The Global Framework

Editor’s Note: This feature was originally published in the winter 2025 print edition of NEXT. To view a PDF of the full issue, visit our publications page.
By Holly Prestidge, MCV Foundation
Photos by Daniel Sangjib Min, MCV Foundation
Hip fractures are easy. Let the interns do it.
Those sentiments proved a startling introduction to geriatric fracture surgeries for Stephen Kates, M.D., professor and chair of the VCU School of Medicine Department of Orthopaedics and the James W. and Frances G. McGlothlin Chair in Orthopaedics.
It was the 1980s, and as a young doctor starting his career in New York, he was struck by the lack of priority given to older people languishing in hospitals, sometimes for days, before receiving hip surgeries due to falls and accidents.
The surgeries were viewed as routine procedures, Dr. Kates recalled, easily handled by junior faculty for a population that largely went ignored.
Dr. Kates — who now serves as second vice president of the American Orthopaedic Association and who was instrumental in founding an international society for the field of geriatric fracture — would go on to create a system of patient-centric standardized care both nationally and around the globe. He brought those standards to VCU Health in 2013 when he joined the faculty.
But he remembers how his initial observations did not match the perception he was fed.
“It was completely wrong,” Dr. Kates recalled. A few of the many books he authored were perched on a bookshelf in his West Hospital office.
“Hip fracture surgeries were not easy, and in fact, they were very difficult,” he said. “And the outcomes were not good.”
Each year, about 330,000 people in the United States over the age of 65 fracture a hip.
It’s a team effort — you have to have folks on these teams who are believers.
Stephen Kates, M.D., professor and chair, VCU School of Medicine Department of Orthopaedics
And in Dr. Kates’ early days, nearly one-third of those patients died in the first year following hip surgery. Some died before they left the hospital. Those who lived beyond a year or so often lost several degrees of functionality within their daily lives. Hip fractures disproportionately affect women, which makes the injury more deadly for them than breast and ovarian cancer combined.
It was grim.
“People weren’t paying attention, and it just struck me,” Dr. Kates said. “The outcomes are bad, the treatments are hard and, ultimately, it usually didn’t go well.”
Despite peers who laughed at him, Dr. Kates took the opportunity to visit patients in nursing homes after their surgeries to get the full picture of their needs. He realized they needed better presurgical care, including shorter waits for surgery. He saw ways to improve postsurgical care, including such simple tasks as sending patients to rehab with a checklist of discharge summaries, contact numbers for their doctors, follow-up appointment dates and lists of their medications.
In other words, opportunity knocked. Dr. Kates — ignoring the skeptics — answered.

A Team of Believers
VCU Health is ranked 33rd nationally in orthopaedics by U.S. News & World Report.
About 250 patients receive hip surgeries at VCU Health each year, or roughly 20% of the Richmond area’s hip fracture patients. Those 20% represent the worst cases. The others are treated at smaller community hospitals.
VCU Health’s program stands on a few central pillars. Most surgeries are performed within 24 hours from the time the patient arrives, regardless of the day of the week, and the surgeries constitute “single-shot” procedures, meaning they’re done right the first time, Dr. Kates said. Another pillar is that patients can begin to walk nearly immediately after the surgery and bearing full weight.
It’s a sea change from decades ago. Gone are the days of a patient waiting for hip surgery simply because their physician’s designated surgery day wasn’t until the next week.
Gone are the myriad sedatives and opiates given to patients during those painful days in waiting, which often caused additional medical issues — delirium, aspiration pneumonia, blood clots — that ultimately worsened their conditions, sometimes fatally.
Gone, too, is the lost connection between hospital and patients once they leave and head to rehab.
VCU Health, the Richmond-area’s first Level I trauma center, not only adopted standardized care for geriatric fracture patients but embraced it. These days, a team composed of Dr. Kates, four orthopaedic trauma surgeons and three joint surgeons exclusively perform all the geriatric fracture surgeries.
“We have a true comprehensive program, but that took a culture change,” Dr. Kates said, namely because until recently, hip fractures weren’t viewed as trauma. “What we’re doing here requires a different mindset because it’s beginning-to-end care.”
He added: “It’s a team effort — you have to have folks on these teams who are believers.”
The Complete Care Package
If surgery is the backbone of VCU Health’s program, specialized care both before and after is its heart, soul and connective tissue.
Even before Dr. Kates arrived, geriatric care was changing on the MCV Campus.
Sarah Hobgood, M.D., a geriatrician and assistant dean for clinical medical education at the VCU School of Medicine, arrived in 2009 with the task of reviving geriatric consultation services, a crucial element that provides co-management care for geriatric patients from the moment they’re admitted to the emergency department to postsurgical rehab and beyond.
“We needed to not only be doing the acute medicine for the patients, but we needed to be thinking about geriatric syndromes associated with hospitalization,” she said, conditions such as dementia, anxiety, delirium and loss of function for activities of daily life, like dressing or bathing.
She immediately connected with surgical teams across the campus to create a network in which everyone was addressing patient needs using standardized care practices, including those created years before by Dr. Kates.
Today, that means orders are activated when patients arrive in the emergency department. Several things happen simultaneously. We try to get everyone on board as quickly as possible, lining up all the pieces of that interdisciplinary puzzle to provide patients with a continuum of care that wasn’t there before.
Sarah Hobgood, M.D., geriatrician and assistant dean for clinical medical education, VCU School of Medicine
Anesthesiologists administer nerve blocks to the patients. Nerve blocks are localized anesthesia that reduce the patient’s pain and are used as an alternative to strong pain medicines. At the same time, Dr. Hobgood’s team gets involved in presurgical evaluations as well as pain management plans.
It is a streamlined process that ensures patients get into surgery quickly without being subjected to unnecessary presurgical tests or lots of heavy drugs that could make them sicker. Conversely, if they have other existing medical issues that need attention, those are incorporated into the plans.

“The longer they are not fixed, the worse the outcomes,” Dr. Hobgood said. “We do our due diligence, but as geriatricians, we do not want to delay people going to the operating room. As much as possible, we want to avoid unnecessary testing.”
While the national standard for getting geriatric fracture patients into surgery is 48 hours, which isn’t consistently followed across the country, VCU Health aims for 24 hours.
We want to prevent the next fracture, so we’re putting all of these things in motion to identify those at high risk and then help them avoid future falls.
Katherine Vita, orthopaedic trauma surgery physician’s assistant, VCU Health Department of Orthopaedics
“Having everyone go directly or as quickly as possible to the operating room was a big cultural shift,” she said. It required educating all parties on the changing models of care related to preoperative categories, which for many years included only two buckets for injuries: emergencies or elective care.
“A broken hip is not an elective surgery,” Dr. Hobgood said, but nor was it an emergency in the sense that the patient would die without immediate intervention.
Thankfully, she said, the two categories expanded about 10 years ago to include a third bucket for urgent care for injuries that were serious enough to need surgery but not emergency surgery.
“That was a huge lift, but it took a lot of education,” she said. Hospitals in particular were concerned about striking a balance between not adding unnecessary burdens to the emergency department and not allowing geriatric patients to wait too long for their surgeries.
Additionally, the consultation team initiates connections for rehabilitation services even before the patients are in surgery.
Roughly 90% of patients will go to a skilled nursing facility to complete their rehab, so part of VCU Health’s multidisciplinary approach engages social workers, physical therapists and occupational therapists from the beginning.
“Ideally, the patient should be ready to go to that rehab facility and not have to spend extra nights in the hospital while someone is looking for a place for them to go,” Dr. Hobgood said. “We try to get everyone on board as quickly as possible, lining up all the pieces of that interdisciplinary puzzle to provide patients with a continuum of care that wasn’t there before.”
A new hip does wonders, but making sure falls don’t happen again is key. Many people, however, do not think about their bone health until it’s too late.
VCU Health has incorporated bone health education into its comprehensive care, said Katherine Vita, an orthopaedic trauma surgery physician’s assistant in the VCU Health Department of Orthopaedics. The greatest predictor of another fall is the first fall.
To curb that, Vita said, when patients follow up with their surgeons after surgery, they are also meeting with advanced practice providers, who can help them identify risks and keep them safe.
“We want to prevent the next fracture, so we’re putting all of these things in motion to identify those at high risk and then help them avoid future falls,” Vita said. They want patients to view this like prevention for other conditions such as heart attacks.
Dr. Hobgood also noted that since she started, it has become mandatory for orthopaedic interns to spend a one-month rotation with geriatric patients.
“The public doesn’t always recognize how important bone health is to their overall health,” she said. “People are living longer, and they’re staying active longer, but that also means they’re hurting themselves as they age.”
VCU Health’s program is a cohesive network of healing and education.
“Here at VCU, we have all these specialists and experts who weigh in and bring it all together,” Vita said. “It really is a meeting of the minds.”
Tip of the Iceberg
Dr. Kates laid titanium hardware on the table, explaining how the sturdy ball-and-socket mechanism is used in hip replacements. If the patient’s bones are brittle, sometimes they will also use cement — the same material found in some kitchen counters. Unless the individual falls again or sustains another major injury, the hardware lasts a lifetime.
Dr. Kates, who created and then taught courses on his standardized care practices, said health systems around the world that have adopted them have seen reduced readmission rates, reduced death rates and reduced costs, both for patients and the hospitals. He said about 90% of U.S. hospitals today use standardized care for hip fracture surgeries.
He considers it a good start.
“We’re just addressing the tip of the iceberg,” Dr. Kates said. “The parts that you can see above the water are the people who’ve already had a fracture and don’t want another one.”
He said that while the vast majority of U.S. women will have a mammogram, a fraction of those — maybe 5% or 10% — will check their bone health well before they’re 65.
Doing so can be as easy as using online calculation tools, like FRAX, a fracture risk assessment tool developed by the University of Sheffield in England. Individuals enter basic information such as age, weight, height, whether they’ve had previous fractures, and a few extra points. The tool calculates the likelihood of a fall within 10 years.
“The large mass under the water that we can’t see, those are the people who haven’t fallen but are high risk,” Dr. Kates said. “We have the tools, we have the medicines, but the final part is fall prevention and bone health.”
If you would like to support the Department of Orthopaedics at the VCU School of Medicine, please contact Andrew Hartley, senior director of development in the VCU Office of Medical Philanthropy and Alumni Relations, at 804-628-5312, or aphartle@vcu.edu. To give to the Division of Geriatric Medicine, please contact Nathan Bick, executive director of development for the Department of Internal Medicine, at 804-827-0387, or ngbick@vcu.edu.
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