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THE CHALLENGE OF GERIATRIC HIP FRACTURES * JOSEPH D. ZUCKERMAN, M.D. Director, Geriatric Hip Fracture Program Hospital for Joint Diseases Orthopedic Institute
STEPHAN R. SAKALES, PH.D. DOROTHY R. FABIAN, ED.D. Geriatric Hip Fracture Program Hospital for Joint Diseases Orthopedic Institute
VICTOR H. FRANKEL, M.D., PH.D. Chairman, Department of Orthopedic Surgery Hospital for Joint Diseases Orthopedic Institute New York, New York
H IP FRACTURES in the geriatric population challenge health professionals involved in their care. Frequently, too much attention is placed on the fracture rather than on the patient who sustains the fracture. Advances in orthopedic surgery over the last 30 years enable us to provide successful fracture treatment in 80 to 90% of the cases. 1,10,12,14,15 However, outcomes of treatment, measured in terms of the patients' ability to return to their preinjury activity and independence, postoperative complications, and mortality often fall far short of our expectations. In this paper we shall discuss the challenging problem of geriatric hip fractures, including their orthopedic management and a description of the results of the interdisciplinary program utilized at the Hospital for Joint Diseases Orthopedic Institute. A number of important characteristics make the management of geriatric hip fractures a growing health care problem. First, it is estimated that in 1985 more than 250,000 hip fractures occurred among patients older than 65. This is a staggering number, considering the services necessary to care for these patients. The problem looms even larger because current predictions indicate that more than 500,000 hip fractures will occur annually by the year 2040. Because the number grows each year, it becomes even more imperative that we find effective ways to manage these difficult patients. *Presented at a meeting of the Section on Geriatric Medicine of the New York Academy of Medicine on June 13, 1988.
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Second, not only are numbers of hip fractures increasing, but the patients are getting older and frailer. These fractures often occur with significant comorbid conditions that further complicate their care. Unfortunately, required care becomes more extensive and complicated and reimbursement has not kept pace. The Diagnosis-Related-Group (DRGs/prospective payment system) does not take into account the significant comorbid conditions in the patient population and their frequent complications. Third, hip fractures in geriatric patients are associated with significant postinjury morbidity and mortality. Most of these patients do not regain their prefracture level of independence.2,7 Skilled nursing care may be required by as many as 50% of patients at the time of discharge from the hospital.5 This has been even more of a problem since the advent of DRGs in which even more importance is placed upon early discharge from hospital.5 Mortality within the first year following fracture has been as high as 40%.3,6,11,16 These studies have shown that mortality is increased for one to two years after the fracture. Fourth, as geriatric hip fracture patients become older and more frail, returning to their homes becomes a formidable task often requiring extensive home care services. Unfortunately, available home care resources and services for the elderly have been dwindling. Recent cutbacks in government funding, particularly Medicare-supported programs, have made it very difficult to provide the needed postdischarge care for these patients. This is particularly true in New York City. We frequently must delay discharges for weeks until home care services become available. Fifth, there is an often unrecognized but very important aspect of hip fractures in the elderly: the effect on the patient's spouse and family. Frequently, the elderly patient who breaks a hip has been the caregiver for a disabled spouse. The hip fracture not only disrupts the patient's life, but may devastate the disabled spouse as well. In these cases, skilled nursing facility placement is often required, not only for the patient but for the spouse. Clearly, the problem of geriatric hip fractures goes far beyond the fracture itself. Geriatric hip fracture patients present complex medical, surgical and psychosocial problems best managed by the coordinated efforts of the different disciplines required for their care. In general, once the hip fracture has occurred, the first step is prompt and proper surgical treatment of the fracture. Operative treatment is the treatment of choice for these fractures, primarily because of the excessively high complication rate associated with recumbent treatment. 17 Although prompt operative management is the treatment of choice for these patients, it is essential that each patient be medically Bull. N.Y. Acad. Med.
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stabilized before surgery. Operative delays in medically unstable patients improve survival, compared to early surgery performed in the medically "unstable" patient.9 Orthopedically, a few important principles must be followed in each case. Hip fractures in the elderly are common, but they are often not given the required in-depth evaluation. Rather, they are quickly categorized and an operative approach is based upon previous experience in "similar" cases. We have often seen surgery performed on hip fractures without appropriate preoperative anteroposterior and lateral radiographs of the fracture. This violates a basic tenet of orthopedic surgery: proper radiographic evaluation of the fracture so that appropriate treatment can be chosen. The choice of surgical procedure is based upon many factors, including patient and fracture characteristics. Regardless of the procedure chosen, it is essential that hip fracture surgery in the elderly be performed meticulously. Hip fractures are important teaching cases, but experience and expertise are absolute necessities for technically successful outcomes. The quality of soft tissue and bone in the elderly requires meticulous care during surgery to obtain fracture reduction, stabilization and healing, and to avoid postoperative wound complications. Another important aspect of hip fracture management involves realistic postoperative rehabilitation programs. We frequently encounter 90-year-old patients who, following hip fracture surgery, have been started on a physical therapy program with the instructions to be "nonweightbearing" on the injured extremity. This is very unrealistic, and in fact can be dangerous to the patient. Virtually all hip fracture surgery in the elderly should allow weightbearing as tolerated ambulation immediately in the postoperative period. This provides the best chance of regaining functional ambulation. TREATMENT RECOMMENDATIONS
Treatment of hip fractures in the elderly should follow the principles of evaluation, surgery, and rehabilitation just outlined. A number of treatment options are available for each fracture. The option chosen should be based upon patient characteristics, fracture characteristics, and surgeon familiarity. Femoral neck fractures have been referred to as the "unsolved fracture" because of the problems of nonunion and osteonecrosis frequently encountered, particularly following displaced fractures. They constituted 48.4% of the fractures in our series. Different classification systems have been utilized for these fractures, but we divide fractures into nondisplaced and displaced categories. Nondisplaced fractures include Garden Type I and Type II fracVol. 66, No. 3, May-June 1990
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tures. Displaced fractures include Garden Type III and Type IV fractures. Displaced fractures are at highest risk for nonunion and osteonecrosis due, in part, to the degree of initial displacement of the fracture, adequacy of fracture reduction, and delay in reduction and surgical stabilization. Multiple treatment options have been utilized for internal fixation of femoral neck fractures, including multiple pin or screw fixation, sliding hip screw, cross-screw fixation, and the Deyerle device. In addition, primary prosthetic replacement has been recommended for displaced fractures, including unipolar replacement (Austin Moore), bipolar replacement, and total hip replacement. We have utilized the following treatment protocol. Nondisplaced femoral neck fractures in patients of any age should be treated with multiple screw fixation. Displaced fractures in patients younger than age 70 should be treated by closed reduction and internal fixation with multiple screws. If an acceptable closed reduction cannot be obtained by closed manipulation, open reduction should be performed followed by internal fixation. For displaced fractures in patients older than 75, we prefer primary prosthetic replacement with a cemented bipolar hemiarthroplasty. For displaced fractures in patients 70 to 75 years old, treatment should be based upon the patient's activity level, functional requirements, and the characteristics of the fracture. Fractures more than four days old and those with significant comminution of the posterior aspect of the femoral neck should be treated by primary prosthetic replacement. However, active and otherwise healthy patients in this age group should be treated with the protocol described for younger patients. We reserve total hip replacement for femoral neck fractures for patients with underlying osteoarthritis or rheumatoid arthritis or those with Paget's disease and prefracture symptomatic involvement of the acetabulum. Intertrochanteric fractures accounted for approximately 48.7% of the fractures in our series. Different classification systems have been proposed, but we divide them into stable and unstable fractures. Stability is based upon an intact posteromedial cortical support. Comminution of the posteromedial portion of the intertrochanteric region destroys an important buttress, thereby allowing the fracture to collapse into varus. Stable fracture patterns are best treated with closed or open reduction and internal fixation, using a sliding hip screw. The sliding hip screw, properly inserted, allows controlled impaction at the fracture site. Intramedullary devices (Ender nails) can also be used to treat stable fracture patterns. These are inserted in a retrograde manner from the supracondylar region of the femur. They are most useful in patients with stable fractures whose skin condition precludes an incision about the hip. Unstable intertrochanteric fractures are difficult to treat. The goal is to convert an unstable fracture to a more stable configuration. Historically, Bull. N.Y. Acad. Med.
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these fractures have been treated with fixed angle nail-plates (Jewett nails) with a very high failure rate. Because these fractures are unstable, with weightbearing they collapsed into varus, resulting in either cutting out of the nail superiorly through the head or penetration of the nail into the acetabulum. To convert the fracture into a more stable configuration, different reduction techniques were developed, incuding the medial displacement osteotomy of Dimon and Hughston,4 Sarmiento's valgus osteotomy,13 and the Wayne County lateral displacement.8 Although these techniques increased the success rate, they developed when fixed angle nail-plates were the device of choice for these fractures. Introduction of the sliding hip screw has been a significant advance in management of these fractures and, in most cases, this device obviates need for these different reduction maneuvers because it allows controlled impaction at the fracture site. When treating unstable intertrochanteric fractures, we prefer an anatomic or near-anatomic reduction with fixation of the posteromedial fragment if possible. The sliding hip screw is the implant of choice. Anatomic reduction and fixation with the sliding hip screw allows impaction at the fracture site to a stable position which, in approximately 80% of the cases, is a medial displaced position. However, when performing anatomic reductions, it is essential to obtain fracture impaction at the time of surgery. If the fracture is not impacted, excessive sliding will be needed during the postoperative period, which often exceeds the sliding capacity of the device. This will essentially convert the sliding hip screw to a fixed angle nail-plate and greatly increase risk of fixation complications. We have also utilized primary prosthetic replacement for select intertrochanteric fractures. These are generally markedly unstable, comminuted fractures in extremely osteoporotic bone in which secure internal fixation would not be possible. This may be a good option for selected patients in whom the risk of failure of internal fixation is very high. Subtrochanteric fractures accounted for 2.9% of the fractures in our series of geriatric patients. In the elderly they generally occur as a result of a simple fall. Classification of these fractures has been based upon the fracture pattern and the presence of medial cortical comminution. Stable subtrochanteric fractures are those in which the medial cortical buttress is intact. Unstable fractures lose this important support. In general, internal fixation in elderly patients should utilize intramedullary devices when possible. These "loadsharing" devices are preferred over "load-bearing" plates and screws. However, with significant medial comminution, intramedullary devices will not provide adequate fixation and a plate/screw device is needed (950 blade plate or condylar screw). The sliding hip screw, in our opinion, is useful only for Vol. 66, No. 3, May-June 1990
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the most proximal subtrochanteric fractures. When the fracture site is distal to the intertrochanteric region, the sliding mechanism will not provide impaction at the fracture site, and the sliding hip screw provides limited fixation of the proximal fragment compared to other available devices. INTERDISCIPLINARY CARE OF GERIATRIC HIP FRACTURE PATIENTS
Hip fractures in the elderly present more than an orthopedic problem. These patients pose a complex medical/surgical and psychosocial problem requiring coordinated management by different disciplines. This interdisciplinary care has been used effectively in geriatric medicine. Therefore, utilizing this treatment approach, the Hospital for Joint Diseases in August 1985 initiated a Geriatric Hip Fracture Program to provide interdisciplinary care for this specific geriatric patient population. The goals for the program were optimization of the inhospital care of geriatric hip fracture patients, improvement in the transition from inhospital to after hospital care utilizing a case management approach, and improvement in outcomes of treatment. To accomplish these goals, a multidisciplinary team was assembled, including an orthopedic surgeon, internist, anesthesiologist, clinical nurse specialist, nutritionist, physical and occupational therapists, inpatient social worker, case manager, ophthalmologist, psychologist/psychiatrist, and gerontologist. Since this was an interdisciplinary program utilizing intensive rehabilitation, specific patient admission criteria were necessary. To be considered for inclusion in the program, patients had to meet the following criteria: age 65 or older, hip fracture of nonpathologic origin (this excluded patients with metastatic disease with limited life expectancy), patient had to be ambulatory with or without assistive devices prior to the fracture, patients must have the capabilities to participate in a rehabilitation program (this would exclude patients with severe dementia). To optimize patient care, all patients were assigned to a specific floor in the hospital. Nursing education on that floor was directed toward geriatric patients with orthopedic injuries. Physical therapy was scheduled twice each weekday and once each weekend day. During hospitalization each patient was evaluated by the inpatient social worker responsible for discharge planning. At the time of discharge the patient was referred to the case manager who met the patient prior to discharge and continued to follow the patient. The case manager acted as patient advocate when postdischarge problems developed, particularly when those problems had to do with delivery of home care services. To facilitate communication within the team, a weekly patient care conference was held. At each conference all patients admitted since the previous Bull. N.Y. Acad. Med.
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meeting were discussed in detail. Patients continuing in the program discussed previously were considered in less detail to monitor progress and discharge planning. This conference was attended by each representative discipline, who provided the results of their initial evaluation or a progress report for each patient in the program. In addition, the case manager reported on patients contacted after discharge and informed the team about their progress in the community. To monitor the results of the program, a Ph.D. trained research associate, skilled in evaluation and measurement, coordinated program research. A data collection form included information for each patient concerning preinjury level of activity, hospital stay, and follow-up status. All data were entered into a computer-based Hip Fracture Registry. Between August 1985 and March 1988, 279 geriatric hip fracture patients were cared for utilizing the interdisciplinary approach described. These patients will be referred to as "program patients." A comparison group of 66 geriatric hip fracture patients treated between January and August 1985 was identified, and will be referred to as "nonprogram patients." The program and nonprogram groups were closely matched with respect to age, sex, fracture type, and comorbid conditions (Table I). The most common comorbidities were hyptertension, atherosclerotic cardiovascular disease, and adult-onset diabetes mellitus. General endotracheal anesthesia was used most commonly in both groups. The duration of surgery and surgical blood loss were also comparable (Table II). The results of the inhospital treatment program were compared with the nonprogram patients (Table III). Postoperative complications were less common in the program group. 60% of program patients had no significant postoperative complications compared to 40% of the nonprogram group. Approximafely 8% of the program patients had two or more postoperative complications compared to almost 29% of the nonprogram group. 11.5% of the program group required transfers to Beth Israel Medical Center for acute medical problems compared to 27.3% of the nonprogram group. Postoperative wound drainage was higher in the nonprogram group compared to the program group. There were no deep infections in either group, and inhospital mortality was essentially the same for both groups. Evaluation of discharge status indicates other differences between the two groups. Almost 86% of the program patients were discharged to home, compared to 74% of the nonprogram patients. Nursing home placement was needed for 9.5% of program patients and 18.6% of nonprogram patients. At the time of discharge, 83.8% of the program group could walk independently Vol. 66, No. 3, May-June 1990
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ID~~~~~~.
769
ZLCERA
AN
TABLE I: CHARACTERISTICS OF PROGRAM AND NONPROGRAM GROUPS Nonprogram Program n=66 n=279 79.4 79.8 Mean age (years) 24.2% 17.6% Male 75.8% 82.4% Female Fracture type 47.0% 48.4% Femoral neck 48.5% 48.7% Intertrochanteric 4.5% 5.8% Subtrochanteric Comorbid conditions 4.5% 10.4% None 16.7% 20.8% One 33.3% 25.8% Two 28.8% 18.3% Three 10.6% 10.8% Four 6.1% 14.0% More than five 2.42 2.42 Mean Most common 31.8% 35.5% Hypertension 28.8% 16.9% Adult onset diabetes mellitus 22.7% 13.6% Arteriosclerotic cardiovascular disease 27.3% 31.2% Medications more than two TABLE II: SURGICAL MANAGEMENT OF PROGRAM AND
NONPROGRAM PATIENTS Fracture Type Femoral neck Internal fixation Prosthesis
Intertrochanteric Internal fixation Prosthesis Subtrochanteric Internal fixation Duration of surgery (minutes) Anesthesia General Regional
Program n=279
Nonprogram n=66
46% 54%
58% 42%
99% 1%
100% 0%
100% 122
100% 112
76% 24%
72% 28%
with assistive devices, compared to 61.8% of the nonprogram group. The length of stay was 4.5 days shorter for the program group (Table IV). This interdisciplinary approach was utilized with the hope of improving inpatient care of geriatric patients with hip fractures. Therefore, the first question is: Did this program improve hospital care? Based upon the results Bull. N.Y. Acad. Med.
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TABLE III: COMPLICATIONS IN PROGRAM AND NONPROGRAM GROUPS
Postoperative complications None One Two Three Four Acute medical transfers Wound drainage (superficial) Deep infection Deaths
Program
Nonprogram
59.9% 32.3% 6.5% 0.7% 0.7% 11.5% 1.8% 0.4%
39.4% 31.8% 24.2% 4.5% 0.0% 27.3% 7.6% 0.0% 4.5%
4.3%
TABLE IV: DISCHARGE STATUS OF PROGRAM AND NONPROGRAM PATIENTS Program Nonprogram Discharge status Home 85.9% 74.4% Skilled nursing facility 9.5% 18.6% Rehabilitation center 4.6% 7.0% Ambulatory status 83.8% 61.8% (Independent ± assistive devices) Length of stay 24.7 days 29.2 days
reported, the answer is yes. Patients within the program developed fewer postoperative complications, required fewer transfers for acute medical problems, could walk better at the time of discharge, required fewer discharges to skilled nursing facilities, and had a shorter length of stay compared with nonprogram patients. These are significant benefits for this challenging patient population. The benefits of this program are not limited to patient care. The research component is also an important benefit of the program. We have designed a data collection form for each patient who enters the program. It provides data related to preinjury level of function, hospital stay (including surgical information and functional abilities at the time of discharge), and follow-up information. It is a prospective data collection system easily utilized by other facilities caring for geriatric hip fracture patients. A second important question is whether our geriatric hip fracture program improved the long-term outcome of the patients. At this time, we are unable to answer this question, but we are currently involved in a two year follow-up study to assess outcome in this patient population. We are specifically evaluating readmissions, reoperations, and mortality, as well as measures of Vol. 66, No. 3, May-June 1990
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functional ability in daily activities. It is our hope that when this information is available, we shall be able to modify the inpatient program to provide a more directed treatment approach. In conclusion, we feel that successful management of geriatric hip fracture patients requires a comprehensive approach addressing surgical, medical, and psychosocial issues. Successful outcomes can no longer be measured only by fracture healing, fixation complications, and mortality. Other important outcome factors must be considered, including discharge status, length of stay, need for home health services, health care costs, ambulatory ability, social and economic well-being, and the effect of the injury and hospitalization on spouse and family. A few years ago, if I were asked what I considered the most challenging aspect of hip fractures in geriatric patients, I would have probably expressed my concern about the difficulty in reducing and fixing an unstable intertrochanteric hip fracture in severely osteoporotic bone. However, in 1989 my answer would be distinctly different. The challenge of geriatric hip fractures lies in the difficulty of successfully treating frail, elderly patients with limited social and financial support, living alone, who suffer hip fractures and feel as if their tenuously balanced existences are collapsing. REFERENCES 1. Bochner, R., Pellici, P., and Lyden, J.: Bipolar hemiarthroplasty for fracture of the femoral neck: Clinical review with special emphasis on prosthetic motion. J. Bone Joint Surg. 70A:100I-10, 1988. 2. Cobey, J.C., Cobey, J.H., Conant, L., et al.: Indicators of recovery from fractures of the hip. Clin. Orthop. 117:258-62, 1976. 3. Crane, J.G. and Kernek, C.B.: Mortality associated with hip fractures in a single geriatric hospital and residential health facility. J. Am. Ger. Soc. 31(8):472-75, 1983. 4. Dimon, J. and Hughston, J.: Unstable intertrochanteric fractures of the hip. J. Bone Joint Surg. 49A:440, 1967. 5. Fitzgerald, J.F., Fagan, L.F., Tierney, W.M., and Dittus, R.S.: Changing patterns of hip fracture care before and after implementation of the prospective payment system. J.A.M.A. 258(2): 218-21, 1987. 6. Hofeldt, F.: Proximal femoral fractures.
Clin. Orthop. 218:12-18, 1987. 7. Jette, A.M., Harris, B.A., Cleary, P.D., and Campion, E.W.: Functional recovery after hip fracture. Arch. Phys. Med. Rehabil. 68:735-40, 1987. 8. Kaufer, H., Matthews, L.S., and Sonstegaard, D.: Stable fixation of intertrochanteric fractures: A biomechanical evaluation. J. Bone Joint Surg. 56A: 899, 1974. 9. Kenzora, J.E., McCarthy, R., Lowell, J.D., and Sledge, C.B.: Hip fracture mortality. Clin. Orthop. 186:45-56, 1984. 10. Madren, F., Linde, F. Anderson, E., et al.: Fixation of displaced femoral neck fractures. Acta Orthop. Scand. 58: 212-16, 1987. 11. Miller, C.W.: Survival and ambulation following hip fracture. J. Bone Joint Surg. 60A:980, 1978. 12. Rao, J., Banzon, M., Weiss, A. and Rayhack, J.: Treatment of unstable intertrochanteric fractures with anatomic Bull. N.Y. Acad. Med.
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reduction and compression hip screw fixation. Clin. Orthop. 175:65-71, 1983. 13. Sarmiento, A. and Williams, E.: The unstable intertrochanteric fracture: Treatment with a valgus osteotomy and I-beam nail-plate: A preliminary report of 100 cases. J. Bone Joint Surg. 52A:1309, 1970. 14. Stern, M. and Angerman, A.: Comminuted intertrochanteric fractures treated with a Leinbach prosthesis. Clin. Orthop. 218:75-80, 1987.
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15. Waddell, J., Czitrom, A., and Simmons, E.: Ender nailing on fractures of the proximal femur. J. Trauma 27(8):911-16, 1987. 16. White, B.L., Fisher, W.D., and Laurin, C.: Rate of mortality for elderly patients after fracture of the hip in the 1980's. J. Bone Joint Surg. 69A: 1335-40, 1987. 17. Winter, W.: Nonoperative treatment of proximal femoral fractures in the demented, nonambulatory patient. Clin. Orthop. 218:97-103, 1987.
THE CHALLENGE OF GERIATRIC HIP FRACTURES * JOSEPH D. ZUCKERMAN, M.D. Director, Geriatric Hip Fracture Program Hospital for Joint Diseases Orthopedic Institute
STEPHAN R. SAKALES, PH.D. DOROTHY R. FABIAN, ED.D. Geriatric Hip Fracture Program Hospital for Joint Diseases Orthopedic Institute
VICTOR H. FRANKEL, M.D., PH.D. Chairman, Department of Orthopedic Surgery Hospital for Joint Diseases Orthopedic Institute New York, New York
H IP FRACTURES in the geriatric population challenge health professionals involved in their care. Frequently, too much attention is placed on the fracture rather than on the patient who sustains the fracture. Advances in orthopedic surgery over the last 30 years enable us to provide successful fracture treatment in 80 to 90% of the cases. 1,10,12,14,15 However, outcomes of treatment, measured in terms of the patients' ability to return to their preinjury activity and independence, postoperative complications, and mortality often fall far short of our expectations. In this paper we shall discuss the challenging problem of geriatric hip fractures, including their orthopedic management and a description of the results of the interdisciplinary program utilized at the Hospital for Joint Diseases Orthopedic Institute. A number of important characteristics make the management of geriatric hip fractures a growing health care problem. First, it is estimated that in 1985 more than 250,000 hip fractures occurred among patients older than 65. This is a staggering number, considering the services necessary to care for these patients. The problem looms even larger because current predictions indicate that more than 500,000 hip fractures will occur annually by the year 2040. Because the number grows each year, it becomes even more imperative that we find effective ways to manage these difficult patients. *Presented at a meeting of the Section on Geriatric Medicine of the New York Academy of Medicine on June 13, 1988.
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Second, not only are numbers of hip fractures increasing, but the patients are getting older and frailer. These fractures often occur with significant comorbid conditions that further complicate their care. Unfortunately, required care becomes more extensive and complicated and reimbursement has not kept pace. The Diagnosis-Related-Group (DRGs/prospective payment system) does not take into account the significant comorbid conditions in the patient population and their frequent complications. Third, hip fractures in geriatric patients are associated with significant postinjury morbidity and mortality. Most of these patients do not regain their prefracture level of independence.2,7 Skilled nursing care may be required by as many as 50% of patients at the time of discharge from the hospital.5 This has been even more of a problem since the advent of DRGs in which even more importance is placed upon early discharge from hospital.5 Mortality within the first year following fracture has been as high as 40%.3,6,11,16 These studies have shown that mortality is increased for one to two years after the fracture. Fourth, as geriatric hip fracture patients become older and more frail, returning to their homes becomes a formidable task often requiring extensive home care services. Unfortunately, available home care resources and services for the elderly have been dwindling. Recent cutbacks in government funding, particularly Medicare-supported programs, have made it very difficult to provide the needed postdischarge care for these patients. This is particularly true in New York City. We frequently must delay discharges for weeks until home care services become available. Fifth, there is an often unrecognized but very important aspect of hip fractures in the elderly: the effect on the patient's spouse and family. Frequently, the elderly patient who breaks a hip has been the caregiver for a disabled spouse. The hip fracture not only disrupts the patient's life, but may devastate the disabled spouse as well. In these cases, skilled nursing facility placement is often required, not only for the patient but for the spouse. Clearly, the problem of geriatric hip fractures goes far beyond the fracture itself. Geriatric hip fracture patients present complex medical, surgical and psychosocial problems best managed by the coordinated efforts of the different disciplines required for their care. In general, once the hip fracture has occurred, the first step is prompt and proper surgical treatment of the fracture. Operative treatment is the treatment of choice for these fractures, primarily because of the excessively high complication rate associated with recumbent treatment. 17 Although prompt operative management is the treatment of choice for these patients, it is essential that each patient be medically Bull. N.Y. Acad. Med.
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stabilized before surgery. Operative delays in medically unstable patients improve survival, compared to early surgery performed in the medically "unstable" patient.9 Orthopedically, a few important principles must be followed in each case. Hip fractures in the elderly are common, but they are often not given the required in-depth evaluation. Rather, they are quickly categorized and an operative approach is based upon previous experience in "similar" cases. We have often seen surgery performed on hip fractures without appropriate preoperative anteroposterior and lateral radiographs of the fracture. This violates a basic tenet of orthopedic surgery: proper radiographic evaluation of the fracture so that appropriate treatment can be chosen. The choice of surgical procedure is based upon many factors, including patient and fracture characteristics. Regardless of the procedure chosen, it is essential that hip fracture surgery in the elderly be performed meticulously. Hip fractures are important teaching cases, but experience and expertise are absolute necessities for technically successful outcomes. The quality of soft tissue and bone in the elderly requires meticulous care during surgery to obtain fracture reduction, stabilization and healing, and to avoid postoperative wound complications. Another important aspect of hip fracture management involves realistic postoperative rehabilitation programs. We frequently encounter 90-year-old patients who, following hip fracture surgery, have been started on a physical therapy program with the instructions to be "nonweightbearing" on the injured extremity. This is very unrealistic, and in fact can be dangerous to the patient. Virtually all hip fracture surgery in the elderly should allow weightbearing as tolerated ambulation immediately in the postoperative period. This provides the best chance of regaining functional ambulation. TREATMENT RECOMMENDATIONS
Treatment of hip fractures in the elderly should follow the principles of evaluation, surgery, and rehabilitation just outlined. A number of treatment options are available for each fracture. The option chosen should be based upon patient characteristics, fracture characteristics, and surgeon familiarity. Femoral neck fractures have been referred to as the "unsolved fracture" because of the problems of nonunion and osteonecrosis frequently encountered, particularly following displaced fractures. They constituted 48.4% of the fractures in our series. Different classification systems have been utilized for these fractures, but we divide fractures into nondisplaced and displaced categories. Nondisplaced fractures include Garden Type I and Type II fracVol. 66, No. 3, May-June 1990
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tures. Displaced fractures include Garden Type III and Type IV fractures. Displaced fractures are at highest risk for nonunion and osteonecrosis due, in part, to the degree of initial displacement of the fracture, adequacy of fracture reduction, and delay in reduction and surgical stabilization. Multiple treatment options have been utilized for internal fixation of femoral neck fractures, including multiple pin or screw fixation, sliding hip screw, cross-screw fixation, and the Deyerle device. In addition, primary prosthetic replacement has been recommended for displaced fractures, including unipolar replacement (Austin Moore), bipolar replacement, and total hip replacement. We have utilized the following treatment protocol. Nondisplaced femoral neck fractures in patients of any age should be treated with multiple screw fixation. Displaced fractures in patients younger than age 70 should be treated by closed reduction and internal fixation with multiple screws. If an acceptable closed reduction cannot be obtained by closed manipulation, open reduction should be performed followed by internal fixation. For displaced fractures in patients older than 75, we prefer primary prosthetic replacement with a cemented bipolar hemiarthroplasty. For displaced fractures in patients 70 to 75 years old, treatment should be based upon the patient's activity level, functional requirements, and the characteristics of the fracture. Fractures more than four days old and those with significant comminution of the posterior aspect of the femoral neck should be treated by primary prosthetic replacement. However, active and otherwise healthy patients in this age group should be treated with the protocol described for younger patients. We reserve total hip replacement for femoral neck fractures for patients with underlying osteoarthritis or rheumatoid arthritis or those with Paget's disease and prefracture symptomatic involvement of the acetabulum. Intertrochanteric fractures accounted for approximately 48.7% of the fractures in our series. Different classification systems have been proposed, but we divide them into stable and unstable fractures. Stability is based upon an intact posteromedial cortical support. Comminution of the posteromedial portion of the intertrochanteric region destroys an important buttress, thereby allowing the fracture to collapse into varus. Stable fracture patterns are best treated with closed or open reduction and internal fixation, using a sliding hip screw. The sliding hip screw, properly inserted, allows controlled impaction at the fracture site. Intramedullary devices (Ender nails) can also be used to treat stable fracture patterns. These are inserted in a retrograde manner from the supracondylar region of the femur. They are most useful in patients with stable fractures whose skin condition precludes an incision about the hip. Unstable intertrochanteric fractures are difficult to treat. The goal is to convert an unstable fracture to a more stable configuration. Historically, Bull. N.Y. Acad. Med.
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these fractures have been treated with fixed angle nail-plates (Jewett nails) with a very high failure rate. Because these fractures are unstable, with weightbearing they collapsed into varus, resulting in either cutting out of the nail superiorly through the head or penetration of the nail into the acetabulum. To convert the fracture into a more stable configuration, different reduction techniques were developed, incuding the medial displacement osteotomy of Dimon and Hughston,4 Sarmiento's valgus osteotomy,13 and the Wayne County lateral displacement.8 Although these techniques increased the success rate, they developed when fixed angle nail-plates were the device of choice for these fractures. Introduction of the sliding hip screw has been a significant advance in management of these fractures and, in most cases, this device obviates need for these different reduction maneuvers because it allows controlled impaction at the fracture site. When treating unstable intertrochanteric fractures, we prefer an anatomic or near-anatomic reduction with fixation of the posteromedial fragment if possible. The sliding hip screw is the implant of choice. Anatomic reduction and fixation with the sliding hip screw allows impaction at the fracture site to a stable position which, in approximately 80% of the cases, is a medial displaced position. However, when performing anatomic reductions, it is essential to obtain fracture impaction at the time of surgery. If the fracture is not impacted, excessive sliding will be needed during the postoperative period, which often exceeds the sliding capacity of the device. This will essentially convert the sliding hip screw to a fixed angle nail-plate and greatly increase risk of fixation complications. We have also utilized primary prosthetic replacement for select intertrochanteric fractures. These are generally markedly unstable, comminuted fractures in extremely osteoporotic bone in which secure internal fixation would not be possible. This may be a good option for selected patients in whom the risk of failure of internal fixation is very high. Subtrochanteric fractures accounted for 2.9% of the fractures in our series of geriatric patients. In the elderly they generally occur as a result of a simple fall. Classification of these fractures has been based upon the fracture pattern and the presence of medial cortical comminution. Stable subtrochanteric fractures are those in which the medial cortical buttress is intact. Unstable fractures lose this important support. In general, internal fixation in elderly patients should utilize intramedullary devices when possible. These "loadsharing" devices are preferred over "load-bearing" plates and screws. However, with significant medial comminution, intramedullary devices will not provide adequate fixation and a plate/screw device is needed (950 blade plate or condylar screw). The sliding hip screw, in our opinion, is useful only for Vol. 66, No. 3, May-June 1990
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the most proximal subtrochanteric fractures. When the fracture site is distal to the intertrochanteric region, the sliding mechanism will not provide impaction at the fracture site, and the sliding hip screw provides limited fixation of the proximal fragment compared to other available devices. INTERDISCIPLINARY CARE OF GERIATRIC HIP FRACTURE PATIENTS
Hip fractures in the elderly present more than an orthopedic problem. These patients pose a complex medical/surgical and psychosocial problem requiring coordinated management by different disciplines. This interdisciplinary care has been used effectively in geriatric medicine. Therefore, utilizing this treatment approach, the Hospital for Joint Diseases in August 1985 initiated a Geriatric Hip Fracture Program to provide interdisciplinary care for this specific geriatric patient population. The goals for the program were optimization of the inhospital care of geriatric hip fracture patients, improvement in the transition from inhospital to after hospital care utilizing a case management approach, and improvement in outcomes of treatment. To accomplish these goals, a multidisciplinary team was assembled, including an orthopedic surgeon, internist, anesthesiologist, clinical nurse specialist, nutritionist, physical and occupational therapists, inpatient social worker, case manager, ophthalmologist, psychologist/psychiatrist, and gerontologist. Since this was an interdisciplinary program utilizing intensive rehabilitation, specific patient admission criteria were necessary. To be considered for inclusion in the program, patients had to meet the following criteria: age 65 or older, hip fracture of nonpathologic origin (this excluded patients with metastatic disease with limited life expectancy), patient had to be ambulatory with or without assistive devices prior to the fracture, patients must have the capabilities to participate in a rehabilitation program (this would exclude patients with severe dementia). To optimize patient care, all patients were assigned to a specific floor in the hospital. Nursing education on that floor was directed toward geriatric patients with orthopedic injuries. Physical therapy was scheduled twice each weekday and once each weekend day. During hospitalization each patient was evaluated by the inpatient social worker responsible for discharge planning. At the time of discharge the patient was referred to the case manager who met the patient prior to discharge and continued to follow the patient. The case manager acted as patient advocate when postdischarge problems developed, particularly when those problems had to do with delivery of home care services. To facilitate communication within the team, a weekly patient care conference was held. At each conference all patients admitted since the previous Bull. N.Y. Acad. Med.
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meeting were discussed in detail. Patients continuing in the program discussed previously were considered in less detail to monitor progress and discharge planning. This conference was attended by each representative discipline, who provided the results of their initial evaluation or a progress report for each patient in the program. In addition, the case manager reported on patients contacted after discharge and informed the team about their progress in the community. To monitor the results of the program, a Ph.D. trained research associate, skilled in evaluation and measurement, coordinated program research. A data collection form included information for each patient concerning preinjury level of activity, hospital stay, and follow-up status. All data were entered into a computer-based Hip Fracture Registry. Between August 1985 and March 1988, 279 geriatric hip fracture patients were cared for utilizing the interdisciplinary approach described. These patients will be referred to as "program patients." A comparison group of 66 geriatric hip fracture patients treated between January and August 1985 was identified, and will be referred to as "nonprogram patients." The program and nonprogram groups were closely matched with respect to age, sex, fracture type, and comorbid conditions (Table I). The most common comorbidities were hyptertension, atherosclerotic cardiovascular disease, and adult-onset diabetes mellitus. General endotracheal anesthesia was used most commonly in both groups. The duration of surgery and surgical blood loss were also comparable (Table II). The results of the inhospital treatment program were compared with the nonprogram patients (Table III). Postoperative complications were less common in the program group. 60% of program patients had no significant postoperative complications compared to 40% of the nonprogram group. Approximafely 8% of the program patients had two or more postoperative complications compared to almost 29% of the nonprogram group. 11.5% of the program group required transfers to Beth Israel Medical Center for acute medical problems compared to 27.3% of the nonprogram group. Postoperative wound drainage was higher in the nonprogram group compared to the program group. There were no deep infections in either group, and inhospital mortality was essentially the same for both groups. Evaluation of discharge status indicates other differences between the two groups. Almost 86% of the program patients were discharged to home, compared to 74% of the nonprogram patients. Nursing home placement was needed for 9.5% of program patients and 18.6% of nonprogram patients. At the time of discharge, 83.8% of the program group could walk independently Vol. 66, No. 3, May-June 1990
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TABLE I: CHARACTERISTICS OF PROGRAM AND NONPROGRAM GROUPS Nonprogram Program n=66 n=279 79.4 79.8 Mean age (years) 24.2% 17.6% Male 75.8% 82.4% Female Fracture type 47.0% 48.4% Femoral neck 48.5% 48.7% Intertrochanteric 4.5% 5.8% Subtrochanteric Comorbid conditions 4.5% 10.4% None 16.7% 20.8% One 33.3% 25.8% Two 28.8% 18.3% Three 10.6% 10.8% Four 6.1% 14.0% More than five 2.42 2.42 Mean Most common 31.8% 35.5% Hypertension 28.8% 16.9% Adult onset diabetes mellitus 22.7% 13.6% Arteriosclerotic cardiovascular disease 27.3% 31.2% Medications more than two TABLE II: SURGICAL MANAGEMENT OF PROGRAM AND
NONPROGRAM PATIENTS Fracture Type Femoral neck Internal fixation Prosthesis
Intertrochanteric Internal fixation Prosthesis Subtrochanteric Internal fixation Duration of surgery (minutes) Anesthesia General Regional
Program n=279
Nonprogram n=66
46% 54%
58% 42%
99% 1%
100% 0%
100% 122
100% 112
76% 24%
72% 28%
with assistive devices, compared to 61.8% of the nonprogram group. The length of stay was 4.5 days shorter for the program group (Table IV). This interdisciplinary approach was utilized with the hope of improving inpatient care of geriatric patients with hip fractures. Therefore, the first question is: Did this program improve hospital care? Based upon the results Bull. N.Y. Acad. Med.
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TABLE III: COMPLICATIONS IN PROGRAM AND NONPROGRAM GROUPS
Postoperative complications None One Two Three Four Acute medical transfers Wound drainage (superficial) Deep infection Deaths
Program
Nonprogram
59.9% 32.3% 6.5% 0.7% 0.7% 11.5% 1.8% 0.4%
39.4% 31.8% 24.2% 4.5% 0.0% 27.3% 7.6% 0.0% 4.5%
4.3%
TABLE IV: DISCHARGE STATUS OF PROGRAM AND NONPROGRAM PATIENTS Program Nonprogram Discharge status Home 85.9% 74.4% Skilled nursing facility 9.5% 18.6% Rehabilitation center 4.6% 7.0% Ambulatory status 83.8% 61.8% (Independent ± assistive devices) Length of stay 24.7 days 29.2 days
reported, the answer is yes. Patients within the program developed fewer postoperative complications, required fewer transfers for acute medical problems, could walk better at the time of discharge, required fewer discharges to skilled nursing facilities, and had a shorter length of stay compared with nonprogram patients. These are significant benefits for this challenging patient population. The benefits of this program are not limited to patient care. The research component is also an important benefit of the program. We have designed a data collection form for each patient who enters the program. It provides data related to preinjury level of function, hospital stay (including surgical information and functional abilities at the time of discharge), and follow-up information. It is a prospective data collection system easily utilized by other facilities caring for geriatric hip fracture patients. A second important question is whether our geriatric hip fracture program improved the long-term outcome of the patients. At this time, we are unable to answer this question, but we are currently involved in a two year follow-up study to assess outcome in this patient population. We are specifically evaluating readmissions, reoperations, and mortality, as well as measures of Vol. 66, No. 3, May-June 1990
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functional ability in daily activities. It is our hope that when this information is available, we shall be able to modify the inpatient program to provide a more directed treatment approach. In conclusion, we feel that successful management of geriatric hip fracture patients requires a comprehensive approach addressing surgical, medical, and psychosocial issues. Successful outcomes can no longer be measured only by fracture healing, fixation complications, and mortality. Other important outcome factors must be considered, including discharge status, length of stay, need for home health services, health care costs, ambulatory ability, social and economic well-being, and the effect of the injury and hospitalization on spouse and family. A few years ago, if I were asked what I considered the most challenging aspect of hip fractures in geriatric patients, I would have probably expressed my concern about the difficulty in reducing and fixing an unstable intertrochanteric hip fracture in severely osteoporotic bone. However, in 1989 my answer would be distinctly different. The challenge of geriatric hip fractures lies in the difficulty of successfully treating frail, elderly patients with limited social and financial support, living alone, who suffer hip fractures and feel as if their tenuously balanced existences are collapsing. REFERENCES 1. Bochner, R., Pellici, P., and Lyden, J.: Bipolar hemiarthroplasty for fracture of the femoral neck: Clinical review with special emphasis on prosthetic motion. J. Bone Joint Surg. 70A:100I-10, 1988. 2. Cobey, J.C., Cobey, J.H., Conant, L., et al.: Indicators of recovery from fractures of the hip. Clin. Orthop. 117:258-62, 1976. 3. Crane, J.G. and Kernek, C.B.: Mortality associated with hip fractures in a single geriatric hospital and residential health facility. J. Am. Ger. Soc. 31(8):472-75, 1983. 4. Dimon, J. and Hughston, J.: Unstable intertrochanteric fractures of the hip. J. Bone Joint Surg. 49A:440, 1967. 5. Fitzgerald, J.F., Fagan, L.F., Tierney, W.M., and Dittus, R.S.: Changing patterns of hip fracture care before and after implementation of the prospective payment system. J.A.M.A. 258(2): 218-21, 1987. 6. Hofeldt, F.: Proximal femoral fractures.
Clin. Orthop. 218:12-18, 1987. 7. Jette, A.M., Harris, B.A., Cleary, P.D., and Campion, E.W.: Functional recovery after hip fracture. Arch. Phys. Med. Rehabil. 68:735-40, 1987. 8. Kaufer, H., Matthews, L.S., and Sonstegaard, D.: Stable fixation of intertrochanteric fractures: A biomechanical evaluation. J. Bone Joint Surg. 56A: 899, 1974. 9. Kenzora, J.E., McCarthy, R., Lowell, J.D., and Sledge, C.B.: Hip fracture mortality. Clin. Orthop. 186:45-56, 1984. 10. Madren, F., Linde, F. Anderson, E., et al.: Fixation of displaced femoral neck fractures. Acta Orthop. Scand. 58: 212-16, 1987. 11. Miller, C.W.: Survival and ambulation following hip fracture. J. Bone Joint Surg. 60A:980, 1978. 12. Rao, J., Banzon, M., Weiss, A. and Rayhack, J.: Treatment of unstable intertrochanteric fractures with anatomic Bull. N.Y. Acad. Med.
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reduction and compression hip screw fixation. Clin. Orthop. 175:65-71, 1983. 13. Sarmiento, A. and Williams, E.: The unstable intertrochanteric fracture: Treatment with a valgus osteotomy and I-beam nail-plate: A preliminary report of 100 cases. J. Bone Joint Surg. 52A:1309, 1970. 14. Stern, M. and Angerman, A.: Comminuted intertrochanteric fractures treated with a Leinbach prosthesis. Clin. Orthop. 218:75-80, 1987.
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15. Waddell, J., Czitrom, A., and Simmons, E.: Ender nailing on fractures of the proximal femur. J. Trauma 27(8):911-16, 1987. 16. White, B.L., Fisher, W.D., and Laurin, C.: Rate of mortality for elderly patients after fracture of the hip in the 1980's. J. Bone Joint Surg. 69A: 1335-40, 1987. 17. Winter, W.: Nonoperative treatment of proximal femoral fractures in the demented, nonambulatory patient. Clin. Orthop. 218:97-103, 1987.
