolism and we do not use clinical criteria alone because of the low specificity. Your suggestion that anticoagulation be used to treat these pulmonary complications is interesting but would clearly need further study. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: RJ Snaith Many thanks for your interest in our paper. The policy on our Unit is not to withhold medication pre or post-operatively for patients undergoing hip fracture surgery. Prolonged periods of fasting can be a major problem in this group so we employ a trauma co-ordinator who arranges the scheduling of our trauma lists and we try to ensure that all unnecessary fasting is avoided but, inevitably, we are not always successful. Confirmation rather than new finding: N. Black Thank you for your interest in our paper. It is important to emphasise that the group of patients who suffer hip fracture is entirely different from patients who undergo elective hip replacement for osteoarthritis. The average age of patients undergoing hip replacement in the UK is 71 years old, whereas the average age of hip fracture patients is 80 years old. Patients with hip fracture have far greater co- morbidities and a 30 day mortality that is 10 times greater. I was very interested to read your article but it is important to recognise that this dealt with a completely different population of patients. Hip fractures and comorbidities: E F Epstein Thank you for your interest in our article. We recognise that pre- admission mobility, dependency and cognitive impairment are confounding variables that influence the outcome and mortality following hip fracture surgery. We prospectively collected data on these variables but it was simply not possible to include every single analysis within our paper. Even with adjustment for pre-injury mobility, residential status and mini- mental test score, multiple co-morbidities remained a risk factor for death within 30 days of surgery. The association of under-nutrition and poor outcome was not evaluated within our study and is something we will clearly need to look at in the future. Unfortunately, admission to hospital in the UK does not mean that a patient’s nutrition will improve. I am sure that any doctor who does a ward round during patient meal times would agree with this. Disease severity will obviously influence outcome and prognosis. In an ideal world, every comorbidity would be evaluated with a system that allowed an estimation of severity. Unfortunately, this is not a realistic proposal in the current NHS and we believe that our work reflects everyday practice within the UK. Ideally, all patients with cardiovascular disease should have an Echo pre-operatively to give some objective measure of the severity of cardiovascular disease. This is simply impossible at the present time with our limited facilities. Effect of Co-morbidities and post-operative complications on mortality after hip fracture in elderly patients: S Toh Statins for hip fracture?Not bio—logical: E Vos I would like to thank Dr Toh and Dr Vos for their interest in our article. The use of statins is outside my area of expertise but I was interested to read their correspondence. This is an area that may require evaluation in a prospective randomised study but such a study would be very difficult to organise. I believe that careful observation and deductive reasoning remains a valid scientific method. At the moment, The British Orthopaedic Association is developing a hip fracture database for the UK. This will allow the collection of prospective data on 50,000 patients per year with hip fracture. Would it be worthwhile to collect data on prior statin use in this study (we did not collect it prospectively in our study)? I would be grateful for their views. Hip fractures in the elderly: should all patients have formal specialist medical assessment? UA Abdulkadir Thank you for your interest in our paper. Thank you for pointing out the discrepancy within our manuscript. Mortality data was available, via the National Office of Statistics, for 12 months on all the patients. Thus, you were correct to conclude that the final follow-up for one year data was 06/05/04. I agree entirely with your comments regarding medical care for these patients. Although not included in our analysis, our data shows that the number of patients being admitted with acute medical comorbidities and hip fracture is steadily rising. This is no surprise, with the aging population. This is a population at high risk of medical problems and there is no doubt that we need to develop and evaluate new systems of care for this frail group of patients. The effect of therapeutic interventions on outcome: A J Butwick Thank you for your interest in our paper. I agree entirely with your conclusion that the interpretation of our study needs to be made with caution and I hope that we have made this clear within the discussion. I have provided additional information on the effect of anaesthesia and mortality in the reply to the response by Dr Reverte-Cejudo and I hope you found this helpful. We have guidelines for pre and post-operative management but not a specific protocol. Given the huge variety of confounding factors you highlight, I am certain that it will never be possible to perform a prospective study, in a clinical setting, that controls all variables. We live in an imperfect world and this inevitably results in imperfect studies with imperfect data. However, I do believe that prospective observational studies, such as ours, which include a large number of patients, do provide useful information. Effect of comorbidities and post-operative complications on mortality after hip fracture in elderly people: G Heyburn Thank you for your interest in our paper. We did not include the ASA grade for two reasons. Firstly, data collection of ASA grade by the anaesthetists in our unit was imperfect and was only completed in 30% of cases. This contrasts with data capture for the rest of the study, which was between 98% and 100%. The second reason for not including the ASA grade was the large inter -observer error in this grading system and the lack of clear definitions for each grade. I am surprised that the patients in Belfast have such high comorbidity. Nottingham has relatively high socio-economic depravation when compared to the rest of the UK and I would not expect our population to be a great deal healthier than those in Belfast. Our data was collected by independent research staff and was based on a review of the previous medical records, the use of proformas for the medical staff who evaluated the patients on admission, interview with the patient and discussion with medical staff when there were areas of uncertainty. I am confident that our data collection is reliable and we have re-audited this on a number of occasions. I should be interested to know how you have managed to persuade your anaesthetic colleagues to provide an ASA grade for every patient, as we would be keen to use the same methodology in Nottingham. I would also be interested to know what methods you have used to ensure standardisation of the ASA grades. Competing interests: None declared |
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Nevil P Hutchinson, Consultant Anaesthetist Royal Sussex County Hospital, Brighton, BN2 5BE, Robert W Hearn
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Roche et al.(1)are to be congratulated on their study. However we are concerned at some of the recommendations made in the discussion section. "experience suggests that they may benefit from specialist senior medical input both before and after surgery." This statement seems in some ways obvious, and in others invidious. When they refer to senior medical input, do they mean physicians or anaesthetists? If the former, then we cannot envisage a physician attaining the necessary competencies to deal with the vissicitudes of early post-operative care without the benefit of extra training, as might be gained from an intensive-care programme or a spell in anaesthesia. Although we support the concept of such patients being reviewed by a physician specialising in care of the elderly, we cannot support the idea of a general physician managing the physiological derangments of the early post-operative period. Our concerns are perhaps validated by the suggestion that follows; that patients may benefit from more, rather than less, red cell transfusion. Besides seeming outside the remit of this observational study, their condensation of the vast body of literature on perioperative red cell transfusion to a handful of papers to make a point that goes against the grain of current thinking in this area illustrates how far from their own territory they have strayed. Indeed, it is a little surprising that the editorial process did not query this part of the paper. The rest of this section makes vague proposals about all manner of monitoring and therapeutic modalities with the universal caveat "may" liberally interspersed to the point that they may just have well written "may not". Such transposition would not have altered the meaning of the text, but may have made it easier for the editors. This is a shame as it spoils what is otherwise an excellent piece of work. Perhaps a better suggestion would be an increase in High Dependency Unit beds so that appropriately qualified senior medical staff can manage these challenging patients more closely in the immediate post-operative period. 1. J J W Roche, R T Wenn, O Sahota, and C G Moran Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study BMJ 2005; 331: 1374 Competing interests: None declared |
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Shi-Min Chang, professor of Orthopedics Shanghai, China
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There is always a gap between imagination and reality. Ideally, all related information should be collected prospectively.In an ongoing study of "functional outcome recovery after hip fracture in geriatric patients", we recorded the following items as co- mobidities:(1) diabetes mellitus, (2) congestive heart failure, (3) cardiac arrhythmia, (4) ischemic heart disease, (5) cerebrovascular accident sequelae, (6)renal disease, (7) mal-nutritional status,(8)Parkinson's disease, (9) hypertension, (10) chronic obstructive pulmonary disease, (11) steroids usage, (12) malignancy, (13) dementia, (14) immunity- lymphocyte count. However, have these covered all the scope of medical problems in old people? We propose to develop a world-wide standard creteria for clinical data collection, both for pre-fracture co-morbidities and post-operation complications. Competing interests: None declared |
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Christopher G Moran, Professor Trauma & Orthopaedic Surgeon Queen's Medical Centre Nottingham NG7 2UH
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Delirium as important postoperative complication after hip fracture in elderly patients: BC van Munster Many thanks for your interest in our paper. We measured the cognitive state on admission using the mini-mental test score, but did not routinely measure this following surgery and so had no prospective measure of change in cognitive state following surgery. This is clearly a deficit in our work, but I would like to stress that it is simply impossible to measure every single variable in such a complex group of patients. Delirium is an important problem post-operatively but the major difficulty lies in establishing cause or effect. Delirium is associated with many post-operative complications, including hypoxia, cardiovascular instability, cerebrovascular events, electrolyte imbalance and is a common side effect of many of the drugs used in the peri-operative period. All of these complications were frequent in our study and, anecdotally, did result in a change in cognitive function in some patients. However, we did not specifically measure this effect. I believe that the vast majority of the cases of delirium are associated with such complications, but would accept that once all these potential causes of delirium have been excluded, there is a small subset of patients who have a change in cognitive status where there is no identifiable cause. Unfortunately, our methodology did not allow us to measure this accurately. A good article that needs to be looked at with a different view …. : A Kommuri Thank you for your interest in our paper. To answer your questions: 1. Unfortunately, our hospital, in common with many in the UK, does not have a combined orthogeriatric unit for elderly patients with acute fracture. Patients do not have routine pre-operative medical review. However, all patients with acute medical co-morbidities are reviewed by the medical team. This is usually the medical specialist registrar, rather than the consultant. In addition, all patients are seen by an anaesthetist prior to surgery. One of the limitations of our study design is that we are not able to say whether pre-operative evaluation by a physician would make any difference to outcome. 2. We measured length of stay as a combination of time on the trauma ward plus time on the rehabilitation ward. For the patients who suffered no post-operative complications the median length of stay was 16 days (IQR 11-27). For those with one complication it was 27 days ( 14-39), with two complications it was 24 days (14-38) and with three or more complications it was 39 days (12-60). This data was analysed using linear regression analysis. The patients with no complications stayed an average of 10.2 days less (p<0.01,95%CI:12-8). There was no significant difference in the length of stay between those with one and two complications, but patients with three complications stayed on average 25 days longer (p<0.01,CI:19-31). However, this raw analysis needs to be interpreted with care as it also includes patients who died. Therefore, some patients with short length of stay only had this because they died early. This is a difficult statistical problem and an analytical conundrum, as death is obviously an important variable and exclusion of these patients will also result in significant bias. We should be grateful for any suggestions you have on how to best analyse this type of data. 3. Our study design does not allow us to comment on the efficacy of chest physiotherapy. 4. Infection rates in our unit are low (deep infection 1.3%). We work closely with the microbiologists and the use of prophylactic antibiotics is carefully controlled. We have not had a major problem with the development of clostridium difficile associated diarrhoea. Precise figures for this type of infection will take further analysis and I will provide these as soon as possible. Inappropriate recommendations: NP Hutchinson Thank you for your interest in our paper. I do not know who is best to manage these patients in the peri-operative period. I agree entirely with your comment that these doctors require adequate training. I suspect that training, experience and an enthusiastic approach to this difficult group of patients is the most important factor rather than the precise background of their specialist training (i.e. internal medicine or anaesthetics). As an experienced author, Dr Hutchinson will appreciate that the BMJ issues guidelines for authors which limit the number of references that can be used in any article. The only way we could provide a complete and comprehension review of the subject, together with a total analysis of all our data, would be to produce a long monograph on the research project. The problem is that nobody would read it and then we would not be having this useful debate. Dr Hutchinson can be reassured that I know my limitations and am always grateful to my anaesthetic and medical colleagues for support in their specialist fields. My personal view is that increased high dependency beds would be the most effective way of managing these patients in the early post-operative period and I agree completely with Dr Hutchinson’s suggestion. However, there is no scientific proof that this is the best system of care for hip fracture patients. I believe that our research paper has highlighted the high incidence of post-operative complications in these frail patients within a system of care that is frequently used in the UK. I hope this debate will lead to the development and investigation of better systems of care. Competing interests: None declared |
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Andor Sebestyén, deputy director County Baranya Health Insurance Fund Administration, 7624 Pécs, Nagy Lajos király útja 3. Hungary, Imre Boncz, Ferenc Tóth, and József Nyárády.
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We read with interest the paper of Roche (1) on the analysis of postoperative mortality in elderly patients after hip fracture. The authors highlighted the significant effect of preoperative risk factors, comorbidities and postoperative infections on mortality. The multifactorial causes influencing mortality after hip fracture were reported by other authors. Johansson (2) found significantly higher mortality among patients with mental dysfunction. Elliott (3) mentioned longer pre-operative delay, increasing age, male gender, higher American Society of Anesthesiology score, lower Mental Test score, and lower activities of daily living (Barthel) score associated with increased risks of death. Weller (4) emphasises the effect of hospital type and surgical delay on mortality after surgery for hip fracture. Early mobilization and rehabilitation of patient reduces the postoperative complications and concurrent mortality (5). An important prerequisite of the early mobilization is the application of a surgical method providing early weight-bearing. We conducted a retrospective database study on the correlation between stability of surgery and postoperative mortality. Data derived from the nationwide administrative database of the National Health Insurance Fund Administration. Our study compared the 0-30 and 0-360 days mortality of patients over 65 with femoral neck fracture (ICD-10: S7200) treated with screw fixation (n=2887) or arthroplasty (n=630). The arthroplasty provides early full weight-bearing while the screw fixation allows only gradual and partial weight-bearing. Patients with polytrauma were excluded from the study. We found significantly lower mortality rates in patients with arthroplasty. The odds ratio of the case fatality rate of screw fixation compared to the 1 reference value of arthroplasty at 0-30 days was 1.9873 (CI: 1.3366-2.9547) and at 0-360 days it was 1.8006 (CI: 1.444-2.2452) (P<0.05). Due to the fact that postoperative mortality in elderly patients after hip fracture is influenced by many factors (anaesthesia, traumatology care, rehabilitation), an interdisciplinary approach is needed to reduce postoperative mortality in elderly. References 1. Roche JJW, Wenn RT, Sahota O, Moran CG. Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 2005; 331:1374-1376. 2. Johansson T, Jacobson SA, Ivarsson I, Knutsson A, Wahlström O. Internal fixation versus total hip arthroplasty in the treatment of displaced femoral neck fractutes. A prospective randomized study of 100 hips. Acta Orthop Scand 2000; 71:597-602. 3. Elliott J, Beringer T, Kee F, Marsh D, Willis C, Stevenson M. Predicting survival after treatment for fracture of the proximal femur and the effect of delays to surgery. J Clin Epidemiol 2003; 56:788-795. 4. Weller I, Wai EK, Jaglal S, Kreder HJ. The effect of hospital type and surgical delay on mortality after surgery for hip fracture. J Bone Joint Surg (Br) 2005; 87-B:361-6. 5. Koval KJ, Aharonoff GB, Su ET, Zuckerman JD. Effect of Acute Inpatient Rehabilitation on Outcome after Fracture of the Femoral Neck or Intertrochanteric Fracture. J Bone Joint Surg (Am) 1998; 80:357-64. Competing interests: None declared |
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Christopher G Moran, Consultant Trauma & Orthopaedic Surgeon Queen's Medical Centre Nottingham NG7 2UH
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A good article that needs to be looked at with a different view…: A Kommuri To answer the final part of your question. I have been able to review the rate of clostridium difficile infection on our Trauma Unit. Over the past four years we have had a total of 24 cases in all trauma cases equating to an instance of 0.8%. Approximately half of these infections occurred in hip fracture patients, which confirms my clinical impression that the instance of clostridium difficile infection is very low on our Unit, thanks to good nursing and safe prescribing practice for antibiotics. Competing interests: None declared |
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Romke van Balen, nursing home physician and university lecturer Leiden University Medical Centre, dept Public Health and Primary Health Care, po box 2088, 2301 CB
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Dear Sir,
We read with interest ”Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study” ( Roche JJW, Wenn RT, Sahota O, Moran CG, BMJ 2005; 331:1374-9)). Roche et al. recommend evaluation of different systems of medical care to establish whether these can reduce the incidence and severity of the complications. We were surprised to read that, in contrast to our findings, in Nottingham University Hospital only 20 % had a postoperative complication during hospital stay and that 40% had no comorbidity at hospital admission. We performed a study to investigate the effect of an early discharge program on mortality and complications of elderly hip fracture patients 1, 2 Patients (n= 208) were followed up until 4 months after hospital admission or death. Comorbid conditions were only registered if patients had complaints, used medication, or experienced a functional limitation as a consequence of these comorbidities at hospital admission. All medical events that required therapeutic intervention were recorded as complications. First, 102 patients remained in hospital for average 26 days; second, 106 patients were enrolled in an early discharge program (average stay 13 days). See table 1 for main characteristics and outcome in regard to comorbidity and complications. Main predictive factors for complications and mortality were age, institutional residence before fracture and number of comorbidities. Main conclusion was that an early discharge program did not affect the number or nature or outcome of complications but shifted the location of occurrence to outside the hospital. The differences between our findings and the results of the study performed in Nottingham could be explained by different definitions of comorbidity and complications. Another explanation, more healthy hip fracture patients in Nottingham, UK, than in Rotterdam, the Netherlands, seems unlikely especially because mortality is comparable. These difference in definitions makes comparison of studies of comorbidity and complications difficult. Moreover,with (in the Netherlands but also in the UK) shortening of the hospital stay of hip fracture patients, we would like to emphasize that the registration, diagnosis and treatment of postoperative complications should not stop at hospital discharge although we are aware of the fact that elderly people with the same characteristics but without a hip fracture also experience many medical events. R. van Balen, MD, PhD
ref: 1. Balen R van, Steyerberg EW, Polder JJ, Ribbers MTL, Habbema JFD, Cools HJM. Hip fracture in elderly patients: outcomes for function, quality of life, and type of residence. Clin Orthop 2001;390:232-43 2. Balen R van, Steyerberg EW, Cools HJM, Polder JJ, Habbema JDF. Early discharge of hip fracture patients from hospital. Transfer of costs from hospital to nursing home. Acta Orthop Scand 2002;73;4915.
Competing interests: None declared |
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