Speaking at the centennial annual meeting of the Clinical Orthopaedic Society, Erika J. Mitchell, MD, was adamant about the magnitude and morbidity associated with fragility fractures, particularly in the hip.

“Statistically speaking, up to half of all women will have fragility fractures in their lifetime, and up to a third of all men,” she explained. “Far more people will have a fragility fracture than will have a heart attack, cancer, or stroke.”

Dr. Mitchell pointed out that the average person is more concerned about cancer than a hip fracture.

“Hip fractures kill,” she said. “The 30-day mortality rate after hip fracture is about 9 percent. It rises to 17 percent if the patient already has an acute medical problem. If a patient has heart failure while being treated for a hip fracture, the 30-day mortality increases to 65 percent. And if a patient has pneumonia after a hip fracture, the 30-day mortality increases to 43 percent.”

According to Dr. Mitchell, the elderly surgical patient presents challenges beyond the scope of primary care physicians.

“We have to worry about acute blood loss,” she said. “Getting these patients to the operating room is an urgent issue. We have to be concerned with anesthetic complications. These are not issues that other physicians face when they are working with chronic conditions.”

Dr. Mitchell outlined her goals in caring for a geriatric patient with a fragility fracture.

“Start care early,” she said. “As soon as the patient is in the door, think about how to optimize him or her for surgery. Get the patient to the operating room within 48 hours if at all possible. Closely monitor the patient for the first few days after surgery to watch for possible complications. Make sure that the patient’s fluid balance is correct; make sure the patient is mobilized, out of bed, and breathing deeply to avoid pneumonia.

“The goal should be to return patients to their previous level of function if at all possible. And we need to help them prevent future fractures.”

According to Dr. Mitchell, delaying surgery for 24 hours or more increases the 1-year mortality rate in older patients. A delay of more than 36 hours reduces the patient’s likelihood of returning to independent living.

Dealing with anticoagulants
In elderly patients, anticoagulants are a specific concern. Dr. Mitchell suggested that patients who are taking aspirin as an anticoagulant continue the medication through the perioperative period. The best approach for patients taking clopidogrel, however, is unclear.

“Honestly, I just operate through it,” she said. “If you are concerned about the anticoagulant, you can rid the patient of it, but there is a tremendous risk in stopping these medications if the patient recently had stent placement.”

Regarding warfarin, she recommended slow reversal, unless the situation is an emergency.

According to Dr. Mitchell, anesthesia is an additional factor that requires special attention in elderly patients. Studies have shown no significant difference in mortality between regional or general anesthesia, although the use of regional anesthesia may reduce the risk of deep venous thrombosis (DVT). However, the presence of anticoagulants increases the risk of spinal bleeding. In addition, the patient’s physical position during surgery must be taken into account.

“If the patient is receiving regional or spinal anesthesia and in a prone or lateral position, it’s very difficult to rapidly intubate them if that becomes necessary,” she said.

Get them moving
Dr. Mitchell emphasized the importance of getting the patient moving as soon as possible after surgery.

“It’s extremely important to get the physical therapist on board the next day,” she said. “The patients will complain: they’re hurting, they’re tired, they don’t want to get out of bed. If nothing else, at least get them out of bed and into a chair.”

To that end, Dr. Mitchell recommended minimizing the use of narcotics and removing any tethers as early as possible.

“Elderly patients with just a minimal amount of dementia can become severely confused in the postoperative period,” she explained, “which may be related to narcotics and the use of restraints. These patients are in a hospital room where it’s light and noisy all day. They don’t have their eyeglasses or their hearing aids; they’re tied down and on narcotics. That’s sensory deprivation.”

Dr. Mitchell also pointed out that orthopaedists should consider the patient’s nutrition.

“The patient didn’t eat the day of surgery,” she said. “The patient didn’t eat the day before surgery either, and often barely eats the day after. That’s 3 days with no nutrition. Talk to the family and the patient. At the very least try and get them to drink a milk shake. They need some sustenance and calories.

“DVT prophylaxis is an im-portant consideration,” added Dr. Mitchell. “Anticoagulants that were stopped for surgery should be restarted as soon as possible. However, if the patient was not on antithrombotic agents beforehand and is at significant risk of falls, then the risk of complications from a fall, such as internal bleeding in the head, may outweigh the risk of pulmonary embolism.”

Dr. Mitchell explained that mechanical DVT prophylaxis remains an option, but urged consideration of the patient’s mental state when choosing that option.

“Intermittent compression devices tie patients down, and if the patient gets confused at night and tries to get out of bed, it can be very dangerous,” she noted.

Prevent the next fracture
“When it comes to follow-through, we orthopaedic surgeons need to do better,” said Dr. Mitchell. “These patients were already frail, and now we’ve injured them. It’s extremely difficult for them to get to and from doctors, and many of them won’t see their primary care physician until long after the surgical intervention.”

Because primary care physicians are often concerned about prescribing bisphosphonates and other anti-osteoporosis medications, only 25 percent to 33 percent of patients are prescribed treatment for osteoporosis after a low-energy fracture, noted Dr. Mitchell. She outlined the following steps that orthopaedic surgeons can take in follow-up:

• Test vitamin D-25 levels.
• Schedule a dual-energy X-ray absorptiometry (DEXA) scan if the patient hasn’t had one in the last 2 years.
• Discuss the situation with the patient and family. If the patient has osteoporosis, check the medications because some can make a patient more prone to falls.
• Talk to the family about addressing poor lighting at home, vision problems, and trip hazards such as throw rugs, wiring, and small pets

“About 50 percent of patients will have a second fracture in 3 to 5 years, which makes the orthopaedic surgeon important in terms of prevention,” she concluded.

Disclosures: Dr. Mitchell—Eli Lilly, BloXR.

Peter Pollack is a staff writer for AAOS Now. He can be reached at ppollack@aaos.org

Bottom Line

• A key goal of treating elderly patients with fragility fractures—particularly hip fractures—is to enable the patient to return to his or her prior level of functioning.
• Elderly patients with hip fractures should be operated on as soon as possible after the fracture to reduce mortality rates
• Patients should be moving as soon as possible after surgery.
• Orthopaedic surgeons should work with patients and their families to improve follow-through and prevent future fractures.

References:

1. Moran CG, Russell T, Wenn BA, Sikand M, Taylor AM. Early Mortality After Hip Fracture: Is Delay Before Surgery Important? J Bone Joint Surg Am, 2005 Mar 01;87(3):483-489.
2. Roche JJ, Wenn RT, Sahota O, Moran CG: Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: Prospective observational cohort study. BMJ 2005;331(7529):1374.
3. ParkerMJ,Handoll HH, Griffiths R: Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev 2004;(4) CD000521.