- Email: [email protected]
(i) Pre- and postoperative medical care and assessment
Current Orthopaedics (2000) 14, 80–85 © 2000 Harcourt Publishers Ltd doi:10.1054/cuor.2000.0092, available online at http://www.idealibrary.com on
Mini-symposium: The difficult neck of femur fracture
(i) Pre- and postoperative medical care and assessment
M. Parker
INTRODUCTION
FLUID BALANCE
Provision of effective care for the hip fracture patient requires the clinician to consider much more than the presenting fracture. A hip fracture following a simple fall may indicate that the patient’s frail and reaching the end of his or her life. The following factors complicate their management:
Case history A lady of 93 years with long standing senile dementia was admitted from a nursing home following a fall. X-rays showed a comminuted trochanteric fracture of the hip (Fig. 1). Blood investigations showed a haemoglobin of 113 g/l and normal electrolytes. The patient was scheduled for internal fixation the next day with a sliding hip screw, but due to the large number of trauma cases that day the operation was delayed a further day. During this period the patient refused to eat or drink and an intravenous infusion was maintained. Urine output was recorded only as ‘wet bed’. At surgery the next day and post-operatively the patient was hypotensive and the urine output was poor despite the infusion of large volumes of crystalloid and colloid. Results of investigations the
1. Decreased physiological reserve and response to trauma. 2. Coexistent medical conditions which may be acutely exacerbated (e.g. Parkinson’s disease, congestive cardiac failure, chronic obstructive airways disease). 3. Pain may be difficult to control and adverse effects of analgesics are more common. 4. Immobility leads to risk of pressure sores, urinary tract and chest infections, constipation and thrombo-embolic complications. 5. Hypoxaemia may be exacerbated by both analgesics and anaesthesia. 6. An acute confusional state easily occurs in this age group. 7. Urinary retention and incontinence may impede accurate assessment of fluid balance. 8. Psychological consequences; many elderly see a hip fracture as leading to either death or permanent disability. The early implementation of a clear treatment plan with goals for discharge is essential to restore both the patient’s and family’s morale.
Fig. 1 A comminuted trochanteric fracture in an elderly patient. This injury will result in considerably more physiological disturbance and risk of death than a femoral shaft fracture in a young motorcyclist.
Martyn Parker MD, FRCS, Orthopaedic Research Fellow, Orthopaedic Department, Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA, UK. Tel: +44 (0)1733 874000. Email: [email protected]
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Pre- and postoperative medical care and assessment day after surgery were haemoglobin 60 g/l, sodium 131 mmol/l, potassium 6.1 mmol/l and urea 19.3 mmol/l. The aforementioned case history is typical of one of the patient reports reviewed in the Confidential Enquiry into Peri-operative Deaths (CEPOD) in those over 90 years of age. Fluid balance is often poorly documented and even when recorded, effective action is not taken. The patient in this case history was probably fluid depleted on admission. Hypovolaemia was exacerbated by inadequate fluid intake pre-operatively and blood loss from the fracture site. The large fall in haemoglobin is a consequence of excessive fluid administration at surgery in conjunction with blood loss at surgery and from the fracture site. Such large changes in haemoglobin are not well tolerated by patients of this age group. The elderly demented patient is considered of low priority and the physiological consequences of this common injury are poorly appreciated. The blood loss from a hip fracture may vary from virtually nil with an undisplaced intracapsular fracture, to in excess of a litre with trochanteric fractures. A blood loss of 1 litre represents a loss of 20% of the blood volume. Fluid intake orally is often minimal and can be exaggerated by nausea and vomiting from opiate analgesia. Medications such as antihypertensives may impair the normal physiological response to trauma, which is already impaired in the elderly population. These factors taken together should lead the clinician to treat a hip fracture as a major injury. The resuscitation and preparation of the hip fracture patient for surgery is difficult. Intra-venous fluids must be started on arrival in hospital, but the fluid regimen must take into account the degree of dehydration, expected blood loss from the fracture and oral intake. For those patients in whom fluid balance is likely to be problematic, strict fluid regulation is essential and urinary catheterisation indicated. Further adjustments need to be made based on the biochemical results. The physician must recognize a fine balance between fluid overload and hypovolaemia. It has been suggested that a more aggressive medical management prior to and during surgery with optimisation of fluid balance will improve outcomes.1,2
THROMBOEMBOLIC PROPHYLAXIS Over the years clinicians have spent a considerable amount of time and energy debating the role of thrombo-embolic prophylaxis. Despite this no clear consensus exists. Opinion is still divided as to whether any prophylaxis at all is required and if prophylaxis is needed, what method to use. A number of questions need to be considered: – what is the current prevalence of thromboembolic complications?
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– how effective are the different methods of prophylaxis? – what are the adverse effects of the different methods? Prevalence This is dependent on what is defined as a thrombotic complication. It is to be expected that some degree of venous thrombosis occurs in all patients after a hip fracture. Sevitt and Gallagher in an autopsy study documented a prevalence of deep venous thrombosis of 83%.3 Using venography or isotope scanning for all patients gives a prevalence of 19–91% for deep vein thrombosis and 10–14% for pulmonary embolism.4,5 The rates as diagnosed in normal clinical practice have been summarized as about 3% for deep vein thrombosis and about 1% for pulmonary embolism.5 As clinical practice changes with earlier surgery and mobilisation, the current rates may be lower than in earlier published reports. Meta-analysis of randomized trials for the different methods of prophylaxis gives the following figures for reduction in the rate of ‘venographic’ deep vein thrombosis: Heparin 39%–24%4 Warfarin 56%–26%5 Aspirin 54%–43%5 Dextran 63%–30%5 Physical methods 19%–6%4 It is important to ask if this reduction in venographic thrombi translate into clinical benefits and do the benefits of prophylaxis outweigh any possible adverse effects incurred? The Cochrane meta-analysis for randomized trials of low dose heparin after hip fracture, reported a non-significant increase in mortality from 8% with no prophylaxis, to 11% for those patients allocated to receive heparin.4 For mechanical devices the trend in mortality was reversed, although the differences were again not statistically significant. The multi-centre PEP trial of aspirin versus placebo after a hip fracture indicated a reduction in thrombotic complications with aspirin but at the expense of increased haemorrhagic complications. Overall there was no significant difference in mortality. The conclusion must be that both pharmacological and mechanical methods can be demonstrated to reduce the incidence of venous thrombosis, but to date it is not possible to demonstrate that this leads to any noteworthy clinical benefit. ANTIBIOTIC PROPHYLAXIS A summation of all randomized trials of peri-operative antibiotic prophylaxis for fracture surgery has been undertaken.6 This indicated that one to three
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doses of an appropriate broad spectrum antibiotic, with the first dose given at the start of the operation, will reduce the incidence of wound, respiratory and urinary infections. More prolonged courses or prophylactic antibiotics are of unproven value. TIMING OF SURGERY The optimum delay from admission to surgery is controversial. It can be argued that a period of time is required to allow for resuscitation and stabilization prior to surgery. This would be more relevant for an extracapsular fracture, with its associated haemodynamic disturbances. Others state that the longer the delay the greater the risk of the problems of recumbency occurring in the elderly, as outlined above. There have been no adequate randomized trials on this subject. The small study of Schultz and colleagues showed an improved outcome for those patients in which surgery was delayed to allow physiological stabilization (on the intensive care unit!).1 Clinical studies using case series of patients have produced conflicting conclusions.5 Until further, carefully conducted studies are undertaken it is reasonable to conclude that surgery should be performed as soon as possible after admission providing adequate resuscitation with intravenous fluids has been undertaken. This is particularly relevant for extracapsular fractures where it must be ascertained that the patient is not dehydrated, the blood pressure is stable and a reasonable urine output has been established. Indications for delaying surgery – – – – – – – – – –
Anaemia (haemoglobin less than about 90–100 g/l) Severe electrolyte imbalance or uraemia Hypovolaemia Congestive cardiac failure Severe hypertension Rapid atrial fibrillation, or other correctable cardiac arrhythmia Acute chest infection Acute exacerbation of chronic chest condition Unstable diabetes mellitus Anticoagulation therapy
The other factor to consider in the timing of surgery relates specifically to internal fixation of an intracapsular fracture. It has been suggested that aspirating the hip of any haemarthrosis will reduce the risk of avascular necrosis of the femoral head. It is thought that the high intracapsular pressure created by a haematoma confined within the joint capsule will impede blood flow to the femoral head by a tamponade effect. This effect may be more marked in an undisplaced intracapsular fracture as the joint capsule is less likely to be torn. To date aspiration of the hip
joint has not been shown to improve clinical outcomes. Furthermore, it has been suggested that early reduction of the fracture is necessary to restore blood flow to the femoral head. The clinical evidence from a number of papers on this topic remains controversial and the role of early surgery remains possibly beneficial but unproven.5 Summary regarding the timing of surgery— – There can be little justification for ‘out of hours’ surgery in this high-risk group of patients. – In about 10% of patients surgery will need to be delayed to improve their medical state. – In those patients where their medical condition cannot be improved, surgery should not be delayed beyond 24 h of admission. – Delaying surgery beyond 48 h from admission will increase the incidence of pneumonia, pressure sores and thrombosis.5
POSTOPERATIVE OXYGEN THERAPY It has been documented that hip fracture patients frequently have episodes of hypoxaemia postoperatively. This hypoxaemia is more common after general anaesthesia in comparison to regional anaesthesia and can be corrected by supplementary oxygen. Unfortunately all the clinical studies to date have been too small to demonstrate that this oxygen supplementation can be translated into clinical benefits. However, because of the potential adverse effects of hypoxia, current practice should include routine oxygen supplementation for the first 12 h and for the first three nights postoperatively.
WEIGHT-BEARING AND MOBILIZATION The time from surgery till mobilization has been reduced over the years and restricted weight-bearing has to a large extent ceased. There is no evidence to support any such practices which will prolong hospital stay and may increase mortality and morbidity. Mobilization For an elderly hip fracture patient it is important to sit the patient out of bed the day following surgery if at all possible. The elderly recumbent patient is unable to eat or drink and becomes ever more dependent. Therefore the postoperative notes for all types of hip fracture surgery must include instructions to begin mobilization without restriction the day after surgery. Any delay in mobilization whilst waiting a check Xray is unnecessary as the surgeon should be confident that the surgery has been correctly performed.
Pre- and postoperative medical care and assessment Weight-bearing Mechanical studies indicate that if a patient is mobilized with strict non-weight bearing, the power of the muscles acting across the hip to keep the limb off the ground will place forces across the hip joint that exceed those that occur with normal weight-bearing. Therefore instructing the patient to mobilize nonweight-bearing with a view to protecting the fixation may actually be increasing the risk of fixation failure. Reduction of the forces across the hip joint may be achieved by partial weight-bearing. In clinical practice, hip fracture patients will all initially mobilize partial weight-bearing because of pain at the fracture site. As the fracture consolidates the pain decreases and the patient will bear more weight on the injured limb. Therefore it is recommended that all patients be allowed to mobilize to tolerance allowing as much weight-bearing as able. It should be expected that an extracapsular fracture will cause more pain on mobilizing in the postoperative period and it may take longer for the patient to regain their mobility. Patients with an intracapsular fracture tend to have less pain postoperatively and mobilize more quickly.
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For those admitted from their own home, discharge is arranged back home with additional community support.7,8 The community support consists of nursing care, home aids and community physiotherapy. The aim is to discharge patients at about 5–10 days after surgery. Once back at home the level of community support is progressively reduced, as the patient becomes more active and independent. 3. Transfer to a rehabilitation ward The concept of a geriatric orthopaedic ward for the rehabilitation of the elderly patient after an orthopaedic injury was popularized in the 1960s.9 Such units have been termed ortho-geriatric wards or GORUs (geriatric orthopaedic rehabilitation units), with joint management of patients by orthopaedic surgeons and geriatricians. The aim is to transfer the patients to a unit more appropriate for their needs as soon as practicable after surgery. Subsequent assessment of the value of such units within randomized trials has been unable to clearly demonstrate their effectiveness.10 4. Transfer to a geriatric ward
REHABILITATION Following surgery there are a number of different management options as listed below. The orthopaedic surgeon needs a clear idea of the difference between these treatment regimens: 1. Discharge back home from the orthopaedic ward 2. Discharge back home from the orthopaedic ward with additional community support 3. Transfer to a rehabilitation ward (ortho/geriatric unit) 4. Transfer to a geriatric ward 5. Transfer to a skilled nursing facility in the community 6. Admission to and discharge from a hip fracture unit 1. Discharge back home from the orthopaedic ward This is the traditional method of management for this condition. The management of the patient on the ward may be augmented by orthopaedic liaison schemes. There is an increasing number of hip fracture patients being treated and increasing pressures on acute orthopaedic beds and because this process is slow in the UK there has been a tendency for one of the other options listed below to be adopted. 2. Discharge back home from the orthopaedic ward with additional community support Those patients admitted from institutional care, are discharged directly back there as soon as practicable.
Debate continues as to whether this is the most effective form of management as it may result in an increased hospital stay.11,12 5. Transfer to a skilled nursing facility in the community This treatment method is used extensively in the US where the financial funding of the health care system has led to hip fracture patients being discharged a few days after surgery to nursing homes or ‘skilled nursing facilities’. Published reports of the effectiveness of such units are sparse and the limited information that is available casts serious doubt on its effectiveness. In a report from America 48% of hip fracture patients were discharged to a nursing home and 81% of these patients were still in the nursing home 6 months later.13 6. Admission to and discharge from a hip fracture unit The concept of a unit dedicated to the treatment of hip fractures is relatively new. The patient is admitted directly to the unit, possibly under the care of a physician in rehabilitation medicine or joint care with the orthopaedic surgeon. All inpatient rehabilitation then occurs there. Given the increasing numbers of hip fractures and the concentration of their treatment in selected hospitals there are now sufficient numbers of patients to justify such an approach. The value of such units has been well documented for stroke, a condition with a similar incidence and associated morbidity and mortality. Published reports of hip fracture
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units are few but one report of such a unit in Sweden indicated a reduction of mean hospital and nursing home bed stay from 79 to 60 days.12
TOTAL PATIENT CARE Generally in orthopaedic surgery, the prevailing management for a hip fracture patient is to decide on a surgical treatment plan based on the X-rays. Other aspects of the patient’s care are left to either the junior orthopaedic staff or by referral to the care of the elderly department. This may not be the most effective care for this complex and heterogeneous group of patients. The average hip fracture patient is a frail elderly female with other medical conditions, which may be exacerbated by the hip fracture. In addition the social situation may be precarious with need for appropriate assessment and assistance. Medical complications that may be encountered are:5 – Cardiovascular: myocardial infarction (2%), congestive cardiac failure, cardiac arrhythmias, deep vein thrombosis (3%), pulmonary embolism (1%) – Respiratory: infection (9%) – Alimentary: constipation, gastrointestinal bleed (1%) – Urinary: infection (13%), retention, incontinence – Skin: pressure sores (12%) – Neurological: cerebrovascular accident (2%) Few orthopaedic surgeons are willing to undertake this total patient care. For the future, consideration should be given as to whether it would be better admitting these patients directly under the care of a physician, and the orthopaedic surgeons confining themselves to the technical aspect of the surgical treatment of the fracture. Some surgeons transfer the care of the patient to the geriatric department after surgery, but this inevitably results in delays and a lost opportunity to provide effective management from the time of the patients admission. Furthermore average hospital stays for hip fracture patients have been progressively reducing over the years, such that some units discharge over half the patients by two weeks. This means that planning for rehabilitation and discharge needs to be started at the time of the patient admission rather than a few days after surgery.
PREVENTION OF FURTHER FRACTURES Fracture prevention is an area that is becoming of increasing importance to the orthopaedic surgeon. Having sustained a hip fracture the patient has a 10% risk of fracturing the other hip. fractures occurring at other sites.5 Controversy exists as how this risk can be
reduced and this is an area of considerable research interest. The aetiology of a hip fracture is multi-factorial, related to an increased tendency to fall, loss of protective reflexes and weakened bone. The following assessments and investigations are recommended: a) Aetiological factors that may merit further investigation or referral: – Dizzy spells or blackouts as opposed to simple fall/trip – Visual impairment – Parkinson’s disease – Chronic renal or liver disease – Previous gastrectomy or malabsorption – Diabetes mellitus – Thyroid disease – Alcohol – Smoking – Drugs causing falls (steroids, antihypertensives, anti-epileptics, sedatives and tranquillisers) b) Investigations indicated for all hip fracture patients: – lying and standing blood pressure – body mass index – full blood count – renal function – electrocardiogram – thyroid function (possible only if clinical signs) In a patient under 60 years of age who sustains a hip fracture with minimal trauma, then the calcium, liver function and testosterone level (males) are indicated. The place of bone densitometry remains controversial. A minimal trauma fracture in an elderly person can be considered as established osteoporosis and ample evidence of reduced bone strength. It can be argued that it is only necessary to measure bone density in younger patients and those in whom the effects of treatment need to be monitored. Having investigated and treated possible aetiological factors then the optimal therapy remains controversial. The following treatment options are available: a) Calcium and vitamin D In the elderly, vitamin D insufficiency results in secondary hyperparathyroidism and osteoporosis. Calcium treatment alone may increase the bone density but probably both calcium and vitamin D are required to reduce the fracture risk. Calcium and Vitamin D tablets are associated with less cost and side effects than other pharmacological methods. Some controversy, however, does exists as to whether both calcium and Vitamin D are needed and how effective the treatment is. Further ongoing placebo trials should help to establish the correct place for this therapy. Evidence to date suggests that it is most likely to be appropriate in those with poor dietary intake and low exposure to sunlight.
Pre- and postoperative medical care and assessment b) Bisphosphonates These drugs preserve bone stock. Questions still remain as to which patients benefit and how long treatment should be continued. Treatment should ideally be monitored with bone densitometry.
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Clinical guidelines for the treatment of hip fractures enable the clinician to provide best practice treatment based on the evidence available from the scientific literature. The Scottish Intercollegiate Guidelines Network (1997) has recently produced updated guidelines for hip fracture treatment.16
c) Hormone replacement therapy This option is possibly only for those patients within 10 years of the menopause, although there is a tendency to use this now in later life. Long-term compliance with hormone replacement therapy is a problem and the newer selective oestrogen receptor modulators such as raloxifene may be appropriate for those who do not want to have a cyclical uterine bleed. Unfortunately the beneficial effects of hormone replacement therapy are possibly lost once treatment is stopped. d) Hip protectors These consist of foam pads, which are placed in pockets in the patient’s undergarments. They absorb the impact of the fall onto the hip and have proved to be highly effective in reducing the occurrence of hip fractures for those wearing them.14 Compliance with the protectors is a problem with only about a third of users wearing them regularly. They are most appropriate for the confused institutional home resident who falls frequently. Other lifestyle changes that should be advised are regular weight-bearing exercise, a diet high in calcium and vitamin D, assessment of the home for hazards and avoidance of smoking and excessive alcohol. This information may be best given in a booklet such as that produced by the National Osteoporosis Society for advice following a hip fracture (Coping with a hip fracture, National Osteoporosis Society, Radstock, Bath 1999). AUDIT AND GUIDELINES In view of the high prevalence of hip fractures it is possible to accumulate enough information regarding the outcome of treatment to be able to compare the\ results between different centres and against national averages. A standard European data set for audit has been devised to assist in these comparisons.15 Routine data collection for hip fracture treatment now occurs in a number of centres throughout Europe.
REFERENCES 1. Schultz RJ, Whitfield GF, LaMura JJ, Raciti A, Krishnamurthy S. The role of physiologic monitoring in patients with fractures of the hip. J Trauma 1985; 25: 309–317. 2. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture; randomised control trial. Br Med J 1997;315:909–912. 3. Sevitt S, Gallagher N. Venous thrombosis and pulmonary embolism: a clinico-pathological study in injured and burned patients. Br J Surg 1961;48:475–489. 4. Handoll HHG, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Awai KA, Milne AA, Gillespie WJ. Prophylaxis using heparin, low molecular weight heparin and physical methods against deep vein thrombosis and pulmonary embolism in hip fracture surgery. Cochrane Database of Systematic Reviews. Oxford: Update Software 1997. 5. Parker MJ, Pryor GA. Hip Fracture Management. Oxford: Blackwell Scientific Publications, 1993. 6. Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures (Cochrane Review). In: The Cochrane Library, Issue 1. Oxford: Update Software, 1999. 7. Pryor GA, Williams DRR. Rehabilitation after hip fractures, Home and hospital management compared. J Bone Joint Surg 1989; 71–4:471–474. 8. Sikorski JM, Davis NJ, Senior J. The rapid transit system for patients with fractures of proximal femur. Br Med J 1985;290:439–443. 9. Devas MB. Geriatric orthopaedics. Br Med J 1974; 1:190–192. 10. Cameron I, Finnegan T, Madhok R, Langhorne P, Handoll H. Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures (Cochrane Review). In: The Cochrane Library, Issue 2. Oxford: Update Software, 1999. 11. Parker MJ, Todd CJ, Palmer CR, Camilleri-Ferrante C, Freeman CJ, Laxton CE, Payne BV, Rushton N. Inter-hospital variations in length of hospital stay following hip fracture. Age and Ageing 1998;27:333–337. 12. Strömberg L, Öhlén G, Svensson O. Prospective payment systems and hip fracture treatment costs. Acta Orthop Scand 1997;68:6–11. 13. Fitzgerald JF, Moore PS, Dittus RS. The care of elderly patients with hip fracture: changes since implementation of the prospective payment system. N Engl J Med 1988; 319: 1392–1397. 14. Parker MJ, Gillespie LD, Gillespie WJ. Hip protectors for preventing hip fractures in the elderly (Cochrane Review). In: The Cochrane Library, Issue 3. Oxford: Update Software, 1999. 15. Parker MJ, Currie CT, Mountain JA, Thorngren K-G. Standardised Audit of Hip Fracture in Europe (SAHFE). Hip International 1998; 8: 10–15. 16. Scottish Intercollegiate Guidelines Network (SIGN). Management of elderly people with fractured hip. No.15;1997.
Mini-symposium: The difficult neck of femur fracture
(i) Pre- and postoperative medical care and assessment
M. Parker
INTRODUCTION
FLUID BALANCE
Provision of effective care for the hip fracture patient requires the clinician to consider much more than the presenting fracture. A hip fracture following a simple fall may indicate that the patient’s frail and reaching the end of his or her life. The following factors complicate their management:
Case history A lady of 93 years with long standing senile dementia was admitted from a nursing home following a fall. X-rays showed a comminuted trochanteric fracture of the hip (Fig. 1). Blood investigations showed a haemoglobin of 113 g/l and normal electrolytes. The patient was scheduled for internal fixation the next day with a sliding hip screw, but due to the large number of trauma cases that day the operation was delayed a further day. During this period the patient refused to eat or drink and an intravenous infusion was maintained. Urine output was recorded only as ‘wet bed’. At surgery the next day and post-operatively the patient was hypotensive and the urine output was poor despite the infusion of large volumes of crystalloid and colloid. Results of investigations the
1. Decreased physiological reserve and response to trauma. 2. Coexistent medical conditions which may be acutely exacerbated (e.g. Parkinson’s disease, congestive cardiac failure, chronic obstructive airways disease). 3. Pain may be difficult to control and adverse effects of analgesics are more common. 4. Immobility leads to risk of pressure sores, urinary tract and chest infections, constipation and thrombo-embolic complications. 5. Hypoxaemia may be exacerbated by both analgesics and anaesthesia. 6. An acute confusional state easily occurs in this age group. 7. Urinary retention and incontinence may impede accurate assessment of fluid balance. 8. Psychological consequences; many elderly see a hip fracture as leading to either death or permanent disability. The early implementation of a clear treatment plan with goals for discharge is essential to restore both the patient’s and family’s morale.
Fig. 1 A comminuted trochanteric fracture in an elderly patient. This injury will result in considerably more physiological disturbance and risk of death than a femoral shaft fracture in a young motorcyclist.
Martyn Parker MD, FRCS, Orthopaedic Research Fellow, Orthopaedic Department, Peterborough District Hospital, Thorpe Road, Peterborough PE3 6DA, UK. Tel: +44 (0)1733 874000. Email: [email protected]
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Pre- and postoperative medical care and assessment day after surgery were haemoglobin 60 g/l, sodium 131 mmol/l, potassium 6.1 mmol/l and urea 19.3 mmol/l. The aforementioned case history is typical of one of the patient reports reviewed in the Confidential Enquiry into Peri-operative Deaths (CEPOD) in those over 90 years of age. Fluid balance is often poorly documented and even when recorded, effective action is not taken. The patient in this case history was probably fluid depleted on admission. Hypovolaemia was exacerbated by inadequate fluid intake pre-operatively and blood loss from the fracture site. The large fall in haemoglobin is a consequence of excessive fluid administration at surgery in conjunction with blood loss at surgery and from the fracture site. Such large changes in haemoglobin are not well tolerated by patients of this age group. The elderly demented patient is considered of low priority and the physiological consequences of this common injury are poorly appreciated. The blood loss from a hip fracture may vary from virtually nil with an undisplaced intracapsular fracture, to in excess of a litre with trochanteric fractures. A blood loss of 1 litre represents a loss of 20% of the blood volume. Fluid intake orally is often minimal and can be exaggerated by nausea and vomiting from opiate analgesia. Medications such as antihypertensives may impair the normal physiological response to trauma, which is already impaired in the elderly population. These factors taken together should lead the clinician to treat a hip fracture as a major injury. The resuscitation and preparation of the hip fracture patient for surgery is difficult. Intra-venous fluids must be started on arrival in hospital, but the fluid regimen must take into account the degree of dehydration, expected blood loss from the fracture and oral intake. For those patients in whom fluid balance is likely to be problematic, strict fluid regulation is essential and urinary catheterisation indicated. Further adjustments need to be made based on the biochemical results. The physician must recognize a fine balance between fluid overload and hypovolaemia. It has been suggested that a more aggressive medical management prior to and during surgery with optimisation of fluid balance will improve outcomes.1,2
THROMBOEMBOLIC PROPHYLAXIS Over the years clinicians have spent a considerable amount of time and energy debating the role of thrombo-embolic prophylaxis. Despite this no clear consensus exists. Opinion is still divided as to whether any prophylaxis at all is required and if prophylaxis is needed, what method to use. A number of questions need to be considered: – what is the current prevalence of thromboembolic complications?
81
– how effective are the different methods of prophylaxis? – what are the adverse effects of the different methods? Prevalence This is dependent on what is defined as a thrombotic complication. It is to be expected that some degree of venous thrombosis occurs in all patients after a hip fracture. Sevitt and Gallagher in an autopsy study documented a prevalence of deep venous thrombosis of 83%.3 Using venography or isotope scanning for all patients gives a prevalence of 19–91% for deep vein thrombosis and 10–14% for pulmonary embolism.4,5 The rates as diagnosed in normal clinical practice have been summarized as about 3% for deep vein thrombosis and about 1% for pulmonary embolism.5 As clinical practice changes with earlier surgery and mobilisation, the current rates may be lower than in earlier published reports. Meta-analysis of randomized trials for the different methods of prophylaxis gives the following figures for reduction in the rate of ‘venographic’ deep vein thrombosis: Heparin 39%–24%4 Warfarin 56%–26%5 Aspirin 54%–43%5 Dextran 63%–30%5 Physical methods 19%–6%4 It is important to ask if this reduction in venographic thrombi translate into clinical benefits and do the benefits of prophylaxis outweigh any possible adverse effects incurred? The Cochrane meta-analysis for randomized trials of low dose heparin after hip fracture, reported a non-significant increase in mortality from 8% with no prophylaxis, to 11% for those patients allocated to receive heparin.4 For mechanical devices the trend in mortality was reversed, although the differences were again not statistically significant. The multi-centre PEP trial of aspirin versus placebo after a hip fracture indicated a reduction in thrombotic complications with aspirin but at the expense of increased haemorrhagic complications. Overall there was no significant difference in mortality. The conclusion must be that both pharmacological and mechanical methods can be demonstrated to reduce the incidence of venous thrombosis, but to date it is not possible to demonstrate that this leads to any noteworthy clinical benefit. ANTIBIOTIC PROPHYLAXIS A summation of all randomized trials of peri-operative antibiotic prophylaxis for fracture surgery has been undertaken.6 This indicated that one to three
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doses of an appropriate broad spectrum antibiotic, with the first dose given at the start of the operation, will reduce the incidence of wound, respiratory and urinary infections. More prolonged courses or prophylactic antibiotics are of unproven value. TIMING OF SURGERY The optimum delay from admission to surgery is controversial. It can be argued that a period of time is required to allow for resuscitation and stabilization prior to surgery. This would be more relevant for an extracapsular fracture, with its associated haemodynamic disturbances. Others state that the longer the delay the greater the risk of the problems of recumbency occurring in the elderly, as outlined above. There have been no adequate randomized trials on this subject. The small study of Schultz and colleagues showed an improved outcome for those patients in which surgery was delayed to allow physiological stabilization (on the intensive care unit!).1 Clinical studies using case series of patients have produced conflicting conclusions.5 Until further, carefully conducted studies are undertaken it is reasonable to conclude that surgery should be performed as soon as possible after admission providing adequate resuscitation with intravenous fluids has been undertaken. This is particularly relevant for extracapsular fractures where it must be ascertained that the patient is not dehydrated, the blood pressure is stable and a reasonable urine output has been established. Indications for delaying surgery – – – – – – – – – –
Anaemia (haemoglobin less than about 90–100 g/l) Severe electrolyte imbalance or uraemia Hypovolaemia Congestive cardiac failure Severe hypertension Rapid atrial fibrillation, or other correctable cardiac arrhythmia Acute chest infection Acute exacerbation of chronic chest condition Unstable diabetes mellitus Anticoagulation therapy
The other factor to consider in the timing of surgery relates specifically to internal fixation of an intracapsular fracture. It has been suggested that aspirating the hip of any haemarthrosis will reduce the risk of avascular necrosis of the femoral head. It is thought that the high intracapsular pressure created by a haematoma confined within the joint capsule will impede blood flow to the femoral head by a tamponade effect. This effect may be more marked in an undisplaced intracapsular fracture as the joint capsule is less likely to be torn. To date aspiration of the hip
joint has not been shown to improve clinical outcomes. Furthermore, it has been suggested that early reduction of the fracture is necessary to restore blood flow to the femoral head. The clinical evidence from a number of papers on this topic remains controversial and the role of early surgery remains possibly beneficial but unproven.5 Summary regarding the timing of surgery— – There can be little justification for ‘out of hours’ surgery in this high-risk group of patients. – In about 10% of patients surgery will need to be delayed to improve their medical state. – In those patients where their medical condition cannot be improved, surgery should not be delayed beyond 24 h of admission. – Delaying surgery beyond 48 h from admission will increase the incidence of pneumonia, pressure sores and thrombosis.5
POSTOPERATIVE OXYGEN THERAPY It has been documented that hip fracture patients frequently have episodes of hypoxaemia postoperatively. This hypoxaemia is more common after general anaesthesia in comparison to regional anaesthesia and can be corrected by supplementary oxygen. Unfortunately all the clinical studies to date have been too small to demonstrate that this oxygen supplementation can be translated into clinical benefits. However, because of the potential adverse effects of hypoxia, current practice should include routine oxygen supplementation for the first 12 h and for the first three nights postoperatively.
WEIGHT-BEARING AND MOBILIZATION The time from surgery till mobilization has been reduced over the years and restricted weight-bearing has to a large extent ceased. There is no evidence to support any such practices which will prolong hospital stay and may increase mortality and morbidity. Mobilization For an elderly hip fracture patient it is important to sit the patient out of bed the day following surgery if at all possible. The elderly recumbent patient is unable to eat or drink and becomes ever more dependent. Therefore the postoperative notes for all types of hip fracture surgery must include instructions to begin mobilization without restriction the day after surgery. Any delay in mobilization whilst waiting a check Xray is unnecessary as the surgeon should be confident that the surgery has been correctly performed.
Pre- and postoperative medical care and assessment Weight-bearing Mechanical studies indicate that if a patient is mobilized with strict non-weight bearing, the power of the muscles acting across the hip to keep the limb off the ground will place forces across the hip joint that exceed those that occur with normal weight-bearing. Therefore instructing the patient to mobilize nonweight-bearing with a view to protecting the fixation may actually be increasing the risk of fixation failure. Reduction of the forces across the hip joint may be achieved by partial weight-bearing. In clinical practice, hip fracture patients will all initially mobilize partial weight-bearing because of pain at the fracture site. As the fracture consolidates the pain decreases and the patient will bear more weight on the injured limb. Therefore it is recommended that all patients be allowed to mobilize to tolerance allowing as much weight-bearing as able. It should be expected that an extracapsular fracture will cause more pain on mobilizing in the postoperative period and it may take longer for the patient to regain their mobility. Patients with an intracapsular fracture tend to have less pain postoperatively and mobilize more quickly.
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For those admitted from their own home, discharge is arranged back home with additional community support.7,8 The community support consists of nursing care, home aids and community physiotherapy. The aim is to discharge patients at about 5–10 days after surgery. Once back at home the level of community support is progressively reduced, as the patient becomes more active and independent. 3. Transfer to a rehabilitation ward The concept of a geriatric orthopaedic ward for the rehabilitation of the elderly patient after an orthopaedic injury was popularized in the 1960s.9 Such units have been termed ortho-geriatric wards or GORUs (geriatric orthopaedic rehabilitation units), with joint management of patients by orthopaedic surgeons and geriatricians. The aim is to transfer the patients to a unit more appropriate for their needs as soon as practicable after surgery. Subsequent assessment of the value of such units within randomized trials has been unable to clearly demonstrate their effectiveness.10 4. Transfer to a geriatric ward
REHABILITATION Following surgery there are a number of different management options as listed below. The orthopaedic surgeon needs a clear idea of the difference between these treatment regimens: 1. Discharge back home from the orthopaedic ward 2. Discharge back home from the orthopaedic ward with additional community support 3. Transfer to a rehabilitation ward (ortho/geriatric unit) 4. Transfer to a geriatric ward 5. Transfer to a skilled nursing facility in the community 6. Admission to and discharge from a hip fracture unit 1. Discharge back home from the orthopaedic ward This is the traditional method of management for this condition. The management of the patient on the ward may be augmented by orthopaedic liaison schemes. There is an increasing number of hip fracture patients being treated and increasing pressures on acute orthopaedic beds and because this process is slow in the UK there has been a tendency for one of the other options listed below to be adopted. 2. Discharge back home from the orthopaedic ward with additional community support Those patients admitted from institutional care, are discharged directly back there as soon as practicable.
Debate continues as to whether this is the most effective form of management as it may result in an increased hospital stay.11,12 5. Transfer to a skilled nursing facility in the community This treatment method is used extensively in the US where the financial funding of the health care system has led to hip fracture patients being discharged a few days after surgery to nursing homes or ‘skilled nursing facilities’. Published reports of the effectiveness of such units are sparse and the limited information that is available casts serious doubt on its effectiveness. In a report from America 48% of hip fracture patients were discharged to a nursing home and 81% of these patients were still in the nursing home 6 months later.13 6. Admission to and discharge from a hip fracture unit The concept of a unit dedicated to the treatment of hip fractures is relatively new. The patient is admitted directly to the unit, possibly under the care of a physician in rehabilitation medicine or joint care with the orthopaedic surgeon. All inpatient rehabilitation then occurs there. Given the increasing numbers of hip fractures and the concentration of their treatment in selected hospitals there are now sufficient numbers of patients to justify such an approach. The value of such units has been well documented for stroke, a condition with a similar incidence and associated morbidity and mortality. Published reports of hip fracture
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units are few but one report of such a unit in Sweden indicated a reduction of mean hospital and nursing home bed stay from 79 to 60 days.12
TOTAL PATIENT CARE Generally in orthopaedic surgery, the prevailing management for a hip fracture patient is to decide on a surgical treatment plan based on the X-rays. Other aspects of the patient’s care are left to either the junior orthopaedic staff or by referral to the care of the elderly department. This may not be the most effective care for this complex and heterogeneous group of patients. The average hip fracture patient is a frail elderly female with other medical conditions, which may be exacerbated by the hip fracture. In addition the social situation may be precarious with need for appropriate assessment and assistance. Medical complications that may be encountered are:5 – Cardiovascular: myocardial infarction (2%), congestive cardiac failure, cardiac arrhythmias, deep vein thrombosis (3%), pulmonary embolism (1%) – Respiratory: infection (9%) – Alimentary: constipation, gastrointestinal bleed (1%) – Urinary: infection (13%), retention, incontinence – Skin: pressure sores (12%) – Neurological: cerebrovascular accident (2%) Few orthopaedic surgeons are willing to undertake this total patient care. For the future, consideration should be given as to whether it would be better admitting these patients directly under the care of a physician, and the orthopaedic surgeons confining themselves to the technical aspect of the surgical treatment of the fracture. Some surgeons transfer the care of the patient to the geriatric department after surgery, but this inevitably results in delays and a lost opportunity to provide effective management from the time of the patients admission. Furthermore average hospital stays for hip fracture patients have been progressively reducing over the years, such that some units discharge over half the patients by two weeks. This means that planning for rehabilitation and discharge needs to be started at the time of the patient admission rather than a few days after surgery.
PREVENTION OF FURTHER FRACTURES Fracture prevention is an area that is becoming of increasing importance to the orthopaedic surgeon. Having sustained a hip fracture the patient has a 10% risk of fracturing the other hip. fractures occurring at other sites.5 Controversy exists as how this risk can be
reduced and this is an area of considerable research interest. The aetiology of a hip fracture is multi-factorial, related to an increased tendency to fall, loss of protective reflexes and weakened bone. The following assessments and investigations are recommended: a) Aetiological factors that may merit further investigation or referral: – Dizzy spells or blackouts as opposed to simple fall/trip – Visual impairment – Parkinson’s disease – Chronic renal or liver disease – Previous gastrectomy or malabsorption – Diabetes mellitus – Thyroid disease – Alcohol – Smoking – Drugs causing falls (steroids, antihypertensives, anti-epileptics, sedatives and tranquillisers) b) Investigations indicated for all hip fracture patients: – lying and standing blood pressure – body mass index – full blood count – renal function – electrocardiogram – thyroid function (possible only if clinical signs) In a patient under 60 years of age who sustains a hip fracture with minimal trauma, then the calcium, liver function and testosterone level (males) are indicated. The place of bone densitometry remains controversial. A minimal trauma fracture in an elderly person can be considered as established osteoporosis and ample evidence of reduced bone strength. It can be argued that it is only necessary to measure bone density in younger patients and those in whom the effects of treatment need to be monitored. Having investigated and treated possible aetiological factors then the optimal therapy remains controversial. The following treatment options are available: a) Calcium and vitamin D In the elderly, vitamin D insufficiency results in secondary hyperparathyroidism and osteoporosis. Calcium treatment alone may increase the bone density but probably both calcium and vitamin D are required to reduce the fracture risk. Calcium and Vitamin D tablets are associated with less cost and side effects than other pharmacological methods. Some controversy, however, does exists as to whether both calcium and Vitamin D are needed and how effective the treatment is. Further ongoing placebo trials should help to establish the correct place for this therapy. Evidence to date suggests that it is most likely to be appropriate in those with poor dietary intake and low exposure to sunlight.
Pre- and postoperative medical care and assessment b) Bisphosphonates These drugs preserve bone stock. Questions still remain as to which patients benefit and how long treatment should be continued. Treatment should ideally be monitored with bone densitometry.
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Clinical guidelines for the treatment of hip fractures enable the clinician to provide best practice treatment based on the evidence available from the scientific literature. The Scottish Intercollegiate Guidelines Network (1997) has recently produced updated guidelines for hip fracture treatment.16
c) Hormone replacement therapy This option is possibly only for those patients within 10 years of the menopause, although there is a tendency to use this now in later life. Long-term compliance with hormone replacement therapy is a problem and the newer selective oestrogen receptor modulators such as raloxifene may be appropriate for those who do not want to have a cyclical uterine bleed. Unfortunately the beneficial effects of hormone replacement therapy are possibly lost once treatment is stopped. d) Hip protectors These consist of foam pads, which are placed in pockets in the patient’s undergarments. They absorb the impact of the fall onto the hip and have proved to be highly effective in reducing the occurrence of hip fractures for those wearing them.14 Compliance with the protectors is a problem with only about a third of users wearing them regularly. They are most appropriate for the confused institutional home resident who falls frequently. Other lifestyle changes that should be advised are regular weight-bearing exercise, a diet high in calcium and vitamin D, assessment of the home for hazards and avoidance of smoking and excessive alcohol. This information may be best given in a booklet such as that produced by the National Osteoporosis Society for advice following a hip fracture (Coping with a hip fracture, National Osteoporosis Society, Radstock, Bath 1999). AUDIT AND GUIDELINES In view of the high prevalence of hip fractures it is possible to accumulate enough information regarding the outcome of treatment to be able to compare the\ results between different centres and against national averages. A standard European data set for audit has been devised to assist in these comparisons.15 Routine data collection for hip fracture treatment now occurs in a number of centres throughout Europe.
REFERENCES 1. Schultz RJ, Whitfield GF, LaMura JJ, Raciti A, Krishnamurthy S. The role of physiologic monitoring in patients with fractures of the hip. J Trauma 1985; 25: 309–317. 2. Sinclair S, James S, Singer M. Intraoperative intravascular volume optimisation and length of hospital stay after repair of proximal femoral fracture; randomised control trial. Br Med J 1997;315:909–912. 3. Sevitt S, Gallagher N. Venous thrombosis and pulmonary embolism: a clinico-pathological study in injured and burned patients. Br J Surg 1961;48:475–489. 4. Handoll HHG, Farrar MJ, McBirnie J, Tytherleigh-Strong G, Awai KA, Milne AA, Gillespie WJ. Prophylaxis using heparin, low molecular weight heparin and physical methods against deep vein thrombosis and pulmonary embolism in hip fracture surgery. Cochrane Database of Systematic Reviews. Oxford: Update Software 1997. 5. Parker MJ, Pryor GA. Hip Fracture Management. Oxford: Blackwell Scientific Publications, 1993. 6. Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures (Cochrane Review). In: The Cochrane Library, Issue 1. Oxford: Update Software, 1999. 7. Pryor GA, Williams DRR. Rehabilitation after hip fractures, Home and hospital management compared. J Bone Joint Surg 1989; 71–4:471–474. 8. Sikorski JM, Davis NJ, Senior J. The rapid transit system for patients with fractures of proximal femur. Br Med J 1985;290:439–443. 9. Devas MB. Geriatric orthopaedics. Br Med J 1974; 1:190–192. 10. Cameron I, Finnegan T, Madhok R, Langhorne P, Handoll H. Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures (Cochrane Review). In: The Cochrane Library, Issue 2. Oxford: Update Software, 1999. 11. Parker MJ, Todd CJ, Palmer CR, Camilleri-Ferrante C, Freeman CJ, Laxton CE, Payne BV, Rushton N. Inter-hospital variations in length of hospital stay following hip fracture. Age and Ageing 1998;27:333–337. 12. Strömberg L, Öhlén G, Svensson O. Prospective payment systems and hip fracture treatment costs. Acta Orthop Scand 1997;68:6–11. 13. Fitzgerald JF, Moore PS, Dittus RS. The care of elderly patients with hip fracture: changes since implementation of the prospective payment system. N Engl J Med 1988; 319: 1392–1397. 14. Parker MJ, Gillespie LD, Gillespie WJ. Hip protectors for preventing hip fractures in the elderly (Cochrane Review). In: The Cochrane Library, Issue 3. Oxford: Update Software, 1999. 15. Parker MJ, Currie CT, Mountain JA, Thorngren K-G. Standardised Audit of Hip Fracture in Europe (SAHFE). Hip International 1998; 8: 10–15. 16. Scottish Intercollegiate Guidelines Network (SIGN). Management of elderly people with fractured hip. No.15;1997.