That advice came from Victor H. Frankel, MD, PhD, president of the New York University (NYU) Hospital for Joint Diseases in New York City. Dr. Frankel then held the position that Dr. Zuckerman now has, as chairman of the hospital’s department of orthopaedic surgery.“He said to me, ‘I think you should study hip fractures,’” recalls Dr. Zuckerman. “It made no sense to me. I had just finished a yearlong fellowship in hip and knee replacement and had spent time at the Mayo Clinic learning all about the shoulder.”

AAOS Now

Published 6/1/2009
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Kathleen Louden

Hip fracture studies lead to better care, understanding

OREF award winner continues efforts to improve outcomes

In 1984, at the start of his career as an orthopaedic surgeon, AAOS President Joseph D. Zuckerman, MD, received some advice that changed his research focus.

But he heeded Dr. Frankel’s advice and began to study an injury that has gained in frequency and importance as the U.S. population has aged. In 1985, he established the hospital’s research-oriented Geriatric Hip Fracture Program.

The resulting 15-year body of research on hip fractures in elderly patients earned special recognition in 2002, when Dr. Zuckerman and his colleague, Kenneth J. Koval, MD, received the Orthopaedic Research and Education Foundation (OREF) Clinical Research Award. The $20,000 award recognizes outstanding clinical research related to musculoskeletal disease or injury.

Unique research focus
“What developed from that one phrase, ‘You should study hip fractures,’ was a multifaceted, multidisciplinary approach to studying the elderly patient who sustains a hip fracture,” Dr. Zuckerman says.

Central to the Geriatric Hip Fracture Program is a registry database with prospectively collected data for approximately 1,500 patients with hip fractures. Data range from patient demographics and prefracture functional status to injury characteristics, details on acute and long-term care, and outcomes. Dr. Zuckerman and his colleagues have used the registry as a foundation for numerous clinical studies.

“We have looked at the problem every way possible: orthopaedically, biomechanically, at the fractures themselves, and at the individual patients who sustain hip fractures,” he says. “We looked at hip fracture patients in a way that others did not, certainly not in orthopaedics or in as great detail as we did.”

A common, serious problem
In the United States, more than 350,000 hip fractures occur annually, most of them in people age 65 or older. An estimated 28 percent of patients who break a hip die within a year of the injury, according to the AAOS. Another 50 percent of patients do not regain the level of mobility that they had before the fracture.

“Even if the fracture heals successfully, many patients can no longer independently accomplish daily activities,” says Dr. Zuckerman.

The main goal of Dr. Zuckerman’s research is to improve the functional outcomes of geriatric patients after they have a hip fracture. He and his associates have performed many studies to try to understand why these elderly patients do not recover their functional abilities as well as surgeons would like.

To help answer this question, Dr. Zuckerman and his group developed a standardized outcomes measure specific to geriatric hip fracture patients. Their Functional Recovery Score helps orthopaedic surgeons determine the extent to which these patients regain their prior ability to perform routine activities—specifically, those activities the patients said were most important in their daily lives. Previously, these patients were evaluated with a hip score for arthritis or did not receive an evaluation of their function.

In studies using the Functional Recovery Score and in other work, Dr. Zuckerman found that many predictors of poor outcomes after hip fracture were unrelated to the fracture or the treatment. Rather, poor outcomes—including reduced function, rehospitalization, and death—more often correlated with older age, comorbidities, low prefracture levels of function, and psychosocial factors, such as institutional residential settings.

“It’s a little humbling,” he says. “The surgery we do is successful in 90 percent to 95 percent of patients, but other things affect how they recover functionally—things we usually can’t control.”

Improving care
Because hip fracture is not just an orthopaedic problem, Dr. Zuckerman believes that a multidisciplinary approach to care is critical.

“Practicing orthopaedic surgeons need to recognize that this is a very challenging population,” he says. “Orthopaedic surgery is a small but important part of overall treatment, which must be multidisciplinary.”

Based on his research and that of other investigators, the AAOS has made hip fractures a priority issue, says Dr. Zuckerman. AAOS created its position statement on hip fractures in seniors in 1999, which called for a comprehensive national response to the growing epidemic of hip fractures, stressing education, prevention and research.

An outgrowth of that position statement was the 2001 National Consensus Conference on Improving the Continuum of Care for Patients with Hip Fracture, which Dr. Zuckerman co-chaired. This consensus group of more than 40 organizations called hip fractures a “public health crisis” that likely will get worse. The U.S. Administration on Aging predicts that the number of Americans age 65 or older will double by 2040. The hip fracture consensus group proposed what Dr. Zuckerman calls “an ambitious agenda” for change, requiring medical, social, and governmental interventions.

Research on prevention needed
Recommendations of the consensus group also included the need for education and research aimed at preventing hip fractures.

Such research requires the collaboration of orthopaedic surgeons and orthopaedic researchers, Dr. Zuckerman says. OREF, with its mission of serving the entire orthopaedic community, recognizes that. “As orthopaedic surgeons, we can’t do enough to support OREF,” he says.

In addition to his expertise on hip fractures, Dr. Zuckerman is a nationally renowned expert on shoulder surgery, as well as on hip, knee, and shoulder replacement. A graduate of the Medical College of Wisconsin, he completed his surgery residency at the University of Washington. He completed a clinical and research fellowship in arthritis surgery at Harvard’s Brigham and Women’s Hospital. In addition, he was a visiting clinician at the Mayo Clinic in Rochester, Minn.

Kathleen Louden is a contributing writer for OREF and can be contacted at communications@oref.org