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Medical Complications and Outcomes After Hip Fracture Repair
Valerie A. Lawrence, MD;
Susan G. Hilsenbeck, PhD;
Helaine Noveck, MPH;
Roy M. Poses, MD;
Jeffrey L. Carson, MD
Arch Intern Med. 2002;162:2053-2057.
ABSTRACT
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Background Most evidence guiding perioperative medical risk management of patients
undergoing hip fracture repair focuses on cardiac and thromboembolic risk.
Little is known of the relative clinical importance of other complications.
Objective To systematically map incidence and outcomes of a broad spectrum of
medical complications after hip fracture repair.
Methods Retrospective cohort study of patients 60 years or older in 20 academic,
community, and Veterans Affairs hospitals. Data on complications and mortality
were abstracted from medical records by trained abstractors using standardized,
pretested forms or the National Death Index.
Results Of 8930 patients, 1737 (19%) had postoperative medical complications.
Cardiac and pulmonary complications were most frequent (8% and 4% of patients,
respectively). Similar numbers of patients had serious cardiac or pulmonary
complications (2% and 3%, respectively). Other complications were gastrointestinal
tract bleeding (2%), combined cardiopulmonary complications (1%), venous thromboembolism
(1%), and transient ischemic attack or stroke (1%). Renal failure and septic
shock were rare. After the index complication, 416 patients had 587 additional
complications. Mortality was similar for serious cardiac or pulmonary complications
(30 day: 22% and 17%, respectively; 1 year: 36% and 44%, respectively) and
highest for patients with multiple complications (30 day: 29%-38%; 1 year:
43%-62%). Complications and death occurred significantly earlier for serious
cardiac than for serious pulmonary complications (1 vs 4 days, 2 vs 8 days, P<.001); length of stay for patients surviving these
complications was similar.
Conclusions Most patients had no medical complications after hip fracture repair.
Serious cardiac and pulmonary complications were equally important in frequency,
mortality, and survivors' length of stay. Patients with multiple complications
had especially poor prognosis.
INTRODUCTION
HIP FRACTURES are an important cause of morbidity and mortality in elders,
with more than 225 000 hip fractures occurring annually in the United
States in patients older than 50 years.1-2 Internists
are frequently asked to help with preoperative risk assessment and perioperative
medical management. Effective risk management requires an understanding of
the full clinical picture of postoperative medical complications, but most
research on perioperative risk has focused on cardiac complications. Recent
evidence suggests that pulmonary complications may be as clinically important,
and, other than venous thromboembolism, we know little about the full spectrum
and outcomes of medical complications after hip fracture repair.3-5 Previous
studies are small, methodologically flawed, or assess only a few complications.6-53 We
therefore analyzed a large cohort of 8930 patients having hip fracture repair
to (1) specifically compare the incidence and outcomes of pulmonary and cardiac
complications and (2) describe the incidence and outcomes of other postoperative
medical complications.
PATIENTS AND METHODS
STUDY DESIGN AND PATIENT POPULATION
We performed a retrospective cohort study of consecutive patients 60
years or older with hip fracture undergoing surgical repair at 20 study hospitals
between 1982 and 1993. Participating hospitals in New Jersey, Texas, Pennsylvania,
and Virginia included 5 university-affiliated hospitals, 2 Veterans Affairs
medical centers, 4 community teaching hospitals, and 9 community hospitals.
The study was approved by the Institutional Review Boards at all participating
facilities. The cohort has previously been described and excluded patients
who refused blood transfusion; had metastatic cancer, multiple myeloma, multiple
trauma, additional operation beside hip fracture repair, or above-the-knee
amputation; or were paraplegic or quadriplegic.54 We
further excluded patients with acute preoperative medical complications and
those with missing information on the date or type of postoperative complications.
OUTCOMES
Medical complications were defined by explicit, standardized criteria
specifically designed for retrospective chart abstraction. Mortality during
hospitalization, at 30 days, and at 1 year was determined by chart audit or
the National Death Index. We assessed inpatient complications and length of
hospital stay until death, discharge, or 30 days, whichever occurred first.
Because 10% of patients underwent surgery 2 days or more after admission,
length of stay was defined from the day of surgery until discharge. We defined
the index complication as the first postoperative medical complication. If
additional complications occurred within 24 hours, the index event was defined
as one of multiple complications. Complications occurring later than 24 hours
after the index event were defined as additional complications. For example,
for a patient with pneumonia followed by a myocardial infarction 12 hours
later, the index event was classified as a combined cardiopulmonary complication.
In contrast, for a patient with pneumonia followed by a myocardial infarction
3 days later, the index event was classified as pneumonia and the myocardial
infarction as an additional complication.
We screened for myocardial infarction in patients with (1) postoperative
chest pain and at least 1 postoperative electrocardiogram (ECG); (2) cardiac
enzymes and at least 1 postoperative ECG; or (3) at least 2 ECGs performed,
with one during the postoperative period. In patients who met these criteria,
up to 3 ECGs were interpreted by the ECG center at the University of Minnesota,
Minneapolis, and myocardial infarction was defined by the criteria of the
Atherosclerosis Risk in Communities Study.55 Myocardial
infarction was definite if any of the following criteria were met: (1) evolving
diagnostic ECG; (2) diagnostic ECG and abnormal cardiac enzyme levels; or
(3) chest pain, abnormal cardiac enzyme levels, and either evolving ST-T wave
or equivocal changes on ECG. Myocardial infarction was considered probable
for (1) chest pain and abnormal cardiac enzyme levels or (2) abnormal cardiac
enzyme levels and evolving ST-T wave changes on ECG. Myocardial infarction
was categorized as possible if the only abnormality was elevated cardiac enzyme
levels.
We defined congestive heart failure by (1) physician diagnosis or chest
radiography consistent with new congestive heart failure or pulmonary edema
and (2) new or increased treatment with diuretics, digoxin, or afterload-reducing
agents. Arrhythmia was defined as chart documentation (progress note, consultation
note, or ECG) of ventricular fibrillation, ventricular tachycardia, atrial
fibrillation, atrial flutter, supraventricular tachycardia, paroxysmal atrial
tachycardia, or multifocal atrial tachycardia. The definition of conduction
defect was chart documentation (progress note, consultation note, or ECG)
of Mobitz type II block, second-degree heart block, complete heart block,
third-degree heart block, sinus pause (>2 seconds), sinus arrest, sick sinus
syndrome, or tachycardia-bradycardia syndrome. We defined emergency cardioversion,
pacemaker placement, or cardiopulmonary resuscitation as chart documentation
in progress notes or consultation notes.
Definite pneumonia was defined as antibiotics plus postoperative chest
radiograph consistent with infiltrate or physician diagnosis of pneumonia.
Pneumonia was defined as possible if any of the following criteria were met:
positive chest radiograph, physician diagnosis, or antibiotic treatment. We
defined respiratory failure as intubation maintained past midnight on the
day of hip fracture repair or reintubation postoperatively.
Gastrointestinal tract bleeding was defined as chart documentation of
hematemesis, coffee-ground emesis, blood per nasogastric tube, melena, or
blood per rectum. Hypotension requiring vasopressors in association with other
complications was considered secondary to the primary complication (eg, pneumonia,
septic shock, or arrhythmia). We defined isolated hypotension requiring vasopressors
as systolic blood pressure less than 90 mm Hg treated with vasopressor agents,
excluding low-dose dopamine. Renal failure was defined as a decline in renal
function requiring hemodialysis. Deep venous thrombosis or pulmonary embolism
required positive duplex ultrasound or venogram, high-probability ventilation-perfusion
scan, or positive pulmonary angiogram. We defined transient ischemic attack
or cerebrovascular accident by physician diagnosis or evidence of new stroke
on computed tomography or magnetic resonance imaging. Septic shock was defined
by physician diagnosis.
To more accurately describe the epidemiology of postoperative cardiac
and pulmonary complications, we categorized these complications as serious
or not serious, using definitions determined by consensus of the investigators.
The following cardiac and pulmonary complications were classified as serious:
definite or probable myocardial infarction, emergency cardioversion, pacemaker
insertion, ventricular fibrillation, respiratory failure, and pneumonia. In
addition, other cardiac complications were explicitly considered serious if
associated with any of the following indicators: cardioversion, pacemaker
insertion, cardiopulmonary resuscitation, ventricular fibrillation, ventricular
tachycardia, supraventricular tachycardia, sick sinus syndrome or other conduction
defect, or hypotension requiring vasopressors.
DATA COLLECTION
Trained abstractors reviewed the entire medical record using standardized,
pretested abstraction forms, an explicit abstraction process, centralized
training of abstraction supervisors from the 4 study sites, and a systematic
prospective data quality assurance process.54 Data
collected included demographic characteristics, medical comorbid conditions,
smoking and alcohol use, medications used before admission and during hospitalization,
preoperative physical examination, laboratory data, cointerventions (eg, thromboembolism
prophylaxis, antibiotic prophylaxis, and physical therapy), variables for
type of fracture and repair, intraoperative data, postoperative complications,
and mortality.54 Chart data to assess independence
in activities of daily living were collected for a global assessment across
all activities and for specific data regarding bed-to-chair transfer, walking
or wheelchair use, feeding, and basic grooming.
ANALYSIS
Complication and mortality rates were calculated with 95% confidence
intervals. Time in days (from surgery to complication and from complication
to death or discharge) was calculated with median values and interquartile
ranges. Statistical comparisons of complication rates, mortality, and time
to complication, death, and discharge were limited to the largest patient
groups: all and serious cardiac complications; all and serious pulmonary complications,
gastrointestinal tract bleeding; and combined cardiopulmonary complications.
We used an analysis of variance approach with  2 (categorical
data) or Kruskal-Wallis (continuous data) tests for independence; if results
were statistically significant, we proceeded to selected pairwise comparisons.
RESULTS
There were 9598 patients potentially eligible for the study. After 637
patients (6.6%) with preoperative medical complications and 31 patients with
missing data were excluded, the final cohort comprised 8930 patients (Table 1). The study population was elderly
(mean age, 80.2 ± 8.7 years), primarily female (79%), white (87%),
and living at home at the time of the fracture (73%). Patients had significant
chronic disease as suggested by multiple markers of comorbidity (individual
diseases, number of prescribed medications, Charlson Comorbidity Index score,
and American Society of Anesthesiologists category). A minority (15%) of patients
were dependent in activities of daily living.
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Table 1. Demographic Characteristics of Cohort
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Table 2 shows the patient-based
incidence of index complications and associated mortality. Of 8930 patients,
81% (7193) had no postoperative medical complications. In the 1737 patients
with complications, 1531 (17%) had 1, 182 (2%) had 2, and 24 (0.3%) had 3
or more complications as their index event. Cardiac and pulmonary complications
were most frequent (8% and 4% of patients, respectively). However, most cardiac
complications were not serious; the incidences of serious cardiac and serious
pulmonary complications were similar (2% and 2.6%, respectively). Other index
complications included combined cardiopulmonary (1.3% of patients), gastrointestinal
tract bleeding (2% of patients), and venous thromboembolism, transient ischemic
attack or cerebrovascular accident, isolated hypotension, and multiple complications
(in about 1% of patients for each). Renal failure requiring dialysis and septic
shock were both rare.
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Table 2. Patient-Specific Index Complications and Mortality in 8930
Patients Undergoing Hip Fracture Repair*
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Of the 1737 patients with complications, 206 (12%) had multiple complications
as their index event. In 416 patients (24% of those with complications), an
additional 587 complications occurred more than 24 hours after the index event.
Among additional complications, cardiac and pulmonary remained most frequent,
with 212 and 200 complications, respectively.
Overall inpatient mortality was 3.3% (292/8930). Patients without complications
had a much lower inpatient mortality rate than patients with any complications
(0.5% vs 15%). Similarly, mortality at 30 days and at 1 year was significantly
lower for patients without complications (Table 2; P<.001 for both). Patients
with multiple complications and renal failure had the highest mortality rates
(29%-38%). Cardiac, pulmonary, and cerebrovascular complications were associated
with higher mortality rates than were gastrointestinal tract bleeding, venous
thromboembolism, and unexplained hypotension.
Patients with both, or combined, cardiac and pulmonary complications
as their index event had higher 30-day and 1-year mortality than patients
with either cardiac or pulmonary complications alone (P<.001). Overall, mortality was higher for patients with pulmonary
than cardiac complications, but was similar for patients with serious cardiac
and pulmonary complications.
Cardiac complications occurred significantly earlier postoperatively
than pulmonary complications (1 vs 4 days; P<.001
for both all and serious complications). For patients who survived, length
of stay was similar (13 and 12 days) after cardiac or pulmonary complications.
However, for those who died, death occurred significantly earlier after serious
cardiac than serious pulmonary complications (2 vs 8 days; P<.001). For other complications, median days between surgery and
the index complications were variable and time to death after the index complication
was often protracted.
Respiratory failure was classified as a pulmonary complication regardless
of its association with other complications. The 116 index cases of respiratory
failure were distributed as follows: 38 isolated, or primary, cases; 3 cases
with pneumonia; 33 cases with cardiac complications; 19 cases with pneumonia
plus cardiac complications; 11 cases with noncardiac complications; and 12
cases associated with noncardiac complications combined with other cardiac
or pulmonary complications. If the 33 patients with respiratory failure and
cardiac complications were reclassified as patients whose index complication
was cardiac, the number of serious pulmonary and serious cardiac complications
would remain similar (196 pulmonary vs 211 cardiac instead of 229 pulmonary
vs 178 cardiac).
COMMENT
We systematically evaluated the spectrum, incidence, and clinical outcomes
of medical complications after hip fracture repair. Most patients (81%) had
no postoperative complications and their mortality was relatively low. For
those with complications, most had only one, but a substantial minority (12%)
had multiple complications as their index event. Mortality was substantially
higher in patients with postoperative complications and was especially high
for those with multiple complications.
Overall, the number of patients with cardiac complications was twice
the number with pulmonary complications, consistent with the common perception
that cardiac events are the most frequent postoperative medical complication.57 However, the higher frequency of cardiac complications
was entirely explained by nonserious complications. For serious pulmonary
and cardiac complications, incidence and mortality were quite similar. For
those who survived these complications, length of hospital stay was also similar.
Among those who died, serious cardiac complications and subsequent death occurred
significantly earlier postoperatively than did serious pulmonary complications.
We searched MEDLINE for studies of mortality or medical complications
after hip fracture repair published since 1966 and found 48 with potentially
relevant data.6-53 Sex
and age characteristics of these studies were similar to those of our large
cohort, but the largest involved only 723 patients and mean size was only
222.6-53 Among
studies published since 1990 with at least 100 patients and mortality data,
mortality rates were 7% to 11% in hospital, 3% to 13% at 30 days, 10% to 28%
at 3 months, and 17% to 43% at 1 year after surgery.1, 6, 12, 21, 29, 41-43,45-46,48 Our
30-day and 1-year mortality rates were at the low end of these ranges, at
4% and 16.4%, respectively.
Few recent studies with at least 100 patients have reported specific
medical complications after hip fracture repair.29, 41-42,46, 48 Among
these, incidence was 7% for cardiac complications, 12% for cardiac failure
(one study, 317 patients), and 6% to 10% for pneumonia (3 studies, 100-317
patients).29, 41-42,48 Rates
from our study are similar but somewhat lower for serious pulmonary and cardiac
complications.
This study had a number of strengths and was designed to address limitations
in previous research. It is the largest study in a single surgical setting
comprehensively evaluated for postoperative complications and their outcomes.
We systematically reviewed medical records using a detailed abstraction instrument
and explicit criteria for index complications and their severity.
This study's primary limitation is its retrospective chart audit design.
Our ascertainment strategy targeted clinically apparent events and so may
have underestimated incidence of some complications. For example, not all
patients had routine postoperative ECGs, and screening for myocardial infarctions
using cardiac enzymes was rarely performed. We detected fewer thromboembolic
events than have prophylaxis trials in which routine surveillance was performed,
although our results represent clinically recognized events.58 In
addition, the age of our data (1982-1993) may be a limitation. However, cohort
studies large enough to accurately evaluate rates of complications will necessarily
span a number of years and/or multiple sites and the data's age is similar
to that of other recently published studies in leading journals.59-61 Changes
in rates of complications since these data were collected may include fewer
myocardial infarctions because of increasing use of perioperative  -antagonists,
less venous thromboembolism with more aggressive prophylaxis, and possibly
less pneumonia with earlier ambulation. Such trends are unlikely to change
the important finding of this study that serious cardiac and pulmonary complications
are similar in frequency and outcomes.
In contrast to other studies of elective surgery, this study tackles
the urgent setting of hip fracture repair with (1) the largest cohort to date
and (2) expanded outcome assessment of complication severity, length of stay
stratified by time of complication and survival status, and mortality at several
time points. These results indicate that most elderly patients have an uncomplicated
course after hip fracture repair. Of those with complications, most have only
one. Few patients have multiple complications, but these patients have the
worst prognosis and little is known about risk management for them.3, 61
Most intervention research has focused on perioperative cardiac risk
reduction. This study indicates that serious pulmonary and cardiac complications
are equally clinically important in incidence, mortality, and length of stay
after hip fracture repair and corroborate results from a previous study of
abdominal surgery.3 The evidence base for pulmonary
operative risk lags behind that for cardiac risk, especially regarding identification
of reliable risk factors and risk reduction strategies.52-53,62-63
AUTHOR INFORMATION
Accepted for publication February 27, 2002.
This study was supported by grant 1 RO1HSO7322 from the Agency for Healthcare
Research and Quality (formerly the Agency for Health Care Policy and Research),
Washington, DC, and the Veterans Evidence-Based Research Dissemination and
Implementation Center (VERDICT), San Antonio, Tex, a Veterans Affairs Health
Services Research and Development Center of Excellence.
Corresponding author: Valerie A. Lawrence, MD, Division of General
Medicine, Department of Medicine, UTHSCSA, 7703 Floyd Curl Dr, Mail Code 7879,
San Antonio, TX 78229-3900 (e-mail: vlawrence{at}uthscsa.edu).
From the Division of General Medicine, Audie L. Murphy Division, South
Texas Veterans Health Care System, San Antonio (Dr Lawrence), and Division
of Medical Oncology (Dr Hilsenbeck) and Division of General Medicine (Dr Lawrence),
Department of Medicine, University of Texas Health Science Center at San Antonio;
Division of General Internal Medicine, Department of Medicine, University
of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School,
New Brunswick, NJ (Ms Noveck and Dr Carson); and Division of General Internal
Medicine, Department of Medicine, Brown University School of Medicine, Providence,
RI, and Memorial Hospital of Rhode Island, Pawtucket (Dr Poses).
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