How Should Patients with Acute Hip Fractures Be Managed Perioperatively?

Patients with their first hip fracture are 2.5 times more likely to have a future fragility fracture.¹⁷ Hospitalists must therefore make secondary prevention a priority. Medical management focuses on maintaining bone strength, slowing further bone loss, and preventing future falls.

Evaluation. A directed history and physical examination should be completed to screen for secondary causes of osteoporosis. A basic laboratory workup is reasonable in the inpatient setting (see Table 2).¹⁷ Other tests, such as a serum and urine protein electrophoresis, can be obtained as clinically indicated.

Patients require counseling directed at lifestyle factors, including the importance of weight-bearing exercise, smoking cessation, and avoidance of excessive alcohol intake. A comprehensive falls assessment is also warranted.

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Table 2. Suggested inpatient evaluation of osteoporosis17Source: Adapted from National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis 2013. Washington, D.C.; 2013. Available at: www.nof.org/files/nof/public/content/file/917/upload/481.pdf. Accessed September 29, 2013.

Treatment. All patients with hip fractures should be discharged from the hospital on calcium and vitamin D supplementation, unless there is a specific contraindication.¹⁸ Guidelines vary by organization, but the National Osteoporosis Foundation’s recommendations are listed in Table 3.^17,19,20 Dietary calcium is usually insufficient to meet the daily requirement.

Bisphosphonates are considered first-line therapy for osteoporosis.¹⁷ The HORIZON trial was a randomized, placebo-controlled study that evaluated annual zoledronic acid infusions in hip fracture patients who were intolerant of oral bisphosphonates.²¹ Zoledronic acid reduced the rate of new fractures by 35% after 1.9 years, with a number needed to treat (NNT) of 19. It also improved survival by 28%, for an NNT of 27. All subjects also received calcium and vitamin D supplementation.

Both hospitalists and orthopedists might worry about bisphosphonates adversely affecting bone healing in the acute setting. Subsequent analyses from the HORIZON trial suggest that bisphosphonates can be safely started as soon as two weeks after surgery.^22,23

Transitions of care. Despite well-established guidelines for the treatment of osteoporosis, patients with hip fractures often are undertreated. A retrospective study of 420 acute hip fracture patients found that only 37% received calcium, 36% received vitamin D, and 31% received a bisphosphonate on discharge.²⁴ A prospective study of 1,075 women with new osteoporotic fractures found that only 17% had started anti-osteoporosis medications at one year.²⁵

Hospitalists should recognize and address potential barriers to appropriate medical therapy. Patient-related obstacles may include the cost of medications, concerns about side effects, and lack of a PCP.^24,25 Hospitalists should document the diagnosis of osteoporosis in the medical record so subsequent providers are attuned to the issue.²⁶ They should also clarify the ownership of osteoporosis across the continuum of care, because medicine consultants, orthopedists, primary care or rehabilitation physicians, and subspecialists may all be involved. Hospitalists can certainly take advantage of this window of opportunity by starting patients on osteoporosis treatment and ensuring smooth transitions of care on discharge.

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Table 3. Recommended calcium and vitamin D intake in osteoporosis17Source: Adapted from National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis 2013. Washington, D.C.; 2013. Available at: www.nof.org/files/nof/public/content/file/917/upload/481.pdf. Accessed September 29, 2013.

Back to the Case

The patient was started on intravenous antibiotics for healthcare-associated pneumonia with improvement of his oxygen requirement to 3 L/min. He underwent a right hemiarthroplasty on hospital day five and tolerated the procedure well. His delirium resolved with treatment of his infection, pain control, discontinuation of lorazepam, and other conservative measures. He was given VTE prophylaxis pre- and postoperatively. His urinary catheter was discontinued on day one after surgery. He was started on calcium supplementation and vitamin D repletion after his 25-OH vitamin D level returned low at 14 ng/mL.