Medical problems in hip fracture patients

Transcription

1 DOI /s y ORTHOPAEDIC SURGERY Medical problems in hip fracture patients Carol Pei Wei Chong Judith A. Savige Wen Kwang Lim Received: 30 October 2009 Ó Springer-Verlag 2010 Abstract Increasing number of older patients are admitted to hospital with hip fractures. This review evaluates the common medical problems that arise as a consequence of having a hip fracture. Older patients with fractures commonly have co-morbidities that require evaluation prior to and after surgery. Joint acute orthopaedic geriatric units have been established to provide comprehensive orthopaedic and medical care with some studies showing a reduction in postoperative complications and mortality. Recommendations surrounding the care of the older orthopaedic patient include early surgical fixation, the use of prophylactic antibiotics and thromboembolic prophylaxis, good perioperative pain control to improve ambulation, delirium detection and management to decrease the risk complications, such as institutionalisation, the avoidance of malnutrition, urinary tract management, osteoporosis management and the promotion of early mobilisation to improve functional recovery. Physicians are well placed to manage these patients with orthopaedic surgeons during the perioperative period. Sufficient evidence exists for most recommendations for fracture patients, but further research is needed in most areas. C. P. W. Chong J. A. Savige W. K. Lim Department of Medicine, Austin and Northern Health, The University of Melbourne, Melbourne, VIC, Australia C. P. W. Chong (&) J. A. Savige W. K. Lim (&) The Northern Clinical Research Centre, The Northern Hospital, 185 Cooper Street, Epping, VIC, Australia carol.chong@nh.org.au W. K. Lim kwang.lim@nh.org.au Keywords Hip fracture Aged Orthopaedic surgery Postoperative care Perioperative care Complications Introduction Increasing numbers of older patients are admitted to hospital with fractures [1]. In 1990, there were 1.6 million fractures worldwide and this is projected to become 6.26 million in 2050 [2]. Hip fractures cause significant mortality and morbidity with 1 year mortality between 14 and 36% [3]. Specific medical care can improve fracture outcome. This review evaluates medical problems that may arise as a consequence of patients having a hip fracture. Given the breadth of topics, a formal systematic review was not undertaken; however, important articles in each area were retrieved and evaluated (Table 1). Comorbid medical problems are common Co-morbid medical problems are common in older patients. In one study, 82% of patients had a significant medical disability that contributed to or complicated a fracture [4]. In addition, more than 90% of patients had problems where the advice of a physician was of value [4]. Common comorbidities were cardiovascular (24%), dementia (24%), stroke (13%) and respiratory disease (14%) [5]. In a large study of patients with hip fractures, postoperative complications occurred in 20% of patients (498/ 2,448) [5]. Patients who had acute heart failure or a postoperative chest infection had a high 30-day mortality of 65% and 43%, respectively. Other preoperative variables that were significantly related to increased mortality were the presence of three or more co-morbidities, respiratory disease and malignancy. Other common complications

2 Table 1 Search strategy Computerised literature search of Medline (1966 to October 2009) the Cochrane library and CINAHL The search was limited to articles in English. Primary and review articles, particularly systematic reviews, were evaluated as well as bibliographies of the retrieved articles with further relevant articles obtained if pertinent. Articles were excluded if they did not relate to orthopaedic surgery Medical subject headings included orthopaedics, orthopaedic procedures, geriatrics, aged, hip fracture, postoperative complications, intraoperative complications, perioperative care, postoperative care and rehabilitation. Keywords and text phrases included the subject headings and additional terms relating to important topics (main headings in this text), such as delirium, nutrition, thromboembolism and urinary retention were deep venous thrombosis or pulmonary embolus (2%), deep infection (1%), urinary tract infection (4%), gastrointestinal haemorrhage (1%), myocardial infarction (1%) and stroke (1%). Therefore, it is important to have an appreciation of patient co-morbidities and monitor closely for postoperative complications given the poorer outcomes that can occur in these patients. For example, heart failure should be treated early with attention to careful fluid balance and chest physiotherapy and good pain management may prevent chest infections. Causes of death The largest published autopsy series of 581 cases of proximal femoral fractures was conducted in Bristol in the UK from 1953 to 1992 [6]. The average age of patients who died was 83 years and most was female (74%). The commonest cause of death was bronchopneumonia (46%), cardiac failure and myocardial infarction (23%) followed by pulmonary embolism (14%). However, this study spanned a period where anticoagulation was not routine in the perioperative period and highlights the importance of prophylactic anticoagulation. Joint acute orthopaedic geriatric management Joint orthopaedic geriatric co-management for the acute older orthopaedic patient has been embraced by some countries and has been evaluated in small studies (see Table 2) [7 11]. This model of care includes a multidisciplinary team (e.g. physiotherapist, occupational therapist and social worker) and case conference is lead by the geriatrician [8]. The benefit of geriatrician involvement includes the management of intercurrent medical problems, promotion of earlier mobilisation, avoidance of delays in rehabilitation and coordination of discharge planning [12]. Most studies have focussed on patients with hip fracture over 65 or 70 years of age. These studies are heterogenous in nature, but in general have found significant reductions in postoperative complications and mortality with geriatrician-led management [7, 10]. Some studies have shown a reduction in length of stay by combining surgical and medical care, leading to more efficient discharge processes [8, 9]. Importantly, this form of co-management has not shown any detrimental consequences and can be implemented within existing hospital frameworks. Evidence-based medical care Preoperative medical management, prevention and treatment of postoperative complications are of utmost important. Evidence-based recommendations have been published to guide patient care [13 15]. Table 3 shows the recommendations for patients with fractures with corresponding levels of evidence. Timing of surgery The timing of surgical repair of hip fracture may affect patient outcome in two ways: (1) delay in surgical fixation causes delay in return to weight bearing which in turn may affect patient s functional recovery or (2) failure to stabilize medical problems before surgery might increase the risk of perioperative complications [13]. Morrison et al. [13] identified 11 studies, mainly cohort studies with one randomized controlled trial, which evaluated anaesthetic techniques that included surgical delay as a variable. These studies suggest that early surgical repair within the first h is associated with a reduction in 1-year mortality. However, a major limitation with the majority of these studies was that they did not control for co-morbid medical illnesses or exclude complex patients. One large observational study that adjusted for active medical problems found that time-to-surgery in hip fracture patients was not associated with short or long-term mortality [16]. Patients who had surgery more than 96 h later did not have significantly increased mortality (hazard ratio = 1.07, 95% CI ) although the risk of decubitus ulcers were higher (OR = 2.2, 95% CI ) [16]. Other benefits from early surgery include earlier ambulation and decreased average hospital length of stay. Surgical fixation Surgical fixation is the mainstay of treatment for most fractures. Kagaya and Shimada s review analysed the differences between conservatively treated hip fractures and operative management [15]. The mortality was 1.7 times higher for conservatively treated patients [17]. Therefore, early operative intervention is recommended. Operative treatment is more likely to result in fracture healing

3 Table 2 Studies of joint acute orthopaedic geriatric units References No. of patients Intervention Main outcome measures Findings Vidan et al. [7] 319 patients RCT Daily multidisciplinary geriatric intervention Naglie [8] 279 patients RCT Interdisciplinary care from internist geriatrician, physiotherapist, occupational therapist, social worker, clinical nurse specialist, twice weekly interdisciplinary rounds Antonelli Incalzi [9] Fisher [10] 287 patients versus 474 retrospective time series 951 patients Prospective observational study (447 patients) with retrospective control (504 patients) Swanson [11] 71 patients older than 55 RCT RCT randomised controlled trial Assigning a geriatrician to provide daily medical care to geriatric patients in an orthopaedic ward Patients over the age 70 Orthopaedic geriatric cocare Daily medical management by a geriatric medicine registrar with weekly geriatrician review Early intervention program Length of stay, death, major medical complications Mortality Functional status, place of residence at 6 months Length of stay Postoperative complications, mortality, los, discharge destination Length of stay, mortality No significant difference in length of stay. Lower in hospital mortality with intervention 0.6% versus 5.8%, P = 0.03 and lower major medical complications 45.2% versus 61.7%, P = No significant difference at 3 or 6 months in the primary or secondary outcomes Subgroup analysis suggested a benefit from interdisciplinary care in patients with mild-mod cognitive impairment Length of stay was significantly shorter in the intervention group Significant reduction in postop complications in the intervention group Significant reduction in mortality (4.7 vs. 7.7%, P \ 0.01) No differences in length of stay or discharge destination Significantly shorter length of stay 21 days versus 32.5 days, P \ 0.01 for the intervention group No difference in mortality Table 3 Recommendations for hip fracture patients Intervention/recommendation Level of evidence Joint orthopaedic geriatric care is of benefit, reducing inpatient complications, length of stay and mortality Timing of surgery should be within h in stable patients Surgical fixation Prophylactic antibiotics should be given perioperatively Thromboembolic prophylaxis should be given (either low-molecular weight heparin or heparin) unless contraindicated Pressure sore prevention Perioperative pain management Delirium detection and management is important minimising the use of sedative drugs and anticholinergic medications Nutritional management with oral protein supplementation in malnourished patients Catheters should be removed the morning after surgery to lower the rate of urinary retention Early mobilisation III-3 I I II II II III-3 Levels of evidence: I evidence obtained from a systematic review of all relevant randomised controlled trials; II evidence obtained from at least one properly designed randomised controlled trial; III-1 evidence obtained from well-designed pseudo-randomised controlled trials (alternate allocation or some other method); evidence obtained from comparative studies with concurrent controls and allocation not randomised (cohort studies), case control studies or interrupted time series with a control group; III-3 evidence obtained from comparative studies with historical control, two or more single-arm studies, or interrupted time series without a parallel control group; IV evidence obtained from case series, either post-test or pre-test and post-test

4 without leg shortening, shorter hospital stay and an increase in return of patients back to their original residence [18]. Arthroplasties for proximal femoral fractures was subject to a Cochrane analysis [19]. There were no significant differences between unipolar and bipolar hemiarthroplasties (7 trials, 857 participants). There was some evidence that patients who receive cemented arthroplasties as compared to uncemented arthroplasties experienced less pain and better mobility. Five studies (608 participants) compared total hip replacement to hemiarthroplasty and found that there was a trend to better functional outcomes after a total hip replacement, but due to lack of patient numbers firm conclusions could not be made. Similarly, another review compared internal fixation of intracapsular proximal femur fractures to arthroplasty. Some studies reported less pain and function was better for cemented arthroplasty in comparison to fixation. There was a trend towards lower mortality for internal fixation (RR 0.85, 95% CI ) with lower risk of medical complications after fixation as compared to arthroplasty. However, there was a lower reoperation rate with arthroplasty. There were no significant differences in mortality at 12 months or the longer term. Prophylactic antibiotics There is considerable evidence from 11 randomised trials that prophylactic antibiotics (first- and second-generation cephalosporins) reduce the risk of deep wound infections by approximately 44% after hip fractures [13]. The evidence suggests that therapy should be given for 24 h (about 3 doses should be given) [14]. Thromboembolic prophylaxis Prevention of thromboembolism is necessary after orthopaedic surgery. After hip surgery, the rate of deep venous thrombosis (DVT) is approximately 27% and the incidence for fatal PE is between 1.4 and 7.5% in the first 3 months [14]. There is clear evidence for the efficacy and use of thromboembolic prophylaxis [13, 14, 20 22]. Prophylaxis against thromboembolism reduces the rate of DVT by approximately 60% [21]. Beaupre et al. conducted a metaanalysis of 32 studies with a total of 3,614 participants with hip fracture found that the use of any heparin treatment versus no treatment (13 trials; 1,199 participants; RR 0.60 (0.50, 0.71)) or a mechanical pumping device versus no treatment (5 trials; 451 participants; RR = 0.31 (0.19, 0.51)) reduced the risk of DVT significantly [14]. This meta-analysis did not find a significant difference between using unfractionated or fractionated heparins. When compared with placebo, low-dose heparin increased the risk of major bleeding by 30%, but the actual percentage increase was small with overall rates of 3.5% in the heparin group and 2.9% placebo group [13]. The current American College of Chest Physicians (ACCP) guidelines recommend routine thromboprophylaxis using fondaparinux (grade 1A), low-molecular weight heparin (grade 1B), unfractionated low-dose heparin (grade 1B) or adjusted dose vitamin K agonist, e.g. warfarin with target INR 2.5, range (grade 1B) [23]. Although an option in some patients, there is a risk of under anticoagulating with the use of warfarin. Aspirin alone as prophylaxis is not recommended (grade 1A) [23]. The duration of prophylaxis for hip fracture patients is recommended for at least 10 days (grade 1A) and an extension up to 35 days is recommended (grade 1A) [23]. This is based on a landmark multicenter, randomized placebo-controlled double blind trial of extended prophylaxis with fondaparinux for 3 weeks after hip fracture surgery [24]. Fondaparinux reduced the risk of venous thromboembolism by 96% (3/208 or 1.4% incidence as compared to 77/220 or 35% in the placebo group). However, there was a trend towards more major bleeding in the fondaparinux group (2.4%) as compared to the placebo group (0.6%), P = 0.06 and there was no mortality difference demonstrated. Further research is needed to determine the optimal duration of prophylactic anticoagulation [13]. Pressure sore prevention There is good evidence for pressure sore prevention that has a postfracture incidence of 10 40% [14]. Patients who develop pressure sores have an increased risk of prolonged hospitalisation and nosocomial infections. Foam (RR = 0.34, 95% CI ) and alternating pressure mattresses (RR = 0.20, 95% CI ) reduced the development of pressure sores in two trials comparing standard orthopaedic care with pressure sore development [25]. Clinicians should ensure that good pressure care occurs by the use of pressure relieving devices and monitoring for pressure areas by ward staff. Perioperative pain control Patients with poorly controlled perioperative pain have increased hospital length of stay, delayed ambulation and decreased 6-month mobility [14, 26]. Morrison et al. performed a prospective cohort study in 411 patients and found that patients with higher pain scores at rest had significantly longer hospital stays (P = 0.03) were more likely to have physical therapy sessions missed or shortened (P = 0.002) were significantly less likely to be ambulating by the third postoperative day (P \ 0.001) and had lower locomotion scores at 6 months (P = 0.02) [26].

5 The optimal analgesic regime specifically for patients with hip fracture has not been well studied. However, the principles derived from the analgesic ladder from the World Health Organisation can be used after hip fracture [27]. For mild pain, non-opioid analgesics, such as paracetamol or antiinflammatory drugs are warranted. However, antiinflammatory medications should be used with caution in older patients due to their gastrointestinal and renal side effects. Weak opioids (e.g. codeine) are recommended for moderate pain and strong opioids for severe pain with dose titrated according to response and effect. It is important to monitor for common side effects such as delirium and constipation that can occur particularly in older hip fracture patients. Other options for analgesia include nerve blocks using local anaesthesia during the perioperative period, including use in the emergency department before surgery to reduce pain [28, 29]. A Cochrane review found that there were significant reductions in pain levels and also the quantity of parenteral or oral analgesia given when nerve blocks were used [28]. There were few complications and none major reported. However, most studies were small and data were limited about clinical outcomes. Interestingly, some studies have suggested that use of analgesia can decrease the incidence of cardiac events. For instance, two small randomized controlled trials (77 patients and 68 patients respectively) evaluated the use of epidural analgesia versus conventional analgesia during the perioperative period for elderly hip fracture patients [30, 31]. One study found that intraoperative myocardial ischaemia was reduced (P = 0.05) and the other found a decrease in preoperative cardiac events (cardiac death, myocardial infarction, unstable angina, heart failure or new onset atrial fibrillation) with the use of epidural analgesia. They also showed that there was less pain in the group of patients receiving epidural analgesia. Adequate pain control may be one approach to reducing cardiac morbidity in these patients, but larger studies are needed to confirm these findings. Delirium detection and management Delirium occurs in up to 61% of patients with hip fracture [13]. Delirium increases the risk of poorer outcomes, complications, mortality and institutionalisation. It interferes with the rehabilitation process and delays functional recovery. In general baseline risk factors for delirium include advanced age, history of cognitive impairment, greater illness severity and history of alcohol use [13]. Specifically for hip fractures, two studies showed that only age, dementia and premorbid functional status predict whether delirium occurred [32, 33]. Precipitating risk factors for delirium have been harder to identify. Two risk factors that have been consistently identified in prospective trials include electrolyte imbalance and some medications classes such as opioids, sedative hypnotics and anticholinergics. Other proposed risk factors, include metabolic disturbances, dehydration, alcohol withdrawal, medications, drug toxicity and sensory problems, urinary retention, environmental changes and psychosocial factors. There are few studies studying the management of delirium in hip fracture patients. Some non-randomized studies have used multiple interventions, such as pre and postoperative geriatric assessment, oxygen therapy for hypoxia and early surgery [34]. However, it was difficult to determine the individual contributions of each component that lead to a reduction in delirium. Nevertheless, environmental factors and supportive re-orientation may reduce the incidence of delirium in some patients and should be encouraged. The role of medications, such as antipsychotics, sedatives and cholinesterase inhibitors is less certain in this patient population. Therefore, ensuring any medical issues are addressed early together with attention to environmental and supportive measures should be the mainstay of treatment. Nutrition Malnutrition is associated with increased surgical morbidity and mortality [14, 35]. In fact, 20% of patients with a hip fracture are severely malnourished that affects many bodily systems and causes wasting of muscles, mental apathy and impaired cardiac function. This leads to impaired mobility and the tendency to develop more postoperative complications. Malnutrition is also linked with an impaired immune response leading to an increased risk of infections postoperatively [35]. Avenell and Handoll [35] reviewed 21 randomised controlled trials involving 1,227 participants who had a hip fracture. They found four trials reviewed nasogatric feeding and found no effect on mortality (RR 0.99, 95% CI ), but studies were heterogeneous in nature. Nasogastric feeding was poorly tolerated. Oral feeds had no statistically significant effect on mortality either (RR 0.89, 95% CI ). However, oral feeds may reduce unfavourable outcomes, namely the combined outcome of mortality and survivors with medical complications (RR 0.52, 95% CI ). Oral supplementation might benefit patients by reducing minor postoperative complications. Urinary tract management Common urinary problems after surgery include urinary retention, incontinence and urinary tract infections. There is a paucity of trials in this area. One small randomised

6 controlled trial found that patients who had their urinary catheter removed the morning after surgery had lower rates of urinary retention [36]. Another study noted that patients who had scheduled intermittent catheterisation immediately after surgery rather than an indwelling catheter for 48 h after surgery achieved spontaneous voiding earlier [37]. Although the evidence is limited, catheters should be taken out as soon as practically possible and may assist in mobilisation. Osteoporosis management and falls prevention The underlying cause of many fractures in the elderly is due to osteoporosis [38]. Amongst 50-year-old women in North America, the estimated lifetime chance of suffering an osteoporotic hip fractures is approximately 18% [38]. Studies have shown that osteoporosis management is often overlooked in an acute hospital. One study found that with geriatric co-management osteoporosis treatment increased from 12 to 69% [10]. The treatment for osteoporosis is important as treatment with bisphosphonates after fracture can also improve survival [39 41]. A randomised control trial using an annual infusion of zoledronic acid within 90 days after hip fracture surgery found an improved survival (28% reduction in deaths vs. placebo) and reduction in the rate of new clinical fractures [39]. In addition to treatment for osteoporosis, a thorough assessment about the circumstances of the fall and attention to factors contributing to the fall are necessary. Prevention of further falls is essential to reduce further morbidity [42]. Functional recovery after hip fracture In most hip fracture patients, mobilisation the day after surgery can occur with acceptable complication rates, discharge destination, mortality and functional level [13]. Kagaya and Shimada reviewed functional outcomes after hip fracture [15]. Unfortunately, the majority of patients do not return to premorbid activities of daily living (ADL) function after hip fracture. One study found that only 56% returned to pre-fracture physical ADLs and 74% fully recovered walking ability after 1 year [15]. Many studies found that cognitive abilities are strongly associated with functional gain. Patients who sustained delirium had poorer ADL score and ambulation at 1 month after surgery. The majority of functional recovery takes place within the first 6 months after hip fracture. With instrumental ADLs, patients who were older and disorientated after surgery recovered least. Therefore, medical factors play a large role in dictating functional recovery. Patient survival and return to pre-fracture level of independence is mainly determined by factors that are beyond the control of an orthopaedic surgeon [43]. Conclusion There are many areas of medical management that needs to be addressed during the perioperative period for older patients with hip fractures. Physicians are well placed to work in partnership with the orthopaedic surgeon to manage older patients with fractures and orthopaedic geriatric units have been established. Further research is needed to improve the specific areas of medical management in older patients with fractures, with a view to decreasing morbidity and mortality in an at risk population. Acknowledgments Dr Carol Chong would like to acknowledge The University of Melbourne, National Health and Medical Research Council and The Northern Clinical Research Centre for postgraduate research scholarships which have enabled her to pursue research in this area. Conflict of interest statement any of the authors. References There is no conflict of interest for 1. 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