Faculty Bibliography

We compared the clinical efficacy and side-effect profiles of aspirin, dextran 40, and low-molecular-weight heparin (enoxaparin) in preventing thromboembolic phenomena after hip fracture surgery. All patients admitted with a diagnosis of hip fracture to our institution between July 1, 1987, and December 31, 1999, were evaluated. Study inclusion criteria were age 65 years or older, previously ambulatory, cognitively intact, home-dwelling, and having a nonpathologic intertrochanteric or femoral neck fracture. Each patient received mechanical thromboprophylaxis (above-knee elastic stockings) and 1 pharmacologic agent (aspirin, dextran 40, or enoxaparin); patients who received aspirin were also given a calf sequential compression device. Meeting the selection criteria and included in the study were 917 patients. Findings included low incidence of thromboembolic phenomena (deep vein thrombosis, 0.5%-1.7%; pulmonary embolism, 0%-2.0%; fatal pulmonary embolism, 0%-0.5%) and no difference among the 3 pharmacologic agents in thromboembolic prophylaxis efficacy. Use of enoxaparin was associated with a significant increase (3.8%) in wound hematoma compared with dextran 40 (1.6%) and aspirin (2.4%) (P<.01). The 3 agents were found not to differ with respect to mortality, thromboembolic phenomena, hemorrhagic complications, or wound complications.

The high incidence of preoperative silent pulmonary embolisms (PEs) among elderly patients with hip fractures has led some authors to recommend making acquisition of arterial blood gas (ABG) levels a routine part of the preoperative workup. In the study reported here, we retrospectively reviewed 254 patients in our hip-fracture database and determined that ABG levels have poor positive predictive value for PEs and add little to the positive predictive value or negative predictive value of careful clinical examination. Therefore, we do not recommend making acquisition of ABG levels a routine part of the preoperative evaluation

Nine-hundred twenty-one community-dwelling patients 65 years of age or older, who sustained an operatively treated hip fracture from July 1, 1987 to June 30, 1998 were followed up for the development of postoperative delirium. The outcomes examined in the current study were postoperative complication rates, in-hospital mortality, hospital length of stay, hospital discharge status, 1-year mortality rate, place of residence, recovery of ambulatory ability, and activities of daily living 1 year after surgery. Forty-seven (5.1%) patients were diagnosed with postoperative delirium. Patients who had delirium develop were more likely to be male, have a history of mild dementia, and have had surgery under general anesthesia. Patients who had postoperative delirium develop had a significantly longer length of hospitalization. They also had significantly higher rates of mortality at 1 year, were less likely to recover their prefracture level of ambulation, and were more likely to show a decline in level of independence in basic activities of daily living at the 1-year followup. There was no difference in the rate of postoperative complications, in-hospital mortality, discharge residence, and recovery of instrumental activities of daily living at 1 year