Aches & Joints

Michael Weaver, MD is an Orthopaedic Trauma Surgeon, at Brigham & Women’s Hospital.

Co-management of elderly orthopaedic patients with a geriatrician has been shown to decrease inpatient length of stay and patient complications (2). At our two institutions, our orthopaedic and geriatric medicine services have collaborated to form a combined service. We have found that this ortho-geriatric service improves patient care, reduces inpatient length of stay, and improves patient and family satisfaction.

Optimal treatment of geriatric patients requires a holistic approach with multiple specialists caring for the patient. Patients are co-managed by an orthopaedic surgeon and a geriatrician throughout their hospitalization (Figure 1). Medications and pain control are optimized to avoid delirium. Nutritionists are involved to maximize metabolic status. Endocrinologists are consulted to assess for osteoporosis, evaluate vitamin D deficiency and to provide advice for reducing the risk of future fracture. Physical therapy plays an integral role in getting patients out of bed and working on fall prevention. By taking this multi-disciplinary approach we improve patient outcomes.

Figure 1: Geriatric patient care is optimized by a multi-disciplinary team approach.

Combined Geriatric Service
Patients with fragility fractures admitted to our two institutions are co-managed by our ortho-geriatric service and are seen daily by both their orthopaedic surgeon and geriatrician.

Our geriatricians perform a thorough pre-operative assessment including a cognitive evaluation. Medications are optimized, with patients stratified based on risk. It is particularly important to avoid delirium-causing medication such as anticholinergics. We work closely with our colleagues in Anesthesia to ensure that patients are cleared expeditiously so that their fracture can be addressed. We strive to take patients to the OR within 24 hours of admission. The risks of complication are minimized when we operate within 24 to 48 hours of a patient’s admission.
Post-operative medication and fluid management are critical. Pain control is also very important, with appropriate dosing of narcotic medication, use of blocks and other regional forms of anesthesia necessary to avoid delirium.

We recently reviewed the effects of instituting the ortho-geriatric services and found that we have reduced length of stay by 1.6 days. In a meta-analysis performed by our geriatric group, we documented a decrease in 30-day and 1-year mortality when geriatric hip fracture patients are treated by similar combined services (3).

Endocrine Consultation
Hip fractures in the elderly are typically fragility fractures and are often associated with osteoporosis. At our institutions, we partner with an endocrinologist to ensure that the appropriate work-up is performed and any metabolic deficiencies or osteoporosis are addressed while the patient is an inpatient.

Vitamin D deficiency is commonplace – particularly here in New England – thus, vitamin D levels should be obtained during the pre-operative work-up. All patients should be on calcium and vitamin D supplementation during their hospitalization and at discharge.

Bone density testing should be performed after the patient is discharged from the hospital, particularly if the results are not recent. When bone mineral density is low, bisphosphonate therapy is useful and has been shown to reduce the risk of further fracture. Care should be taken to avoid use of bisphosphonates for more than 5-years as long-term use may be related to atypical femoral fractures (4). Teriparatide (Forteo) may be useful for recalcitrant cases.

Surgical Challenges
Geriatric fractures can be challenging. Poor bone quality and previous surgeries can limit fixation options and make surgery difficult.

Femoral Neck Fractures (Total hip arthroplasty (THA) vs. hemiarthroplasty):
Many of our geriatric patients lead active lifestyles. THA provides a higher level of pain relief and improve function when compared with hemiarthroplasty. However, THA exposes patients to a longer surgery with a higher blood loss and increases a patient’s risk of dislocation. Relative contra-indications to THA include neuromuscular disorders like Parkinson’s disease, difficulty or inability to adhere to hip precautions and advanced age. In both operations I avoid the use of taper type stems as these act as wedges, increase hoop stresses, and can lead to periprosthetic fractures in patients with poor bone quality. When bone quality is compromised, cement fixation provides immediate stability for the femoral prosthesis and reduces the risk of periprosthetic fracture.

Peritrochanteric Hip Fractures (Cephalomedullary Nail vs. Sliding Hip Screw):
Not all fractures do better when treated with a cephalomedullary nail. Subtrochanteric, reverse obliquity and unstable (3- & 4-part) patterns tend to do better with intramedullary fixation. I prefer to use a sliding hip screw (DHS) for simple 2-part intertrochanteric hip fractures as this implant spares the abductors. The DHS is also substantially less expensive.

Other fixation options: Occasionally, previous surgery or pre-existing deformity precludes standard fixation of hip fractures. It is thus useful to be familiar with techniques such as the use of blade plates and proximal femoral locking plates (Figure 2).

Figure 2A: 78F with a previous cemented long stemmed total knee replacement. She now presents with subtrochanteric femur fracture.

Figure 2B: The cemented stem precludes intramedullary fixation which would be the standard treatment for this fracture pattern. Instead she is treated with open reduction and fixation with a 95 degree blade plate (right). The tip of the stem is spanned by the plate to avoid a stress riser effect.

Summary
Geriatric fractures are best managed with a multidisciplinary approach. Bringing together orthopaedic surgeons, geriatricians, anesthesiologists, endocrinologists, nurses, therapists and nutritionists improves patient care and optimizes outcomes.

References

1. Braithwaite RS, Col NF, Wong JB. Estimating Hip Fracture Morbidity, Mortality and Costs. J Amer Geriatrics Soc 2003; 51(3):364-370.
2. Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN, Budge MM. Outcomes for Older Patients With Hip Fractures: The Impact of Orthopedic and Geriatric Medicine Co-care. J Ortho Trauma 2006; 20(3):172-180.
3. Konstantin V, Grigoryan MS, Javedan H, Rudolph SM. Ortho-Geriatric Models and Optimal Outcomes: A Systematic Review and Meta-Analysis. J Trauma (submitted).
4. Weaver MJ, Miller M, Vrahas MS. The Orthopaedic Implications of Disphosphonate Therapy. J Am Acad Ortho Surg 2010; 18:367-374.

Filed under: Hip, Joint Replacement, Physician Education, Trauma, Trauma Rounds | Tagged: elderly, Geriatrics, Joint Replacement | Leave a Comment »