What is the optimal time frame for operative management of a hip fracture in an 88-year-old female with a history of controlled hypertension and previous coronary artery bypass graft (CABG)?

From the Guidelines

For an 88-year-old female with a hip fracture, surgery should ideally be performed within 24-48 hours of the injury. This timeframe balances the need for prompt surgical intervention with appropriate preoperative medical optimization. Given her history of controlled hypertension and previous coronary artery bypass graft, a brief preoperative cardiac evaluation is reasonable but should not significantly delay surgery. Early surgical intervention for hip fractures in elderly patients reduces complications such as pressure ulcers, pneumonia, venous thromboembolism, and mortality. Prolonged immobilization increases these risks substantially. The absence of current cardiac symptoms is reassuring, though her age and cardiac history warrant attention to perioperative fluid management, pain control, and hemodynamic stability. Preoperative optimization should include assessment of volume status, correction of electrolyte abnormalities, and review of medications, but these measures should occur concurrently with surgical preparation rather than delaying the procedure beyond the recommended timeframe. According to the most recent guidelines, such as the 2022 AAOS clinical practice guideline summary: management of hip fractures in older adults 1, surgery within 24-48 hours of hospital admission is recommended, as it is associated with better outcomes.

Some key points to consider in the management of this patient include:

• The importance of prompt surgical intervention to reduce the risk of complications associated with prolonged immobilization
• The need for a brief preoperative cardiac evaluation, given the patient's history of coronary artery bypass graft
• The importance of perioperative fluid management, pain control, and hemodynamic stability, given the patient's age and cardiac history
• The need to assess volume status, correct electrolyte abnormalities, and review medications preoperatively, without delaying the procedure beyond the recommended timeframe.

Overall, the goal is to balance the need for prompt surgical intervention with the need for appropriate preoperative medical optimization, in order to minimize the risk of complications and improve outcomes for the patient.

From the Research

Operative Management Timing

• The provided studies do not directly address the optimal timing for operative management after a hip fracture injury.
• However, it is generally recommended that operative management for hip fractures should occur as soon as possible, ideally within 24 to 48 hours after the injury, to reduce the risk of complications and improve outcomes 2, 3.
• The exact timing may depend on various factors, including the patient's overall health, medical history, and the presence of any comorbidities.
• In the case of the 88-year-old female patient with a history of controlled blood pressure and a previous coronary artery bypass graft, it is essential to carefully evaluate her cardiac risk and optimize her medical management before surgery 4, 5.

Preoperative Care

• Preoperative care is crucial in preparing the patient for surgery and reducing the risk of complications.
• This includes conducting preoperative tests and clinical assessments, providing patient education, and optimizing medical management 6.
• The preoperative period is an opportunity to identify and address any potential issues that may impact the patient's outcome, such as cardiac risk factors or other comorbidities 2, 3.