Orthogeriatric Care Guidelines
Core Recommendation
Orthogeriatric comanagement with shared responsibility between geriatricians and orthopedic surgeons on a dedicated orthogeriatric ward should be implemented for all elderly patients with hip fractures, as this model demonstrates the shortest time to surgery, shortest hospital stay, and lowest mortality rates at both in-hospital and 1-year follow-up. 1
Essential Components of Orthogeriatric Care
Immediate Assessment and Preoperative Management
Pain Control:
- Administer nerve blocks immediately upon presentation, which significantly reduces acute pain in hip fracture patients 1
- Provide multimodal analgesia before diagnostic investigations begin 1
Preoperative Workup:
- Perform chest X-ray, ECG, complete blood count, coagulation studies, blood typing, and renal function tests 1
- Assess for malnutrition, electrolyte/volume disturbances, anemia, cardiac disease, pulmonary disease, and baseline cognitive function 1
- Identify and treat exacerbations of chronic conditions or acute medical illness 1
Surgical Timing:
- Surgery must occur within 24-48 hours of admission to significantly reduce short-term and mid-term mortality and prevent complications from immobility (pressure ulcers, pneumonia) 1, 2
- Any delay beyond 48 hours increases mortality risk and complications 2
Multidisciplinary Team Structure
The Shared Care Model (Level IA Evidence, Grade A Recommendation):
- Joint daily rounds with geriatrician and orthopedic surgeon on a dedicated orthogeriatric ward 1
- This integrated model outperforms both geriatric consultation services and usual orthopedic care alone 3, 4
- Comprehensive geriatric assessment performed by the geriatric team member 1
Team Composition:
- Geriatrician and orthopedic surgeon as co-leaders 5
- Anesthesiologist, physiatrist, physiotherapist, and nursing staff 5
- Coordination with general practitioners for discharge planning 1
Perioperative Management
Immediate Postoperative Care:
- Remove urinary catheters on postoperative day 1 to reduce infection risk 6
- Mobilize patients to standing or seated position on postoperative day 1 6
- Allow weight-bearing as tolerated to promote early mobilization 7
Medical Optimization:
- Monitor daily for delirium, which worsens prognosis in elderly patients 8
- Assess nutritional status and maintain adequate hydration 1, 8
- Provide appropriate thromboembolic prophylaxis with low molecular weight heparin or mechanical compression 8
Rehabilitation and Secondary Prevention
Early Rehabilitation (Level IIA Evidence, Grade B Recommendation):
- Begin physical training and muscle strengthening immediately post-fracture 1
- Continue long-term balance training and multidimensional fall prevention 1
- Early mobilization reduces thromboembolism risk 8
Secondary Fracture Prevention:
- Every patient ≥50 years with a fragility fracture must be systematically evaluated for subsequent fracture risk 1, 2
- Assess clinical risk factors, perform DXA of spine and hip, evaluate for vertebral fractures, assess fall risk, and identify secondary osteoporosis 1
- Initiate pharmacological treatment with medications proven to reduce vertebral, non-vertebral, and hip fracture risk 1, 2
- Ensure adequate calcium and vitamin D intake, smoking cessation, and alcohol limitation 1
- Refer to Fracture Liaison Service for coordinated secondary prevention 7
Outcomes Achieved by Orthogeriatric Comanagement
Mortality Reduction:
- In-hospital mortality reduced by 40% (RR 0.60,95% CI 0.43-0.84) 4
- Long-term mortality reduced by 17% (RR 0.83,95% CI 0.74-0.94) 4
- One-year mortality significantly lower with integrated care model (OR 0.31,95% CI 0.10-0.96) 3
Functional Outcomes:
- Instrumental activities of daily living improved at 4 months (3.56 points, p=0.008) and 12 months (4.28 points, p=0.002) 9
- Basic activities of daily living significantly better at 12 months 9
- Prevents functional decline and maintains independence 9
Process Measures:
- Higher probability of surgery within 48 hours (OR 2.62,95% CI 1.40-4.91) 3
- Reduced length of hospital stay 3, 4
Critical Pitfalls to Avoid
Avoid Geriatric Consultation-Only Models:
- Consultation services without shared care responsibility do not achieve the same mortality reduction or functional outcomes as integrated comanagement 3, 6
- The integrated care model with daily shared rounds outperforms on-demand consultative services on all quality indicators 6
Do Not Delay Surgery for Medical Optimization:
- Prolonging immobility and pain beyond 48 hours causes more harm than benefit 1
- Balance acute medical optimization against the risks of delayed surgery 1
Do Not Overlook Secondary Prevention: