Geriatric Orthopaedic Trauma

Transcription

1 Geriatric Orthopaedic Trauma EMS & Trauma Conference Seattle, WA September 2018 Lisa A. Taitsman, MD, MPH

2 Disclosures Teach at AO courses AOA Committee OTA Committees Editorial board Journal of Orthopaedic Trauma Geriatric Orthopaedic Surgery and Rehabilitation

3 Fragility Fractures A major public health issue million fractures $17 billion direct cost million $25 billion Life time risk of osteoporosis-related fracture Women 1:2 Men 1:4

4 The Data Centers for Disease Control and Prevention (CDC) National Center for Health Statistics Morbidity and Mortality Weekly Report National Highway Traffic Safety Administration American Academy of Orthopaedic Surgery Various articles

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7 The growing demographic The 65 and older age group is the fastest growing segment of the population US census data % of population are 65 or older % of population are 65 or older More than 40 million older adults will be licensed drivers by 2020

8 Elderly Injuries In 2000 in the US, nearly 37,500 people ages 65 and older died from injuries In 2002 in the US, nearly 2,670,000 people ages 65 and older suffered nonfatal injuries

9 Annual hospitalizations for fractures by site Fracture 65+ Total Percent Hand/forearm 24,000 86,000 28% Humerus 27,000 61,000 44% Spine 35,000 74,000 47% Pelvis 35,000 55,000 64% Femur/ hip 296, ,000 81% Tib/fib 15,000 72,000 21% Ankle 21, ,000 19% Foot 2,000 24,000 8% Based on data

10 Nonfatal injuries in persons 65+ in 2002 Mechanism Number of injuries Total 65+ population Age-adjusted rate per 100,000 Falls 1,640,080 35,601,917 4,532 Struck 206,853 35,601, MVA 193,068 35,601, Pedestrian struck 14,531 35,601, Cyclist 10,823 35,601, MCA 2,453 35,601,917 7 Total injuries 2,669,606 35,601,917 7,425 Total US population 288,368,706 CDC data, 2002

11 Elderly Drivers Drivers over age 65 have higher crash death rates per mile driven than all but teen drivers In 2001 in the US, 7,525 people ages 65 and older died in motor vehicle crashes In 2002 in the US, over 220,000 adults ages 65 and older suffered nonfatal injuries as occupants in motor vehicle crashes

12 Mechanism Injury Falls Low energy/ ground level Ladders MVC MCC Bikes/ sports Abuse Medical Cardiac event Stroke GI bleed Medication Osteoporosis

13 Elderly Drivers From , the number of motor vehicle deaths among older adults rose 14% and the number of nonfatal motor vehicle injuries climbed 19% During 2002, most traffic fatalities involving older drivers occurred during the daytime (81%) and on weekdays (72%) 75% of the crashes involved another vehicle

14 Falls in the Elderly Falls are: the leading cause of injury deaths a leading cause of fractures and traumatic brain injuries most common cause of nonfatal injuries and hospital admissions for trauma In 2001, over 1.6 million seniors were treated in emergency departments for fallrelated injuries

15 Falls in the Elderly More than one-third of adults ages 65 years and older fall each year Approximately 3% to 5% of older adult falls cause fractures Based on the 2000 census, this translates to 360,000 to 480,000 fall-related fractures each year

16 Falls in the Elderly In 2001, more than 11,600 people ages 65 and older died from fall-related injuries Of those who fall, 20% to 30% suffer moderate to severe injuries such as hip fractures or head trauma Among people ages 75 years and older, those who fall are four to five times more likely to be admitted to a longterm care facility for a year or longer

17 The cost of falls The total cost of all fall injuries for people age 65 or older in 1994 was $27.3 billion By 2020, the cost of fall injuries is expected to reach $43.8 billion (in today s $$)

18 Hip Fractures Of all fall-related fractures, hip fractures lead to the greatest number of deaths, severe health problems and reduced quality of life In 1999 in the US, 338,000 hospital admissions for hip fractures

19 Hip Fractures In 1991, Medicare costs for hip fractures were estimated to be $2.9 billion From 2000 to 2040, the number of people age 65 or older is projected to increase from 34.8 million to 77.2 million By the year 2040, the number of hip fractures is expected to exceed 500,000

20 Who is at risk for hip fractures Women sustain about 80% of all hip fractures Hip fracture rates increase exponentially with age for both men and women People ages 85 years and older are 10 to15 times more likely to sustain hip fractures than are people ages 60 to 65

21 Hip Fracture Epidemiology 350,000 hospital admissions / year Female >75% Falls ~90% Average Age F = 77yrs M = 72yrs Lifetime Risk F = 1:5 M = 1:20 Cost ~$10 billion per year

22 Risk Factors for Hip Fracture Female gender Advanced age Caucasian or Asian Race Osteoporosis Prior fx after age 50 Maternal h/o fragility fx Frequent falls Cummings et al, NEJM 1995

23 Fragility Fractures in the US (in thousands) Burge et al

24 Relative Cost 80% 70% 60% 50% 40% 30% Volume Cost 20% 10% 0% Hip Vertebral Wrist Pelvis Other Burge et al

25 The cost of hip fractures Hospital admissions for hip fractures among people over age 65 have increased from 230,000 admissions in 1988 to 338,000 admissions in 1999 expected to exceed 500,000 by the year 2040 Assuming 5% inflation and the growing number of hip fractures, the total annual cost of these injuries is projected to reach $240 billion by the year 2040

26 Hip Fractures Significant Morbidity (1) Only 50% return to premorbid walking independence Significant Mortality (US, 2005) (2) 30 day 180 day 360 day Women 5% 14% 22% Men 12% 23% 33% 1) Keene et al, BMJ ) Brauer et al, JAMA 2009

27 Growing aging populaiton 60 US Population 65+ (in millions) Aging population Recent Plateau of incidence rate

28 Number of Fractures Increasing US Population 65+ By the year 2050, there will be (in millions) an estimated 650,000 hip Aging population fractures annually in the US This is nearly 1,800 hip fractures Recent Plateau of incidence rate Brown JOT 2012 AAOS website

29 Mortality

30 Chicken or the Egg Hip Fracture- not just an orthopaedic problem, geriatric disease Top 4 associated co-morbidities Men Women COPD 34% 24% CHF 29% 25% Diabetes 25% 20% H/O or Acute MI 13% 9%

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32 Interrochanteric Fractures

33 AO/ OTA classification

34 AO/ OTA classification

35 Intertrochanteric Fractures Instability

36 Deforming Forces & Deformities Muscular Attachments Abductors External Rotators Psoas Deformity Shortening External Rotation Varus

37 Treatment Goals Return patient to pre injury functioning Minimize complications Maintain alignment Obtain fracture union

38 Intertrochanteric Fractures Surgical options Sliding Hip Screw (Dynamic Hip Screw) Trochanteric Stabilization Plate Medullary Hip Screw Angled Blade plate Proximal Femoral Locking Plate Arthroplasty

39 Intertrochanteric Fracture DHS

40 Intertrochanteric Fracture Nail

41 Compression Hip Screw vs Trochanteric Nail

42 Sliding Hip Screw vs Nail What are surgeons choosing? ABOS Part II case data % Nails % Nails This change has occurred despite a lack of evidence in the literature supporting the change and in the face of the potential for more complications. Anglen et al, JBJS-Am 2008

43 Sliding Hip Screw vs Nail Cochrane Review Parker and Handoll 2002, 2004, 2005, 2008, 2010 In the 2010 review: 43 studies with many different implants Many trials with insufficient evidence for a difference

44 Sliding Hip Screw vs Nail SHS lower complication rates vs IM nails SHS appears superior for STABLE trochanteric fx -However many different of nails -Old nail design with more complication Nails are better for unstable fracture patterns Be sure of your fracture pattern!!! Unstable IT fx, reverse obliquity

45 Sliding Hip Screw vs Nail Medicare data over 15 year Variables: OR time, revision surgery and mortality during 1 st year No difference since 2000

46 Sliding Hip Screw vs Nail JBJS BR 2012 JBJS 2013 JBJS 2013

47 Sliding Hip Screw vs Nail Nail superior for unstable fractures J Orthop Trauma 2013

48 Femoral Neck Fractures

49 Femoral Neck Fractures Intracapsular hip fxs Subcapital Transcervical Basicervical

50 Femoral Neck Fractures Intracapsular hip fxs Subcapital Transcervical Basicervical

51 Femoral Neck Fractures Intracapsular hip fxs Subcapital Transcervical Basicervical

52 Garden Classification I II Impacted valgus Nondisplaced III Incomplete varus IV Complete displaced

53 Pauwel s Classification < 30 o 30 o -50 o > 50 o

54 Femoral Neck Fractures Nondisplaced Fxs Nondisplaced/ Valgus impacted Displaced Fxs

55 Options Fix Replace

56 Treatment Considerations What is the fracture classification? How old is the patient? How old is the patient s bone? Can the patient withstand a second surgery? Individualize treatment plan

57 Treatment options Non displaced Non op Percutaneous internal fixation Displaced Young Closed or open reduction, Internal fixation Old Replacement (arthroplasty)

58 Internal Fixation vs Arthroplasty Reserve Internal Fixation for the young Arthroplasty is the treatment of choice Improved functional outcomes Fewer complications Fewer revision surgeries Gjertsen JBJS-Am 2010; Leonardsson JBJS-Br 2010; Tidermark JBJS-Br 2004; Blomfeldt JBJS-Am 2005; Rogmark Acta Orthop 2006; Tidermark Acta Orthop 2003

59 International Trends Displaced Femoral Neck Fxs US and International Survey Internal fixation for patients <60 Controversial for patients Arthroplasty for patients > 80 Bhandari et al, JBJS-Am., 2005

60 Femoral Neck Fracture Screws

61 Reduction In situ fixation

62 Femoral Neck Fracture Hemiarthroplasty

63 Hemiarthroplasty Total Hip

64 Hemiarthroplasty vs Total Hip 14 studies/ 1890 patients 4 randomized trials Total Hip Arthroplasty Lower re-operation rate Better functional hip scores 2010 Hemiarthroplasty Lower dislocation rate Fewer general complications Burgers et al, Int Orthop 2012 Yu et al, CORR, 2012

65 Femoral Neck Fractures Clearly controversy remains Ongoing biomechanical studies Best constructs? FAITH Trial Hemi v. Total hip

66 Subtrochanteric Fracture

67 Subtrochanteric Fracture and shaft

68 Subtrochanteric Fracture

69 Subtrochanteric Fracture Blade plate

70 Periprosthetic Below a hemiarthroplasty

71 Periprosthetic Below a DHS

72 Value of traction

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74 To do right Choose the best implant

75 To do right

76 To do right Surgical technique Fracture reduction Implant position Patient factors Osteoporosis Prior surgery

77 Operated at outside hospital

78 Operated at outside hospital

79 Compression Hip Screw Tip-Apex Distance TAD < 25 mm on AP + Lateral Baumgaertner et al, JBJS, 1995, 1997

80 Learning!!

81 Open reduction Provisional fixation

82 Compare the reduction

83 6 week follow up

84 What about for medullary hip screws?

85 Literature YES! Clinical and Biomechanical studies Tip- Apex distance matters for medullary devices too!! Lolo-Escolar, et al Injury, 2010 Geller, et al, Int. Orthop, 2010 Kuzyk, et al, JOT, 2012 Nutchtern, et al, JOT 2014 Bruijn et al. JBJS 2012

86 Tips and Tricks Fracture reduction Nail starting point is important AP and Lateral Guide wire position must be PERFECT Center and deep on both views

87 The Jig

88 The Jig X X

89 Standard versus Long Nail Personal preference Literature does not really give an answer Injury 2012

90 Standard versus Long Nail Similar results Erez J of Trauma 2014 Kleweno JOT 2014 Boone JOT 2014 Kanakaris JOT 2015 Frisch Orthopedics 2016

91 Distal Locking Yes Especially for unstable fractures J Orthop Trauma 2013

92 73 yo female s/p fall

93 73 yo female s/p fall

94 73 yo female s/p fall

95 73 yo female s/p fall

96 Over the next few months.

97 Revision 5 months later

98 Old Challenges Reverse obliquity fractures Recognition of fracture pattern DHS is a suboptimal way to manage these injuries

99 Pre Operative Considerations

100 Patient Specific Risks Is the patient medically optimized?

101 Surgical Specific Risk Early surgery Decreased complications Reduced length of hospital stay Surgery should be performed within hours when not contraindicated Our goal - ED evaluation completed in 2 hours - To OR within 24 hours Kenzora et al, CORR, 1984 Sexson et al, JOT, 1987 White et al, JBJS, 1987 Daugaard, et al, Acta Ortho, 2012

102 Venous Thromboembolic Disease Prophylaxis

103 VTE Prophylaxis

104 Chest Guidelines 2012 For Hip Fractures Minimum of days of anticoagulation Low Molecular Weight Heparin preferred over other pharmacologic agents Start >12 hrs post op Falck-Ytter et al, Chest 2012

105 AAOS VTE prophylaxis guidelines 2012 For elective total hip and knee arthroplasty Chemical and/ or mechanical prophylaxis recommended Adjust for patient factors Routine duplex ultrasound screening not recommended Jacobs et al, JBJS 2012 (summary)

106 Post Operative Considerations/ Improving Patient Outcomes

107 Post Operative Considerations Early Mobilization Pain Management Delirium Prevention Osteoporosis Prevent the second fracture Nutrition Falls Assessment

108 Early Mobilization Most patients weight bearing as tolerated Improved functional outcomes Decreased complications delirium DVT Reduced de-conditioning

109 Early Mobilization WEIGHT BEARING AS TOLERATED

110 Pain management in ED JAGS 2016 CJEM 2016

111 Delirium Prevention Easier to prevent than treat! Medications Geriatric team! Environment Sensory aids Glasses, hearing aids Sleep Hydration

112 Osteoporosis Assessment and Management Vitamin D Calcium Bisphosphonates DEXA Falls assessment Prevent the next fracture!

113 The second hip fracture

114 The second hip fracture Norwegian data base, 10 year period, 81,867 primary hip fx, pt > 50 yo Time Total no. second hip fractures Cumulative incidence of second hip fracture Women % % Men HR in women compared to men 3 months ( ) 6 months ( ) 1 year ( ) 2 years ( ) 3 years ( ) 4 years ( ) 5 years ( ) 10 years ( ) Omsland, et al, in Bone 2013.

115 The second hip fracture 826 pts with primary hip fx 71 secondary fxs (30 month mean) 12/283 (4.2%) 59/543 (10.9%) bisphosphonate users noncompliant (non-user) Osteoporosis Int. Dec 2012

116 Osteoporosis

117 Osteoporosis Assessment Nov Meta-analysis 12 studies Women with wrist fracture at an increased risk for hip fracture (RR 1.43)

118 Osteoporosis Assessment Opportunistic screening

119 Osteoporosis Assessment Frequencies and proportion estimates of osteoporosis diagnosis via retrospective CT stratified by diagnostic threshold Osteoporosis Diagnostic Cut Point Patients with Osteoporosis by Retrospective CT Diagnosis Patients with Osteoporosis but without Diagnosis or Medication in Discharge Data Average HU N % (95% CI) N % (95% CI) < (41-55) (32-52) < (66-79) (38-55) < (81-91) (39-54)

120 Co-Management

121 Usual Care (UC) University Hosp Ortho & Hospitalists Geriatric Fx Center (GFC) Community Teaching Hosp Dedicated Ward / Service Co-management Ortho & Geriatricians Baseline Characteristics GFC UC Age*, yrs Male, % Community Dwelling*, % Comorbidity Score* Dementia*, % * = p < 0.05

122 Effective Care Model Outcome GFC (n = 193) UC (n = 121) P Value (adjusted) Time to Surgery 21.1 hrs 37.4 hrs 0.02 In-Hospital Mortality 1.6% 2.5% 0.07 Length of Stay 4.6 days 8.3 days < day Readmission rate 9.8% 13.2% 0.12 Complications overall 30.6% 46.3% <0.001 Postop infection, % <0.001 Thromboembolism, % Cardiac, % Stroke, % Bleeding, % Delirium, % <0.001

123 Co-management Journal of Trauma year study- 547 patients Time to OR 17% 12 month mortality 20% 11% Independence in daily living 23.7% 24.5%

124 Involved Specialties

125 Co-management

126 In Summary Hip fractures: Routine yet complicated Still controversy regarding optimal implants Role for further study Improved outcomes Team approach Osteoporosis

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128 Osteoporotic Ankle Fractures Issues: Precarious Soft Tissues Maintaining Fixation & Stability Comorbidities

129 Study #PTS Age Management Conclusions Beauchamp (1983) 126 >50 55 pts cast 71 op Ali (1987) 100 >60 50 nonop 50 op Salai (2000) 84 >65 16 nonop 49 op No difference motion Higher complication in op group Non op higher malunion and nonunion More satisfaction op group Non op higher AOFAS scores 1/3 op group HW removal Makawana(2001) 47 >55 22 nonop 21 op Higher functional outcomes scores in op group More complications op group Srinivasan (2001) 74 >70 All ORIF 84% return to pre injury ambulatory status Pagliaro (2001) 23 >65 All ORIF 100% union 2 post op complications amp Davidovitch (2004) >60 <60 All ORIF Slower recovery. Steady improvement Similar AOFAS scores Strauss and Egol. Injury, 2007

130 Technical Tips- Fibula Locked plates Osteoporotic bone Short segments Comminution Small plates work

131 Technical Tips- Fibula Locked plates Multiple plates

132 Technical Tips- Fibula Locked plates Multiple plates Fixation to tibia Syndesmosis screws More purchase in tibia

133 Technical Tips- Fibula Locked plates Multiple plates Fixation to tibia Intramedullary implants Stacked intramedullary k-wires K-wires placed first

134 Technical Tips- Fibula Locked plates Multiple plates Fixation to tibia Intramedullary implants External Fixator

135 Technical Tips- Fibula Locked plates Multiple plates Fixation to tibia Intramedullary implants External Fixator Posterior Malleolus Fixation

136 Technical Tips- Medial Malleolus Bicortical screws Caution with lag techniques Augment with washers as needed Long screws

137 Technical Tips- Medial Malleolus Bicortical screws Tension band Small fragments Augment screws

138 Technical Tips- Medial Malleolus Bicortical screws Tension band Plates Vertical fractures Small fragments

139 76 yo female s/p fall Distal humerus fracture

140 65 yo female Multiple medical problems Not every fracture or patient needs an operation

141 68 yo female s/p fall Significant psych history

142 69 yo male s/p fall Multiple medical problems- Head injury Transferred with humeral head dislocated for 5 days

143 Polytrauma 85 yo female s/p mva Multiple fractures