The Orthogeriatric Model: Shared Care for Hip Fractures

Visual Element: A cyclical diagram of the "Patient Pathway" highlighting the touchpoints of the Orthogeriatric team: Admission -> Optimization -> Surgery -> Rehab -> Secondary Prevention.

The "Silver Tsunami" is not just approaching; it is already battering the shores of our healthcare systems. As the global population ages, the incidence of fragility fractures, particularly neck of femur (NOF) and intertrochanteric hip fractures, is rising exponentially. For anyone in orthopaedic surgery training, mastering the management of these patients is no longer just a requirement—it is the bedrock of acute orthopaedic practice.

A hip fracture must no longer be viewed merely as a broken bone requiring mechanical stabilization. It is increasingly recognized by the medical community as a sentinel event—a glaring marker of frailty and systemic decline that carries a 30-day mortality rate of nearly 10%, and a staggering 1-year mortality rate of 20-30%. To put this into perspective for your patients and their families, a hip fracture in an octogenarian carries a prognosis that rivals, and often exceeds, many newly diagnosed metastatic cancers.

Historically, these complex, frail patients were managed in stark "silos." They were admitted to a busy surgical ward, fixed mechanically by a "carpenter" focused solely on the radiograph, and then managed post-operatively by junior surgical residents who were ill-equipped to handle complex medical comorbidities like acute-on-chronic kidney injury, undiagnosed severe aortic stenosis, or polypharmacy-induced delirium. This fragmented approach inevitably led to delayed surgeries, prolonged fasting times, unchecked medical complications, and ultimately, dismal patient outcomes.

The paradigm shift to Orthogeriatrics—a truly integrated, shared care model between Orthopaedic Surgeons and Geriatricians—is arguably the single most important advancement in hip fracture care in the last two decades. It has saved more lives than any new implant design or surgical approach ever could.

This article comprehensively explores the mechanics of the orthogeriatric model, the landmark evidence underpinning it, and the practical, actionable implications for the treating surgeon. Whether you are managing the ward on a busy weekend or deep into your fellowship exam preparation, understanding these systems is critical.

The Evolution of Care Models

To appreciate where we are, we must understand the historical context. We can categorize the systemic approach to hip fracture care into three distinct evolutionary stages:

1. The Traditional Model (The Surgical Silo)

• Structure: The patient is admitted exclusively under the Orthopaedic Surgery team. Medical teams (internal medicine, cardiology, geriatrics) only review the patient if formally "consulted" for a specific, acute problem (e.g., "fast AF," "chest pain," "uncontrolled BSL").
• Result: Highly reactive, fragmented care. Chronic medical issues are either missed entirely or treated far too late in the physiological cascade. The surgical team spends hours managing medical wards rather than operating, leading to burnout and unacceptably high morbidity and mortality rates.

2. The Medical Consultant Model (The Liaison Service)

• Structure: The patient remains admitted under the Orthopaedic service, but a physician or geriatrician performs a routine "drop-in" ward round, usually a few times a week.
• Result: A marginal improvement, but fundamentally flawed by a lack of true ownership. The physician operates as a "guest" on the surgical ward. Recommendations are written in the chart, but often delayed in execution because the surgical juniors are in theatre. There is no shared accountability for system-level metrics like time-to-theatre.

3. The Shared Care (Orthogeriatric) Model - The Gold Standard

• Structure: Joint or concurrent admission. The patient is co-managed from the precise moment they enter the Emergency Department.
• Ownership: The roles are explicitly defined yet deeply synergistic: The Surgeon owns the bone; The Geriatrician owns the biology.
• Evidence and Mandates: This is no longer optional. It is mandated and heavily audited by the Australian & New Zealand Hip Fracture Registry (ANZHFR), the UK's National Hip Fracture Database (NHFD) via the "Blue Book," and the American College of Surgeons Geriatric Surgery Verification program. It is unequivocally proven to reduce in-hospital mortality, minimize the length of stay, lower 30-day readmission rates, and improve the return to pre-morbid residential status.

Key Components of the Orthogeriatric Pathway

Visual Element: An interactive checklist for "Pre-op Optimization" vs "Post-op Care".

Successful surgical education requires moving beyond textbook anatomy and understanding the entire patient journey. Let's break down the pathway into actionable phases.

Phase 1: Rapid Optimization (The first 24-48 hours)

The ultimate goal in this phase is not to make the patient "healthy." An 88-year-old with a fractured hip, heart failure, and COPD will not be healthy by tomorrow morning. The goal is to make them "fit for surgery" as safely and rapidly as possible.

• Time to Theatre: The universal target across modern registries is surgery within 36 to 48 hours of presentation. Delay beyond this window is an independent, statistically significant predictor of increased 30-day and 1-year mortality. Every hour counts.
• Anticoagulation Reversal: This requires rapid, pre-agreed hospital protocols. For Warfarin, Vitamin K and Prothrombinex (PCC) are utilized to quickly normalize the INR. For DOACs (Apixaban, Rivaroxaban), specialized reversal agents (like Andexanet alfa) exist but are rarely used for hip fractures due to cost and pro-thrombotic risk; more commonly, surgery is strategically timed based on the time of the last dose and the patient's creatinine clearance (often safely proceeding at 48 hours post-dose).
• Fluid Resuscitation: Nearly every elderly patient presenting with a fall and a long lie on the floor is profoundly dehydrated, often presenting with an acute kidney injury (AKI) and lactic acidosis. Aggressive, yet carefully monitored, IV fluid resuscitation (typically balanced crystalloids) must begin in the ED.
• Nerve Blocks: The Fascia Iliaca Block (FIB) or Femoral Nerve Block should be administered in the Emergency Room. This is standard of care. Opioid-sparing analgesia drastically reduces the incidence of pre-operative and post-operative delirium, limits respiratory depression, and allows the patient to sit up for chest physiotherapy.
• The "Golden Ticket": These patients must be prioritized on the trauma list. They are not elective "add-ons" to be done at 8 PM; they are physiological emergencies requiring daytime, consultant-led operating when the hospital is fully staffed.

Phase 2: Intra-operative Decisions

The operating theatre is where technical precision meets physiological limitation. Your decisions here dictate the patient's rehab potential.

• Anaesthesia: The debate between Spinal (Neuraxial) versus General Anaesthesia (GA) is classic. While historical bias heavily favored spinals, the recent landmark REGAIN trial (Regional versus General Anesthesia for Promoting Independence after Hip Fracture) showed no significant difference in 60-day survival or the incidence of post-operative delirium between the two techniques. The choice should be individualized by the anaesthetist, focusing heavily on meticulous blood pressure management to avoid end-organ hypoperfusion.
• Surgical Goal: "Get it right, first time." Revision surgery in this demographic carries an astronomically high mortality rate.
  • Displaced Intracapsular (Neck of Femur): Hemiarthroplasty is the workhorse. However, for independently mobile, cognitively intact patients, Total Hip Replacement (THR) is increasingly indicated (supported by the HEALTH trial and NICE guidelines) due to lower revision rates for acetabular wear and better long-term functional scores. Cemented stems are the gold standard for hemiarthroplasty, demonstrating lower periprosthetic fracture rates compared to uncemented stems (as strongly supported by registry data and the WHiTE 5 trial).
  • Extracapsular (Intertrochanteric): The Sliding Hip Screw (SHS / DHS) remains the gold standard for stable A1/A2 fracture patterns. Cephalomedullary Nails (CMN) are indicated for unstable, reverse oblique, or subtrochanteric patterns. For SHS, achieving a Tip-Apex Distance (TAD) of < 25mm (Baumgaertner's criteria) is critical to prevent screw cut-out.
  • The Crucial Paradigm: The surgical construct—whether a cemented hemi, a DHS, or a Nail—must be biomechanically robust enough to allow Immediate Full Weight Bearing (WBAT). If your fixation is tenuous and you mandate "touch weight bearing" in a 90-year-old, you have effectively sentenced them to permanent bed rest, hospital-acquired pneumonia, pressure ulcers, and likely death.

Phase 3: Post-operative Care (Geriatrician Led, Surgeon Supported)

Once the wound is closed, the biology takes over. The orthogeriatrician leads this phase, but the surgical team must remain actively engaged.

• Delirium Management: Post-operative delirium is the "orthopaedic emergency of the brain." It drastically prolongs admission and increases mortality. We must use routine screening tools like the 4AT. Management is rarely pharmacological; it requires aggressive identification and treatment of underlying triggers using the "PINCH ME" mnemonic: Pain, Infection (chest/urine), Nutrition/Constipation, Hydration, Medication, Environment.
• Mobilization: Day 1 mobilization is mandatory. The mantra is "Dangle and Dance." Getting the patient upright improves functional residual capacity in the lungs, reduces DVT risk, and reorients the patient to combat delirium.
• Nutrition and VTE: Early oral feeding, high-protein supplements, and strict adherence to VTE prophylaxis protocols (typically Low Molecular Weight Heparin like Enoxaparin) are non-negotiable standards of care.
• Wound Care: Minimize dressing changes. A sealed, undisturbed modern dressing should stay in place for 7-10 days unless clinically indicated, drastically reducing surgical site infection rates.

Phase 4: Secondary Prevention (Don't forget the next one)

Fixing the current fracture is only half the battle. If a patient leaves the hospital without a plan to prevent the next fall, the system has failed. Half of all hip fracture patients have had a prior fragility fracture that was ignored.

• Bone Health Optimization: The diagnosis of osteoporosis is effectively made clinically by the presence of the fragility fracture. Depending on renal function and dental status, patients should be commenced on bone protection—intravenous Zoledronic acid, Denosumab, or at minimum, optimized Calcium and Vitamin D supplementation—prior to discharge.
• Falls Assessment: Why did they fall? Was it mechanical tripping, or was it syncope, a new arrhythmia, orthostatic hypotension from polypharmacy, or worsening visual impairment? The geriatric team's comprehensive falls assessment and the implementation of a Fracture Liaison Service (FLS) are vital to preventing them from returning next month with a contralateral hip fracture or a fatal subdural hematoma.

The Surgeon's Role in the Team: Leadership, Not Just Carpentry

It is incredibly easy for orthopaedic trainees and consultants to feel relegated to the role of mere "technicians" in this heavily medicalized model. This is a dangerous misconception. Surgeons must be visible leaders in the orthogeriatric pathway.

1. Systemic Advocacy: We must relentlessly fight for daytime theatre access. We must educate hospital administrators that a hip fracture is an acute surgical priority, not an inconvenience that can wait until the weekend is over.
2. Uncompromising Technical Excellence: A cemented hemiarthroplasty must be executed perfectly. A poorly positioned stem, an intra-operative periprosthetic fracture, or a dislocating hip due to poor tissue tensioning completely derails the geriatrician's ability to rehabilitate the patient.
3. Clear Communication: The post-operative note must clearly, unequivocally document the stability of the fixation and explicitly state "Full Weight Bearing As Tolerated." Ambiguity in the operation report breeds hesitation in the physiotherapy team, delaying mobilization.

The ANZHFR Clinical Care Standards

For those operating in Australia and New Zealand (and similarly mirrored in the UK NHFD), the Registry actively measures hospital performance against seven strict clinical care standards. Knowing these is essential for both clinical practice and board examinations:

1. Care at presentation: Documented pain assessment within 30 minutes of ED arrival.
2. Pain management: Use of multimodal analgesia, specifically prioritizing early nerve blocks.
3. Model of care: Formal, documented management under a recognized Orthogeriatric shared-care model.
4. Timing of surgery: Surgical intervention occurring less than 48 hours from presentation.
5. Mobilization: Documented opportunity to mobilize on the day of, or the day following, surgery.
6. Refracture prevention: Initiation of active pharmacological bone protection therapy prior to discharge.
7. Transition of care: A comprehensive, individualized, multidisciplinary care plan provided to the patient and their primary care physician upon discharge.

Conclusion

The Orthogeriatric model is a triumph of systems engineering and collaborative medicine. It forces us to acknowledge that an elderly patient presenting with a fractured hip is not just a collection of broken parts requiring carpentry, but a highly complex, fragile physiological system in acute distress.

By stepping out of our surgical silos and treating the patient collaboratively with our geriatric colleagues, we achieve something profound. We don't just fix the X-ray; we restore dignity, we preserve independence, and most importantly, we save lives. Mastering this pathway is the true mark of an exceptional modern orthopaedic surgeon.