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Surgical Management of the Hip in the Elderly Patient
Perioperatiue Care of the Older Patient
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Surgical Management of the Hip in the Elderly Patient Matthew Ochs, MD*
With hip fracture as the leading traumatic event in the elderly and with degenerative arthritis increasing in frequency with age, hip surgery is the most important orthopedic procedure in the elderly. In 1980, 267,000 hip fractures were reported in the United States,'l 90% in the over-65 population. This figure is expected to rise to 500,000 per year within the next 10 years.41The great majority of these patients are treated with an open surgical procedure. Because excess morbidity occurs frequently as a result of the procedure, the initial injury, or a comorbidity, comprehensive perioperative evaluation and management are essential in assuring an acceptable outcome. In general, complications associated with hip surgery can be divided into two general types: those related to the injury and its treatment and those due to comorbidity. Much of the potential medical morbidity can be avoided if the surgeon, primary care physician, nursing staff, and physical therapist work closely as a team. Whereas some sources of morbidity and poor functional outcome are largely unavoidable, they can often be anticipated and their negative impact on the patient minimized. HIP FRACTURE Pathogenesis Hip fractures result from two major changes seen in aging. Arguably the most important of these is a loss in postural stability with age, leading to an increased incidence of falls.= Supporting this concept is the finding that bone mass in patients who sustain a fracture is similar to that in agematched controls, suggesting that fractures segregate to the portion of the population who are fallers. Other investigators, however, have pointed out that fractures are uncommon in patients with bone mass of greater than 1.0 gm/cm2and increases dramatically with increasing osteopenia, with the ma-
*Chief, Section of Geriatric Medicine, Department of Veterans Affairs Medical Center; Assistant Professor of Internal Medicine and Preventive Medicine, University of Tennessee, Memphis, Tennessee Clinics in Geriatric Medicine-Vol.
6, No. 3, August 1990
571
jority of fractures occumng below a density of 0.8 g ~ n / c m ~ .Unfortunately, *.~~ since bone mass decreases linearly with age, the majority of persons over the age of 80 have bone mass in the at-risk range. These two factors then explain why the incidence of hip fracture doubles every 5 years after the age of 50.* With the introduction of successful open reduction and internal fixation of hip fractures by Smith-Petersen in 1931,* significant improvement in the 75% mortality associated with this condition became possible.34 Oneyear mortality following hip fracture is now reported to be 15-30%,24,34,37,49 increasing to 50-70%37,57 in patients who sustain hip fracture in a nursing home. Hip fractures are generally divided into three types: femoral neck, intertrochanteric, and subtrochanteric. Fracture of the femoral neck and the intertrochanteric region make up 97%of hip fractures and are divided fairly evenly between the two types. Because subtrochanteric fractures comprise only 3% of proximal femoral fractures, they will not be dealt with in this article. Femoral Neck Fractures Fracture of the femoral neck has long been referred to as the "unsolved fracture" owing to a significant failure rate after primary fixation." Surgical and postsurgical complications in femoral neck fractures are in large part related to two anatomic features of the proximal femur. First, both the femoral neck and head lie entirely within the joint capsule and therefore have no periosteum. Secondly, the arterial supply to the femoral head is closely applied to the femoral neck and is usually disrupted if the fracture fragments are displaced. These facts lead respectively to nonunion of the fracture and avascular necrosis of the femoral head with subsequent late ~ ~femoral . ~ 3 neck fractures fixed by open reduction segmental c o l l a p ~ e . ~ .In and internal fixation (ORIF), large series show an average rate of nonunion of 15% and a similar incidence of avascular necrosis and late segmental collapse.36,43,56 Surgical Procedures for Femoral Neck Fractures The primary goal for all fractures of the hip is to provide a solid union as early as possible to allow early weight bearing and good functional recovery. This is balanced against performing a procedure that will lead to the lowest overall perioperative morbidity and mortality. In general, four types of surgical procedures can be performed. The simplest of these with the lowest reported perioperative morbidity and mortality is Knowles pinning. In this procedure (Fig. l), multiple pins are advanced from the trochanteric region into the femoral neck and head. This procedure can be performed quickly and under local anesthesia. Although Knowles pinning does not provide compression of the two fracture fragments, it does provide reasonable stability. Functional recovery may be impaired because this fixation is not sturdy enough to allow full weight bearing for up to 3 months postoperatively. Also, penetration of the femoral head with subsequent hip pain is not uncommon. A second method of fixation is illustrated by the Jewett nail (Fig 2). This is a single piece device with an intramedullary nail that is driven into
Figure 1. Femoral neck fracture repaired by placement of three Knowles pins from the lateral aspect of the greater trochanter into the femoral head.
the femoral neck and head and secured to the femoral shaft with a series of screws. Again, no compression of fracture fragments is ~rovided,but the stability of the device is sufficient to allow postoperative weight bearing and ambulation. A third device and probably the most frequently used is the sliding nail or compression screw (Fig. 3). Available in several varieties, the basic premise of these devices is that after being driven into the femoral head, the sliding screw can be tightened down, drawing the fracture fragments together (compression) and holding them firmly in place. Theoretically, this should provide better contact between the fragments and allow improved healing. This has not, however, solved the problem of nonunion in femoral neck fractures. Because of this, a fourth procedure, either hemiarthroplasty (Fig. 4) or total hip arthroplasty (Fig. 5) is often performed in displaced femoral neck fractures. l3 Many surgeons routinely use arthroplasty for all displaced femoral neck fractures, as it effectively eliminates the complications of avascular necrosis with late segmental collapse and non~ n i o n . ~The , ~ most ~ , ~ commonly ~ performed procedure, hemiarthroplasty, involves the resection of the femoral neck and head, reaming of the femoral canal, and placement of a noncemented metallic prosthesis such as the Austin-Moore. This procedure has the advantage of being stable for immediate full weight bearing, but does have several drawbacks. Postoperative dislocation occurs in up to 15%of cases, requiring reduction followed by prolonged traction, casting, or reoperation.13 If the patient is active and has a good life expectancy, eventual degeneration of the acetabulum will occur
Figure 2. A single piece Jewett nail fixation of an intertrochanteric fracture. With medial displacement of the fracture fragments, the rigid nail has penetrated the femoral head, causing pain and limitation of motion of the hip.
owing to cartilage trauma by the prosthetic head, necessitating revision to a total hip arthroplasty. To prevent these problems, the routine use of total hip arthroplasty has been suggested as the primary procedure for management of displaced femoral neck fractures. This requires replacement of both the femoral head and the acetabular surface, and while theoretically being the best procedure to avoid complications of nonunion-segmental collapse, dislocation, and subsequent degeneration of the acetabuluml5-higher perioperative m ~ r b i d i t y ' ~and , ~ ~problems ,~~ with late loosening of the components have kept this from being adopted as a universally accepted treatment of choice. Intertrochanteric Fractures
The procedures for stabilization of intertrochanteric fractures differ somewhat from those for femoral neck fractures, although methods of fixation are similar (Fig. 6). Unfortunately, fractures of the intertrochanteric region . ~ .more 2 ~ o s t e o p o r o t i ~ ,leading ~ ~ . ~ ~to difficulty are usually c o m m i n ~ t e d ~ . ~and with good anatomic reduction of fragments and subsequent instability of the f i ~ a t i o n .Because ~ . ~ ~ the vascular supply to the femoral neck and head is not
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SURGICALMANAGEMENT OF THE HIPIN THE ELDERLY PATIENT
575
Figure 3. Femoral neck fracture repaired using a Richards compression screw. The screw is driven into the femoral head and is locked in place by a set screw on its lateral end.
commonly affected and because the bone in this area has a periosteum, avascular necrosis and nonunion are uncommon complications. The most widely used fixation device is a sliding nail or compression screw, which allows the medial collapse of the fracture fragments often seen with comminuted intertrochanteric fractures. l7 This reduces the problem of late penetration of the femoral head by the fixation device. Rigid hardware such as the Jewett nail is less often used and arthroplasty is seldom necessary. Because of problems with comminution and resultant instability, patients with intertrochanteric fractures can be expected to have delayed weight bearing, a poorer functional outcome, and higher mortality than those with fractures of the femoral neck.2.9.76
Nonoperative Treatment of Hip Fracture Morbidity and mortality increase with increasing comorbidity of patient~.~ Patients ? confined to nursing homes at the time of the fracture are at especially high risk for perioperative complication^.^^^^ In this dependent population, preoperative limitation in mobility defines a cohort in whom return to ambulatory status is uncommon. Therefore, conservative non-
Figure 4. Femoral head and neck are resected for the placement of a noncemented Austin-Moore prosthesis.
operative management in this group has been looked to as an alternative management.48Mortality and morbidity have been reported to be reduced in patients managed in the nursing home setting rather than transferred to an acute care hospital. With careful management of pain and skin integrity, major complications were eliminated. Patients became pain free after 4-6 weeks. This positive experience with nonoperative management has not been noted by others but deserves further
OSTEOARTHROSIS The second common indication for hip surgery in elderly individuals is to relieve pain in patients with degenerative arthritis. Although some arthroplasties will be performed in elderly patients with rheumatoid arthritis, the great majority of patients will have a diagnosis of primary or secondary osteoarthritis. In these patients, pain that disrupts normal daily activities and interrupts sleep is the indication for surgical intervention regardless of ~ ~ , ~hip fracture, this is an elective procedure the age of the ~ a t i e n t .Unlike and therefore allows adequate time for preoperative evaluation. In general,
Figure 5. Cemented total hip arthroplasty. The femoral neck and head are resected and the acetabulum is reamed to accept a high density polyethylene socket. Both components are cemented in place.
patients referred for arthroplasty to relieve arthritis pain will have better functional status and a higher bone mass than those patients with hip fractures.16 This latter point should be noted, since it has been found by several investigators that osteoarthritis is more prevalent in persons with higher bone mass and is decreased in patients with osteopenia. This may be due to increased rigidity of the subchondral plate in patients with higher bone mass, leading to an increased susceptibility to subchondral microfractures and subsequent degeneration of the cartilage in the primary load-bearing area.16Surgically, this is a favorable factor because these patients, as opposed to those with fractures, have good bone stock necessary for success of the prosthesis.
Total Hip Arthroplasty Unlike open reduction and internal fixation of fractures for which hardware provides stability until healing can occur, in arthroplasty the hardware must serve as the primary load-bearing structure for the life of the patient. This makes the durability of hardware and cement of primary concern in long-term prosthesis survival. A primary concern is the life expectancy of
I1
Figure 6. Richards compression screw repair of an intertrochanteric fracture. Note that as medial displacement of the fracture has occurred, the tip of the compression screw has moved with the femoral head by sliding laterally through the plate.
the prosthesis in a more active person in whom repetitive impact-loading often leads to failure due to loosening of components (usually the femoral stem) or actual fracture of the femoral component.I3Therefore, procedures in younger patients are often designed to preserve bone while avoiding the placement of a prosthesis and have included cup arthroplasty and arthrodesis. These procedures are rarely considered for elderly patients with arthritis of the hip; total hip arthroplasty is the only procedure of importance in this population. In large series with average follow-up of 12-15 years, 3-14% of arthroplasties show loosening of the femoral component, with 2-4% requiring revision.49Loosening is the primary cause of failure in total hip arthroplasty and probably has its genesis in several factors, all of which relate to the bonelcement i n t e r f a ~ e . ' ~In. ~patients ~ undergoing revision and in autopsy studies, the formation of pannus and/or a true synovium is seen at the bonelcement interface. Although this may represent a primary tissue response to acrylic cement, it may also be the product of thermal damage of bone caused by the exothermic reaction occurring during the polymerization of the cement." As cement techniques improve, long-term failure due to loosening should become less problematic. To avoid the problem of loosening, noncemented prostheses that pro-
mote long-term stability by allowing the ingrowth of bone have been developed. These prostheses have a microporous surface material that is applied to a solid metal stem. Initially, these are "press fit" by reaming the femoral shaft slightly smaller than the prosthesis and then driving the stem into place. Autopsy studies have demonstrated bony ingrowth, but problems have still been identified. Two primary concerns are the failure of the attachment between the surface coatings50and the stem of the prosthesis and loss of strength of the prosthesis due to heating required to fuse the porous material to the stem. These problems are still being investigated, and, at present, the cemented total hip arthroplasty is still the standard procedure. Other problems leading to failure after total hip arthroplasty include fracture of the prosthesis, fracture of the femoral shaft,39penetration of the femoral shaft by the stem, infection, and dislocation and loosening of the acetabular component. All these should be looked for in the patient who develops pain after total hip arthroplasty, although further discussion is beyond the scope of this article. In the great majority of older patients, joint prostheses will remain intact for life and will lead to a substantial improvement in pain and mobility. Whereas overall morbidity and mortality do increase with age, age alone should not preclude surgery, because excellent results can be obtained even into the ninth decade.62.a
PREOPERATIVE EVALUATION Preoperative assessment is dealt with in detail elsewhere in this volume and so will be considered only briefly here. Although careful planning, evaluation, and preoperative training can be accomplished in the patient undergoing elective total hip arthroplasty, it is less possible in patients presenting with hip fracture. In general, early surgical intervention for hip fracture is desirable to reduce the time of immobilization but should not preclude careful medical evaluation and ~tabilization.~.~3 No adverse effect on outcome has been seen with increasing time between fracture and surgical intervention up to 7 days. Proceeding to surgery before medical stabilization leads to poor outcome.43Cardiac risk should be assessed using Goldman's criteria,27and in high-risk patients perioperative Swan-Ganz monitoring may be recommended. Chronic pulmonary disease, a critical factor in intraabdominal and thoracic procedures, is less critical in hip surgery.38Use of peak expiratory flow rate (PEFR) may define a population at risk of pulmonary complications, with 70% mortality reported in patients with PEFR less than 100 Umin and few deaths occurring in patients with PEFR of greater than 200 Umin.24Other medical factors important in perioperative management are control of diabetes,14treatment of underlying infections, and assessment of mental status. Preoperative assessment of mental status is particularly important, as preoperative cognitive impairment is a predictor of postoperative d e l i r i ~ mA. ~preoperative mental status evaluation using a scorable instrument such as the Mini Mental State Examination (MMSE) or the Short Portable Mental Status Questionnaire (SPMSQ) also establishes a baseline that may be valuable in patient assessment when postoperative confusion
occurs. A comprehensive review of medications is also essential. Medications with anticholinergic activity are reported to be the most important factor associated with postoperative delirium.4 Premorbid functional ability, mobility, and social support are also part of the preoperative evaluation and are discussed in the section on rehabilitation and outcome. PERIOPERATIVE COMPLICATIONS With careful management, many complications can be avoided or substantially reduced. Responsibility lies with the entire team and requires close cooperation among the surgeon, the primary physician, nursing st&, and the rehabilitation team. Deep Vein Thrombosis and Pulmonary Emholism Although deep vein thrombosis (DVT) and pulmonary embolism (PE) are the most extensively studied complications of hip surgery, they represent an area where adequate preventive measures have not been universally a d ~ p t e dThe . ~ incidence of DVT in hip fracture patients not receiving prophylaxis has been reported to be 40-60%. Since approximately 20% of patients with DVT can be expected to have at least one pulmonary embolus, the rate of PE in hip surgery patients would be expected to be 10-15%.28 The incidence of fatal PE in these patients is reported to be 2-lo%, making it the single most important cause of postoperative death.2s.55Ultrasonography has replaced venography as the method of choice for diagnosing DVT, having the advantages of portability, lower morbidity, and excellent sensitivity and specificity.3,44.75 Measures to decrease the incidence of DVT have included the use of subcutaneous or intravenous h e p a r i ~ ~external , ~ ~ , ~ pneumatic ~ ,~~ low molecular weight dextran, and compression, p h e n i n d i ~ n ewarfarin,% heparin with dihydroergotamine (DHE).25Even with these prophylactic measures, incidence of DVT in hip surgery remains at about 20%. Current recommendations are for the use of low-dose Coumarin (warfarin) starting the day of surgery with the prothrombin time adjusted to 1.5times cont~-01.~~ With this therapy, no significant increase in postoperative hemorrhagic complications is seen with a 60% decrease in DVT. Significant resistance to the use of anticoagulants still exists. A recent survey of orthopedic surgeons reported that while the majority use some form of DVT prophylaxis, the most commonly used measure is aspirin and 10% used no prophylaxis at alLw Pressure Ulcers In hip fracture patients, it should be recognized that significant pressure necrosis of skin may occur before the patient arrives on the ward but will often take days to develop fully. Tissue damage can occur during long lies prior to receiving medical attention and can be further promoted by the combination of immobility and hard surfaces in ambulances, emergency rooms, and x-ray suites. Twenty to 70%of patients with hip fracture develop
pressure sores, the majority being present by the fifth hospital day.73,74The most common areas dected are in the pelvic girdle and the feet, particularly the sacrum and heels. With pressure ulcers developing after admission to the hospital,74two important environmental factors-41) the firmness of hospital beds in patients immobilized and given narcotic analgesics and (2) inadequately padded operating tables--can lead to necrosis. Identification of at-risk patients using a scorable instrument such as the Norton scale or one of its modification^^^ is important, because this allows special intervention for high-risk patients. Prevention through the routine use of four-inch eggcrate mattresses and heel protectors is effective. These simple preventive measures are extremely cost-effective because pressure ulcers significantly increase length of hospital stay.74 Delirium
Postoperative confusion is a major cause of morbidity in the elderly and usually represents a response to systemic stressors rather than primary central nervous system (CNS) disease.4 Overall, the incidence of postoperative confusion has been reported in 30-50% of patients undergoing surgical management of hip fracture and significantly prolongs length of hospital ~ t a y . ~ , ~ ~ The clinical evaluation of delirium should be directed toward identification of stressors such as medications, underlying infection, fecal impaction, electrolyte shifts, hypoxemia, and myocardial infarction. As mentioned previously, the use of medications with anticholinergic side effects is an important factor for the development of d e l i r i ~ mOf . ~ note, delirium has not been found to be related to the type of anesthesia used or to the duration of the surgical procedure, with a similar incidence seen in patients undergoing general anesthesia with halothane or local epidural block.33~~~ Direct evaluation of the CNS with computed tomographic (CT) scanning, lumbar puncture, or electroencephalography (EEG) is warranted only if meningitis, cerebrovascular accident, or seizure activity is strongly suspected. Delirium is commonly seen on postoperative days 1 to 5 with resolution by day 7.46If no treatable cause can be found, care is supportive with control of psychotic symptoms with low-dose haloperidol to prevent injury. During the period of confusion, patients are at higher risk for developing other complications such as pneumonia, urinary tract infection, and pressure ulcers. Urinary Retention and Urinary Tract Infection
Urinary tract infection (UTI) is reported in 10-20% of hip surgery patients, whereas urinary retention occurs in 28-52%.8.52Reasons for the high frequency of retention are not entirely known, although a primary effect of anesthetic agents and the use of narcotic analgesics postoperatively are postulated as potential causes. The prophylactic use of an indwelling urethral catheter inserted at the time of surgery and retained for 24 hours postoperatively has been shown to decrease the occurrence of retention without affecting the incidence of UTI and can be advocated for routine management.8,52Use of a catheter for more than 48 hours, however, is associated with an increase in UTI.
Other Perioperative Complications Substantial improvement in wound infection rates has been seen since the advent of laminar flow o~erating " suites and the routine use of broad spectrum antibiotics in the perioperative period.58Current recommendations are for the use of a cephalosporin for 48 hours postoperatively. Infection rates at the operative site are still reported to be 1-3%; the majority of these are superficial, with very few affecting bone or hardware. Other complications include postoperative pneumonia, myocardial infarction, and traumatic neuropathy. Neuropathies resulting from traction or pressure injuries to peripheral nerves are seen in less than 1% of patients following hip surgery.61Unlike intraabdominal or intrathoracic procedures, hip surgery presents only a minor increased risk of perioperative pulmonary complications in the patient with chronic pulmonary disease. However, as previously mentioned, PEFR of less than 100 Wmin may define a population at high risk. As with patients undergoing other procedures, individuals being considered for elective hip replacement should be instructed to stop smoking, preferably 8 weeks prior to surgery, and all attempts should be made to treat chronic bronchitis. In the patient considered to have a high cardiac risk, of significant concern is the potential for intraoperative hypotension. In patients undergoing hip surgery, this risk can be related to two factors: (1) the increased incidence of hypotension in patients undergoing spinal anesthesia, and (2)hypotension seen after the introduction of acrylic cement during total hip arthroplasty. In this latter group, significant drop in mean systolic pressure is believed to be due to the introduction of acrylic monomer into the systemic circulation. Recognition of these factors suggests that patients undergoing hip replacement with a cemented prosthesis in whom spinal or epidural anesthesia is planned and who have coronary artery disease represent a population at high risk, requiring more intensive preoperative and intraoperative monitoring.
REHABILITATION Substantial differences in recovery between patients treated for hip fracture and those undergoing elective total hip arthroplasty can be expected. Since the latter group will have better bone stock, better premorbid medical status, a lower incidence of neurologic disorders, and the opportunity for careful preoperative assessment, postoperative functional recovery should be optimal. Also, since elective arthroplasty is being done for a condition that has caused pain and has impaired mobility preoperatively, improved functional capacity is the rule, with good to excellent functional results in 95% of patients at 10 years.4gAlthough this success rate may decline with increasing age at operation, review of the results in patients in their 80s is still positive, with more than 90% of patients returning home and having a good functional result at 2 years.l2 Recovery of patients following hip fracture is less favorable and can often be predicted preoperatively. Risk factors for poor functional outcome include premorbid dementia and poor mobility, intertrochanteric fracture,
and advanced age. Several large series report that of patients surviving one year postfracture, only 50% will achieve prefracture functional status.53 Prefracture Status The most important risk factors are those of premorbid status; prefracture mobility is the strongest predictor of postfracture f ~ n c t i o n . " , ' ~Persons ,~~ with limited ambulation prior to the fracture are unlikely to regain ambulatory status, whereas those who were able to ambulate independently and leave their homes are likely to have a good outcome. Mobility serves as a rough indicator of major organ system function as patients with poor prefracture mobility usually have significant neurologic, cardiovascular, or musculoskeletal problems that will significantly impede rehabilitation. Mental status is also a predictor of outcome, with premorbid dementia being an indicator of poor functional outcome. In one study, patients with decreased mental status preoperatively had only a 25% chance of regaining independent function, whereas 70% of those persons with normal premorbid mental status reached independence. lg Age is also noted to be an independent risk factor in functional recovery and ability to return home postfracture. l2 Premorbid living arrangements are important in predicting ability to return home.lG12 Patients living with others have the greatest chance of returning home, whereas those living alone will often experience a change in living arrangements. Only 50-75% of surviving patients remain independent at one year.30Not surprisingly, patients residing in a nursing home at the time of fracture can be expected to have a poor outcome, with reasonable recovery of functional capacity in only 2 6 3 0 % of cases. Type of fracture is also related to functional recovery; several series report slower and less complete recovery in intertrochanteric fractures as compared with femoral neck fractures. In accordance with this, a comprehensive interdisciplinary team approach to rehabilitating hip fracture patients has been found to have the greatest impact on patients with intertrochanteric fractures, decreasing their hospital length of stay by over 20%.71
THE IMPACT OF PROSPECTIVE PAYMENT The management of elderly hip fracture patients is a complex task in a high-risk population, and cost of acute hospital care is highly variable.' Of great concern is the impact of the Medicare prospective payment system (PPS). Diagnosis related group (DRG) losses are highly dependent on the occurrence of postoperative complications, particularly in patients with significant comorbidity. Alarmingly, hospital charges went from an average of $15,000 in patients without complications to $38,000 when complications occurred, an increase of 150%.56Increasing costs under DRGs has also led to an increasing number of early discharges to community nursing homes, with hospital lengths of stay decreasing by 42% from 21.9 days to 12.6 days The final effect of this early discharge policy since introduction of PPS.21,22 has been a dramatic increase in patients remaining indefinitely in community nursing homes. One third of all patients studied who were alive at one year resided in a community nursing home compared with only 9% prior to
PPS.21,22 It is questioned whether this increase in rate of institutionalization will offset the apparent savings in acute care dollars and underlines the need for nonacute care comprehensive rehabilitation facilities. It also suggests that successful rehabilitation is difficult to achieve in the limited environment of the community nursing home. Whereas it is difficult to measure the cost of PPS in human terms, current data suggest that for hip fracture patients it is substantial. A possible cost-effective alternative to the problem of longterm recovery from hip fracture and its attendant costs has been suggested in the British health care system. One demonstration project showed a similar decline in average length of stay from 22 to 14.6 days through early home discharge with in-home team management of extended postoperative rehabilitation.67 Nearly 70% of all patients admitted from home were able to return home at an average of 14.6 days. Whereas no data are presented on long-term functional recovery, the concept is readily adaptable.
SUMMARY Hip surgery is the most common major orthopedic procedure performed in the elderly. The indications are fracture and pain secondary to degenerative arthritis. Patients undergoing hip replacement for arthritis have excellent outcomes with decreased pain, increased mobility, and a low mortality. Age should not be a contraindication to hip replacement, with patient selection being made on the basis of symptomat~log~ and overall health. In hip fracture, the prognosis is more guarded. Poor functional outcome results from complications of the fracture, such as avascular necrosis of the femoral head and fracture nonunion in femoral neck fractures and instability with delayed weight bearing in intertrochanteric fractures. In addition, patients sustaining hip fracture are more likely to have significant comorbidity and subsequent perioperative complications. Pressure ulcers, delirium, deep venous thrombosis, urinary retention and urinary tract infection, and cardiac events are the most frequent complications seen. These complications can be anticipated and prevented with careful preoperative assessment and postoperative prophylactic management. A team approach including the orthopedic surgeon, primary care physician, nursing st&, and physical therapists is essential for optimal outcome.
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6. Broos PLO, Stappaerts KH, Luiten EJT, et al: Endoprosthesis: The best way to treat unstable intracapsular hip fractures in elderly patients. Unfallchirurg 90:347-350, 1987 7. Calandruccio RA, Anderson WE: Post-fracture avascular necrosis of the femoral head: Correlation of experimental and clinical studies. Clin Orthop 152:49-84, 1980 8. Carpiniello VL, Cendron M, Altman HG, et al: Treatment of urinary complications after total joint replacement in elderly females. Urology 32:186-188, 1988 9. Caudle RJ, Hopson CN, Clarke R: Unstable intertrochanteric fractures of the hip. Orthop Rev 16:538-549, 1987 10. Ceder L, Stromqvist B, Hanson LI: Effects of strategy changes in the treatment of femoral neck fractures during a 17-year period. Clin Orthop 218:53-57, 1987 11. Ceder L, Svensson BS, Thorngren KG: Statistical prediction of rehabilitation in elderly patients with hip fractures. Clin Orthop 152:185-190, 1980 12. Ceder L, Thorngren KG, Wallden B: Prognostic indicators and early home rehabilitation in elderly patients with hip fractures. Clin Orthop 152:173-184, 1980 13. Crenshaw AH (ed): Campbell's Operative Orthopedics, ed 7. St. Louis, C.V. Moshy Co, 1987 14. Davidson TI, Bodey WN: Factors influencing survival following fractures of the upper end of the femur. Injury 17:12-14, 1986 15. Delamarter R, Moreland JR: Treatment of acute femoral neck fractures with total hip arthroplasty. Clin Orthop 218:68-74, 1987 16. Dequeker J: The relationship between osteoporosis and osteoarthritis (osteoarthrosis). Clin Rheum Dis 11:271-296, 1985 17. Doppelt SH: The sliding compression screw-today's best answer for stabilization of intertrochanteric hip fracture. Orthop Clin North Am 11:507-523, 1980 18. Doyle DJ, Turpie AGG, Hirsh J, et al: Adjusted subcutaneous heparin or continuous intravenous heparin in patients with acute deep vein thrombosis: A randomized trial. Ann Intern Med 107:441-445, 1987 19. El Banna S, Raymal L, Gerebtzof A: Fractures of the hip in the elderly: Therapeutic and medico-social considerations. Arch Gerontol Geriatr 3:311-319, 1984 20. Evans EM: The treatment of trochanteric fractures of the femur. J Bone Joint Surg 31B:190-203, 1949 21. Fitzgerald J, Fagan LF, Tierney WM, et al: Changing patterns of hip fracture care before and after implementation of the prospective payment system. JAMA 258:218-221, 1987 22. 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 319:1392-1397, 1988
23. Furstenberg L, Mezey MD: Mental impairment of elderly hospitalized hip fracture patients. Compr Gerontol 1:80-85, 1987 24. Galasko CSB, Rushton S, Sylvester BS, et al: The significance of peak expiratory flow rate in assessing prognosis of elderly patients undergoing operations of the hip. Injury 16:398-401, 1985 25. Gent M, Roberts RS: A meta-analysis of the studies of dihydroergotamine plus heparin in the prophylaxis of deep vein thrombosis. Chest 89:3965-3995, 1986 26. Gingras MB, Clarke J, Evarts CM: Prosthetic replacement in femoral neck fractures. Clin Orthop 152:147-157, 1980 27. Goldman L, Caldera DL, Nussbaum SR, et al: Multifactorid index of cardiac risk in noncardiac surgical procedures. N Engl J Med 297:845-850, 1977 28. Gruber UF: Prevention of fatal pulmonary embolism in patients with fractures of the neck of the femur. Surg Gynecol Ohstet 161:37-42, 1985 29. Halpin PJ, Nelson CL: A system of classification of femoral neck fractures with special reference to choice of treatment. Clin Orthop 1524-48, 1980 30. Hammer AJ: Intertrochanteric fractures in an elderly white South African population. S Afr Med Trans 743126126, 1988 31. Holmberg S, Kalin R, Thorngren KG: Treatment and outcome of femoral neck fracture: An analysis of 2418 patients admitted from their own homes. Clin Orthop 218:42-52, 1987 32. Holmberg S , Thorngren KG: Statistical analysis of femoral neck fractures based on 3053 cases. Clin Orthop 218:32-41, 1987
33. Hughes D, Bowes JB, Brown MW: Changes in memory following general or spinal anaesthesia for hip arthroplasty. Anaesthesiology 43:114-117, 1988 34. Hui SL, Slemenda CW, Johnston CC: Baseline measurement of bone mass predicts fracture in white women. Ann Intern Med 111:355-361, 1989 35. Hunter GA: Should we abandon primary prosthetic replacement for fresh displaced fractures of the neck of the femur? Clin Orthop 152:158-161, 1980 36. Hyers TM, Hull RD, Weg JG: Antithrombotic therapy for venous thromboembolic disease. Chest 89 (Suppl):26S-35S, 1986 37. Iverson BF, Aalberg JR, Naver LS: Complications of fractures of the femoral neck. Ann Chir Gynaecol75:341-344, 1986 38. Jackson CV: Preoperative pulmonary evaluation. Arch Intern Med 148:2120-2127, 1988 39. Jensen JS, Barfod G, Hansen D, et al: Femoral shaft fracture after hip arthroplasty. Acta Orthop Scand 59:9-13, 1988 40. Jette AM, Harris BA, Cleary PD, et al: Functional recovery after hip fracture Arch Pbys Med Rehabil 68:735-740, 1987 41. Josefsson G, Dahlqvist A, Bodfors B: Prevention of thromboembolism in total hip replacement: Aspirin versus dihydroergotamine-heparin. Acta Orthop Scand 58:626-629, 1987 42. Kelsey JL: Epidemiology of diseases of the hip: Review of the literature. Int J Epidemiol 6:269-280, 1977 43. Kenzora JE, Sledge RD, Lowell JD, et al: Hip fracture mortality. Clin Orthop 186:45-56, 1984 44. Lensing AWA, Prandoni P, Brandjes D, et al: Detection of deep-vein thrombosis by realtime B-mode ultrasonography. N Engl J Med 320342-345, 1989 45. Lewinnek GE, Kelsey J, White AA, et al: The significance and a comparative analysis of the epidemiology of hip fractures. Clin Orthop 15235-43, 1980 46. Lomholt JRB, Haxholdt 0 , Kehlet H, et al: Immediate and long-term mental recovery from general versus epidural anesthesia in elderly patients. Acta Anaesthesiol Scand 27:4449, 1983 47. Lowell JD: Results and complications of femoral neck fractures. Clin Orthop 152:162-172, 1980 48. Lyon LJ, Nevins MA: Management of hip fractures in nursing home patients: To treat or not to treat. J Am Geriatr Soc 32:391-395, 1984 49. McCoy TH, Salvati E, Ranawat CS, et al: A fifteen-year follow-up study of one hundred Charnley low-friction arthroplasties. Orthop Clin North Am 19:467-476, 1988 50. Manley MT, Kotzar G, Stern LS, et al: Effects of repetitive loading on the integrity of porous coatings. Clin Orthop 217:293-302, 1987 51. Melton LJ, Wahner HW, Richelson LS, et al: Osteoporosis and the risk of hip fracture. Am J Epidemiol 124:254-261, 1986 52. Michelson JD, h t k e PA, Steinberg ME: Urinary-bladder management after total jointreplacement surgery. N Engl J Med 319:321-326, 1988 53. Miller CW: Survival and ambulation following hip fracture. J Bone Joint Surg 60A:930-933, 1978 54. Mjoberg B: Loosening of the cemented hip prosthesis: The importance of heat injury. Acta Orthop Scand 57(Suppl221):1-40, 1986 55. Montrey JS, Kistner RL, Kong AYT, et al: Thromboembolism following hip fracture. J Trauma 25:534-537, 1985 56. Monoz E, Johanson H, Margolis I, et al: DRG's, orthopedic surgery and age at an academic medical center. Orthopedics 11:1645-1651, 1988 57. Niemann KMW, Mankin H: Fractures about the hip in an institutionalized patient population. 11. Survival and ability to walk again. J Bone Joint Surg 50A:1327-1340, 1968 58. Norden CW: Prevention of bone and joint infections. Am J Med 78(Suppl 6B):229-232, 1985 59. Norton D, McLaren R, Exton-Smith AN: An Investigation of Geriatric Nursing Problems in Hospital. Edinburgh, Churchill Livingstone, 1975 60. Paiement GD, Wessinger SJ, Harris WH: Survey of prophylaxis against venous thromboembolism in adults undergoing hip surgery. Clin Orthop 223:188-193, 1987 61. Pellicci P, Salvati E: Complications of hip surgery. Part 11. Adult patients. Contemp Orthop 10:27-39, 1985
62. Petersen VS, Solgaard S, Simonsen B: Total hip replacement in patients aged 80 years and older. J Am Geriatr Soc 37:219-222, 1989 63. Phillips TW, Grainger RW, Cameron HS, et al: Risks and benefits of elective hip replacement in the octogenarian. Can Med Assoc J 137:492-500, 1987 64. Pogrund H, Kenan S, Frank1 U, et al: Another look at the pertrochanteric fracture of the femur: The relationship to osteoporosis. Injury 18:36-39, 1987 65. Poplinger AR, Pillar T: Hip fracture in stroke patients: Epidemiology and rehabilitation. Acta Orthop Scand 563226227, 1985 66. Powers PJ, Gent M, Jay RM, et al: A randomized trial of less intense postoperative warfarin or aspirin therapy in the prevention of venous thromhoembolism after surgery for fractured hip. Arch Intern Med 149:771-774, 1989 67. Pryor GA, Williams DRR, Myles JW, et al: Team management of the elderly patient with hip fracture. Lancet 1(8582):401-403, 1988 68. Radin EL: Loosening of total hip replacement prostheses. Orthop Rev 16:134-136, 1987 69. Smith-Petersen MN, Cave EF, Vangarder GW: Intracapsular fractures of the neck of the femur-treatment by internal fixation. Arch Surg 23:715-759, 1931 70. Speed K: The unsolved fracture. Surg Gynecol Obstet 60:341-352, 1935 71. Sukales SR, Zuckerman JD: Interdisciplinary hospital care of geriatric hip fracture patients. The Older Patient (Summer:l5-el), 1989 72. U.S. Department of Health and Human Services: Detailed diagnoses and surgical procedures for patients discharged from short stay hospitals. Washington DC, 1984 73. Versluysen M: How elderly patients with femoral fracture develop pressure sores in hospital. Br Med J 292:1311-1313, 1986 74. Versluysen M: Pressure sores in elderly patients: The epidemiology related to hip operations. J Bone Joint Surg 67B:10-13, 1985 75. White RH, McGahau JP, Daschbach MM, et al: Diagnosis of deep-vein thrombosis using duplex ultrasound. Ann Intern Med 111:297-304, 1989 76. Wickstrom I, Holmherg I, Steffansson T, et al: Survival of female geriatric patients after hip fracture surgery: A comparison of 5 anesthetic methods. Acta Anaesth Scand 26:607-614, 1982 77. Winter WG: Non-operative treatment of proximal femoral fractures in the demented nonambulatory patient. Clin Orthop 218:97-103, 1987 Address reprint requests to Matthew Ochs, MD VA Medical Center (111H) 1030 Jefferson Avenue Memphis, TN 38104
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0749-0690190 $0.00 .20
Surgical Management of the Hip in the Elderly Patient Matthew Ochs, MD*
With hip fracture as the leading traumatic event in the elderly and with degenerative arthritis increasing in frequency with age, hip surgery is the most important orthopedic procedure in the elderly. In 1980, 267,000 hip fractures were reported in the United States,'l 90% in the over-65 population. This figure is expected to rise to 500,000 per year within the next 10 years.41The great majority of these patients are treated with an open surgical procedure. Because excess morbidity occurs frequently as a result of the procedure, the initial injury, or a comorbidity, comprehensive perioperative evaluation and management are essential in assuring an acceptable outcome. In general, complications associated with hip surgery can be divided into two general types: those related to the injury and its treatment and those due to comorbidity. Much of the potential medical morbidity can be avoided if the surgeon, primary care physician, nursing staff, and physical therapist work closely as a team. Whereas some sources of morbidity and poor functional outcome are largely unavoidable, they can often be anticipated and their negative impact on the patient minimized. HIP FRACTURE Pathogenesis Hip fractures result from two major changes seen in aging. Arguably the most important of these is a loss in postural stability with age, leading to an increased incidence of falls.= Supporting this concept is the finding that bone mass in patients who sustain a fracture is similar to that in agematched controls, suggesting that fractures segregate to the portion of the population who are fallers. Other investigators, however, have pointed out that fractures are uncommon in patients with bone mass of greater than 1.0 gm/cm2and increases dramatically with increasing osteopenia, with the ma-
*Chief, Section of Geriatric Medicine, Department of Veterans Affairs Medical Center; Assistant Professor of Internal Medicine and Preventive Medicine, University of Tennessee, Memphis, Tennessee Clinics in Geriatric Medicine-Vol.
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jority of fractures occumng below a density of 0.8 g ~ n / c m ~ .Unfortunately, *.~~ since bone mass decreases linearly with age, the majority of persons over the age of 80 have bone mass in the at-risk range. These two factors then explain why the incidence of hip fracture doubles every 5 years after the age of 50.* With the introduction of successful open reduction and internal fixation of hip fractures by Smith-Petersen in 1931,* significant improvement in the 75% mortality associated with this condition became possible.34 Oneyear mortality following hip fracture is now reported to be 15-30%,24,34,37,49 increasing to 50-70%37,57 in patients who sustain hip fracture in a nursing home. Hip fractures are generally divided into three types: femoral neck, intertrochanteric, and subtrochanteric. Fracture of the femoral neck and the intertrochanteric region make up 97%of hip fractures and are divided fairly evenly between the two types. Because subtrochanteric fractures comprise only 3% of proximal femoral fractures, they will not be dealt with in this article. Femoral Neck Fractures Fracture of the femoral neck has long been referred to as the "unsolved fracture" owing to a significant failure rate after primary fixation." Surgical and postsurgical complications in femoral neck fractures are in large part related to two anatomic features of the proximal femur. First, both the femoral neck and head lie entirely within the joint capsule and therefore have no periosteum. Secondly, the arterial supply to the femoral head is closely applied to the femoral neck and is usually disrupted if the fracture fragments are displaced. These facts lead respectively to nonunion of the fracture and avascular necrosis of the femoral head with subsequent late ~ ~femoral . ~ 3 neck fractures fixed by open reduction segmental c o l l a p ~ e . ~ .In and internal fixation (ORIF), large series show an average rate of nonunion of 15% and a similar incidence of avascular necrosis and late segmental collapse.36,43,56 Surgical Procedures for Femoral Neck Fractures The primary goal for all fractures of the hip is to provide a solid union as early as possible to allow early weight bearing and good functional recovery. This is balanced against performing a procedure that will lead to the lowest overall perioperative morbidity and mortality. In general, four types of surgical procedures can be performed. The simplest of these with the lowest reported perioperative morbidity and mortality is Knowles pinning. In this procedure (Fig. l), multiple pins are advanced from the trochanteric region into the femoral neck and head. This procedure can be performed quickly and under local anesthesia. Although Knowles pinning does not provide compression of the two fracture fragments, it does provide reasonable stability. Functional recovery may be impaired because this fixation is not sturdy enough to allow full weight bearing for up to 3 months postoperatively. Also, penetration of the femoral head with subsequent hip pain is not uncommon. A second method of fixation is illustrated by the Jewett nail (Fig 2). This is a single piece device with an intramedullary nail that is driven into
Figure 1. Femoral neck fracture repaired by placement of three Knowles pins from the lateral aspect of the greater trochanter into the femoral head.
the femoral neck and head and secured to the femoral shaft with a series of screws. Again, no compression of fracture fragments is ~rovided,but the stability of the device is sufficient to allow postoperative weight bearing and ambulation. A third device and probably the most frequently used is the sliding nail or compression screw (Fig. 3). Available in several varieties, the basic premise of these devices is that after being driven into the femoral head, the sliding screw can be tightened down, drawing the fracture fragments together (compression) and holding them firmly in place. Theoretically, this should provide better contact between the fragments and allow improved healing. This has not, however, solved the problem of nonunion in femoral neck fractures. Because of this, a fourth procedure, either hemiarthroplasty (Fig. 4) or total hip arthroplasty (Fig. 5) is often performed in displaced femoral neck fractures. l3 Many surgeons routinely use arthroplasty for all displaced femoral neck fractures, as it effectively eliminates the complications of avascular necrosis with late segmental collapse and non~ n i o n . ~The , ~ most ~ , ~ commonly ~ performed procedure, hemiarthroplasty, involves the resection of the femoral neck and head, reaming of the femoral canal, and placement of a noncemented metallic prosthesis such as the Austin-Moore. This procedure has the advantage of being stable for immediate full weight bearing, but does have several drawbacks. Postoperative dislocation occurs in up to 15%of cases, requiring reduction followed by prolonged traction, casting, or reoperation.13 If the patient is active and has a good life expectancy, eventual degeneration of the acetabulum will occur
Figure 2. A single piece Jewett nail fixation of an intertrochanteric fracture. With medial displacement of the fracture fragments, the rigid nail has penetrated the femoral head, causing pain and limitation of motion of the hip.
owing to cartilage trauma by the prosthetic head, necessitating revision to a total hip arthroplasty. To prevent these problems, the routine use of total hip arthroplasty has been suggested as the primary procedure for management of displaced femoral neck fractures. This requires replacement of both the femoral head and the acetabular surface, and while theoretically being the best procedure to avoid complications of nonunion-segmental collapse, dislocation, and subsequent degeneration of the acetabuluml5-higher perioperative m ~ r b i d i t y ' ~and , ~ ~problems ,~~ with late loosening of the components have kept this from being adopted as a universally accepted treatment of choice. Intertrochanteric Fractures
The procedures for stabilization of intertrochanteric fractures differ somewhat from those for femoral neck fractures, although methods of fixation are similar (Fig. 6). Unfortunately, fractures of the intertrochanteric region . ~ .more 2 ~ o s t e o p o r o t i ~ ,leading ~ ~ . ~ ~to difficulty are usually c o m m i n ~ t e d ~ . ~and with good anatomic reduction of fragments and subsequent instability of the f i ~ a t i o n .Because ~ . ~ ~ the vascular supply to the femoral neck and head is not
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Figure 3. Femoral neck fracture repaired using a Richards compression screw. The screw is driven into the femoral head and is locked in place by a set screw on its lateral end.
commonly affected and because the bone in this area has a periosteum, avascular necrosis and nonunion are uncommon complications. The most widely used fixation device is a sliding nail or compression screw, which allows the medial collapse of the fracture fragments often seen with comminuted intertrochanteric fractures. l7 This reduces the problem of late penetration of the femoral head by the fixation device. Rigid hardware such as the Jewett nail is less often used and arthroplasty is seldom necessary. Because of problems with comminution and resultant instability, patients with intertrochanteric fractures can be expected to have delayed weight bearing, a poorer functional outcome, and higher mortality than those with fractures of the femoral neck.2.9.76
Nonoperative Treatment of Hip Fracture Morbidity and mortality increase with increasing comorbidity of patient~.~ Patients ? confined to nursing homes at the time of the fracture are at especially high risk for perioperative complication^.^^^^ In this dependent population, preoperative limitation in mobility defines a cohort in whom return to ambulatory status is uncommon. Therefore, conservative non-
Figure 4. Femoral head and neck are resected for the placement of a noncemented Austin-Moore prosthesis.
operative management in this group has been looked to as an alternative management.48Mortality and morbidity have been reported to be reduced in patients managed in the nursing home setting rather than transferred to an acute care hospital. With careful management of pain and skin integrity, major complications were eliminated. Patients became pain free after 4-6 weeks. This positive experience with nonoperative management has not been noted by others but deserves further
OSTEOARTHROSIS The second common indication for hip surgery in elderly individuals is to relieve pain in patients with degenerative arthritis. Although some arthroplasties will be performed in elderly patients with rheumatoid arthritis, the great majority of patients will have a diagnosis of primary or secondary osteoarthritis. In these patients, pain that disrupts normal daily activities and interrupts sleep is the indication for surgical intervention regardless of ~ ~ , ~hip fracture, this is an elective procedure the age of the ~ a t i e n t .Unlike and therefore allows adequate time for preoperative evaluation. In general,
Figure 5. Cemented total hip arthroplasty. The femoral neck and head are resected and the acetabulum is reamed to accept a high density polyethylene socket. Both components are cemented in place.
patients referred for arthroplasty to relieve arthritis pain will have better functional status and a higher bone mass than those patients with hip fractures.16 This latter point should be noted, since it has been found by several investigators that osteoarthritis is more prevalent in persons with higher bone mass and is decreased in patients with osteopenia. This may be due to increased rigidity of the subchondral plate in patients with higher bone mass, leading to an increased susceptibility to subchondral microfractures and subsequent degeneration of the cartilage in the primary load-bearing area.16Surgically, this is a favorable factor because these patients, as opposed to those with fractures, have good bone stock necessary for success of the prosthesis.
Total Hip Arthroplasty Unlike open reduction and internal fixation of fractures for which hardware provides stability until healing can occur, in arthroplasty the hardware must serve as the primary load-bearing structure for the life of the patient. This makes the durability of hardware and cement of primary concern in long-term prosthesis survival. A primary concern is the life expectancy of
I1
Figure 6. Richards compression screw repair of an intertrochanteric fracture. Note that as medial displacement of the fracture has occurred, the tip of the compression screw has moved with the femoral head by sliding laterally through the plate.
the prosthesis in a more active person in whom repetitive impact-loading often leads to failure due to loosening of components (usually the femoral stem) or actual fracture of the femoral component.I3Therefore, procedures in younger patients are often designed to preserve bone while avoiding the placement of a prosthesis and have included cup arthroplasty and arthrodesis. These procedures are rarely considered for elderly patients with arthritis of the hip; total hip arthroplasty is the only procedure of importance in this population. In large series with average follow-up of 12-15 years, 3-14% of arthroplasties show loosening of the femoral component, with 2-4% requiring revision.49Loosening is the primary cause of failure in total hip arthroplasty and probably has its genesis in several factors, all of which relate to the bonelcement i n t e r f a ~ e . ' ~In. ~patients ~ undergoing revision and in autopsy studies, the formation of pannus and/or a true synovium is seen at the bonelcement interface. Although this may represent a primary tissue response to acrylic cement, it may also be the product of thermal damage of bone caused by the exothermic reaction occurring during the polymerization of the cement." As cement techniques improve, long-term failure due to loosening should become less problematic. To avoid the problem of loosening, noncemented prostheses that pro-
mote long-term stability by allowing the ingrowth of bone have been developed. These prostheses have a microporous surface material that is applied to a solid metal stem. Initially, these are "press fit" by reaming the femoral shaft slightly smaller than the prosthesis and then driving the stem into place. Autopsy studies have demonstrated bony ingrowth, but problems have still been identified. Two primary concerns are the failure of the attachment between the surface coatings50and the stem of the prosthesis and loss of strength of the prosthesis due to heating required to fuse the porous material to the stem. These problems are still being investigated, and, at present, the cemented total hip arthroplasty is still the standard procedure. Other problems leading to failure after total hip arthroplasty include fracture of the prosthesis, fracture of the femoral shaft,39penetration of the femoral shaft by the stem, infection, and dislocation and loosening of the acetabular component. All these should be looked for in the patient who develops pain after total hip arthroplasty, although further discussion is beyond the scope of this article. In the great majority of older patients, joint prostheses will remain intact for life and will lead to a substantial improvement in pain and mobility. Whereas overall morbidity and mortality do increase with age, age alone should not preclude surgery, because excellent results can be obtained even into the ninth decade.62.a
PREOPERATIVE EVALUATION Preoperative assessment is dealt with in detail elsewhere in this volume and so will be considered only briefly here. Although careful planning, evaluation, and preoperative training can be accomplished in the patient undergoing elective total hip arthroplasty, it is less possible in patients presenting with hip fracture. In general, early surgical intervention for hip fracture is desirable to reduce the time of immobilization but should not preclude careful medical evaluation and ~tabilization.~.~3 No adverse effect on outcome has been seen with increasing time between fracture and surgical intervention up to 7 days. Proceeding to surgery before medical stabilization leads to poor outcome.43Cardiac risk should be assessed using Goldman's criteria,27and in high-risk patients perioperative Swan-Ganz monitoring may be recommended. Chronic pulmonary disease, a critical factor in intraabdominal and thoracic procedures, is less critical in hip surgery.38Use of peak expiratory flow rate (PEFR) may define a population at risk of pulmonary complications, with 70% mortality reported in patients with PEFR less than 100 Umin and few deaths occurring in patients with PEFR of greater than 200 Umin.24Other medical factors important in perioperative management are control of diabetes,14treatment of underlying infections, and assessment of mental status. Preoperative assessment of mental status is particularly important, as preoperative cognitive impairment is a predictor of postoperative d e l i r i ~ mA. ~preoperative mental status evaluation using a scorable instrument such as the Mini Mental State Examination (MMSE) or the Short Portable Mental Status Questionnaire (SPMSQ) also establishes a baseline that may be valuable in patient assessment when postoperative confusion
occurs. A comprehensive review of medications is also essential. Medications with anticholinergic activity are reported to be the most important factor associated with postoperative delirium.4 Premorbid functional ability, mobility, and social support are also part of the preoperative evaluation and are discussed in the section on rehabilitation and outcome. PERIOPERATIVE COMPLICATIONS With careful management, many complications can be avoided or substantially reduced. Responsibility lies with the entire team and requires close cooperation among the surgeon, the primary physician, nursing st&, and the rehabilitation team. Deep Vein Thrombosis and Pulmonary Emholism Although deep vein thrombosis (DVT) and pulmonary embolism (PE) are the most extensively studied complications of hip surgery, they represent an area where adequate preventive measures have not been universally a d ~ p t e dThe . ~ incidence of DVT in hip fracture patients not receiving prophylaxis has been reported to be 40-60%. Since approximately 20% of patients with DVT can be expected to have at least one pulmonary embolus, the rate of PE in hip surgery patients would be expected to be 10-15%.28 The incidence of fatal PE in these patients is reported to be 2-lo%, making it the single most important cause of postoperative death.2s.55Ultrasonography has replaced venography as the method of choice for diagnosing DVT, having the advantages of portability, lower morbidity, and excellent sensitivity and specificity.3,44.75 Measures to decrease the incidence of DVT have included the use of subcutaneous or intravenous h e p a r i ~ ~external , ~ ~ , ~ pneumatic ~ ,~~ low molecular weight dextran, and compression, p h e n i n d i ~ n ewarfarin,% heparin with dihydroergotamine (DHE).25Even with these prophylactic measures, incidence of DVT in hip surgery remains at about 20%. Current recommendations are for the use of low-dose Coumarin (warfarin) starting the day of surgery with the prothrombin time adjusted to 1.5times cont~-01.~~ With this therapy, no significant increase in postoperative hemorrhagic complications is seen with a 60% decrease in DVT. Significant resistance to the use of anticoagulants still exists. A recent survey of orthopedic surgeons reported that while the majority use some form of DVT prophylaxis, the most commonly used measure is aspirin and 10% used no prophylaxis at alLw Pressure Ulcers In hip fracture patients, it should be recognized that significant pressure necrosis of skin may occur before the patient arrives on the ward but will often take days to develop fully. Tissue damage can occur during long lies prior to receiving medical attention and can be further promoted by the combination of immobility and hard surfaces in ambulances, emergency rooms, and x-ray suites. Twenty to 70%of patients with hip fracture develop
pressure sores, the majority being present by the fifth hospital day.73,74The most common areas dected are in the pelvic girdle and the feet, particularly the sacrum and heels. With pressure ulcers developing after admission to the hospital,74two important environmental factors-41) the firmness of hospital beds in patients immobilized and given narcotic analgesics and (2) inadequately padded operating tables--can lead to necrosis. Identification of at-risk patients using a scorable instrument such as the Norton scale or one of its modification^^^ is important, because this allows special intervention for high-risk patients. Prevention through the routine use of four-inch eggcrate mattresses and heel protectors is effective. These simple preventive measures are extremely cost-effective because pressure ulcers significantly increase length of hospital stay.74 Delirium
Postoperative confusion is a major cause of morbidity in the elderly and usually represents a response to systemic stressors rather than primary central nervous system (CNS) disease.4 Overall, the incidence of postoperative confusion has been reported in 30-50% of patients undergoing surgical management of hip fracture and significantly prolongs length of hospital ~ t a y . ~ , ~ ~ The clinical evaluation of delirium should be directed toward identification of stressors such as medications, underlying infection, fecal impaction, electrolyte shifts, hypoxemia, and myocardial infarction. As mentioned previously, the use of medications with anticholinergic side effects is an important factor for the development of d e l i r i ~ mOf . ~ note, delirium has not been found to be related to the type of anesthesia used or to the duration of the surgical procedure, with a similar incidence seen in patients undergoing general anesthesia with halothane or local epidural block.33~~~ Direct evaluation of the CNS with computed tomographic (CT) scanning, lumbar puncture, or electroencephalography (EEG) is warranted only if meningitis, cerebrovascular accident, or seizure activity is strongly suspected. Delirium is commonly seen on postoperative days 1 to 5 with resolution by day 7.46If no treatable cause can be found, care is supportive with control of psychotic symptoms with low-dose haloperidol to prevent injury. During the period of confusion, patients are at higher risk for developing other complications such as pneumonia, urinary tract infection, and pressure ulcers. Urinary Retention and Urinary Tract Infection
Urinary tract infection (UTI) is reported in 10-20% of hip surgery patients, whereas urinary retention occurs in 28-52%.8.52Reasons for the high frequency of retention are not entirely known, although a primary effect of anesthetic agents and the use of narcotic analgesics postoperatively are postulated as potential causes. The prophylactic use of an indwelling urethral catheter inserted at the time of surgery and retained for 24 hours postoperatively has been shown to decrease the occurrence of retention without affecting the incidence of UTI and can be advocated for routine management.8,52Use of a catheter for more than 48 hours, however, is associated with an increase in UTI.
Other Perioperative Complications Substantial improvement in wound infection rates has been seen since the advent of laminar flow o~erating " suites and the routine use of broad spectrum antibiotics in the perioperative period.58Current recommendations are for the use of a cephalosporin for 48 hours postoperatively. Infection rates at the operative site are still reported to be 1-3%; the majority of these are superficial, with very few affecting bone or hardware. Other complications include postoperative pneumonia, myocardial infarction, and traumatic neuropathy. Neuropathies resulting from traction or pressure injuries to peripheral nerves are seen in less than 1% of patients following hip surgery.61Unlike intraabdominal or intrathoracic procedures, hip surgery presents only a minor increased risk of perioperative pulmonary complications in the patient with chronic pulmonary disease. However, as previously mentioned, PEFR of less than 100 Wmin may define a population at high risk. As with patients undergoing other procedures, individuals being considered for elective hip replacement should be instructed to stop smoking, preferably 8 weeks prior to surgery, and all attempts should be made to treat chronic bronchitis. In the patient considered to have a high cardiac risk, of significant concern is the potential for intraoperative hypotension. In patients undergoing hip surgery, this risk can be related to two factors: (1) the increased incidence of hypotension in patients undergoing spinal anesthesia, and (2)hypotension seen after the introduction of acrylic cement during total hip arthroplasty. In this latter group, significant drop in mean systolic pressure is believed to be due to the introduction of acrylic monomer into the systemic circulation. Recognition of these factors suggests that patients undergoing hip replacement with a cemented prosthesis in whom spinal or epidural anesthesia is planned and who have coronary artery disease represent a population at high risk, requiring more intensive preoperative and intraoperative monitoring.
REHABILITATION Substantial differences in recovery between patients treated for hip fracture and those undergoing elective total hip arthroplasty can be expected. Since the latter group will have better bone stock, better premorbid medical status, a lower incidence of neurologic disorders, and the opportunity for careful preoperative assessment, postoperative functional recovery should be optimal. Also, since elective arthroplasty is being done for a condition that has caused pain and has impaired mobility preoperatively, improved functional capacity is the rule, with good to excellent functional results in 95% of patients at 10 years.4gAlthough this success rate may decline with increasing age at operation, review of the results in patients in their 80s is still positive, with more than 90% of patients returning home and having a good functional result at 2 years.l2 Recovery of patients following hip fracture is less favorable and can often be predicted preoperatively. Risk factors for poor functional outcome include premorbid dementia and poor mobility, intertrochanteric fracture,
and advanced age. Several large series report that of patients surviving one year postfracture, only 50% will achieve prefracture functional status.53 Prefracture Status The most important risk factors are those of premorbid status; prefracture mobility is the strongest predictor of postfracture f ~ n c t i o n . " , ' ~Persons ,~~ with limited ambulation prior to the fracture are unlikely to regain ambulatory status, whereas those who were able to ambulate independently and leave their homes are likely to have a good outcome. Mobility serves as a rough indicator of major organ system function as patients with poor prefracture mobility usually have significant neurologic, cardiovascular, or musculoskeletal problems that will significantly impede rehabilitation. Mental status is also a predictor of outcome, with premorbid dementia being an indicator of poor functional outcome. In one study, patients with decreased mental status preoperatively had only a 25% chance of regaining independent function, whereas 70% of those persons with normal premorbid mental status reached independence. lg Age is also noted to be an independent risk factor in functional recovery and ability to return home postfracture. l2 Premorbid living arrangements are important in predicting ability to return home.lG12 Patients living with others have the greatest chance of returning home, whereas those living alone will often experience a change in living arrangements. Only 50-75% of surviving patients remain independent at one year.30Not surprisingly, patients residing in a nursing home at the time of fracture can be expected to have a poor outcome, with reasonable recovery of functional capacity in only 2 6 3 0 % of cases. Type of fracture is also related to functional recovery; several series report slower and less complete recovery in intertrochanteric fractures as compared with femoral neck fractures. In accordance with this, a comprehensive interdisciplinary team approach to rehabilitating hip fracture patients has been found to have the greatest impact on patients with intertrochanteric fractures, decreasing their hospital length of stay by over 20%.71
THE IMPACT OF PROSPECTIVE PAYMENT The management of elderly hip fracture patients is a complex task in a high-risk population, and cost of acute hospital care is highly variable.' Of great concern is the impact of the Medicare prospective payment system (PPS). Diagnosis related group (DRG) losses are highly dependent on the occurrence of postoperative complications, particularly in patients with significant comorbidity. Alarmingly, hospital charges went from an average of $15,000 in patients without complications to $38,000 when complications occurred, an increase of 150%.56Increasing costs under DRGs has also led to an increasing number of early discharges to community nursing homes, with hospital lengths of stay decreasing by 42% from 21.9 days to 12.6 days The final effect of this early discharge policy since introduction of PPS.21,22 has been a dramatic increase in patients remaining indefinitely in community nursing homes. One third of all patients studied who were alive at one year resided in a community nursing home compared with only 9% prior to
PPS.21,22 It is questioned whether this increase in rate of institutionalization will offset the apparent savings in acute care dollars and underlines the need for nonacute care comprehensive rehabilitation facilities. It also suggests that successful rehabilitation is difficult to achieve in the limited environment of the community nursing home. Whereas it is difficult to measure the cost of PPS in human terms, current data suggest that for hip fracture patients it is substantial. A possible cost-effective alternative to the problem of longterm recovery from hip fracture and its attendant costs has been suggested in the British health care system. One demonstration project showed a similar decline in average length of stay from 22 to 14.6 days through early home discharge with in-home team management of extended postoperative rehabilitation.67 Nearly 70% of all patients admitted from home were able to return home at an average of 14.6 days. Whereas no data are presented on long-term functional recovery, the concept is readily adaptable.
SUMMARY Hip surgery is the most common major orthopedic procedure performed in the elderly. The indications are fracture and pain secondary to degenerative arthritis. Patients undergoing hip replacement for arthritis have excellent outcomes with decreased pain, increased mobility, and a low mortality. Age should not be a contraindication to hip replacement, with patient selection being made on the basis of symptomat~log~ and overall health. In hip fracture, the prognosis is more guarded. Poor functional outcome results from complications of the fracture, such as avascular necrosis of the femoral head and fracture nonunion in femoral neck fractures and instability with delayed weight bearing in intertrochanteric fractures. In addition, patients sustaining hip fracture are more likely to have significant comorbidity and subsequent perioperative complications. Pressure ulcers, delirium, deep venous thrombosis, urinary retention and urinary tract infection, and cardiac events are the most frequent complications seen. These complications can be anticipated and prevented with careful preoperative assessment and postoperative prophylactic management. A team approach including the orthopedic surgeon, primary care physician, nursing st&, and physical therapists is essential for optimal outcome.
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