No, urine analysis is not necessary at all in any real emergency case, e.g. hip fracture in the elderly patient, which has to be treated within 24 hours. Best regards, A. Katzer

Dear Alexander

Thank you very much. Best regards

Agree with Alexander. Only necessary if there are symptoms of infection at first presentation. Urine analysis is not a standard in our elderly fracture care center

Dear Rene

I agree with you and Alexander. In Brazil is very common urine analysis in the preoperative laboratory examination. Thank you very much

Dear colleagues! I agree with you, if there are no any symtoms or anamnesis of urinary tract infection. With best regards Aare Märtson

From the surgical point-of-view not necessary. Possible antibiotic administration perioperatively would cover the urinary tract infection. But as a part of preoperative screening for anesthesiological or internal reasons possible pathological finding may surely influence the timing of surgery!

I think to do the test would be the best surgical workup but should not delay surgery just treat accordingly

Dear Aare, Michal and Peter

Thank you very much for your opinions.Best regards

If the urinary infection is symptomatic we can treat with antibiotics therapy but is not necessary delay the surgical treatment

Dear Vito

Thank you very much.Best regards

Dear Dr. Elias, I think preoperative assessment of C1-2 might be mandatory in elderly patients with abnormal metabolic parameters and osteoporosis.

Dear Ali

Thank you very much

Dear colleagues,

The urinary tract infection may threaten with postoperative infection and compromise the THR result for hip fracture in the elderly. On the other hand the delay of the emergency operation for doing urinary analysis may cause other serious complications. Our practice is to take urine for analysis preoperatively in symptomatic cases. The operation should be done under the standard perioperative antibiotic prophylaxe without delay. Postoperatively, appropriate antibiotics should be administered (changed) according to the results of the urine analysis and bacterial sensitivity.

Dear Panayot

The good sense should prevail. Thank you very much

Dear Wietse

Thank you very much

Dear Colleagues,

I think that the thing more important is to treat quickly the hip fracture. We use a standard perioperative antibiotic prophilaxis. Only if The patient has high temperature we delay The surgery after some clinicall analysis .

Dear Roberto

I agree

Thank you very much

Why is this an emergency if you are doing a hemiarthroplasty? I think the risk of waiting a short period of time is overblown. Also no real reason to wait, just check the urine and start appropriate treatment. Wider coverage probably not a bad idea. If they are sick enough to have a uti prior to admission then they are at high risk of complications no matter what.

Dear Jacob

When I said hip fracture in the elderly was aiming to perform an osteosynthesis and sometimes arthroplasty.

Thanks for the comments

Dear Jacob

When I said hip fracture in the elderly was aiming to perform an osteosynthesis and sometimes arthroplasty.

Thanks for the comments

check. definitely an emergency there. Are these neck or intertroch fx's? If a neck fx is displaced is there an age or health status after which you would do an arthroplasty regardless of pre-injury hip pain? Still think a urinalysis is reasonable to guide antibiotics.

very good logical discussion. I think the organism for UTI and infection of the post operative wound are usually different.

Dear Arjun

Thank you for your participation

Regards

Urine analysis is a routine part of the preoperative work up in my department. If there are indications of infection, the antimicrobials are given. However, it usually is not a cause of delay in the surgery unless there are systemic features of infection.

Dear Ravi

I appreciate your comments

Thank you very much

Regards

Dear nelson

Whats your mean?is it femoral neck fracture?in our department we do complete lab test such as UA ,CBC,BUN cr and ..... for patients more than 50 years old as routine. Are you agree with Rockwood opinion about femoral neck fracture surgery result within 1 week?

Kind regards

Dear Daneshpoo

May be femoral neck or trochanteric. Yes I agree

Thank you very much

Regards

Thanks dear dr nelson

Can i ask you about time of surgery in femoral neck fracture?i mean your operation will be emergency or as soon as possible?

kind regards

Dear Seyed

As soon as possible

Regards

Thanks dear nelson

best wishes

In our department all pertrochanteric or subcapital fracture are fixed in 48 hours of admition unless medical condition as severe respiratory or heart disease contraindicate the surgery. UTI for as is not a contraindication, but it's interesting because is cause of bacteriemia and potential infection for hardware or implants.

Some one know papers about this issue?

Thnaks Dr Nelson for the good question .

We would operate asap under antibiotic prophylaxis after doing a urine culture if required. Most of the elderly may have a urinary culture positive with low colony count and no raise in wbc counts with no neutrophil differential increase. Would aim at having these out and ambulating as early as possible with minimal discomfort and pain.

Dear Rajeev

Thank you very much for your comments

Regards

In my department the surgery is performed as soon as possible. Is performed urine culture forever. Delaying surgery, waiting for urine culture worsen the final results.

Dear Paolo

I agree with your opinion : waiting for urine culture worsen the final results.

Thank you

Regards

Of course!

Hip fracture must be operated it in the first 48 hours, if patient´s condition allows tis

All hip facture surgery must be performed under antibiotic (and antithrombotic) prophylaxis;

Also blood transfusion must be allowed (restrictive transfusion criteria must be appied). Allogeneic blood transfusion has been strongly related with nosocomial infection

Dear José-Garcia

Thank you very much for your comment.

Regards

I think routine urine examinations and chest x-rays are useless and waste of time and resources for every surgical patients. It should be abandoned except for relevant patients.

Dear Sabin

Thank you very much

Regards

I am agree with Dr Subedi.

But, also coagulation tests are mostly unuseless and a waste of money!

The classical and standard assays (Quick time and aTTP) do not predict bleeding risk

Dear Jose Garcia

Once again thank you very much for your active participation

Regards

Yes Dr. Jose maybe a research paper on review protocol regarding these pre-op tests can be written... but who is willing to do that?

And saving costs!

Patients status vary and individual differences are always present.

Urinary infection is a comorbidity, but if you are planning early surgery and if that is the only comorbidity, then it certainly is not the reason for the delay

in my opinion, urinary infections in patients with hip fracture are bigger and more frequent postoperative than preoperative problem

Dear Dragan

I agree with you

Thank you very much

Regards

Hip fracture surgery in elderly is emergency because early treatment reduce mortality.

Dear Cen

thank you very much

Regards

We analyzed a cohort of patients > 75 YO with hip fracture. Even if patients suffered from an urinary infection, surgery were performed as soon as possible (average 23 h). Antibiotics were delivered preoperatively. The major problem in a geriatric population (> 75 YO) are the comorbidities. We chose this option to initiate rehabilitation as soon as possible. We observed a marked reduction (risk ratio 0.43) in the risk of death at 6 months.

Our results are in the ref: PLoS One. 2014 Jan 15;9(1):e83795. doi: 10.1371/journal.pone.0083795. eCollection 2014.

Postoperative admission to a dedicated geriatric unit decreases mortality in elderly patients with hip fracture.

Boddaert J, Cohen-Bittan J, Khiami F, Le Manach Y, Raux M, Beinis JY, Verny M, Riou B.

Regards

Dear F. Khiami

Thank you for your opinion

Best regards

It is importand to differentiate between asymptomatic bacteriuria which is not a pathology and a symptomatic bacteriuria which means a preasence of urinary tract infection and may deserve treatment. I think it is important during preoperative evaluation to ask the patients specifically regarding the urinary tract symptoms and to perform an investigation only if the symptoms are present and act accordingly.

Dear Rihard

Thank you very much

Best regards

Hip fractures in ederly patients are a emergecy surgery and so the symptomatic or asymptomatic bacteriuria become a secondary disease and they are treatable with the antibiotical profilaxis bifore The surgery. As soon you know the result of the urinary colture you can start The correct antibiocotherapy.

Dear Roberto

Thank you very much

Best regards

Urinary tract infections occur in very high level (percent) in elderly with hip fracture as a comorbidity. We treat them operatively without delay and antibiotics therapy pre and post op. Before starting with antibiotics it is important urin analysis + urinoculture and also haemoculture. Delayed surgery is associated according our results with higher rate of complications.

Dear Cen

I agree with your comment: delayed surgery increases the rate of complications in hip fracture in the elderly. Thank you very much.

Best regards

This is a very good question and a great area to work on.Many hip fractures are increasingly treated by joint  replacement ( either hemi or total hip arthroplasty) surgery nowadays. In elective hip replacement ,we all know that urinary retention should be treated before the joint, but this policy may delay an emergent surgery which has many complications including UTI itself. I do agree with ( and practice)asking for urinalysis before surgery in all hip fractures and start treating them with additional antibiotics (in addition to routine preop antibiotics), and perform surgery ASAP. 

Dear Mehrdad

Thank you for your opinion. Best regards

No.  The study's results won't impact the decision to operate.

Screening asymptomatic patients with a UA should be reserved for pregnant females and patients who will undergo a urologic procedure.  Beyond that, the study introduces unacceptably high rates of false positive rates, and the outcome of overdiagnosis is increased direct costs, harming patients (C. Diff, resistance, allergic rxn, etc.), and the indirect costs of that harm. 

If you're going to get a UA and culture, make sure the patient has symptoms first.  If the patient is delirius, use your judgment.  But keep in mind that delirium is more common in the elderly, and that the elderly have a much higher prevalence of bacteriuria without a UTI.  Also note that emergency medicine departments are notorious for ordering UAs with reflex cultures, regardless of whether or not these patients are symptomatic. Are we missing systems-based interventions to curb this overutilization?

I'm unaware of any high quality evidence that supports the contrary.  Please advise if the evidence is out there!  (Incidentally, the attached publication provides a nice overview of what to consider, including the validity of the UA for various symptom-based scenarios.) 

Thank you.