Osteoporos Int (2010) 21 (Suppl 4):S535–S546
DOI 10.1007/s00198-010-1418-8
REVIEW
How to optimize patients for geriatric fracture surgery
D. Marsland & P. L. Colvin & S. C. Mears & S. L. Kates
Received: 18 August 2010 / Accepted: 14 September 2010
# International Osteoporosis Foundation and National Osteoporosis Foundation 2010
Abstract Low-energy fragility fractures account for >80%
of fractures in elderly patients, and with aging populations,
geriatric fracture surgery makes up a substantial proportion
of the orthopedic workload. Elderly patients have markedly
less physiologic reserve than do younger patients, and
comorbidity is common. Even with optimal care, the risk of
mortality and morbidity remains high. Multidisciplinary
care, including early orthogeriatric input, is recommended
to anticipate and treat complications. This article explores
modern treatment strategies for this challenging group of
patients and provides guidance for systematically preparing
and optimizing elderly patients before surgery, based on
best available current evidence and recommendations by
relevant health organizations.
Keywords Osteoporosis
D. Marsland : S. C. Mears
Department of Orthopaedic Surgery, Johns Hopkins University/
Johns Hopkins Bayview Medical Center,
Baltimore, MD, USA
P. L. Colvin
Division of Geriatric Medicine, The Johns Hopkins University/
Johns Hopkins Bayview Medical Center,
Baltimore, MD, USA
S. L. Kates
Department of Orthopaedic Surgery, University of Rochester,
Rochester, NY, USA
S. C. Mears (*)
c/o Elaine P. Henze, BJ, ELS, Medical Editor and Director,
Editorial Services, Department of Orthopaedic Surgery,
Johns Hopkins Bayview Medical Center,
4940 Eastern Ave., #A665,
Baltimore, MD 21224-2780, USA
e-mail: ehenze1@jhmi.edu
Introduction
Osteoporosis is the most common bone disease in adults
[1], and in patients ≥75 years old, low-energy trauma
causes >80% of fractures, signifying the fragility of such
patients [2]. Geriatric fracture surgery now constitutes a
large portion of the orthopedic workload, with major cost
implications [2]. Surgical treatment for elderly patients
poses unique clinical challenges and requires strategies that
incorporate multidisciplinary input to optimize patient care.
Even with optimal care, elderly trauma patients have
significantly higher morbidity and mortality compared with
the general population [3] and often require expensive
aftercare after hospital discharge. In one study of 100
consecutive patients >70 years old who sustained multiple
injuries, 94% had been living independently before hospi-
talization, but at the 1-year follow-up, 72% were living in
nursing homes [4].
Currently, hip fractures comprise approximately one
quarter of the fragility fractures requiring hospital admis-
sion [5], and despite improvements in surgical and medical
services, mortality remains high at approximately 30% at
1 year [6].
Overall, hip fracture incidence has declined in many
countries in the last decade, possibly as a result of a general
improvement in health, but the incidence of hip fracture in
patients >90 years old is increasing in many countries [2].
An understanding of age-related changes that these patients
undergo may help to optimize surgical and medical care
and plan discharge to a suitable environment. Modern
protocols recommend early orthogeriatric input for patients
[7] and delivery of perioperative care by anesthesiologists
experienced in dealing with elderly patients [7].
This article explores the comorbidity associated with
elderly patients and how to identify patients at risk for
S536
developing complications. A systematic approach to the
medical optimization of patients for surgery based on
current evidence is discussed, and the overall goals for
care are described, with a particular focus on the functional
needs of elderly patients.
Identifying at-risk patients
The elderly patient is a complex entity medically, cogni-
tively, psychosocially, and functionally. According to the
World Health Organization [8], the older or elderly person
has been agreed on by the United Nations as being
≥60 years old. However, the World Health Organization
[8] acknowledges that the definition of “elderly” varies
between countries based on population life expectancy; for
example, in Africa, ≥50 years old is considered old.
Comorbidity, defined as “a concomitant but unrelated
pathologic or disease process” [9], commonly exists in
elderly patients with fractures; in decreasing frequency, the
most common comorbidities are cardiovascular disease,
chronic obstructive airways disease, cerebrovascular
disease, diabetes mellitus, and renal disease [10]. In one
report of patients with hip fractures, 35% were identified as
having at least one comorbidity and 17% as having two
comorbidities [11]. The number and type of comorbidities
directly influence outcome in patients with fractures [12,
13]. Comorbidity can be used to predict the risk of death
and the development of complications from surgery
perioperatively and postoperatively [12]. It may also
directly correlate with rehabilitation potential [14]. The
goals of care may be strongly influenced by the presence of
concurrent disease and should be considered on an
individual patient basis.
Numerous scoring systems for predicting outcome have
been developed and validated, and they may identify
patients at high risk so that more effective monitoring and
treatment can be delivered early and thus potentially reduce
complications [15]. For example, the Charlson Comorbidity
Index [16] has been validated to predict mortality, disability,
readmission rate, and length of stay [15]. Compared with
other scales, such as the Charlson Comorbidity Index,
Cumulative Illness Rating Scale, Index of Coexistent
Diseases, Kaplan scale, and Chronic Disease Score, the
Geriatrics Index of Comorbidity has been shown to be the
best predictive scoring system for mortality in elderly
patients [17]. Although many such scores are useful for
research purposes, they can be complex and difficult to use
in clinical practice. Some scoring systems, such as the
Physiologic and Operative Severity Score for Enumeration,
are useful for the general population but may be of limited
value for specific, homogenous elderly patients with fracture
[12, 18]. The Disease Count Index has been used for
Osteoporos Int (2010) 21 (Suppl 4):S535–S546
in-patient rehabilitation, but it has not been validated for use
for the care of patients with acute fractures [15].
Specific indicators known to influence outcome, such as
electrolyte and fluid balance [10, 19], are complicated by
the vascular stiffening and reduced cardiac and renal
physiologic reserve observed in the elderly. Numerous
predictive factors have been identified in association with
increased mortality in patients with hip fracture, including
general health, preoperative mobility, cognitive state, and
preoperative residence [10, 20]. One study of 2,963 patients
with hip fracture indicated 3% had existing renal disease
[10], 20% of those patients had low serum sodium, 9% had
abnormal serum potassium, and 25% had elevated serum
creatinine. The risk of mortality was found to be signifi-
cantly increased in patients with abnormal sodium (low or
raised) and elevated creatinine [10]. Elevated urea has also
shown to be an independent risk factor for increased
mortality at all time intervals from 30 days to 2 years after
surgery [10].
The Nottingham Hip Fracture Score has recently been
validated as a tool with which to predict mortality at
30 days, based on a study of 4,967 patients with a 30-day
mortality of 10.2% [12]. Independent predictors for
mortality in patients with hip fracture included age
>86 years, male sex, two or more comorbidities, a mini-
mental test score ≤6 of 10, and anemia. This tool is simple
to use and may be valuable for internal audit and also for
more accurate, interhospital outcome comparisons, such as
mortality with adjustments made for case mix, which
previously has not been possible. Clinical decision making
by anesthesiologists and surgeons may be modified
according to an accurate assessment of risk, and a scoring
system may allow a better informed discussion among
medical teams, patients, and relatives.
Timing of surgery
Studies assessing the effect of surgical delay on clinical
outcome in elderly fracture patients have been largely
confined to hip fractures. Early surgery potentially reduces
mortality and morbidity by allowing early mobilization.
The recommendation that patients with hip fracture undergo
surgery within 24–48 h is based on cohort studies [21–24]
and has been embraced by several consensus guidelines [5,
7]. Early surgery has also been shown to reduce hospital
length of stay and severe pain [24, 25], but the effect on
mortality is less clear [26]. If the time to surgery is
determined by the number and severity of comorbid
conditions, as has been suggested by one study that
controlled for comorbid conditions [25], then the higher
mortality associated with delay may be secondary to the
comorbid conditions and may not be directly the result of a
Osteoporos Int (2010) 21 (Suppl 4):S535–S546
delay in surgery. Data from a modern large surgical unit
failed to show a reduction of mortality after hip fracture
surgery performed before 48 h, but it did show that a delay
>4 days significantly increased mortality [26].
Early surgery for high-energy fractures in the elderly is
also supported [3], although the evidence is limited. In one
study of 326 patients >60 years old, the mortality rate was
18% for patients with delayed treatment and 11% in
patients whose fractures were stabilized within 24 h,
although the difference was not statistically significant
[27]. Observational studies have concluded that early
fracture stabilization and early total care in the elderly
reduce the risk of pulmonary complications, systemic
sepsis, and subsequent multiorgan failure [28, 29].
Although early surgery is supported in the literature,
early surgery without adequate fluid resuscitation and
proper medical optimization may be detrimental [7]. In
general, we suggest surgical repair of hip fracture within the
first 24–48 h of admission for patients without clinically
significant medical conditions who need to be stabilized. In
the absence of strong research evidence for other fracture
groups, the timing of surgery should be tailored to the
patient according to individual risk assessment.
Systematic preparation of the patient for early surgery
A careful history and physical examination are essential for
preoperative risk assessment. Relevant risk factors can be
identified, and coexisting medical conditions can be
stabilized to decrease postoperative complications. The
potential benefit of interventions that may delay surgery
should be weighed against the possibility that prolonged
bed rest may worsen deconditioning, muscle loss, and bone
loss and may increase the risk of complications of
immobility, such as skin breakdown, deep venous throm-
bosis, and pneumonia. Measures to prevent decubitus
formation and thromboembolic prophylaxis should be
considered for patients when surgery is delayed.
Most patients with acute fractures present with some
degree of dehydration, which is caused by poor oral intake
before arriving at the hospital, by the effects of opioid
analgesics for pain control, and by having food and water
withheld in anticipation that they may go directly to
surgery. Fluid status should be assessed, and intravenous
fluids should be provided to correct any deficit and to
maintain hydration. Older, frail patients are particularly at
risk of dehydration, especially if there is a lengthy time
delay before fluid resuscitation [10] or if there is a delay in
diagnosis [30]. Restoration of fluid balance is therefore
essential, and the optimization of intraoperative intravascu-
lar volume has been shown to reduce hospital length of stay
and shorten postoperative recovery [31]. If possible, fluid
S537
resuscitation should be commenced before hospital admis-
sion [5]. Protocol-guided fluid resuscitation may be useful,
especially for the initial fluid management of patients on
admission to the emergency department, but to our
knowledge, their efficacy has not been studied. Although
we have found no clear guidance regarding fluid manage-
ment in elderly patients with fractures, the medical team
should aim to correct electrolyte imbalance and dehydra-
tion, and saline is considered the most appropriate fluid [5].
However, fluid status is not always easy to determine
clinically in elderly patients, and given their reduced
cardiovascular reserve, fluid overload is possible. The
concept of aggressive fluid resuscitation guided by invasive
blood pressure monitoring in patients with hip fracture has
emerged in recent years [32], but few hospitals offer this
level of input because of restrictions in high-dependency
unit bed availability and unproven efficacy. More research
is required before this type of protocol can be routinely
recommended because the long-term benefits and potential
for increased mortality are unknown [32].
A thorough evaluation may uncover previously unrecog-
nized medical conditions, but it should focus on common
concerns for elderly patients preparing to undergo orthope-
dic surgery, and particular attention should be paid to the
risk of cardiovascular, pulmonary, cognitive, and diabetic
complications.
Analgesia
Pain after hip fracture is severe and therefore analgesia
should be administered as a priority [7]. Effective analgesia
and good pain control may reduce the development of
postoperative delirium, and many hospitals now employ
dedicated acute pain teams whose services should be
invoked early [5]. In fact, confused patients often receive
less adequate analgesia because medical staff commonly
rely on the self-reporting of pain and potentially miss other
physiologic and behavioral clues such as moaning, tachy-
cardia, or sweating [5]. Titration of intravenous opiates is
considered the most effective analgesic method and should
be administered before transfer of the patient to a trolley or
radiography table [7]. Patients with hip fracture may also
benefit from regional analgesia techniques such as nerve
blocks [33].
Cardiovascular investigation and treatment
The revised Goldman Cardiac Risk Index, one of several
risk indices available with which to estimate perioperative
cardiovascular risk, is simple to use, validated, and has
good predictive value [34]. Patients at low cardiovascular
S538
risk (approximately 88% of all patients [35]) usually do not
require additional evaluation before surgery. Patients at
high cardiovascular risk (approximately 2% of all
patients) are often treated with beta-blockers [35, 36]
even if they do not have other indications for starting beta-
blockers, and they usually require additional cardiac
consultation before surgery. Patients at intermediate
cardiovascular risk (approximately 10% of all patients
[35]) are a heterogeneous group: some are treated with
medications alone and some undergo noninvasive testing
to determine whether additional testing is necessary. In
general, the recent trends in managing perioperative
cardiovascular risk have been to minimize delay to
surgery and decrease the use of beta-blockers.
A common cause for delaying surgery is the completion
of investigations for the consideration of revascularization
interventions before surgery. The indications for revascu-
larization are the same for surgical patients with high
cardiovascular risk but with stable coronary artery disease
as it is for patients who are not having surgery. Revascu-
larization is indicated for patients with left main coronary
artery disease, severe three-vessel disease, or angina
refractory to medical therapy. Surgical patients with stable
coronary artery disease but without these established
indications for revascularization may not benefit from
preoperative revascularization [37]. Moreover, any reduc-
tion in cardiovascular risk that is provided by preoperative
revascularization is in part counterbalanced by the risks
associated with the revascularization procedure itself [38]
and with the risks attributable to a delay in surgery. The
Coronary Artery Surgery study [38] showed that patients
treated with coronary artery bypass graft before noncardiac
surgery had a lower risk for cardiac events during the
surgery (0.9% versus 2.4% for patients treated without
revascularization), but that the benefit was offset by the
1.4% mortality associated with the coronary artery bypass
graft procedure itself.
Beta-Blockers have been commonly used to prevent
cardiovascular events in patients undergoing noncardiac
surgery [35, 36], but a large randomized study of their
efficacy and safety has suggested that beta-blockers may
benefit only the highest risk patients and may increase the
risk of perioperative death and stroke in some patients [36].
In noncardiac surgery, patients at high cardiovascular risk
have significantly lower mortality with beta-blocker therapy,
those at intermediate cardiovascular risk have a small
benefit, and those at low cardiovascular risk have no benefit
and may possibly be harmed [36]. If patients are already
taking beta-blockers at the time of their fracture, beta-blocker
therapy should be continued in most cases to avoid the risks
associated with its sudden discontinuation. If beta-blocker
therapy is initiated, then it should be commenced as soon as
is practical, and the dose should be titrated to achieve a
Osteoporos Int (2010) 21 (Suppl 4):S535–S546
target heart rate while blood pressure response and central
nervous system effects are monitored. If the patient has no
other indications for beta-blocker therapy, then it should be
tapered and discontinued 1 month after surgery.
Chronic use of angiotensin-converting enzyme inhibitors
and angiotensin II receptor antagonists has been associated
with increased hypotension during the induction of anes-
thesia. However, the decision to discontinue these agents
before surgery is controversial [39, 40]. Most of the few
studies that address this issue have been in patients having
vascular surgery who likely have moderate to high
cardiovascular risk [41–43]. However, the risk of clinically
significant hypotension appears to be less in patients having
noncardiac surgery. A retrospective analysis of patients who
had elective noncardiac surgery showed more frequent
moderate hypotension during induction of anesthesia in
patients who took the angiotensin-converting enzyme
inhibitors/angiotensin II receptor antagonists on the morn-
ing of surgery (60%) than in patients who discontinued the
medication during the day before surgery (45%) [44]. There
was no difference between the groups in the incidence of
severe hypotension, use of vasopressors, or incidence of
postoperative complications [44]. Intravascular volume
deficits likely contribute to the incidence and severity of
hypotension during the induction of anesthesia in patients
chronically using angiotensin-converting enzyme inhibi-
tors/angiotensin II receptor antagonists, again emphasizing
the importance of perioperative fluid management.
Because postoperative hypotension is not uncommon in
our experience, we consider decreasing the doses of some
antihypertensive medications on the day of admission.
Cardiac murmurs are common in the elderly. Patients
known to have a cardiac murmur are likely to have
previously had an echocardiogram, and unless symptoms
have altered, repeat investigation is not warranted. Early
review by the on-call anesthetist and orthogeriatric team
may be useful in determining the nature of a cardiac
murmur clinically so that a decision can be made on
whether an echocardiogram is necessary, thereby prevent-
ing unnecessary delays to surgery.
The most important cardiac murmur is caused by aortic
stenosis. Aortic stenosis has an incidence of approximately
3% in patients >75 years old [45], and if it is suspected
clinically, echocardiography should be performed [46]. A
study of 272 patients with hip fracture and previously
undiagnosed murmurs revealed that patients with aortic
stenosis were significantly older and had significantly lower
Abbreviated Mental Test scores than those of 3,698 patients
with hip fracture without aortic stenosis [47]. The mortality
rate of the patients with aortic stenosis was not significantly
different from the control group, and the severity of the
aortic stenosis did not affect outcome. In patients with
severe aortic stenosis (30 patients), mortality was 10% and
Osteoporos Int (2010) 21 (Suppl 4):S535–S546
36.7% at 30 days and 1 year, respectively. As the severity
of aortic stenosis increased, there was a significant trend
toward patients receiving general anesthesia over spinal
anesthesia and invasive blood pressure monitoring [47].
The 2001 National Confidential Enquiry into Perioperative
Deaths report recommended echocardiographic assessment of
all cardiac murmurs [48], in contrast to guidelines published
by the American College of Cardiology and the American
Heart Association that recommend against the use of routine
additional investigation of cardiac disease for noncardiac
surgery [49]. Investigations such as echocardiography are not
always possible or necessary before urgent surgery. One
study of 235 patients with hip fractures showed that patients
undergoing preoperative cardiac testing had significantly
longer delays to surgery than did those who did not undergo
cardiac investigation (3.3 versus 1.9 days, respectively) [50].
None of the patients in that study had alterations in
orthopedic or medical treatment secondary to the results of
the cardiac testing [50].
The absence of echocardiography should not lead to
delays in stabilizing the fracture [7] because the risk of
surgical delay outweighs the benefit of waiting for the
results of those preoperative tests. Routine cardiac investi-
gation in addition to electrocardiography is not recommen-
ded before surgery for patients with hip fracture. Clinical
suspicion of perioperative cardiac risk is as reliable for risk
stratification as cardiac testing, and therefore, the use of
additional cardiac investigation should be guided by
clinical assessment [50].
Pulmonary issues and infection
A history of exercise intolerance, unexplained dyspnea, or
cough may suggest unrecognized chronic lung disease.
Optimizing treatment before surgery for patients with ob-
structive lung disease or asthma is prudent. Treatment may
include inhalers, glucocorticoids, and antibiotics for selected
patients. Lung expansion maneuvers, such as incentive
spirometry, reduce postoperative pulmonary complications
and are more effective if patient teaching begins before
surgery. However, this approach may be impossible in
confused, noncompliant patients. Early surgery and resultant
early ambulation often form the most effective treatment
strategy in patients with fractures. Adequate postoperative
pain control may help to minimize postoperative pulmonary
complications by enabling earlier ambulation and improving
the patient’s ability to take deep breaths. Preoperative and
postoperative physiotherapy and early mobilization may also
help reduce chest complications [7].
Geriatric fracture patients are at particular risk for
infection, especially if the fracture results in immobility.
Meta-analyses of antibiotic prophylaxis in hip fracture
S539
surgery has shown a significant reduction in the incidence
of deep and superficial wound infection after surgery and a
reduced risk of urinary tract and chest infections [51, 52]. A
single-dose regimen with ceftriaxone has been shown to be
cost-effective [51]. Based on such evidence, broad-
spectrum prophylactic antibiotics are recommended at the
time of surgery. Most microbiology departments have
developed local prophylactic antibiotic protocols for elderly
patients with hip fractures, which often take into account
infection risk factors such as previous nursing home care.
In some cases, the fracture may be an underlying sign of
major medical illness secondary to infection. Urinary tract and
chest infections are common and should be treated with
intravenous antibiotics when urgent surgery is required; such
comorbidities should not delay surgery [7, 46] unless patients
have evidence of cardiovascular instability resulting from
sepsis. In that situation, delay may be appropriate and may
allow patients to receive adequate fluid resuscitation with
appropriate intravenous antibiotics. Given that the clinical
assessment of fluid balance can be difficult in elderly septic
patients, invasive blood pressure monitoring and escalation
of care to a high-dependency unit may be necessary, unless
doing so would contradict the patient’s wishes or the medical
team considers escalation to be futile or inappropriate.
Delirium
Preoperative delirium is present in approximately 13.5–
33% of patients with hip fracture on admission to the
hospital [53] and is frequently underdiagnosed [54].
Delirium on admission to hospital is associated with
worsening physical and cognitive functional scores at
6 months and a slower recovery generally [53]. Risk
factors for the development of delirium include advanced
age, prefracture cognitive impairment, depression, psycho-
tropic medication use, illness severity, vision or hearing
impairment, dehydration, electrolyte imbalances, and ad-
mission to a hospital from a care institution [53, 55, 56].
Patients with elevated serum white cell counts on admission
have also been identified as having an increased risk of
acute confusion [53].
Most cases of delirium in patients with hip fracture occur
after surgery, affecting 50–61% of such patients [54, 57, 58].
Causes are multifactorial and include medication use, choice
of anesthetic during surgery, sensory/environmental factors,
infection, urinary retention, and fluid/electrolyte disturbance.
Pain can contribute to delirium, and adequate analgesia can
decrease that risk; however, although narcotics are effective
in the treatment of pain, they also produce sedation and may
contribute to delirium. The treatment of pain is multimodal
and should include scheduled doses of nonopiates such as
acetaminophen. Although opiates are considered the most
S540
effective analgesia for hip fracture [5], consideration should
be given to using other agents that optimize pain control and
minimize the dose of narcotics used. Nonpharmacologic
methods can be helpful in reducing delirium, such as
reorientation and consideration of sleep patterns. Another
factor that can contribute to delirium is unrecognized
benzodiazepine or alcohol withdrawal. History of drug or
alcohol use obtained from the patient on admission or the
patient’s family or friends after the onset of delirium and
physical examination findings can suggest the diagnosis of
withdrawal.
Although measures to control dangerous behaviors may
be necessary, the fundamental tactic is to avoid factors that
can cause or aggravate delirium and to identify and treat
underlying acute illnesses that may contribute. If it is
necessary to start temporary treatment for dangerous
behaviors, then identifying target behaviors and starting
treatment with the lowest possible dose of haloperidol is
recommended. Long-acting benzodiazepines should be
avoided.
The type of anesthetic chosen may also play a role in
reducing delirium. Even very low doses of anesthetic have
been shown to produce profound anesthesia in the elderly
[59]. A recent study assessing the use of spinal anesthetic
and very light sedation resulted in reduced postoperative
delirium in elderly patients undergoing hip fracture repair
[60].
Management of diabetes
Careful assessment of patients with diabetes before surgery
should include determining the type of diabetes, the patient’s
usual medication regimen, and any previous complications.
It should be recognized that diabetes mellitus is associated
with an increased risk of asymptomatic coronary heart
disease and also perioperative infection. The goal of
perioperative management of diabetes is to maintain the
patient’s fluid and electrolyte balance, prevent ketoacidosis,
and avoid excessive hyperglycemia and hypoglycemia.
Patients with diabetes are a heterogeneous group, and the
perioperative management of patients with different types of
diabetes requires different approaches. Patients with type 1
diabetes mellitus are insulin deficient and prone to develop-
ing ketoacidosis even when their glucose level is not
extremely elevated. A common oversight is to withhold
their long-acting insulin during the perioperative period and
risk developing ketoacidosis. Patients with type 1 diabetes
should be given approximately one half of their usual daily
insulin dose, even when it is anticipated that there will be no
or little oral intake. Patients with type 2 diabetes are not
ketosis-prone, but they are susceptible to developing a
nonketotic hyperosmolar state that may lead to volume
Osteoporos Int (2010) 21 (Suppl 4):S535–S546
depletion and neurologic complications, although they may
also develop ketoacidosis when under extreme stress.
The goal of perioperative diabetic management is to
avoid excessive hyperglycemia and hypoglycemia, but the
optimal glycemic target is not clear. The glycemic target
has been investigated in patients in intensive care units:
tight glucose control (80–110 mg/dL) in heterogeneous
intensive care unit patients failed to show a benefit in
reducing mortality [61]. In general, the target for glycemic
control in the perioperative period is glucose concentrations
below 180–200 mg/dL. Very tight glycemic control is
associated with a high incidence of hypoglycemia [62].
Anemia
Anemia may exist acutely or as a chronic disease; in the
latter case, the patient may already be receiving therapy.
Acute blood loss from a hip fracture can be up to 500 mL
[10], but femoral diaphyseal fractures may result in profound
blood loss despite relative normal serum markers on
admission. An admission hemoglobin concentration ≤10 g/
dL−1 is an independent predictor for increased mortality at
30 days in patients with hip fractures [12]. However,
perioperative transfusion in such patients with hemoglobin
concentrations >8 g/dL−1 does not appear to be beneficial in
terms of mortality [63], although patients with the ischemic
heart disease probably benefit from transfusion at higher
hemoglobin levels [64]. With the lack of strong research
evidence, the threshold for blood transfusion should be
considered on an individual basis for all elderly patients with
fractures, and liaison with the attending anesthesiologist and
orthogeriatrician is encouraged.
Anticoagulation management
Part of a preoperative workup is assessment of the bleeding
risk. Most commonly, this risk is affected by medications
that lead to an anticoagulant effect through different
pathways. The most common agents prescribed that may
cause problems with postoperative bleeding are clopidogrel
and warfarin.
Clopidogrel is an oral antiplatelet agent used in the
treatment of symptomatic atherosclerosis, acute coronary
syndrome without ST segment elevation, and ST elevation
myocardial infarction. The use of clopidogrel has increased
with the advent of coronary artery stenting procedures [65,
66]. It works by an irreversible blockade of the adenosine
diphosphate receptor, P2Y12, on platelet cell membranes,
which allows for cross-linking of platelets by fibrin.
Clopidogrel’s effect lasts for the entire lifespan of the
platelets, which is 7–9 days. It is thought that clopidogrel
Osteoporos Int (2010) 21 (Suppl 4):S535–S546
must be discontinued for 7–9 days for platelets to form a
plug and allow for optimal blood clotting. Clopidogrel is
usually stopped 7–9 days before elective surgery.
The treatment of a patient with an acute hip fracture
who is taking clopidogrel is currently debated. One
retrospective review of 21 patients showed it to be safe
to operate without delay on patients taking clopidogrel
[67]. Another study showed that delay related to anti-
platelet treatment led to higher mortality in patients after
hip fracture repair [68]. A third study, however, found that
ten patients whose repair was delayed for 5 days had less
bleeding after surgery [69].
Although to our knowledge there is no consensus or
level 1 or 2 evidence for the treatment of patients on
clopidogrel [70–72], the basic debate is whether the
increased risk of bleeding caused by immediate surgery is
worth the risk of increased morbidity and mortality from a
delay of 7 to 9 days. The current protocol for patients
taking clopidogrel at our two institutions is immediate
surgery. Whether or not there is a role for transfusion of
platelets in such patients has been questioned. Platelet
transfusion has not been our standard, and we think it
should be reserved for patients who would have a bleeding
problem after surgery. It should be noted that this
recommendation is level 5 evidence.
Warfarin is another commonly used oral anticoagulant
for preventing arterial and venous thrombosis. This vitamin
K antagonist results in a prolongation of the international
normalized ratio (INR), which may lead to a delayed hip
fracture repair. To perform such a repair, the INR must be
normalized to reduce the risk of surgical bleeding. This
goal can be accomplished by (1) discontinuing warfarin to
allow for the INR to normalize naturally, (2) administering
low-dose vitamin K, (3) administering fresh-frozen plasma
(FFP), and/or (4) administering prothrombin complex
concentrates. Each method has pros and cons. The length
of the delay to surgical repair may produce increased
morbidity and mortality. Therefore, reversal of warfarin for
conditions such as atrial fibrillation is considered safe and
appropriate if it facilitates early surgery [7]. In contrast, the
use of vitamin K may lead to prolongation of the time
needed to anticoagulate the patient postoperatively. The use
of FFP leads to blood product transfusion risks such as
allergy, transfusion-related acute lung injury, infection, and
the potential risk of volume overload.
A safe INR for hip fracture repair is thought to be ≤1.5
[73], but the ideal INR does vary depending on the type of
procedure involved. Percutaneous screw fixation has a
much lower risk of bleeding than that of total hip
arthroplasty. The consequences of a major bleed in a
patient with a total hip arthroplasty are also much more
severe and can lead to hematoma, infection, and possibly
joint removal.
S541
Simple waiting to achieve the desired INR has been
shown to be safe but the length of the wait is variable;
depending on the INR on admission, it may take up to
4 days [73, 74]. Vitamin K may be administered orally or
parentally, but parenteral vitamin K has not shown to be
better than the oral for INR reversal [75, 76]. The use of
oral vitamin K has been shown to be safe in reversing the
effects of warfarin [77, 78]. The use of FFP as a means of
reversing warfarin for surgery has been studied less
frequently. Clinical guidelines recommend strongly against
the use of FFP for preoperative reversal of anticoagulation
and state “There is no justification for using FFP to reverse
a prolonged INR in the absence of bleeding” [79]. Little
evidence exists for the use of prothrombin complex
concentrates, but it may be an alternative to FFP [80]. To
our knowledge, the use of FFP to aggressively reverse
anticoagulants in the hip fracture population has not been
extensively studied. The potential risks of delay and
immobilization must be weighed against those of transfu-
sion. Quality evidence for directing treatment is lacking.
Nutrition
To improve outcome, perioperative nutrition is another area
that could be maximized. Routine testing of serum albumin
provides a window into a patient’s nutritional status.
Several authors have studied the effect of perioperative
nutritional supplements. The results suggest that these
supplements may be effective in improving nutrition [81–
84], decrease complications [81, 82, 85], increase muscular
strength [86], shorten rehabilitation [87], and decrease
bedsores [88]. One study showed a limited effect of
supplementation and suggested that its use be restricted to
subgroups of patients at high risk [89].
In conclusion, nutritional supplements seem to be
effective [81–88] in the hip fracture population and are
recommended in the perioperative period. One approach to
the patient with a hip fracture is to obtain an albumin level
during the admission laboratory studies. A low albumin
level (serum albumin level ≤3 g/dL), which is common, is
an indication that nutritional supplementation should be
ordered and a nutrition consult considered.
Goals for care
During the initial assessment of the geriatric fracture patient, it
is essential to establish the patient’s expectations and wishes
for care, such as the desire for “do not resuscitate”, “do not
intubate”, and specifics of supportive care should it become
necessary. Many patients will have previously made their
wishes known, and up to 44% of patients >70 years old have
S542
standing do-not-resuscitate orders [90]. It is also common
that these wishes are not respected in emergency situations.
Existing orders should be reviewed with the patient or family
and then renewed in compliance with local health codes or
laws. This step is particularly important before surgery
because cardiac arrest or the requirement for prolonged
intubation and escalation of care could arise perioperatively.
If no advanced directive has been offered by the patient,
discussion with the patient about the potential need for
resuscitation during surgery should also be reviewed with the
family and documented in the medical record. It has been
shown that this discussion is often inadequate and that
frequently elderly patients have overly optimistic views
about the success of cardiopulmonary resuscitation [90];
even with access to an intensive care unit, patients >70 years
old have only a 39% chance of immediate survival after
cardiopulmonary arrest [91]. The medical team should
determine whether or not the patient desires the appointment
of a decision maker in case the patient would be unable to
make important medical decisions, such as during the
perioperative period. To ensure the patient’s specific wishes
are respected during the hospitalization, the surgeon,
anesthesiologist, geriatrician, and care team members should
all be aware of these care preferences. Many institutions use
specific forms to document these important decisions, but the
discussions should also be clearly documented in the medical
chart to prevent misunderstandings.
Functional assessment
The preoperative assessment should include a careful
functional assessment. One of the most important ways in
which to assess function is a detailed history of the patient’s
ambulation status (i.e., the ability to ambulate unassisted,
with assistance from another person, or with an assistive
Table 1 Common conditions to
optimize for geriatric fracture Problem
surgery
Timing of surgery
Fluid management
Cardiovascular high-risk patients
Patients with aortic stenosis
Pulmonary conditions
Delirium
Diabetes
Anemia
Clopidogrel use
Warfarin anticoagulated patient
Nutritional status
Goals for care
Functional assessment
Osteoporos Int (2010) 21 (Suppl 4):S535–S546
device, or the inability to ambulate at all). The elderly
population is heterogeneous. Some patients have very poor
preoperative function and may reside in a skilled nursing
facility, whereas others of equal age may be very active and
playing recreational sports or still working. This heteroge-
neity impacts the outcomes after surgery. Patients who
reside in a nursing home before surgery rarely regain their
prefracture functional status [92], and patients with poor
preoperative function have a considerably worse prognosis
after sustaining fractures. To help stratify the patient’s
preoperative functional status, there are several validated
scoring systems. One such system is the Parker Mobility
Score, which assesses three areas of function and stratifies
the patient’s mortality risk based on those areas [93].
Patients with poor preoperative function are much more
likely to have poor outcomes. Several scoring systems have
been shown to directly predict poor outcomes after hip
fracture surgery, for example, the New Mobility Score [94]
and the cumulative ambulation score [95]. The latter is
predictive for length of hospital stay, 30-day mortality, and
postoperative medical complications; one study showed it
to be superior to the New Mobility Score and Mental Score
in its association with these short-term outcome measures
[95].
The impact of comorbidity is reflected in physical
functional status. Elderly patients with fractures frequently
present with multiple comorbidities, which may have a
negative impact on postoperative functional status. Func-
tional decline is recognized as an important “geriatric
syndrome” that leads to poor outcomes in older adults
[96]. Saliba et al. [97] have described a function-based
targeting system that can help predict functional decline and
mortality in elderly patients. This Vulnerable Elders
Survey-13 Score evaluates the patient’s ability to perform
six physical and five functional activities and includes a
self-rated health assessment [97, 98].
Recommended countermeasure to optimize patient
Early surgery (<24 h) to decrease complications
Restoration of fluid status to euvolemic status
Cardiology consultation, most need beta-blockers
Cardiac testing only if advised by medical consultant
Optimize medical treatment preoperatively
Avoidance is best; treat contributing conditions
Maintain glucose levels between 100 and 180 mg/dL
Correct hemoglobin level to ≥10 g/dL before surgery
Proceed with early surgery
Correct international normalized ratio to ≤1.5 preoperatively
Use dietary supplements to improve nutrition
Establish goals for care on admission
Each patient needs a preoperative functional assessment
Osteoporos Int (2010) 21 (Suppl 4):S535–S546
Assessing a patient’s activities of daily living (ADLs),
i.e., bathing, dressing, feeding, toileting, transferring, and
continence, can help further stratify postoperative and
rehabilitation outcomes. The Katz Index of Independence
for Activities of Daily Living [99] has been used to assess
functional status for many years. The ADLs tend to be lost
in a predictable manner with aging. Careful assessment of
the ADL can help predict the patient’s prognosis [99].
Penrod et al. [100] have used age, ADL independence, and
mobility status to classify patients with hip fracture into
categories that accurately predict their outcomes, poten-
tially allowing services to plan rehabilitation needs and
differentially target these subgroups preoperatively. Such
systems may also increase the efficient use of resources
such as occupational therapy, physiotherapy, and other
rehabilitation health teams.
Summary
Geriatric patients with hip fractures who need orthopedic
surgery are among the most challenging patients to treat.
Often, they do not have typical manifestations of clinical
disease, and their comorbid conditions can go unrecognized
even by experienced and skilled clinicians. A potentially
more productive approach is to anticipate that all geriatric
patients will have multiple medical, cognitive, social, and
functional factors that will impact on their risk of surgery
and their speed and limits of recovery. Most geriatric patients
with hip fracture will be dehydrated to some degree and will
need assessment and usually support of their fluid status, and
all geriatric patients are at higher risk for developing
delirium or cardiovascular and pulmonary complications
than younger adults. By anticipating that these risks are
common, the treatment team can systematically consider and
minimize factors that contribute to the risk. Early clinical
assessments by the anesthesiologist, surgeon, and orthoger-
iatrician should help identify patients at high risk so that
preoperative investigations are ordered and obtained rapidly
to prevent unnecessary delay. Table 1 summarizes the
common conditions addressed in this manuscript and lists
the necessary countermeasures with which to treat them.
Stratification of patients into low-, medium-, or high-risk
groups may further help to communicate with the anesthetic
team, and scoring systems such as the Nottingham Hip
Fracture Index or the Charlson Comorbidity Index are useful
tools in this situation.
In essence, elderly fracture patients should undergo surgery
as soon as their medical condition is optimized. Optimal care
is a team effort, and communication among team members,
patients, and their families is critical. Communication should
be clear and frequent, with legible, written notes and readily
available opportunities to discuss clinical and treatment issues
S543
as they arise. This process promotes better care, team
cohesiveness, better understanding of the concerns of other
disciplines, professional learning, and clear communication
with the patient and the family regarding the plan of care,
clinical progress, and expectations for recovery.
Conflicts of interest Dr. Stephen L. Kates is a speaker with Eli Lilly
& Co. and has received a research grant from Synthes, Inc. The
remaining authors declare no conflicts of interest.
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