This article is more than 5 years old. Information may no longer be current.
Team postop care approach vital for patients with fragility fractures
Orthopaedists must prioritize older osteoporotic patients’ fracture care with overall needs.
Click Here to Manage Email Alerts
TORONTO — Well-planned preoperative and postoperative care designed to manage the overall medical needs of elderly patients with fragility fractures is just as important as good surgical care, according to one British orthopaedic surgeon.
When elderly patients present with fracture, they often have comorbid conditions, said David Marsh, FRCS, professor of clinical orthopaedics at Royal National Orthopaedic Hospital in Stanmore, England.
“The first step is keeping the patient alive, for hip fracture is a life-threatening condition,” Marsh said at the International Osteoporosis Foundation World Congress of Osteoporosis.
Not surprisingly, “These patients often present with severe systemic disease in addition to their fracture. But rather than rushing them to the operating room on the day of the fracture or day after the fracture, we should work with the other members of the treatment team” to treat a concomitant heart problem or improve their lung or kidney function.
If there are no comorbid conditions and patients are medically fit, the orthopaedist should strive to perform surgery within 24 hours of the injury occurring, Marsh said.
Rehabilitation offers gains
He said postoperative rehabilitation is a necessary step to minimize the potential for another fracture. Ideally, patients should be followed in an orthogeriatrics unit to ensure proper rehabilitation and increase the opportunity for early mobilization.
“This is why it is important for orthopaedic surgeons and geriatricians to sit in on meetings together and talk about the management of elderly fracture patients,” said Marsh, a co-author of guidelines for care of fragility fracture patients, published by the British Orthopaedic Association. “The acute care comes from the skills of the surgeon, but rehabilitation and prevention of further fracture becomes a multidisciplinary effort.”
An International Ambassador for the Bone and Joint Decade, Marsh said that osteoporosis is largely untreated in most health systems when patients present with fracture.
“In every country, in most fracture units, the fractures are treated and osteoporosis is ignored and the patients are discharged,” Marsh said. “It’s the orthopaedic surgeon’s responsibility to make sure his patients are coming into a system where, by one mechanism or another, they will all get assessed for osteoporosis and treated if necessary and assessed for the tendency to fall. The biggest predictor of having a fragility fracture is having had one already.”
More preventive measures
Patients should also strive to get sufficient vitamin D and calcium, avoid smoking and minimize alcohol intake. Performing weight-bearing exercises is also an important preventive step, he said.
Likewise, bisphosphonates should be administered to patients who are at least 75 years old and have had a fragility fracture, Marsh said. They can also be administered to younger patients who sustain fracture, depending on their bone mineral density measurement (ie, T score less than –2.5), he said.
Whether fractures in the elderly are osteoporotic or nonosteoporotic, the healing process is prolonged compared to fractures in younger patients, Marsh added.
Consequently, there is a need for joint implants that can optimize the functional result from acute fracture management. Those implants may be augmented with biologic agents.
“Our fixation devices have to last longer and secure bone for a longer period of time as healing takes place in elderly patients who sustain a fracture,” Marsh said.
Marsh also said that most of the implants that are available today were designed for young bone. Consequently, “A lot more needs to be done to accelerate fracture healing in the elderly, such as focusing on new molecules, cells and electrical stimulation.”
For more information:
- Marsh D. Post-fracture management. Presented at the IOF World Congress on Osteoporosis. June 2-6, 2006. Toronto.