In Reply

We thank Dr. Khan et al. for their comments regarding our recent Clinical Concepts and Commentary of the perioperative management of elderly patients with hip fracture¹  and for giving us the opportunity to extend the discussion.

Dr. Khan et al. are correct when indicating that mortality rates may be lower in countries such as Northern European countries, which have been at the forefront of care improvement for elderly patients with hip fracture and orthogeriatric concept.^2,3  However, we do not agree with Dr. Khan et al. who consider that a randomized trials concerning early surgery would be unethical. First, the facts are that, in most countries including ours, and in contrast to what is thought and/or recommended more than 50% of these patients are still operated later than 48 h. Second, such a trial will not compare early and late surgery (which we agree would be considered as unethical) but rather accelerated surgery versus standard of care, whatever is standard of care in the participating institutions, as suggested by the HIP ATTACK (HIP Fracture Accelerated Surgical TreaTment And Care tracK) investigators.⁴  Third, we think that a randomized trial is necessary to definitely convince emergency physicians, anesthesiologists, and orthopedic surgeons that hip fracture is an urgent procedure in elderly patients, just because we must recognize that this is not yet the case everywhere.

Concerning perioperative score, we clearly need more efficient scores than the American Society of Anesthesiologist score, particularly when considering this aged, frailty, and comorbid population. The Nottingham Hip Fracture Score may work better that the American Society of Anesthesiologist score, but its discrimination is not very high (area under the receiving operating characteristic curve: 0.76) and its calibration not so good,⁵  and we think that Nottingham Hip Fracture Score may not appropriately assess all dimensions of the “preoperative characteristics” of these elderly patients, which include of course comorbidities but also frailty and previous walking capacity. Moreover, it should be pointed that other variables may play an important prognostic role such as the delay for surgery, perioperative hemodynamic stability, and the occurrence of perioperative complications, potentially limiting the efficiency of a preoperative score.

Concerning benzodiazepine withdrawal, we think that Dr. Khan et al. made a link with perioperative sedation, which was clearly not our intention. We only want to indicate that, particularly in France which is probably a good candidate for the World championship of psychotropic drug use in the general population,⁶  physicians must carefully ask the patient for possible chronic benzodiazepine administration (sometimes for years) because it may be responsible for withdrawal in the postoperative period with potential deleterious consequences (delirium, epileptic crisis with fall, etc.).

We fully agree with the suggestion by Dr. Khan et al. to promote close international collaboration to develop active research on this topic because our population is aging and hip fracture is frequent and has devastating consequences in elderly patients. More clinical research is clearly required for this major health problem.