Hip fracture surgery riskier than hip replacement

Physicians have long assumed that patients undergoing surgery for a hip fracture have a higher risk of death and major complications.

This is compared to patients undergoing an elective total hip replacement, because hip fracture patients are often older and have more chronic diseases.

A new study published in The Journal of the American Medical Association (JAMA) says the hip fracture patients due indeed have worse outcomes — but this is not entirely explained by age or chronic illness.

The researchers studied almost 700,000 hip surgery patients more than 45 years old in France between 2010 and 2013. They found that the total hip replacement patients were younger, more commonly men and had less other medical problems than hip fracture patients.

They also found that, indeed, there were more deaths among the hip fracture patients, with a total of 3.4 per cent dying before hospital discharge compared to 0.18 percent of total hip replacement surgery patients.

Even when the demographics of the patients were matched by gender, age and medical conditions, they found hip fracture patients had a 1.8 per cent chance of dying compared to 0.3 per cent of elective hip replacement patients, and those with a hip fracture had a 5.9 percent chance of major post operation complications, compared to 2.3 per cent of those patients who underwent an elective hip replacement.

The research team was led by Dr. Yannick Le Manach, an assistant professor of anesthesia for the Michael G. DeGroote School of Medicine of McMaster and a member of the Population Health Research Institute of McMaster and Hamilton Health Sciences.

“The fact that the hip fracture patients were older and had more health problems does account for some of the difference in outcomes,” Le Manach said. “But it may be that hip fracture is tied to other physiologic processes that aren’t present in the circumstances of people going for an elective hip replacement. More research is needed.”

The senior author of the study, Dr. P.J. Devereaux, professor of medicine and director of Cardiology for the Michael G DeGroote School of Medicine, said that even after balancing hip fracture and elective hip replacement patients for age and comorbid diseases, the patients with a hip fracture do much worse than the patients with the elective hip replacement.

“This means that there is something unique to the hip fracture and this holds out hope that we can modify this issue and improve outcomes,” said Devereaux.

“We believe that what is different about the hip fractures is that they create acute inflammation, drive our stress response (sympathetic system), and activate our coagulation system. Moreover, hip fracture patients are immobilized and fast for 24-48 hours while waiting for surgery. We are now testing if accelerated surgery will allow us to reverse the negative impact of these pathways initiated by the hip fracture.”