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Functional recovery after operative treatment of femoral neck fractures in an institutionalized elderly population
Functional Recovery After Operative Treatment of Femoral Neck Fractures in an Institutionalized Elderly Population Yoram Folman, MD, Reuven Gepstein, MD, Albert Assaraf, MD, Shimon Liberty, MD ABSTRACT. Folman Y, Gepstein R, Assaraf A, Liberty S. Functional recovery after operative treatment of femoral neck fractures in an institutionalized elderly population. Arch Pbys Med Rebabil 1994;75:454-6. l Agreement that hip fracture is best treated surgically stems from the fact that early mobilization of the patient reduces morbidity and mortality. This concept was tested in 54 elderly, institutionalized patients with femoral neck fractures who were operatively treated. The patients were reviewed within 12 months after being injured. Their average age was 81.2 years, and 94% of the patients were women. Seventy-five percent of the study population had neurological disease or heart disease and were thus limited in their motivation or ability to participate in a rehabilitation program. Only 16.7% of the patients regained their overall functional ability and only 12.9% returned to their pre-injury, ambulatory status. The therapeutic concept should be reviewed and the conservative approach be given serious consideration. 0 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation
Since the beginning of the 20th century, the medical profession has recognized that a femoral neck fracture is an injury with complications beyond those of a simple fracture. Attention was drawn to the many questions surrounding its treatment by Speed,’ who labeled it “the unsolved fracture” in a 1935 report. Internal fracture fixation was introduced in the 1950s and De Palma’ declared that “The poorer the general condition of the patient, the more urgent is early surgical intervention. This is a life-saving procedure.” Survival was seen as tantamount to early ambulation and it seemed logical to assume that early ambulation depended upon a mechanical solution to fixate the fracture. However, increased clinical experience showed a high morbidity and mortality rate of 30% among persons who had surgery within the first year after the initial fracture.3-5 Nonetheless, surgical intervention-that is, fixation of the femoral neck fracture-is still considered the treatment for which the risk-benefit balance, a criterion for every medical treatment, is accepted as positive. This presumption was tested in an institutionalized geriatric population that is recognized for its poor mental and physical condition, in comparison to a parallel age group in the general population. METHOD Fifty-four patients who had sustained femoral neck fracture while they were permanent residents of a governmental geriatric institution comprised our study group. All fractures had occurred at least 1 year before the examination. The From the Department of Orthopaedic Surgery (Drs. Folman, Assaraf, Liberty), Hillel-Jaffe Hospital, Hadera and the Department of Orthopaedic Surgery (Dr. Gepstein) Meir Hospital, Kfar Saba, Israel. Submitted for publication January 15, 1993. Accepted in revised form May 25, 1993. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Yoram Folman, MD, Department of Orthopaedic Surgery. Hillel-Jaffe Hospital, Hadera 38100, Israel. 0 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation ooo3-9993/94/75040098$3.00/0
Arch Phys Med Rehabil Vol75,
April 1994
patients had surgery at the regional hospital and returned to the institution’s rehabilitation ward within 72 hours. Once a plateau of functional ability was reached, they were institutionalized according to that same level of functional ability. Personal data concerning the patients were gathered, the patients’ preoperative state of health was defined, and the characteristics of the direct complications following the operation were reviewed. The overall ability of each patient was determined by three levels: (1) Independent (I) (capable of functioning without assistance); (2) Enfeebled (E) (partially dependent on assistance); and (3) Nursed (N) (completely dependent on assistance) . The patients’ ambulatory ability was determined by four levels: (1) Unassisted (U); (2) Tripod-supported (T); (3) Person-supported (P); (4) Wheelchair-bound (W). RESULTS Women comprised 95% of the study population; 88% of the women were widows, hence the term “widow’s disease” that is often associated with this disorder. The average age of the 54 patients was 8 1.2 years; the age range was 67 to 96 years, with 3.7% of the patients between 60 and 69 years of age, 33.3% between 70 and 79 years, 53.7% between 80 and 89 years, and 9.3% between 90 and 99 years. The incidence of concommitant disease in the study population included central nervous system, 53.7%; cardiovascular system, 57.4%; respiratory system, 7.4%; and diabetes mellitus, 14.8%. Thirty-nine (72.2%) of the fractures were classified as extra-articular and the surgical procedure was internal fixation with an axial compression hip screw device (Richard screw). Fifteen fractures (27.8%) were classified as intraarticular and the surgical procedure was a hemiarthroplasty (Austin-Moore prosthesis). Postoperative complications are shown in table 1. Changes in the patients’ overall ability are shown in figure 1. Twenty-six (96.3%) of the 27 independent patients deteriorated in their overall functional level; 18 (66.6%) became
RECOVERY Table 1: The Incidence
of Postoperative
Complication Urinary tract infection Deep vein thrombosis Respiratory distress Pressure sore Congestive heart failure Sphincter incontinence Reactive depression Operative wound infection Operative wound hematoma Failure of fixation
AFTER
FEMORAL
Complications
n
Percent
17 10 10
31.5 18.5 18.5 16.7 14.8 14.8 14.8 13.0 3.7 3.7
9 8 8 8 7 2 2
enfeebled (IE); and 8 (29.6%) became nursed (IN). Fourteen (63.3%) of the 22 enfeebled patients deteriorated in their overall functional level (EN). Nine of the total 54 patients (16.7%) did not deteriorate in their overall functional level (II, EEL Changes in the patients’ ambulatory ability are shown in figure 2. Of the 43 unassisted walkers, 41 (95.3%) deteriorated in their ambulation, 19 (44.2%) became tripod-supported (UT), 10 (23.3%) became person-supported (UP), and 12 (27.9%) became wheelchair-bound (UW). Of the 9 tripodsupported patients, 4 (44.4%) deteriorated in their ambulation, 1 (11.1%) became person-supported (TP), and 3 (33.3%) became wheelchair-bound (TW). One patient who had been person-supported became wheelchair-bound (PW).
DETERIORATION
II
IE 18
IN 8
EI
EE 8
EN 14
NI
NE
NN 5
1
NECK FRACTURE,
Folman
DETERIORATION UU
UT
UP
UW
TU
TT 5
TP
TW 3
PU
PT
PP
PW 1
Wu
WT
WP
W-W 1
2
19
12
1
Fig 2-The outcome in ambulatory ability. U, unassisted walker; T, tripod-supported; P, person-supported; W, wheelchair-bound. Letters in each square represent the preoperative and postoperative status of the patients. (Example: UT = a subject who walked unassisted prior to operation but who became tripod-supported afterwards).
Seven patients of the total 54 (12.9%) returned to their preoperative level of ambulation (II, TT). The level of ambulation according to age group (table 2) gives an overall picture of the inverse ratio between functional recovery and progressive age factor. DISCUSSION This elderly population is characterized by gradual deterioration of most of the body systems. About half of the patients examined suffered from chronic brain disturbance. chronic heart disease, or a combination of both. The femoral neck fracture constitutes an acute risk factor in addition to the other general chronic disturbances. The 54 patients in this review suffered femoral neck fractures while residing in a geriatric institution where patients are under continual supervision concerning their health and
According
to Age Group
Group U&T
IMPROVEMENT
Fig l-The outcome in overall ability. I, independent; E, enfeebled; N, nursed. Letters in each square represent the preoperative and postoperative status of patients (Example: IN = a subject who had been independent prior to operation hut who became nursed afterwards.)
10
IMPROVEMENT
Table 2: Ambulation
4
455
Group P&W
Age (yr)
No.
%
No.
%
60-69 70-79 80-89 90-99
0 9 19 2
0.0 50.0 65.5 40.0
, ; 10 3
lOO.(I 50.0 34.5 60.(1
Arch Phys Med Rehabil Vol75,
April 1994
456
RECOVERY
AFTER
FEMORAL
functional ability. Their referral for operative intervention was supported by a positive estimate concerning their ability to withstand the operation and a good prognosis for functional rehabilitation. However, the postoperative functional ability was disappointing. One year after the operation, only 16.7% (9/54) of the injured patients returned to their preoperative functional level. Changes in ambulatory ability pointed to a similar tendency. After 1 year, only 12.9% (7/54) of the patients regained their preoperative ambulatory ability. One half (26/ 52) of the patients lost their ambulatory status. Percentages of similar deterioration have been reported in other centers.5-7 What is the reason for the high percentage of deterioration? The 54 examinees lived in a fulltime institution where the medical and nursing support ensured maximum uniformity of the environmental factor. The level of physiotherapeutic practice was also uniform, given that strenuous exercising does not necessarily contribute to faster rehabilitation. It appears that the personal data in each case dictated the level of rehabilitational success. It is logical to presume that old age had a negative effect. The comparison of ambulatory ability in relation to age gave an unexpected result. There were more successful cases among the SO-year-old patients than among the 70-year-old group, while the 90year-old patients dealt with the problem better than did the 60-year-old group. The explanation apparently lies in the superior inherent systemic health of the patients who had lived longer. Support for this assumption lies in the reported inverse ratio between the mortality percentages following femoral neck fracture and the ages of the patients.’ Medical records of the rehabilitation failures show that 75% of the patients had neurological diseases or heart diseases that limited respectively their motivation and ability to rehabilitate. Such medical conditions would eventually have resulted in their being placed in an institution in the first place. The separation of these elderly patients from a familiar, permanent framework, the effect of the anaesthetic, the
Arch Phys bled Rehabil Vol75,
April 1994
NECK FRACTURE,
Folman
drugs, and the pain following the operation are more than enough to undermine their already shaky mental and physical conditions. Postoperative functional regression was almost a rule. The risk-benefit balance was negative in the full-time institution population. An alternative approach to surgical treatment consists of a limited period of bed rest followed by gradual progression towards walker-assisted mobility through wheelchair confinement. Supporters of this approach say that union of femoral neck fracture is the rule rather than the exception and that the majority of the patients would, with time, become pain free without operational intervention.“-” The continuation of treatment in an environment familiar to the patient, by an existing team and for a reasonable fee were offered as advantages per se. Our study indicates that debilitated elderly patients who have surgical intervention for treatment of femoral neck fractures rarely recover function; consequently, in such cases a conservative approach to treatment should be considered. References 1. Speed K. The unsolved fracture. Surg Gynecol Obstet 1935;60:371. 2. De Palma AF. Fracture of the upper end of the femur. In: De Palma AF, editor. The management of fractures and dislocations, Philadelphia: Saunders, 1970:1236-1325. 3. Ecker ML, Joyce JJ, Kohl EJ. The treatment of trochanteric hip fractures using a compression screw. J Bone Joint Surg (Am) 1975;57A:23-7. 4. Gordon PC. The probability of death following a fracture of the hip. Can Med Assoc J 1971;105:47-62. 5. Miller CW. Survival and ambulation following hip fracture. J Bone Joint Surg (Am) 1978;60A:930-933. 6. Moller BN, Lucht V, Grymer F, Bartholdy NJ. Early rehabilitation following osteosynthesis with sliding hip screw for trochanteric fractures. Stand .I Rehabil Med 1985;17:39-43. 7. Nieman KMW. Mankin HJ. Fractures about the hip in an institutionalized patient population. J Bone Joint Surg (Am) 1968;50A: 1327-40. 8. Jette AM, Harris BA, Clear-y PD, Campion EW. Functional recovery following hip fracture. Arch Phys Med Rehabil 1987;68:735-40. 9. White BL, Fisher WD, Larvin CA. Rate of mortality for elderly patients after fracture of the hip in the 1980’s. J Bone Joint Surg (Am) 1978;69A:1335-40. 10. Frew JFM. Conservative treatment of intertrochan-teric fractures, J Bone Joint Surg (Br) 1972;54B:748-9. 11. Lyon LJ, Nevins MA. Management of hip fracture in nursing home patients: to treat or not to treat. J Am Geriatr Sot 1984;32:391-5.
Since the beginning of the 20th century, the medical profession has recognized that a femoral neck fracture is an injury with complications beyond those of a simple fracture. Attention was drawn to the many questions surrounding its treatment by Speed,’ who labeled it “the unsolved fracture” in a 1935 report. Internal fracture fixation was introduced in the 1950s and De Palma’ declared that “The poorer the general condition of the patient, the more urgent is early surgical intervention. This is a life-saving procedure.” Survival was seen as tantamount to early ambulation and it seemed logical to assume that early ambulation depended upon a mechanical solution to fixate the fracture. However, increased clinical experience showed a high morbidity and mortality rate of 30% among persons who had surgery within the first year after the initial fracture.3-5 Nonetheless, surgical intervention-that is, fixation of the femoral neck fracture-is still considered the treatment for which the risk-benefit balance, a criterion for every medical treatment, is accepted as positive. This presumption was tested in an institutionalized geriatric population that is recognized for its poor mental and physical condition, in comparison to a parallel age group in the general population. METHOD Fifty-four patients who had sustained femoral neck fracture while they were permanent residents of a governmental geriatric institution comprised our study group. All fractures had occurred at least 1 year before the examination. The From the Department of Orthopaedic Surgery (Drs. Folman, Assaraf, Liberty), Hillel-Jaffe Hospital, Hadera and the Department of Orthopaedic Surgery (Dr. Gepstein) Meir Hospital, Kfar Saba, Israel. Submitted for publication January 15, 1993. Accepted in revised form May 25, 1993. No commercial party having a direct financial interest in the results of the research supporting this article has or will confer a benefit upon the authors or upon any organization with which the authors are associated. Reprint requests to Yoram Folman, MD, Department of Orthopaedic Surgery. Hillel-Jaffe Hospital, Hadera 38100, Israel. 0 1994 by the American Congress of Rehabilitation Medicine and the American Academy of Physical Medicine and Rehabilitation ooo3-9993/94/75040098$3.00/0
Arch Phys Med Rehabil Vol75,
April 1994
patients had surgery at the regional hospital and returned to the institution’s rehabilitation ward within 72 hours. Once a plateau of functional ability was reached, they were institutionalized according to that same level of functional ability. Personal data concerning the patients were gathered, the patients’ preoperative state of health was defined, and the characteristics of the direct complications following the operation were reviewed. The overall ability of each patient was determined by three levels: (1) Independent (I) (capable of functioning without assistance); (2) Enfeebled (E) (partially dependent on assistance); and (3) Nursed (N) (completely dependent on assistance) . The patients’ ambulatory ability was determined by four levels: (1) Unassisted (U); (2) Tripod-supported (T); (3) Person-supported (P); (4) Wheelchair-bound (W). RESULTS Women comprised 95% of the study population; 88% of the women were widows, hence the term “widow’s disease” that is often associated with this disorder. The average age of the 54 patients was 8 1.2 years; the age range was 67 to 96 years, with 3.7% of the patients between 60 and 69 years of age, 33.3% between 70 and 79 years, 53.7% between 80 and 89 years, and 9.3% between 90 and 99 years. The incidence of concommitant disease in the study population included central nervous system, 53.7%; cardiovascular system, 57.4%; respiratory system, 7.4%; and diabetes mellitus, 14.8%. Thirty-nine (72.2%) of the fractures were classified as extra-articular and the surgical procedure was internal fixation with an axial compression hip screw device (Richard screw). Fifteen fractures (27.8%) were classified as intraarticular and the surgical procedure was a hemiarthroplasty (Austin-Moore prosthesis). Postoperative complications are shown in table 1. Changes in the patients’ overall ability are shown in figure 1. Twenty-six (96.3%) of the 27 independent patients deteriorated in their overall functional level; 18 (66.6%) became
RECOVERY Table 1: The Incidence
of Postoperative
Complication Urinary tract infection Deep vein thrombosis Respiratory distress Pressure sore Congestive heart failure Sphincter incontinence Reactive depression Operative wound infection Operative wound hematoma Failure of fixation
AFTER
FEMORAL
Complications
n
Percent
17 10 10
31.5 18.5 18.5 16.7 14.8 14.8 14.8 13.0 3.7 3.7
9 8 8 8 7 2 2
enfeebled (IE); and 8 (29.6%) became nursed (IN). Fourteen (63.3%) of the 22 enfeebled patients deteriorated in their overall functional level (EN). Nine of the total 54 patients (16.7%) did not deteriorate in their overall functional level (II, EEL Changes in the patients’ ambulatory ability are shown in figure 2. Of the 43 unassisted walkers, 41 (95.3%) deteriorated in their ambulation, 19 (44.2%) became tripod-supported (UT), 10 (23.3%) became person-supported (UP), and 12 (27.9%) became wheelchair-bound (UW). Of the 9 tripodsupported patients, 4 (44.4%) deteriorated in their ambulation, 1 (11.1%) became person-supported (TP), and 3 (33.3%) became wheelchair-bound (TW). One patient who had been person-supported became wheelchair-bound (PW).
DETERIORATION
II
IE 18
IN 8
EI
EE 8
EN 14
NI
NE
NN 5
1
NECK FRACTURE,
Folman
DETERIORATION UU
UT
UP
UW
TU
TT 5
TP
TW 3
PU
PT
PP
PW 1
Wu
WT
WP
W-W 1
2
19
12
1
Fig 2-The outcome in ambulatory ability. U, unassisted walker; T, tripod-supported; P, person-supported; W, wheelchair-bound. Letters in each square represent the preoperative and postoperative status of the patients. (Example: UT = a subject who walked unassisted prior to operation but who became tripod-supported afterwards).
Seven patients of the total 54 (12.9%) returned to their preoperative level of ambulation (II, TT). The level of ambulation according to age group (table 2) gives an overall picture of the inverse ratio between functional recovery and progressive age factor. DISCUSSION This elderly population is characterized by gradual deterioration of most of the body systems. About half of the patients examined suffered from chronic brain disturbance. chronic heart disease, or a combination of both. The femoral neck fracture constitutes an acute risk factor in addition to the other general chronic disturbances. The 54 patients in this review suffered femoral neck fractures while residing in a geriatric institution where patients are under continual supervision concerning their health and
According
to Age Group
Group U&T
IMPROVEMENT
Fig l-The outcome in overall ability. I, independent; E, enfeebled; N, nursed. Letters in each square represent the preoperative and postoperative status of patients (Example: IN = a subject who had been independent prior to operation hut who became nursed afterwards.)
10
IMPROVEMENT
Table 2: Ambulation
4
455
Group P&W
Age (yr)
No.
%
No.
%
60-69 70-79 80-89 90-99
0 9 19 2
0.0 50.0 65.5 40.0
, ; 10 3
lOO.(I 50.0 34.5 60.(1
Arch Phys Med Rehabil Vol75,
April 1994
456
RECOVERY
AFTER
FEMORAL
functional ability. Their referral for operative intervention was supported by a positive estimate concerning their ability to withstand the operation and a good prognosis for functional rehabilitation. However, the postoperative functional ability was disappointing. One year after the operation, only 16.7% (9/54) of the injured patients returned to their preoperative functional level. Changes in ambulatory ability pointed to a similar tendency. After 1 year, only 12.9% (7/54) of the patients regained their preoperative ambulatory ability. One half (26/ 52) of the patients lost their ambulatory status. Percentages of similar deterioration have been reported in other centers.5-7 What is the reason for the high percentage of deterioration? The 54 examinees lived in a fulltime institution where the medical and nursing support ensured maximum uniformity of the environmental factor. The level of physiotherapeutic practice was also uniform, given that strenuous exercising does not necessarily contribute to faster rehabilitation. It appears that the personal data in each case dictated the level of rehabilitational success. It is logical to presume that old age had a negative effect. The comparison of ambulatory ability in relation to age gave an unexpected result. There were more successful cases among the SO-year-old patients than among the 70-year-old group, while the 90year-old patients dealt with the problem better than did the 60-year-old group. The explanation apparently lies in the superior inherent systemic health of the patients who had lived longer. Support for this assumption lies in the reported inverse ratio between the mortality percentages following femoral neck fracture and the ages of the patients.’ Medical records of the rehabilitation failures show that 75% of the patients had neurological diseases or heart diseases that limited respectively their motivation and ability to rehabilitate. Such medical conditions would eventually have resulted in their being placed in an institution in the first place. The separation of these elderly patients from a familiar, permanent framework, the effect of the anaesthetic, the
Arch Phys bled Rehabil Vol75,
April 1994
NECK FRACTURE,
Folman
drugs, and the pain following the operation are more than enough to undermine their already shaky mental and physical conditions. Postoperative functional regression was almost a rule. The risk-benefit balance was negative in the full-time institution population. An alternative approach to surgical treatment consists of a limited period of bed rest followed by gradual progression towards walker-assisted mobility through wheelchair confinement. Supporters of this approach say that union of femoral neck fracture is the rule rather than the exception and that the majority of the patients would, with time, become pain free without operational intervention.“-” The continuation of treatment in an environment familiar to the patient, by an existing team and for a reasonable fee were offered as advantages per se. Our study indicates that debilitated elderly patients who have surgical intervention for treatment of femoral neck fractures rarely recover function; consequently, in such cases a conservative approach to treatment should be considered. References 1. Speed K. The unsolved fracture. Surg Gynecol Obstet 1935;60:371. 2. De Palma AF. Fracture of the upper end of the femur. In: De Palma AF, editor. The management of fractures and dislocations, Philadelphia: Saunders, 1970:1236-1325. 3. Ecker ML, Joyce JJ, Kohl EJ. The treatment of trochanteric hip fractures using a compression screw. J Bone Joint Surg (Am) 1975;57A:23-7. 4. Gordon PC. The probability of death following a fracture of the hip. Can Med Assoc J 1971;105:47-62. 5. Miller CW. Survival and ambulation following hip fracture. J Bone Joint Surg (Am) 1978;60A:930-933. 6. Moller BN, Lucht V, Grymer F, Bartholdy NJ. Early rehabilitation following osteosynthesis with sliding hip screw for trochanteric fractures. Stand .I Rehabil Med 1985;17:39-43. 7. Nieman KMW. Mankin HJ. Fractures about the hip in an institutionalized patient population. J Bone Joint Surg (Am) 1968;50A: 1327-40. 8. Jette AM, Harris BA, Clear-y PD, Campion EW. Functional recovery following hip fracture. Arch Phys Med Rehabil 1987;68:735-40. 9. White BL, Fisher WD, Larvin CA. Rate of mortality for elderly patients after fracture of the hip in the 1980’s. J Bone Joint Surg (Am) 1978;69A:1335-40. 10. Frew JFM. Conservative treatment of intertrochan-teric fractures, J Bone Joint Surg (Br) 1972;54B:748-9. 11. Lyon LJ, Nevins MA. Management of hip fracture in nursing home patients: to treat or not to treat. J Am Geriatr Sot 1984;32:391-5.