General surgeon vs ortho with hip ORIF

[truthseeker]

Does anyone know roughly what the percentages are nationwide how many Hip ORIFs are done by general surgeons vs by orthopedic surgeons?

We have a general surgeon who does them as well as doing hip prostheses and we are researching the standard of care. In my experience outside my current place of employment, Orthos do many more and have better outcomes.

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[PediBoneDoc]

you know i can not give you the percentages of boney surgery, such as hip ORIF, femoral neck pinning, and hemi vs tha, done by general surgeons. in the past, there have been some general surgeons who were trained in boney surgery. in europe, there are some trauma surgeons that will also do fracture work.

in the united states, the standard of care is dictated by what is standard in your region of the country. so standards can vary. that being said, the general standard of care is that bone docs do bone surgery.

although most proximal femur fractures in ederly patients are relatively easy to fix, there are a significant number of complications that can occur which cause long term disability. there are more issues than just "bone broke me fix."

in general, most hospitals will require some training in specific areas and therefore most general surgeons will not be credentialled to do that type surgery. in with todays medical malpractice climate, it does not benefit you to take on that risk. it is why i have a general surgeon do my anterior spine approaches. it also gives me a break while they close

 

[truthseeker]

Thanks for the info. I am a PT in a hospital. My background is in outpatient ortho. I am in a rural hospital now and we have a general surgeon that is US trained. In years past, we have not had ortho backup and the nearest one was about 40 miles away so he evidently took on those procedures. Now we have orthos that come here on outreach and do some of the THAs and TKAs but the general surgeon does the neck fractures and intertroch fx.

the DON was asking about the standard of care and I didn't think that there was a universal "best practice"

Usually, he says non-weight bearing for 2-4 weeks, then a gradual increase to FWB at 8 weeks. The problem is that most of the patients with this dx have dementia or Parkinsons or something else that prevents them from following his WB precautions and they run the risk of pneuomnia, atelectasis, skin breakdown etc . . . and he is unapproachable about allowing earlier WB (most orthos that I have worked with usually allow WB as tolerated unless the repair is thought to be particularly tenuous).

Any other feedbackf rom you or others would be helpful.

 

[dawg44]

I agree totally with the Pedibonedoc. They may have had some training in it, but the bottom line is can you deal with your own complications because surgeons don't like to take care of other people's screw ups. Yeah a general surgeon may do OK pinning a hip or even a hemiarthroplasty but what happens if he breaks off the greater trochanter or splits the calcar putting down a prosthesis. He could also have a DHS screw protrude through the head and screw up the acetabulum. Can he do a total hip? Cup position can be a challenge sometimes for even seasoned orthopods. I can do flexor tendons all day long but I don't because I don't want to ever have to do a tenolysis. Do what you know and do it well.

 

[dawg44]

Thanks for the info. I am a PT in a hospital. My background is in outpatient ortho. I am in a rural hospital now and we have a general surgeon that is US trained. In years past, we have not had ortho backup and the nearest one was about 40 miles away so he evidently took on those procedures. Now we have orthos that come here on outreach and do some of the THAs and TKAs but the general surgeon does the neck fractures and intertroch fx.

the DON was asking about the standard of care and I didn't think that there was a universal "best practice"

Usually, he says non-weight bearing for 2-4 weeks, then a gradual increase to FWB at 8 weeks. The problem is that most of the patients with this dx have dementia or Parkinsons or something else that prevents them from following his WB precautions and they run the risk of pneuomnia, atelectasis, skin breakdown etc . . . and he is unapproachable about allowing earlier WB (most orthos that I have worked with usually allow WB as tolerated unless the repair is thought to be particularly tenuous).

Any other feedbackf rom you or others would be helpful.

Its anecdotal I know but I think most orthopods are going to be more confident in their repair to allow early weightbearing. That's why we are there in the first place.

 

[truthseeker]

Dawg, you are preaching to the choir. Our surgeon is just a big fish in our little pond and, like I said, he is unapproachable about this until he screws up enough of them. Really, not that many, its just that the recovery is so slow because of the WB status.

Thanks for the replies.

 

[SOUNDMAN]

I am a former orthopedic PA and there was a general surgeon in the town I practiced in that did all the hip fractures, spine stuff, etc but that was also because there were not any orthopods that would come up there and work in the town. That was obviously some time ago and now the town is doing well, the hospital is thriving and there are 4 orthopods that serve that area. The general surgeon retired several years ago, and was the mayor for sometime, but now has gone about retired life.

So I have seen it before and heard of it, but I would think that with any complications the extent of the general surgeons training could be exceeded quite rapidly and that would be the problem.

In a addition, nearly any hip fracture we had, we would do PWBAT minimum, unless the fracture/bone quality was so poor that it warranted a period of NWB status, however this was definitely the exception to our treatment plan and not the norm.

 

[pedisurg]

Its anecdotal I know but I think most orthopods are going to be more confident in their repair to allow early weightbearing. That's why we are there in the first place.

This is a funny statement. Fracture stability and ability to hold weight depend on much more than just repair confidence, like fracture pattern, quality of bone, etc....

The orthopaedic literature suggests that in the elderly, they are very often unable to "comply" with weight bearing restrictions when asked specifically to perform weightbearing task. So if you are concerned enough about an elderly patient to operate on them to allow mobility to decrease morbidity, you need to make them weight bearing as tolerated. Zuckerman's article in JBJS regarding post-operative weight bearing after femoral neck/intertroch fractures, hammer's home the old orthopaedic adage" "treat them like a dog".

A dog doesn't walk on a broken leg until it stops hurting enough to weight bear, later in its healing stage. Zuckerman showed that elderly patients progressively increase the amount of weight they place on the injured leg voluntarily! They have a built in defense mechanism for surgeon not confident in their reduction or fixation

I know several general surgeons in very rural areas nailing femurs, etc. Its a necessity in some places, and we all know there are very difficult hip fractures, and bread and butter ones. The ability of that surgeon to recognize his limitations and refer to someone else is important!

 

[dawg44]

I agree completely and thats the reason I have nearly all go WBAT. The biggest difference is your quote. An orthopod is going to more than likely know that and know the literature. He's going to know things like Tip Apex distance on Gamma Nails and DHS and staying above the lesser troch on perc screws and the position to put the screws, which feeds into the confidence point that I was trying to make.

 

[truthseeker]

This is a funny statement. Fracture stability and ability to hold weight depend on much more than just repair confidence, like fracture pattern, quality of bone, etc....

The orthopaedic literature suggests that in the elderly, they are very often unable to "comply" with weight bearing restrictions when asked specifically to perform weightbearing task. So if you are concerned enough about an elderly patient to operate on them to allow mobility to decrease morbidity, you need to make them weight bearing as tolerated. Zuckerman's article in JBJS regarding post-operative weight bearing after femoral neck/intertroch fractures, hammer's home the old orthopaedic adage" "treat them like a dog".

A dog doesn't walk on a broken leg until it stops hurting enough to weight bear, later in its healing stage. Zuckerman showed that elderly patients progressively increase the amount of weight they place on the injured leg voluntarily! They have a built in defense mechanism for surgeon not confident in their reduction or fixation

I know several general surgeons in very rural areas nailing femurs, etc. Its a necessity in some places, and we all know there are very difficult hip fractures, and bread and butter ones. The ability of that surgeon to recognize his limitations and refer to someone else is important!

I love that. Treat them like a dog. perfect. Even the most demented patient will self limit weightbearing associated with pain. It is immediate and will remind them every time until it is no longer important.

 

[tega]

This is a funny statement. Fracture stability and ability to hold weight depend on much more than just repair confidence, like fracture pattern, quality of bone, etc....

The orthopaedic literature suggests that in the elderly, they are very often unable to "comply" with weight bearing restrictions when asked specifically to perform weightbearing task. So if you are concerned enough about an elderly patient to operate on them to allow mobility to decrease morbidity, you need to make them weight bearing as tolerated. Zuckerman's article in JBJS regarding post-operative weight bearing after femoral neck/intertroch fractures, hammer's home the old orthopaedic adage" "treat them like a dog".

A dog doesn't walk on a broken leg until it stops hurting enough to weight bear, later in its healing stage. Zuckerman showed that elderly patients progressively increase the amount of weight they place on the injured leg voluntarily! They have a built in defense mechanism for surgeon not confident in their reduction or fixation

I know several general surgeons in very rural areas nailing femurs, etc. Its a necessity in some places, and we all know there are very difficult hip fractures, and bread and butter ones. The ability of that surgeon to recognize his limitations and refer to someone else is important!

well said...i alwys wondered how an 87 year female determined how to 33.75% weight bear