Geriatric Fracture Patient Co-management
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Trauma Rounds Case Reports from the Mass General Hospital and Brigham & Women’s Hospital A Quarterly Case Study Volume 4, Winter 2013 Michael J Weaver, MD In the United States, hip fractures represent a significant medical burden. The annual cost of caring for geriatric patients with hip fractures is $10 - 15 billion. As the Baby Boomer generation continues to age, the number of patients with hip fractures is expected to rise dramatically. The rate of mortality at one year in this patient population runs between 12 and 37% (1). Co-management of elderly orthopaedic patients with a geriatri- cian has been shown to decrease inpatient length of stay and patient complications (2). At our two institutions, our ortho- paedic and geriatric medicine services have collaborated to form a combined service. We have found that this ortho- geriatric service improves patient care, reduces inpatient length of stay, and improves patient and family satisfaction. Optimal treatment of geriatric patients requires a holistic ap- proach with multiple specialists caring for the patient. Patients are co-managed by an orthopaedic surgeon and a geriatrician throughout their hospitalization (Figure 1). Medications and pain control are optimized to avoid delirium. Nutritionists are involved to maximize metabolic status. Endocrinologists are consulted to assess for osteoporosis, evaluate vitamin D defi- ciency and to provide advice for reducing the risk of future frac- ture. Physical therapy plays an integral role in getting patients out of bed and working on fall prevention. By taking this multi-disciplinary approach we improve patient outcomes. Combined Geriatric Service Patients with fragility fractures admitted to our two institutions are co-managed by our ortho-geriatric service and are seen daily by both their orthopaedic surgeon and geriatrician. Our geriatricians perform a thorough pre-operative assessment including a cognitive evaluation. Medications are optimized, with patients stratified based on risk. It is particularly impor- tant to avoid delirium-causing medication such as anticholiner- gics. We work closely with our colleagues in Anesthesia to en- sure that patients are cleared expeditiously so that their fracture can be addressed. We strive to take patients to the OR within 24 hours of admission. The risks of complication are minimized when we operate within 24 to 48 hours of a patient’s admission. Post-operative medication and fluid management are critical. Pain control is also very important, with appropriate dosing of narcotic medication, use of blocks and other regional forms of anesthesia necessary to avoid delirium. We recently reviewed the effects of instituting the ortho- geriatric services and found that we have reduced length of stay by 1.6 days. In a meta-analysis performed by our geriatric group, we documented a decrease in 30-day and 1-year mortal- ity when geriatric hip fracture patients are treated by similar combined services (3). Endocrine Consultation Hip fractures in the elderly are typically fragility fractures and are often associated with osteoporosis. At our institutions, we partner with an endocrinologist to ensure that the appropriate work-up is performed and any metabolic deficiencies or osteo- porosis are addressed while the patient is an inpatient. Vitamin D deficiency is commonplace – particularly here in New England – thus, vitamin D levels should be obtained dur- ing the pre-operative work-up. All patients should be on cal- cium and vitamin D supplementation during their hospitaliza- tion and at discharge. Trauma Rounds, Volume 4, Winter 2013 1 P A R T N E R S O R T H O P A E D I C Geriatric Fracture Patient Co-management Figure 1: Geriatric patient care is optimized by a multi-disciplinary team approach.
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Transcript of Geriatric Fracture Patient Co-management
Trauma Rounds Case Reports from the Mass General Hospital and Brigham & Women’s Hospital A Quarterly Case Study Volume 4, Winter 2013
Michael J Weaver, MDIn the United States, hip fractures represent a significant medical burden. The annual cost of caring for geriatric patients with hip fractures is $10 - 15 billion. As the Baby Boomer generation continues to age, the number of patients with hip fractures is expected to rise dramatically.
The rate of mortality at one year in this patient population runs between 12 and 37% (1).Co-management of elderly orthopaedic patients with a geriatri-cian has been shown to decrease inpatient length of stay and patient complications (2). At our two institutions, our ortho-paedic and geriatric medicine services have collaborated to form a combined service. We have found that this ortho-geriatric service improves patient care, reduces inpatient length of stay, and improves patient and family satisfaction.Optimal treatment of geriatric patients requires a holistic ap-proach with multiple specialists caring for the patient. Patients are co-managed by an orthopaedic surgeon and a geriatrician throughout their hospitalization (Figure 1). Medications and pain control are optimized to avoid delirium. Nutritionists are involved to maximize metabolic status. Endocrinologists are consulted to assess for osteoporosis, evaluate vitamin D defi-ciency and to provide advice for reducing the risk of future frac-ture. Physical therapy plays an integral role in getting patients out of bed and working on fall prevention. By taking this multi-disciplinary approach we improve patient outcomes.Combined Geriatric Service
Patients with fragility fractures admitted to our two institutions are co-managed by our ortho-geriatric service and are seen daily by both their orthopaedic surgeon and geriatrician.Our geriatricians perform a thorough pre-operative assessment including a cognitive evaluation. Medications are optimized, with patients stratified based on risk. It is particularly impor-tant to avoid delirium-causing medication such as anticholiner-gics. We work closely with our colleagues in Anesthesia to en-sure that patients are cleared expeditiously so that their fracture can be addressed. We strive to take patients to the OR within 24
hours of admission. The risks of complication are minimized when we operate within 24 to 48 hours of a patient’s admission.Post-operative medication and fluid management are critical. Pain control is also very important, with appropriate dosing of narcotic medication, use of blocks and other regional forms of anesthesia necessary to avoid delirium.We recently reviewed the effects of instituting the ortho-geriatric services and found that we have reduced length of stay by 1.6 days. In a meta-analysis performed by our geriatric group, we documented a decrease in 30-day and 1-year mortal-ity when geriatric hip fracture patients are treated by similar combined services (3).Endocrine Consultation
Hip fractures in the elderly are typically fragility fractures and are often associated with osteoporosis. At our institutions, we partner with an endocrinologist to ensure that the appropriate work-up is performed and any metabolic deficiencies or osteo-porosis are addressed while the patient is an inpatient.Vitamin D deficiency is commonplace – particularly here in New England – thus, vitamin D levels should be obtained dur-ing the pre-operative work-up. All patients should be on cal-cium and vitamin D supplementation during their hospitaliza-tion and at discharge.
Trauma Rounds, Volume 4, Winter 2013 1
P A R T N E R S O R T H O P A E D I C
Geriatric Fracture Patient Co-management
Figure 1: Geriatric patient care is optimized by a multi-disciplinary team approach.
Bone density testing should be performed after the patient is discharged from the hospital, particularly if the results are not recent. When bone mineral density is low, bisphosphonate therapy is useful and has been shown to reduce the risk of fur-ther fracture. Care should be taken to avoid use of bisphos-phonates for more than 5-years as long-term use may be related to atypical femoral fractures (4). Teriparatide (Forteo) may be useful for recalcitrant cases.Surgical Challenges
Geriatric fractures can be challenging. Poor bone quality and previous surgeries can limit fixation options and make surgery difficult.Femoral Neck Fractures (Total hip arthroplasty (THA) vs. hemiarthro-plasty): Many of our geriatric patients lead active lifestyles. THA provides a higher level of pain relief and improve function when compared with hemiarthroplasty. However, THA exposes pa-tients to a longer surgery with a higher blood loss and increases a patient’s risk of dislocation. Relative contra-indications to THA include neuromuscular disorders like Parkinson’s disease, diffi-culty or inability to adhere to hip precautions and advanced age. In both operations I avoid the use of taper type stems as these act as wedges, increase hoop stresses, and can lead to periprosthetic fractures in patients with poor bone quality. When bone quality is compromised, cement fixation provides immediate stability for the femoral prosthesis and reduces the risk of periprosthetic frac-ture.Peritrochanteric Hip Fractures (Cephalomedullary Nail vs. Sliding Hip Screw): Not all fractures do better when treated with a cepha-lomedullary nail. Subtrochanteric, reverse obliquity and unsta-ble (3- & 4-part) patterns tend to do better with intramedullary fixation. I prefer to use a sliding hip screw (DHS) for simple 2-part intertrochanteric hip fractures as this implant spares the ab-ductors. The DHS is also substantially less expensive.Other fixation options: Occasionally, previous surgery or pre-existing deformity precludes standard fixation of hip fractures. It is thus useful to be familiar with techniques such as the use of blade plates and proximal femoral locking plates (Figure 2).
Summary
Geriatric fractures are best managed with a multidisciplinary approach. Bringing together orthopaedic surgeons, geriatri-cians, anesthesiologists, endocrinologists, nurses, therapists and nutritionists improves patient care and optimizes outcomes.Michael Weaver, MD, is an Orthopaedic Trauma Surgeon at Brigham & Women’s Hospital, Boston, MA.
References1. Braithwaite RS, Col NF, Wong JB. Estimating Hip Fracture Morbidity, Mor-
tality and Costs. J Amer Geriatrics Soc 2003; 51(3):364-370.2. Fisher AA, Davis MW, Rubenach SE, Sivakumaran S, Smith PN, Budge MM.
Outcomes for Older Patients With Hip Fractures: The Impact of Orthopedic and Geriatric Medicine Co-care. J Ortho Trauma 2006; 20(3):172-180.
3. Konstantin V, Grigoryan MS, Javedan H, Rudolph SM. Ortho-Geriatric Mod-els and Optimal Outcomes: A Systematic Review and Meta-Analysis. J Trauma (submitted).
4. Weaver MJ, Miller M, Vrahas MS. The Orthopaedic Implications of Disphos-phonate Therapy. J Am Acad Ortho Surg 2010; 18:367-374.
P A R T N E R S O R T H O P A E D I C T R A U M A R O U N D S
2 Trauma Rounds, Volume 4, Winter 2013
Trauma FacultyMark Vrahas, MD — 617-726-2943Partners Chief of Orthopaedic [email protected]
Mitchel B Harris, MD — 617-732-5385Chief, BWH Orthopedic [email protected] Malcolm Smith, MD, FRCS — 617-726-2794Chief, MGH Orthopaedic [email protected] Lhowe, MD — 617-724-2800MGH Orthopaedic [email protected]
Michael Weaver, MD — 617-525-8088BWH Orthopedic [email protected]
Jesse Jupiter, MD — 617-726-5100MGH Hand & Upper Extremity [email protected]
David Ring, MD — 617-724-3953MGH Hand & Upper Extremity [email protected]
Brandon E Earp, MD — 617-732-8064BWH Hand & Upper Extremity [email protected]
George Dyer, MD — 617-732-6607BWH Hand & Upper Extremity [email protected]
John Kwon, MD — 617-643-5701MGH Foot & Ankle [email protected]
Please share your comments online, or by email:Mark Vrahas, MD / [email protected] Center for Outpatient Care, Suite 3C55 Fruit Street, Boston, MA 02114
Editor in Chief Mark Vrahas, MD
Program DirectorSuzanne Morrison, MPH(617) [email protected]
Editor, PublisherArun Shanbhag, PhD, MBAwww.MassGeneral.org/orthowww.BrighamAndWomens.org/orthopedics
Figure 2: 78F with a previous cemented long stemmed total knee replacement. She now presents with subtrochanteric femur fracture (left). The cemented stem precludes intramedullary fixation which would be the standard treatment for this fracture pattern. Instead she is treated with open reduction and fixation with a 95 degree blade plate (right). The tip of the stem is spanned by the plate to avoid a stress riser effect.
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