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 upon us. As the population ages, the incidence of fragility fractures, particularly hip fractures, is rising exponentially. A hip fracture is no longer viewed merely as a broken bone; it is recognized as a sentinel event—a marker of frailty that carries a 1-year mortality rate of 20-30%, rivaling many cancers.

Historically, these patients were managed in "silos": admitted to surgery, fixed by a carpenter, and treated by junior residents for their complex medical comorbidities. This led to poor outcomes. The paradigm shift to Orthogeriatrics—a shared care model between Orthopaedic Surgeons and Geriatricians—is arguably the single most important advancement in hip fracture care in the last 20 years.

This article explores the mechanics of this model, the evidence behind it, and the practical implications for the treating surgeon.

The Evolution of Care Models

We can categorize hip fracture care into three evolutionary stages:

1. Traditional Model (The Silo)

• Structure: Patient admitted to Ortho ward. Medics only see patient if "consulted" for a specific problem (e.g., "fast AF").
• Result: Reactive care. Medical issues are missed or treated late. High mortality.

2. Medical Consultant Model

• Structure: Patient admitted to Ortho, but has a routine drop-in by a physician.
• Result: Better, but often lacks ownership. The physician is a "guest" on the ward.

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

• Structure: Joint admission. The patient is co-managed from the moment they hit the ED.
• Ownership: The Surgeon owns the bone; The Geriatrician owns the biology.
• Evidence: Mandated by the Australian & New Zealand Hip Fracture Registry (ANZHFR) and the UK "Blue Book". Proven to reduce in-hospital mortality, length of stay, and readmission rates.

Key Components of the Orthogeriatric Pathway

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

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

The goal is not to make the patient "healthy" (impossible), but to make them "fit for surgery" as quickly as possible.

• Time to Theatre: The target is < 36-48 hours. Delay is an independent predictor of mortality.
• Anticoagulation Reversal: Rapid protocols for Warfarin (Prothrombinex) and DOACs.
• Fluid Resuscitation: Most elderly falls patients are dehydrated / acute kidney injury (AKI).
• Nerve Blocks: Fascia Iliaca Block (FIB) in the ER. Opioid-sparing analgesia reduces delirium.
• The "Golden Ticket": Prioritizing these patients on the trauma list. They are not "add-ons"; they are emergencies.

Phase 2: Intra-operative Decisions

• Anaesthesia: Spinal (Neuraxial) vs GA. While mortality data is similar, Spinal is preferred to reduce chest infections and postoperative delirium, provided hypotension is managed.
• Surgical Goal: "Get it right, first time."
  • Displaced Intracapsular: Hemiarthroplasty (or Total Hip for fit active patients). Cemented stems are the standard (lower revision rate, better fixation).
  • Extracapsular: CMN (Nail) or DHS (Slide).
  • Crucial Goal: The construct must allow Immediate Full Weight Bearing. If you restrict weight bearing in a 90-year-old, you sentence them to bed rest, pneumonia, and death.

Phase 3: Post-operative Care (Geriatrician Led)

• Delirium Management: The "orthopaedic emergency of the brain." 4AT screening. Treating underlying causes (Pain, Infection, Constipation, Urinary Retention - "PINCH ME").
• Mobilization: Day 1. "Dangle and Dance."
• Nutrition: High protein supplements.

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

• Bone Health: Start Bisphosphonates (Zoledronic acid) or Denosumab.
• Falls Assessment: Why did they fall? Syncope? Polypharmacy? Home hazards? If you fix the hip but ignore the fall, they will be back with a subdural next month.

The Surgeon's Role in the Team

It is easy for surgeons to feel like "technicians" in this model. This is incorrect. We are leaders.

1. Advocacy: Fighting for theatre time.
2. Technical Excellence: A cemented hemiarthroplasty must be done perfectly. A cement reaction or a periprosthetic fracture is a disaster.
3. Communication: We must clearly document the stability of the fixation to empower the physios to mobilize the patient fearlessly.

The ANZHFR Clinical Care Standards

The Registry measures hospitals against 7 standards:

1. Care at presentation (Pain assessment).
2. Pain management (Nerve blocks).
3. Orthogeriatric model of care.
4. Timing of surgery (<48h).
5. Mobilization (Day 1).
6. Refracture prevention (Bone meds).
7. Transition of care.

Conclusion

The Orthogeriatric model is a triumph of systems engineering in medicine. It acknowledges that an elderly patient is not just a collection of broken parts, but a complex physiological system. By treating the patient collaboratively, we don't just fix the X-ray; we save the life.