Dr. Kanu Okike, an orthopaedic trauma specialist affiliated with Kaiser Permanente in Honolulu, answers four questions about hip fractures, among other things. [Related information can be found in the Orthopaedia chapter on hip fractures.]

Orthopaedia: Most geriatric hip fracture patients in the US likely get their care under Medicare. What do you think are the potential benefits for a patient getting geriatric hip fracture care at a place like Kaiser, where you work, even if they are Medicare eligible?

 

Dr. Kanu Okike: While prior research outside the Kaiser Permanente system has repeatedly documented racial and ethnic disparities in hip fracture outcomes, we recently published an analysis of hip fracture patients which found that racial and ethnic minority patients within the Kaiser Permanente system fare as well as their white counterparts. Although our study was not designed to determine the reasons for these findings, anecdotally I can tell you that the protocols in place within the Kaiser Permanente system greatly reduce the variability in care that can often be seen in other settings.

In general, variability in healthcare is a bug, not a feature. For example, Peter Pronovost famously showed that if hospital staff simply adhered to the standard protocols for inserting central intravenous catheters, the infection rate goes way down. In orthopaedic surgery, pre-operative checklists have essentially eliminated wrong site surgery. While this reduction of variability helps all patients, the benefits may be particularly great for historically disadvantaged groups, for whom differences in treatment often means inferior care.

Orthopaedia: You practice in Hawaii, which is consistently ranked first in the nation for racial and ethnic diversity. What do you think are important racial and ethnic issues in geriatric hip fracture in the United States today?

Dr. Kanu Okike: As noted above, racial and ethnic minority patients treated within the U.S. healthcare system have often been found to experience inferior care. With regard to hip fractures, for example, studies outside the Kaiser Permanente system have repeatedly found that minority patients tend to experience longer delays to surgery even after controlling for medical comorbidities. In contrast, our analysis found that time to surgery did not differ between Asian, Black, Hispanic and White patients within the national Kaiser Permanente system. While all patients can benefit from the care provided by an integrated healthcare system such as Kaiser Permanente, the benefits may be particularly great for minority patients and others who have been shown to be at risk for disparities in outcome when treated within the broader U.S. healthcare system.

But yes, I have lived and worked in Hawaii for 10 years now, after spending the first several decades of my life on the East Coast. While racial and ethnic issues do certainly exist in the state, I have found them to be considerably less prominent than in other places I have worked. On a personal note, I have also found Hawaii to be a wonderful place to practice as a Black orthopaedic surgeon. While microaggressions were a common occurrence while living and working in Boston, I have found them to be exceedingly rare here in the islands, which does wonders for one’s overall health and wellbeing.

 

Orthopaedia: There is a quotation attributed to Reginald Watson Jones, saying that “we come to the world under the brim of the pelvis and go out through the neck of the femur.” This alludes to the high mortality rate associated with geriatric hip fracture–on the order of 25% in the first year alone. Given that geriatric hip fracture is, if not caused by, at least associated with old age and senescence, is it reasonable to hope for lower mortality rates?

Dr. Kanu Okike: Without surgery, the one-year mortality rate following hip fracture in the elderly might be around 60-80%. As you noted, with prompt surgical treatment we have succeeded in lowering that rate to 20-25%. However, there has been little to no progress in further reducing that figure over the past several decades, despite the many medical advances that have occurred over that time period. There are some who believe that hip fracture is but a step in the pathway between an underlying condition (frailty) and the final outcome (death). I personally am not that fatalistic! I’m still hopeful that we will be able to succeed in reducing hip fracture mortality in our older patients. For example, simply reducing the variability in treatment noted above could possibly help to move the needle.

Orthopaedia: The standard of care in medicine is defined as what the community believes is the right thing to do. Then again, the community can be wrong! Is there some aspect of conventional wisdom about geriatric hip fracture that should, at the minimum, be rigorously tested (if not supplanted)?

Dr. Kanu Okike: In the management of femoral neck fractures in the elderly, the current standard of care is replacement for displaced (Garden III and IV) fractures and fixation for nondisplaced (Garden I and II) fractures. However, we recently published a study (JBJS 2019) which found that 1 in 8 every nondisplaced femoral neck fractures treated with fixation went on to require reoperation! Given the great morbidity and mortality associated with reoperation in this population, this figure is quite problematic. The old mantra that all nondisplaced femoral neck fractures should be fixed is probably no longer true; what remains is for us to determine whether there is a subset of nondisplaced femoral neck fractures that can be fixed, or if we should be replacing all of them (as we already do for displaced femoral neck fractures in the elderly). Personally, I have become much more selective in choosing the nondisplaced femoral neck fractures that I am going to fix. If a patient has any risk factors that have previously been associated with failure of fixation (such as angulation on the lateral x-ray, disruption of the medial cortex, age over 80, or female gender), I will now replace those fractures, even if they’re Garden I or II, which represents an important change in my practice over the past 5-10 years.