JBJS welcomes reader comments on published articles. Letters to the Editor are reviewed by JBJS editors but are not peer-reviewed. To submit your letter, please follow the "submit a response" link that appears in the content box at the upper right of the full text of the article.

Letters to the Editor to:

Scientific Articles:
Amer N. Al-Ani, Bodil Samuelsson, Jan Tidermark, Åsa Norling, Wilhelmina Ekström, Tommy Cederholm, and Margareta Hedström
Early Operation on Patients with a Hip Fracture Improved the Ability to Return to Independent Living. A Prospective Study of 850 Patients
J Bone Joint Surg Am 2008; 90: 1436-1442 [Abstract] [Full text] [PDF]
*Letters to the Editor: Submit a response to this article

Electronic letters published:

[Read Letter to the Editor] Dr. Al-Ani and Colleagues respond to Dr. Bidwai
Amer N. Al-Ani, Jan Tidermark and Margareta Hedström   (21 August 2008)
[Read Letter to the Editor] Role of delay for medical optimisation of hip fracture patients
Amit S Bidwai, Timothy N Board   (21 August 2008)

Dr. Al-Ani and Colleagues respond to Dr. Bidwai 21 August 2008
Previous Letter to the Editor Top
Amer N. Al-Ani,
Orthopaedic surgeon
Karolinska University Hospital, Huddinge,
Jan Tidermark and Margareta Hedström

Send letter to journal:
Re: Dr. Al-Ani and Colleagues respond to Dr. Bidwai

amer.al-ani{at}karolinska.se Amer N. Al-Ani, et al.

We thank Dr Bidwai for his interest in our article (1). As pointed out in his letter, the results of our study contribute to the growing evidence that early operative treatment is beneficial for patients with hip fractures. However, none of the questions raised by Dr Bidwai can be given an answer based on our paper and we are not aware of any other paper that can support an evidence based answer.

If you ask us for our opinion, we do believe that the time taken to medically optimize patients most often is justified provided that this process is performed in close collaboration with the attending anesthesiologist and that the indication for potentially time-consuming preoperative medical investigations are balanced against the negative effect of the prolonged waiting time.

Our present goal is to perform surgery on hip fracture patients as soon as possible and always within 24 hours. Prior to the surgical procedure, we believe that pain should be minimized and that the fasting time be as short as possible in order to reduce the metabolic response to stress. Moreover, our aim is to allocate our resources so we can avoid being forced to perform hip fracture surgery during the night.

References: 1.Amer N. Al-Ani, Bodil Samuelsson, Jan Tidermark, Åsa Norling, Wilhelmina Ekström, Tommy Cederholm, and Margareta Hedström Early Operation on Patients with a Hip Fracture Improved the Ability to Return to Independent Living. A Prospective Study of 850 Patients J Bone Joint Surg Am 2008; 90: 1436-1442
Role of delay for medical optimisation of hip fracture patients 21 August 2008
Next Letter to the Editor Top
Amit S Bidwai,
Speciality Registrar in Trauma and Orthopaedic Surgery
Wrightington and Wigan Hospitals,
Timothy N Board

Send letter to journal:
Re: Role of delay for medical optimisation of hip fracture patients

bidwai2000{at}yahoo.co.uk Amit S Bidwai, et al.

To the Editor:

The article by Al-Ani et al.(1) has stimulated much debate in our institution about the optimal treatment protocol for patients with hip fractures. This paper adds to the growing body of evidence that seems to indicate that timing of surgery is the most important predictor of outcome for these patients,and that the stress response of the patient to trauma is critical.

We are particularly interested in the 31% of patients who had surgery delayed because they required time for medical optimisation. Since there is mounting evidence in the literature favoring early surgical intervention as the most important factor in outcome, we would ask the authors to comment on whether the time taken to medically optimize patients is justified and secondly, should we be operating on these patients as soon as possible, including during the night?

We recognize the difficulties of answering these questions in the absence of evidence based studies. As the authors rightly point out, randomized controlled trials for these patients are not always appropriate and certainly we would struggle to achieve ethical approval for a randomized controlled trial which compared a cohort patients who underwent surgery within 24 hours despite having potentially reversible medical conditions with a cohort that included patients who were medically optimized pre-operatively.

Are we to conclude from the present study that whatever the medical status of the patient, the more important variable in outcome is time to surgery due to the nature of the catabolic stress response to trauma? Time delays for medical optimisation may actually be detrimental to patient outcome.

The authors did not receive any outside funding or grants in support of their research for or preparation of this work. Neither they nor a member of their immediate families received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, division, center, clinical practice, or other charitable or nonprofit organization with which the authors, or a member of their immediate families, are affiliated or associated.

References:

1.Amer N. Al-Ani, Bodil Samuelsson, Jan Tidermark, Åsa Norling, Wilhelmina Ekström, Tommy Cederholm, and Margareta Hedström Early Operation on Patients with a Hip Fracture Improved the Ability to Return to Independent Living. A Prospective Study of 850 Patients J Bone Joint Surg Am 2008; 90: 1436-1442