Home | Business News | Browse by Publication | T | The Journal of Musculoskeletal Medicine

Managing hip fractures in older patients: perioperative decision making: each patient's functional goals are critical factors.

Article Excerpt
ABSTRACT: Hip fractures in older patients are projected to increase in frequency as the US population continues to age. A thorough history and physical examination is essential. The initial workup should include radiographic imaging. Operative stabilization is the treatment of choice for most femoral neck or intertrochanteric hip fractures. The goals should be to achieve a stable reduction to allow for early patient mobilization, restore the patient's preinjury level of function, and minimize the risk of medical complications. Postoperative complications are associated with mortality and diminished return of function. All patients with hip fractures should receive perioperative deep venous thrombosis chemoprophylaxis, unless it is contraindicated. A multidisciplinary approach to postoperative rehabilitation can shorten the inpatient stay and decrease the mortality rate.

This is the seventh in a special series of articles, invited to celebrate our 25th anniversary of publication, in which leading physicians discuss the key points of clinical decision making for common musculoskeletal problems, particularly in the primary care setting.

Hip fractures in older patients are associated with significant morbidity and mortality. They occur most frequently in these patients and are projected to increase in frequency as the US population continues to age.

A thorough history and physical examination is essential to ensure that medical management of comorbidities before surgical intervention is optimized and to evaluate other potential injuries associated with the inciting event. The patient's functional and social status should be assessed to help predict and plan the clinical outcome. Each patient's functional goals are critical factors in surgical decision making; these goals should be considered by the patient, his or her family, the primary care physician, and the surgeon. In determining the ideal setting for reaching rehabilitation goals, coordination between a social worker, case manager, physiatrist, and the patient and his family is invaluable.

In older patients, we perform operative fixation with screws in nondisplaced fractures and either hemiarthroplasty or total hip arthroplasty in displaced fractures; in younger patients, we attempt closed or open reduction and operative fixation in almost all fractures. We avoid use of a hemiarthroplasty or total hip arthroplasty in younger patients because they probably will outlast the life span of the implant and subsequently require revision surgery (or surgeries). The younger and more active the patient, the more likely (and earlier) he will wear out his prosthesis and require a revision,which will result in less bone stock with each subsequent surgery. Therefore, we attempt operative fixation after reduction in almost all younger patients.

In this article, we describe the epidemiology of hip fractures in older patients, the medical evaluation, and the surgical options and risk factors. We also discuss the postoperative complications and rehabilitation.

EPIDEMIOLOGY

About 250,000 hip fractures occur in the United States each year at an annual cost of about $9 billion. (1) Based on conservative assumptions, the population of US persons 65 years and older is projected to grow to 78 million in the year 2050 from 35 million in 2000 (1); accord

ingly, the incidence of hip fractures is expected to double by 2050. (2)

Trochanteric hip fractures represent almost half of proximal femur fractures; the female-to-male ratio ranges...

View this article FREE - Now for a Limited Time, try Goliath Business News
Free for 3 Days!