Fractures of the Proximal Femur: Improving Outcomes [1 ed.] 9780323315357, 9781437736311, 9781437706956, 2010029515

Table of contents :
Copyright
Contents
Contributors
Preface
Foreword
Epidemiology/Population Studies: Scope of the Problem
Frailty
Falls and Fractures
After the Fracture
Summary
References
Skeletal Assessment of Fractures of the Proximal Femur
Radiologic Evaluation
Computed Tomography
Magnetic Resonance Imaging
Bone Scan
Special Types of Fractures
Avulsion Fractures
Pathologic Fractures
Stress Fractures
Summary
References
General Assessment and Optimization for Surgery
Medical Assessment of a Patient with a Hip Fracture
Epidemiology and Outcome
Perioperative Complications
Optimal Timing of Surgery
Does Delay to Hip Fracture Repair Result in Worse Outcomes?
Determinants of Perioperative Risk
Surgery-Specific Risk
Patient-Specific Risk: Acute Derangements in Physiology and Homeostasis
Patient-Specific Risk: Acute Derangements of the Cardiovascular System
Cardiac Risk Assessment
Cardiac Risk Optimization
Coronary Revascularization
Beta-Blockers
Alpha-2 Agonists
Statins
Valvular Heart Disease
Etiology of the Fracture
Fall Resulting in Hip Fracture
Pulmonary Risk Assessment and Optimization
Diabetes Management and Optimization
Liver Disease Assessment and Optimization
Perioperative Renal Dysfunction and Optimization of the Patient with Renal Disease
Dementia and Delirium
Prevention of Venous Thrombosis and Thromboembolism
Anticoagulant Management
Antiplatelet Agent Management
Summary
References
Regional versus General Anesthesia for Fractures of the Proximal Femur
General Anesthesia
Preoperative Preparation
Technique
Benefits
Risks
Regional Anesthesia
Options
Techniques
Benefits
Contraindications
Risks
Special Considerations
Postoperative Cognitive Dysfunction
Time and Cost Issues
Summary
References
Improving Pain Management and Patient Outcomes Associated with Proximal Femur Fractures
Pain, Acute Pain, and the Prevention of Chronic Pain
Multimodal Balanced Analgesia
Undertreatment of Pain
During Hospitalization
After Hospital Discharge
Assessment of Pain
Multidimensional Tools
Unidimensional Tools
Observational (Behavioral) Tools in Elderly Patients with Cognitive Impairment
Pharmacotherapy: Drugs Commonly Used in Multimodal Analgesia
Acetaminophen
Nonsteroidal Anti-inflammatory Drugs
Duration of Action and Potency
Cardiovascular Risk
Bone Healing
Gastrointestinal Complications
Optimization in Pain Control
Opioid Therapy
Underuse and Underdosing in Pain Control
Opioid Receptors
Morphine
Codeine
Hydromorphone
Oxycodone
Meperidine
Fentanyl
Methadone
Tramadol
Mixed Agonist-Antagonist Opioids and Partial Agonist Opioids
Naloxone
Oral and Parenteral Delivery Routes
Use of Patient-Controlled Analgesia and “Given When Needed” Analgesia
Elderly Patients and Opioid Drugs
Complication Limiting Opioid Use
Delirium and the Undertreatment of Pain
Opioid-Induced Respiratory Depression
Monitoring for Respiratory Depression
Use of Naloxone
Gabapentin and Pregabalin
Regional Anesthesia and Pain Control
Fascia Iliaca Block
Femoral and Lumbar Plexus (Psoas Compartment) Blocks
Neuraxial Opioid and Morphine Sulfate Extended-Release Liposome Injection (DepoDur)
Optimizing Pain Management
References
Femoral Neck Fractures: Reduction and Fixation
Defining the Injury
Classification
Historical Background
Classification System of Garden
Classification System of Pauwels
AO Classification
Classification System of Linton
Diagnosis
Conventional Radiography
Advanced Imaging
Treatment Options
Nonoperative Treatment
Operative Treatment
Nondisplaced Femoral Neck Fractures
Displaced Femoral Neck Fractures
Fixation Options
Internal Fixation with Multiple Cancellous Lag Screws
Internal Fixation with Sliding Hip Screw Devices
Reduction Techniques
Closed Reduction
Open Reduction
Fixation Techniques
Cannulated Screw Fixation
Dynamic Hip Screw Fixation
References
Femoral Neck Fractures: Arthroplasty
Indications
Examination
Imaging
Treatment Options
Surgical Technique
Anesthesia and Positioning
Exposure of the Femoral Neck and Removal of the Femoral Head
Acetabular Preparation
Femoral Preparation
Implantation
Wound Closure
Postoperative Considerations
References
Combined Fractures of the Hip and Femoral Shaft
Incidence
Mechanism of Injury and Pathophysiology
Initial Diagnosis and Assessment
Management Options and Controversies
Improving Outcomes
Areas of Uncertainty
Should a Displaced Femoral Neck Fracture Be Fixed before Fixation of the Femoral Shaft?
What Type of Implant Should Be Used for the Femoral Shaft Fracture?
Do Cephalomedullary Nails Provide Improved Fixation?
Complications
Summary
References
Femoral Neck Fractures:
Treatment of Nonunion
Diagnosis and Preoperative Considerations
Salvage Procedures
Proximal Femoral Valgus Osteotomy for Femoral Head Preservation
Bone Grafting for Femoral Neck Fracture Nonunion
Total Hip Arthroplasty for Femoral Neck Fracture Nonunion
Summary
References
Trochanteric Fractures: Sliding Hip Screw
History
Construction and Biomechanics
Indications
Classification of Trochanteric Fractures
Clinical Relevance
Revised Concept of Instability of Pertrochanteric Fractures
Comparison of Sliding Hip Screw and Intramedullary Hip Nail
Biomechanics
Surgical Technique
Biologic Benefits
Comparative Clinical Studies
Preoperative Planning
Radiologic Examination
Contraindications
Selection
Surgical Technique
Patient Positioning on the Fracture Table
Positioning of the Image Intensifier
Reduction
Final Radiologic Preoperative Assessment
Draping
Approach
Fracture Fixation
Wound Closure
Postoperative Management
Specific Complications
References
Trochanteric Fractures: Intramedullary Devices
Aims of Treatment
Rationale for Intramedullary Nailing of Extracapsular Hip Fractures
Indication and Fracture Types
Ao/Ota 31A1
Ao/Ota 31A2
Ao/Ota 31A3
Operative Technique
Positioning
Reduction
Closed and Percutaneous Reduction Techniques
Gaining Control of Flexion Dislocation
Control of Varus Angulation
Open Reduction
Skin and Fascial Incision
Nail Entry Point
Lag Screw Positioning
Interfragmentary Compression
Static or Dynamic Mode
Distal Locking
Intramedullary Nails in Segmental Fractures
Postoperative Management
Implant Removal
Pitfalls of Intramedullary Devices
Cephalomedullary Nails with a Single Interlocking Screw
Cephalomedullary Nails with a Lag Screw and an Antirotation Screw or Pin
Next-Generation Cephalomedullary Nails
Summary
References
Complications of Trochanteric Fractures
Overview of Complications
Intraoperative Complications
Complications During Surgical Wound Healing
Complications During Fracture Healing
Complications Developing or Persisting After Surgical Site or Fracture Healing
Inadequate Reduction
Injury of Pelvic Vessels by Guidewire
Incorrect Position of the Lag Screw in the Femoral Head
Rotation of the Femoral Head During Insertion of the Lag Screw
Incorrect Length of the Lag Screw
Problems During Nail Insertion
Problems with Distal Locking
Problems with the Instrumentation Set
Wound Healing Disturbances and Infection
Causes
Prevention
Treatment
Mechanical Failure of Internal Fixation
Causes
Levels of Mechanical Failure
Proximal Level
Fracture Level
Distal Level
Prevention
Treatment
Collapse of Fragments and Medial Displacement of the Femoral Shaft
Central Perforation of the Femoral Head by the Lag Screw
Migration and Intrapelvic Protrusion of the Lag Screw
Necrosis of the Femoral Neck
Delayed Union, Nonunion, and Malunion
Leg Length Discrepancy
Postoperative Fracture of the Femoral Shaft
Subcapital Fracture of the Femoral Neck
Thigh Pain
Abductor Pain
Injuries to Femoral Vessels
Type of Fracture
Mechanism of Injury
Time to Development
Clinical Diagnosis
Imaging Methods
Prevention
Treatment
Avascular Necrosis of the Femoral Head
Incidence
Causes
Risk Factors
Time to Development
Classification and Stage of Development
Diagnosis
Prevention
Treatment
References
Subtrochanteric Fractures: Intramedullary Fixation
History
Küntscher Y-Nail, Detensor
Zickel Nail
Russell-Taylor Nail
Gamma Nail
Gliding Nail, Proximal Femoral Nail, Proximal Femoral Nail Antirotation, Targon-PF
Letzius Nail
Küntscher Condylocephalic Nail
Ender Nailing
Classification
Boyd and Griffin
Fielding and Magliato
Zickel
Seinsheimer
Waddell
Russell and Taylor
Ao/Ota
Preoperative Planning and Choice of Implant
Operative Technique
Patient Positioning
Fracture Reduction
Surgical Approach
Entry Point
Preparation of the Medullary Canal
Nail Insertion
Lag Screw Insertion
Distal Screw Locking
Wound Closure
Follow-up Care and Physical Therapy
Common Surgical Errors
Incorrect Reposition
Trochanteric-Diaphyseal Distraction
Incorrect Introduction of the Nail
Nail Incarceration
Fracture of the Lateral Cortex of the Femur
Fracture of the Femoral Shaft by the Nail
Incorrect Position and Length of Lag Screws
Problems with Distal Locking
References
Subtrochanteric Fractures: Plate Fixation
Epidemiologic, Anatomic, and Biomechanical Overview
Classifications and Stability
AO Classification
Russell-Taylor Classification
Seinsheimer Classification
Waddell Classification
Therapeutic Plate Options
95-Degree Condylar Plate
95-Degree Dynamic Condylar Screw
135-Degree Compression Plates (Dynamic Hip Screw)
Complications and Pitfalls
95-Degree Condylar Plate
95-Degree Dynamic Compression Screw
135-Degree Dynamic Hip Screw
Salvage Procedures
Outlook
References
Deep Vein Thrombosis and Thromboembolism: Prevention and Treatment in Hip Fracture Patients
Incidence
Fatal Pulmonary Embolism
Symptomatic Venous Thromboembolism
Pathogenesis
Hypercoagulability
Venous Stasis
Endothelial Damage
Prophylaxis
General Measures
Early Mobilization
Neuraxial Anesthesia
Mechanical Methods
Graduated Compression Stockings
Intermittent Pneumatic Compression Devices
Foot Pumps
Chemical Methods
Aspirin
Warfarin
Low-Molecular-Weight Heparins
Pentasaccharide
Direct Anti-Xa Inhibitors and Direct Thrombin Inhibitors
Combined Methods
Duration of Use
Guidelines
Summary
References
Investigation and Management of Postoperative Delirium
Definition
Epidemiology
Pathophysiology
Diagnosis
Risk Factors
Preexisting Patient Factors
Intraoperative Factors
Postoperative Factors
Prevention
Management
Summary
References
Rehabilitation: Improving Outcomes for Patients Following Fractures of the Proximal Femur
Issues in Rehabilitation Care for Patients with a Fracture of the Proximal Femur
Patient Characteristics
Health Care Services Issues
Cost of Care
Reframing Rehabilitation Across the Health Care Continuum
SIGN Guidelines for the Prevention and Management of Hip Fracture in Older Persons
“Blue Book” for the Care of Patients with Fragility Fractures
Total Joint Network Integrated Model of Care
Model of Care for Patients with a Hip Fracture
Principles of Optimized Rehabilitation Care
Access and Patient Flow Across the Health Care Continuum
Timely Surgery
Transition Between Services
Discharge Planning
Optimal Clinical Practice
Surgery to Maximize Functioning
Optimal Medical Care
Clinical Pathways
Management of Delirium, Dementia, and Depression
Delirium
Dementia
Depression
Screening and Management of the Three Ds
Functional Activity
Early Mobilization
Weight-bearing Status
Rehabilitation Scheduling
Considerations for Those with Frailties or Cognitive Issues
Community Care
Secondary Prevention
Osteoporosis
Falls Prevention
Performance Measurement and Model Implementation
Performance Measurement
Model Implementation
Summary
References
Preventing the Second Hip Fracture: Addressing Osteoporosis in Hip Fracture Patients
Patient Profile
Fracture Risk Assessment
Determinants of Future Fracture Risk
Advanced Age
Prior Fragility Fracture
Tendency to Fall
Vitamin D Insufficiency or Frank Deficiency
Secondary Osteoporosis
Bone Mineral Density
Does the Elderly Patient with Hip Fracture Require Bone Mineral Density Testing for Osteoporosis to be Optimally Managed?
Components of an Effective Osteoporosis Care Strategy
Correction of Vitamin D Insufficiency or Deficiency
Calcium Supplementation
Falls Prevention
Bone Mineral Density Testing
Education and Motivation of the Patient
Pharmacologic Treatment
Adherence to Osteoporosis Treatment
Involvement of Different Specialties
Barriers to Osteoporosis Care
Patient-Related Barriers
Advanced Age
Cognitive Impairment
Comorbidity
Polypharmacy
Patient Frailty and Social Isolation
Physician Barriers
System Barriers
Cost and System of Remuneration
Postfracture Care Environment
Systems Approach to the Management of Osteoporosis
What Is the Role of the Orthopaedic Surgeon?
Summary
References
Best Surgical Practices
Overview
Optimal Surgical Tactic
Postoperative Weight Bearing
Surgical Strategies
Intracapsular Hip Fractures
Overview
Femoral Neck Fractures: Definitions
Stable Femoral Neck Fractures Should be Fixed
Unstable Femoral Neck Fractures: Replacement
Versus Fracture Fixation
Fracture Fixation Tips, Tricks, and Controversies
Reduction.
Fixation.
Replacement.
Extracapsular Fractures
Overview of Surgical Strategies
Pertrochanteric Fractures with Intact Lateral Cortex (Types 31A1 and 31A2)
Type 31A1 Fractures
Type 31A2 Fractures
Fracture Fixation Tips, Tricks, and Controversies
Dynamic Compression
Bridging Fixation
Replacement
Pertrochanteric Fractures with Lateral Cortical Fracture (Type 31A3)
Fracture Fixation Tips, Tricks, and Controversies
Compression
Bridging Fixation
Replacement
Subtrochanteric Fractures
Summary
References
Best Rehabilitation Practices
Overview
Organizing Rehabilitation Services
Definition of Rehabilitation
Rehabilitation Setting
Rehabilitation Program
Bridging the Health Care Continuum
Direct Home with Outpatient Care
Free-standing Rehabilitation Hospital or Acute Care Hospital with an Inpatient Rehabilitation Unit Inpatient Rehabilitation ...
Inpatient Rehabilitation Services: Guidelines for Common Medical Issues Encountered During Rehabilitation
Delirium
Medical Comorbidities
Cognitive Impairment and Dementia
Diagnosis of Dementia
Management of Dementia
Pain Management
Psychiatric and Psychological Issues
Inpatient Rehabilitation Services and Interprofessional Care: Concept and Guidelines for Common Rehabilitation Issues
Early Mobilization
Therapy in the Nonoperative Group
Therapy in the Postoperative Group
Functional Performance
Discharge Planning
Environmental Assessment
Social Support Assessment
Community Reintegration
Ongoing Interprofessional Care
Prevention of Falls
Prevention of Falls in the Community
Prevention of Falls in Care Homes
Prevention of Fractures: Osteoporosis
Functional Independence Measure Score
Summary
References

Citation preview

Fractures of the Proximal Femur: Improving Outcomes

Fractures of the Proximal Femur: Improving Outcomes James P. Waddell, MD, FRCSC Professor of Orthopaedic Surgery University of Toronto School of Medicine Division of Orthopaedic Surgery St. Michaels Hospital Toronto, Ontario Canada

1600 John F. Kennedy Blvd. Ste 1800 Philadelphia, PA 19103-2899

Fractures of the Proximal Femur: Improving Outcomes ISBN: 978-1-4377-0695-6 Copyright © 2011 by Saunders, an imprint of Elsevier Inc. All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any means, electronic or mechanical, including photocopying, recording, or any information storage and retrieval system, without permission in writing from the publisher. Details on how to seek permission, further information about the Publisher’s permissions policies and our arrangements with organizations such as the Copyright Clearance Center and the Copyright Licensing Agency, can be found at our website: www.elsevier.com/permissions. This book and the individual contributions contained in it are protected under copyright by the Publisher (other than as may be noted herein).

Notice Knowledge and best practice in this field are constantly changing. As new research and experience broaden our understanding, changes in research methods, professional practices, or medical treatment may become necessary. Practitioners and researchers must always rely on their own experience and knowledge in evaluating and using any information, methods, compounds, or experiments described herein. In using such information or methods they should be mindful of their own safety and the safety of others, including parties for whom they have a professional responsibility. With respect to any drug or pharmaceutical products identified, readers are advised to check the most current information provided (i) on procedures featured or (ii) by the manufacturer of each product to be administered, to verify the recommended dose or formula, the method and duration of administration, and contraindications. It is the responsibility of practitioners, relying on their own experience and knowledge of their patients, to make diagnoses, to determine dosages and the best treatment for each individual patient, and to take all appropriate safety precautions. To the fullest extent of the law, neither the Publisher nor the authors, contributors, or editors assume any liability for any injury and/or damage to persons or property as a matter of products liability, negligence or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in the material herein.

Chapter 10, “Trochanteric Fractures: Sliding Hip Screw,” and Chapter 12, “Complications in Trochanteric Fractures,” by Jan Bartonícˇek. Jan Bartonícˇek retains copyright to text. Library of Congress Cataloging-in-Publication Data Fractures of the proximal femur : improving outcomes / [edited by] James P. Waddell. -- 1st ed. p. ; cm. Includes bibliographical references. ISBN 978-1-4377-0695-6 (pbk. : alk. paper) 1. Femur--Fractures. I. Waddell, J. P. (James P.) [DNLM: 1. Femoral Fractures--surgery. 2. Hip Fractures--surgery. WE 855] RD560.F73 2011 617.1'58--dc22 2010029515

Acquisitions Editor: Kim Murphy Developmental Editor: Joan Ryan Publishing Services Manager: Anne Altepeter Team Manager: Radhika Pallamparthy Senior Project Manager: Doug Turner Project Manager: Preethi Varma Designer: Louis Forgione Printed in People’s Republic of China Last digit is the print number: 9

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Contributors

Jan Bartonícˇek, MD Professor of Orthopaedic Surgery Orthopaedic Department Third Faculty of Medicine Charles University and University Hospital Královské Vinohrady Prague, Czech Republic Peter Biberthaler, MD Associate Professor Consultant Trauma and Orthopedic Surgery Department of Surgery—Downtown Ludwig-Maximilians-University Munich Munich, Germany Earl R. Bogoch, MD, FRCSC Medical Director, Mobility Program Li Ka Shing Knowledge Institute and the Mobility Program Clinical Research Unit St. Michael’s Hospital; Professor Department of Surgery University of Toronto Toronto, Ontario, Canada Bok Man Chan, MBBS, FRCPC Director, Acute Pain Management Pain Management Service Department of Anaesthesia St. Michael’s Hospital Toronto, Ontario, Canada Angela M. Cheung, MD, PhD, FRCPC Associate Professor Divisions of General Internal Medicine and Endocrinology Department of Medicine; Director Centre of Excellence in Skeletal Health Assessment Joint Department of Medical Imaging; Director University Health Network Osteoporosis Program University of Toronto Toronto, Ontario, Canada

Judy Ann David, MD, Dip NB Associate Professor Physical Medicine and Rehabilitation Tamilnadu Dr. MGR Medical University Chennai, Tamilnadu, India; Associate Professor Physical Medicine and Rehabilitation Christian Medical College Hospital Vellore, Tamilnadu, India Pavel Douša, MD, PhD Assistant Professor Orthopaedic and Traumatology Department Third Medical School Charles University; Orthopedist University Hospital Králoské Vinohrady Prague, Czech Republic Victoria I.M. Elliot-Gibson, MSc Research Coordinator Li Ka Shing Knowledge Institute and the Mobility Program Clinical Research Unit St. Michael’s Hospital Toronto, Ontario, Canada John F. Flannery, MD, FRCPC Medical Director MSK Rehabilitation Program Toronto Rehabilitation Institute Toronto, Ontario, Canada; Consultant Physiatrist University Health Network Mount Sinai Hospital and St. John’s Rehabilitation Hospital Toronto, Ontario, Canada Dagmar K. Gross, MSc President MedSci Communications & Consulting Co. Glace Bay, Nova Scotia, Canada

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Contributors

Gordon A. Higgins, BSc, MBChB, MRCS (Eng), FRCS (Tr & Orth) Orthopaedic Consultant Torbay Hospital South Devon Healthcare NHS Foundation Trust; Chief, The Torbay Hip and Knee Clinic Lawes Bridge, Torquay, United Kingdom

Janet E. Legge McMullan, RN, BScN, MN Project Director Holland Orthopaedic and Arthritis Centre Sunnybrook Health Sciences Centre Implementation Branch, Access to Care Wait Times Ontario Ministry of Health and Long-Term Care Toronto, Ontario, Canada

Aaron Hong, BSc, MSc, MD, FRCPC Staff Anesthesiologist Department of Anesthesia St. Michael’s Hospital University of Toronto Toronto, Ontario, Canada

Mirek M. Otremba, MD, BSc, FRCPC Assistant Professor of Medicine University of Toronto; Director Medical Consultation Service Mount Sinai Hospital Toronto, Ontario, Canada

Hans J. Kreder, MD, MPH, FRCSC Professor University of Toronto Orthopaedic Surgery and Health Policy Management and Evaluation; Chief, Holland MSK Program; Marvin Tile Chair & Chief Division of Orthopaedic Surgery Sunnybrook Health Science Center Toronto, Ontario, Canada Florian Kutscha-Lissberg, MD Trauma Consultant Department of Trauma Surgery Medical University of Vienna Vienna, Austria

Dawn H. Pearce, MD, FRCPC Musculoskeletal Radiologist Department of Radiology St Michael’s Hospital Toronto, Ontario, Canada Patrick Platzer, MD Trauma Consultant Department of Trauma Surgery Medical University of Vienna Vienna, Austria Tania Di Renna, MD Department of Anesthesiology The Ottawa Hospital Ottawa, Ontario, Canada

Paul R.T. Kuzyk, BSc (Eng.), MASc, MD, FRCSC Clinical Fellow Division of Orthopaedics Department of Surgery University of Toronto Toronto, Ontario, Canada

Andreas H. Ruecker, MD Lead Senior Consultant Trauma, Hand and Reconstructive Surgery University Hospital Hamburg—Eppendorf Hamburg, Germany

Peter Leung, MD, FRCPC Director, Chronic Pain Management Pain Management Service Department of Anaesthesia St. Michael’s Hospital Toronto, Ontario, Canada

Emil H. Schemitsch, MD, FRCSC Head Division of Orthopaedic Surgery St. Michael’s Hospital; Professor of Surgery University of Toronto Toronto, Ontario, Canada

Rhona McGlasson, BScPT, MBA Project Director Holland Orthopaedic and Arthritis Centre Sunnybrook Health Sciences Centre Implementation Branch, Access to Care Wait Times Ontario Ministry of Health and Long-Term Care Toronto, Ontario, Canada

Gerhild Thalhammer, MD Trauma Consultant Department of Trauma Surgery Medical University of Vienna Vienna, Austria

Contributors

James P. Waddell, MD, FRCSC Professor of Orthopaedic Surgery University of Toronto School of Medicine Division of Orthopaedic Surgery St. Michaels Hospital Toronto, Ontario, Canada Michael G. Walsh, MD Assistant Professor Epidemiology and Biostatistics School of Public Health State University of New York, Downstate Brooklyn, New York David Warwick, MD, BM FRCS, FRCS(Orth) Consultant Orthopaedic Surgeon Reader in Orthopaedic Surgery University of Southampton Southampton, United Kingdom Keith Winters, MD, FRACS Clinical Fellow Foot and Ankle Reconstruction Royal Bournemouth Hospital Bournemouth, Dorset, United Kingdom

Camilla L. Wong, MD, MHSc, FRCPC Geriatrician Assistant Professor Adjunct Scientist Division of Geriatrics University of Toronto Li Ka Shing Knowledge Institute St. Michael’s Hospital Toronto, Ontario, Canada Joseph D. Zuckerman, MD Professor and Chairman Surgeon-in-Chief Department of Orthopaedic Surgery NYU Hospital for Joint Diseases NYU Langone Medical Center New York, New York

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Preface

A hip fracture is a life-changing event, not only for the patient but also for their family, friends, and companions. It is increasingly recognized that hip fractures pose not only a personal cost but also a significant societal cost because of the morbidity and mortality that tends to accompany fractures of the proximal femur. For too long the emphasis on hip fracture management has been exclusively surgical. Though no one disputes that a well-performed operation is essential for patient recovery, there are many aspects of hip fracture care that need to be addressed in order to maximize the outcome for the patient. This book attempts to address these other significant issues while providing the most current recommendations regarding the surgical management of fractures of the proximal femur. In this text we define the scope of the problem and then detail for the reader the most current information regarding the prevention and treatment of osteoporosis. Orthopaedic surgeons have an obligation to learn more about osteoporosis and become actively engaged in the treatment of patients who have this condition and come

to their attention as a consequence of a proximal femoral fracture. In addition, we address the appropriate medical assessment of these patients and provide insight into current methods for treatment of the common comorbidities found in these older patients. Radiology, anesthetic techniques, and postoperative pain management are all addressed in separate chapters. Detailed surgical techniques for femoral neck fractures, intertrochanteric fractures, and subtrochanteric fractures are provided in a comprehensive fashion and are illustrated by diagrams, photographs, and radiographs. The important aspects of postoperative management— including common postoperative complications, delirium, and dementia—are all covered as well, as is a structured rehabilitation program. I believe that this book is the most comprehensive text currently available for hip fracture management and that, by implementing the recommendations contained herein, outcomes for proximal femoral fractures indeed will be improved. James P. Waddell, MD, FRCSC

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Foreword

Dr. Waddell has devoted a career spanning more than 35 years to the study of the best methods of treating hip fractures to improve patient outcome. His personal investigative efforts have covered the full gamut of hip fractures, including femoral neck fractures, intertrochanteric hip fractures, subtrochanteric hip fractures, and associated variants. He has personally analyzed, both in the laboratory and in the clinical setting, optimum biomechanical and clinical methods of stabilizing these fractures or treating them with arthroplasty. This career-long effort now culminates in the comprehensive book Fractures of the Proximal Femur. Dr. Waddell and his 30 authors have provided the orthopaedic community with a comprehensive treatise on the most recent advances in hip fracture epidemiology, preventative strategies, surgical techniques, osteoporosis diagnosis and treatment, and comprehensive rehabilitation strategies. The authors, who are primarily mid career, have significant clinical experience and bring an academic focus to the area. This provides readers with thoroughly researched and referenced chapters on the various types of hip fractures and their optimum treatment.

With the current North American burden of hip fracture of approximately 400,000 per year predicted to escalate to 500,000 per year by 2020, this effort is timely. This book is appropriate for trainees who are attempting to understand the basics of these principles and the experienced community surgeons who are in the trenches and managing these fractures on a daily basis. The balanced approach is to be commended because it provides the reader with a comprehensive understanding of the mechanisms of injury and the pathology of frailty, as well as optimum methods of osteoporosis diagnosis and treatment following hip fracture and ideal rehabilitative strategies. Clearly, hip fracture most often occurs in the setting of aging with diminishing strength and balance and deteriorating bone quality. It is important for the orthopaedic surgeon to focus as much on these issues as on the optimization of surgical treatment. This book is a welcome contribution to any orthopaedic library, will be widely read and cited, and will be a lasting tribute to Dr. Waddell’s devotion to improving patient care for individuals with hip fracture. Marc F. Swiontkowski, MD TRIA Orthopaedic Center Minneapolis, Minnesota

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Michael G. Walsh and Joseph D. Zuckerman

Epidemiology/Population Studies: Scope of the Problem Frailty 3 Falls and Fractures

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Hip fracture represents a tremendous burden on the health care system and public health in general. More than 320,000 people were admitted to hospitals for hip fracture in 2004 in the United States.1 In 1996, the Centers for Disease Control and Prevention estimated the annual cost of hip fracture to be $2.9 billion.2 Today, by some estimates that include all direct and indirect costs, it is as high as $12 billion.3 Even more strikingly, in 1990 it was projected that by 2040 there will be between 530,000 and 840,000 incident cases of hip fracture per year in the United States.4 From an economic perspective, the cost of hip fracture is tremendous. The morbidity and mortality secondary to hip fracture are equally astounding. Roughly 20% of patients who have hip fracture, or 1 in 5, will die in the year following the fracture,5 and most of these patients will die in the first months of recovery.6 Disability increases substantially following hip fracture and is such that the attendant musculoskeletal dysfunction puts the patient at even higher risk for a second fracture or multiple fractures. To understand the scope of hip fracture outcomes, it is necessary to begin with an understanding of the precursors to the fracture itself. A risk profile is built as an amalgam of physical structure and function and the patient’s environment. This profile encompasses both a syndromic and an event, or outcome, framework, which will ultimately map the individual through the states of frailty and falling to fracture and fracture outcomes sequelae.

Frailty Frailty represents a syndrome and therefore is recognized as a cluster of symptoms.7 The syndrome is expressed as diminished physiologic reserve, which is characterized by

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After the Fracture 7 Summary 10

gait and balance abnormality, weight loss, muscle weakness, loss of energy, and diminished physical activity.7–10 Frailty is a serious public health burden because the syndrome is associated with increased risk of falls, low-velocity fractures, significant disability, and mortality.11 Indeed, these sequelae often follow this course directly as a chain reaction. Moreover, the syndrome components are generally highly correlated and interactive. For example, physical inactivity leads to increased muscle weakness and diminished gait performance, which in turn make physical activity, ambulation in particular, more difficult. This aggregation of risk through cumulative causal pathways hastens the progression of frailty and leads to more substantive disability, which may be directly related to, or entirely independent of, a traumatic event (e.g., hip fracture). Central to a conceptual framework for frailty, and by extension hip fracture outcomes, is physiologic reserve. The extent to which one can recover following physical insult or stress is an indication of one’s physiologic reserve and is mediated by aging, physical activity, comorbidity, affect, and cognitive functioning. Individual reserve declines naturally with age, but aging alone is not sufficient for pathologically depleted physiologic reserve. Therefore, frailty is essentially an inability to (1) respond to environmental challenge and (2) recover from injury or disease. As such, because it is characterized by degraded physiologic reserve, frailty not only increases risk of fracture by increasing risk for falling and response to falls, but also increases the likelihood of poor fracture outcomes because of the body’s inability to respond robustly to the traumatic insult. The frail patient who has had a hip fracture then is caught in a vicious cycle of diminished function and poor adaptive response that is not 3

4

Introduction

easily mitigated by postoperative rehabilitation either in the hospital or at home. As such, it is critical to assess the patient’s whole medical history, physical functioning, and cognitive status as they existed before the fracture. Consensus on the clinical designation of frailty has proven difficult, particularly because many clinicians consider frailty and disability synonymous. This viewpoint misses the relevance of preclinical frailty for the development of subsequent morbidity and disability and in turn causes the opportunity for early preventive intervention to be lost. For example, in the context of musculoskeletal dysfunction and hip fracture in particular, gait has been closely associated with frailty in clinical practice. Gait is defined as the pattern of movement during walking and is generally a key component to the frailty complex. The importance of walking to the overall maintenance of homeostasis cannot be overstated. Normal musculoskeletal, cardiopulmonary, and neurologic functioning are mediated in no small part by the mechanics and chemistry of walking. Moreover, the components of gait strongly influence the mechanics of walking. These components are gait speed, walking cadence (the number of steps walked over a given time period), and stride length. The degeneration in gait speed associated with normal aging appears to result from a decrease in stride length rather than a reduction in cadence.12 This finding is important because diminished gait speed can be improved in aging individuals with proper physical conditioning. The Frailty Task Force of the American Geriatric Society proposed a list of criteria to be used in classifying frailty that is now accepted as a working definition for clinical practice.7 According to this definition, the frailty syndrome is defined by three or more of the following symptoms: (1) unintentional weight loss (4–5 kg in year); (2) self-reported exhaustion; (3) weakness (grip strength

90 mm Hg c. Transfusion to keep hematocrit >30% 2. Fluid and electrolyte balance: a. Treatment to restore serum sodium, potassium, and glucose to normal limits (glucose