Geriatric Hip Fractures: Pearls for the Hospitalist Jason W. Stoneback, MD Assistant Professor, Univ. of Colorado SOM Director, Orthopedic Trauma and Fracture Surgery Service Director, Orthopedic Inpatient Medical Services University of Colorado Hospital 12 th Annual Rocky Mountain Hospital Medicine Symposium Denver, CO October 9, 2014 Disclosures Speakers Bureau-Synthes Learning Objectives Recognize how different fracture types, physiologic age and pre-fracture functional status impact treatment decisions in geriatric hip fx s. Appreciate how collaborative geriatric hip fracture protocols improve patient outcome, decrease mortality rates and improve cost effectiveness. Understand geriatric hip fx patients benefit from decreased delay to OR and how surgeon, preoperative workup and OR availability can influence this.
What is the next best step? 78 y/o female with PMHx HTN s/p fall from standing onto right hip with Garden IV femoral neck fracture. Community ambulator with Hx prior hip pain. A) Closed reduction intramedullary nailing B) Closed reduction percutaneous pinning C) Right hip hemiarthroplasty D) Right total hip arthroplasty What is the next best step? 78 y/o female with PMHx HTN s/p fall from standing onto right hip with Garden IV femoral neck fracture. Community ambulator with Hx prior hip pain. A) Closed reduction intramedullary nailing B) Closed reduction percutaneous pinning C) Right hip hemiarthroplasty D) Right total hip arthroplasty
Geriatric Hip Fracture Types Intertrochanteric Femur Fx s Femoral Neck Fx s Geriatric Hip Fracture Types Intertrochanteric Femur Fx s Femoral Neck Fx s Sliding Hip Screws Cephalomedullary Nail Short nails Long nails Percutaneous screws Hemiarthroplasty Total Hip Arthroplasty
Hemiarthroplasty vs Total Hip Arthorplasty Displaced femoral neck fracture Hx of prior hip pain/arthritis Cognitive function Pre-fracture functional status 5 randomized and 4 quasi-randomized controlled trials 1208 patients Mortality and infection rates: No difference Reoperation rate: HA > THA (RR 2.43, p 0.0002) Zi-Sheng, et al. Journal of Arthoplasty 2012 Short and long term pain rates: HA > THA (RR 42.07 and 8.02 respectively) Dislocation rate: THA > HA (RR 0.49, p 0.001) Zi-Sheng, et al. Journal of Arthoplasty 2012
What is the next best step? 80 y/o female s/p same level fall with left intertrochanteric femur fracture. Household ambulator, PMHx of HTN, DM, dementia and stable CHF. Admit to: A) Orthopedic Surgery B) Geriatric Service C) Hospitalist Medicine Service D) Doesn t matter if you have a collaborative approach Fracture Outcomes = / Functional Outcomes Basic ADLs 27% DO NOT recover prefracture functional status Recovery: 59% by 3 months 71% by 6 months 73% by 12 months Predictive factors for regaining BADL function Koval, et al. Clin Orthop Relat Res. 1998 Age < 85 years No pre-fx comorbidities Living with another person
Instrumental ADLs 52% DO NOT recover prefracture functional status Recovery: 34% by 3 months 42% by 6 months 48% by 12 months Predictive factors for regaining IADL function Koval, et al. Clin Orthop Relat Res. 1998 Age < 85 years (12 months) 850 pts femoral neck fxs 43.1% mortality 1 year 75% mortality 5 years Stewart, et al. Injury. 2011 How can we do better? Admission to operation time!17% 12 month mortality rate 20.4% -> 11.5% Higher percentage of patients remaining independent for ADL s Leung, et al. J Trauma. 2011
Orthop Clin N Am 2013 Orthop Clin N Am 2013 Hip Fracture Protocols Improve patient outcome Decrease length of stay Improve cost effectiveness
What is the next best step? 72 y/o male s/p slip and fall on black ice (lives in Tennessee) with right femoral neck fracture. Community ambulator, with Hx of HTN, cirrhosis and prostate CA. Admitted Friday morning at 3 AM to Orthopedic Service with Hospitalist consult. HMCS should see pt pre-op: A) After rounding on current patients B) Tomorrow because pt just got admitted C) ASAP D) After morning handoff (7:30 AM-8 AMish) Decreased time to OR improves mortality/outcomes Significant difference in mortality between patients having surgery within 24 hours of admission (20%) and those having surgery beyond 24 hours of admission (50%). Hamlet, et al. Am J Orthop 1997 When the factors of patient age, sex and number of preexisting medical conditions were controlled, operative delay > 48 hours approximately doubled the risk of the patient dying before the end of the first post-operative year. Zuckerman, et al. JBJS 1995 Factors Effecting Delay to Surgery and Length of Stay for Hip Fracture Patients Dedicated Orthopedic Trauma/Fracture Service surgeon availability and OR during weekdays Longer Delay to Surgery (DTS) Independent Risks Factors: Day of week admitted: Thursday-Saturday > Sunday-Wednesday Increasing ASA Patients requiring pre-op cardiac testing Ricci, et al. JOT 2014
Factors Effecting Delay to Surgery and Length of Stay for Hip Fracture Patients Increased hospital length of stay (LOS) Independent Risk Factors: ASA Male gender Day of Admission Pts admitted Thursday or Friday had longer LOS Pts admitted Thursday or Friday (mean 8.5-9.1 days LOS) Pts admitted other days (mean 7.3-7.9 days LOS) Ricci, et al. JOT 2014 Summary Geriatric patients with displaced femoral neck fx s who are physiologically young, community ambulators and without cognitive deficits benefit from total hip arthoplasty over hemiarthroplasty. Collaborative geriatric hip fracture protocols improve patient outcomes, decrease mortality rates and improve cost effectiveness. Summary Geriatric patients benefit from decreased delay to OR.
Thank you