S. Yogesh, S.M. Chockalingam, L. Rajesh Kumar

Department of Orthopaedic, Kauvery Hospital, Cantonment, Trichy

Correspondence: smch17@gmail.com

Dr Chokalingam

Analysis of femoral neck fracture in octogenarians and its management

The 6 million population in India above 80 years in 2013 will rise up to 30 million in 2050 [1]. The grand elderly suffers from co-morbidities like osteoporosis, medical problems, financial problems and most of them are dependent on others for their care. Falls are the 5th leading cause of death in elderly [2]. 5 % of those elderly people who have falls have major fractures like fracture neck of femur, distal radius fracture, and vertebral fractures.

femoral-neck1
femoral-neck2

A fracture of femur is a significant trauma in life, that occurring in an elderly is disabling. If left untreated leads to high mortality and morbidity. We have analyzed the neck of femur fracture in 80+years and above, admitted in Kauvery Hospital, Cantonment from 2009 -2015, the management and their outcome.

Study materials and Methods:

The Study period was 2009-2015; we analyzed patients aged 80 and above admitted for Fracture neck of femur.

22 patients were chosen based on the criteria; they were followed up for a mean of 4 years.

It was a retrospective study with data collected prospectively. Medical records were reviewed and latest follow up was done through telephone

Fracture incidence to presentation to hospital:

< 2 days-13 patients (59%) >2 days-9 patients (41%)

Delay in surgery for more than 48 hours – 7 (32%)

More than three significant co morbidities – 8 cases (36%)

Results of the Study

Survival after the surgery (total 22 cases)

femoral-neck3

The one-year mortality of 14% is well below the international rate of 25% [3]

Complications (Surgery specific):

The surgery specific morbidities like wound infection, hip dislocation following surgery, revision surgery, Instability was nil.

Symptomatic DVT was in 2 cases (9%).

Medical complications were:

RTI-1, Electrolyte imbalance-2, CAUTI (catheter associated urinary tract infection)-2, Bed sore-1

Discussion

Results of the study indicates that people aged 80 years and ambulatory who sustain a fracture neck of femur, if operated and rehabilitated, do well in the short and medium term.

The literature review suggests high mortality rate in this group of patients. However, we have gratifying results.

  • Low mortality rate was due to early intervention as soon as the patient presented, and due to managing their co morbidities [4] with the help of a multispecialty team that included Orthopaedician, Anesthetist, Cardiologist, Geriatrician, Diabetologist, Nephrologist and others who cared for the patient preoperatively, which resulted in stabilization of the patient.
  • The delayed presentations of patients to the hospital had no effect on the post operative outcomes.
  • Surgical management was delayed intentionally up to 48hours to medically stabilize the patient.
  • The duration of the hospital stay was from 5-14 days, which was possible due to early mobilization and co- management.
  • We do not recommend chemical thromboembolic prophylaxis in this group of patients. We recommend mechanical thromboprophylaxis. (Our incidence of DVT – 9% PE – Nil). The mechanical venous thromboembolism care given to all the elderly was effective (91%). International literature states that pneumatic compression reduces the relative risk by 63%. The pneumatic DVT pump is efficient in DVT prophylaxis.
  • Functional independence is the need for the elderly; when deprived leads to life of solitude and depression. The care for the elderly is focused upon achieving functional independence for them. In our practice we did not deny surgery citing age and co morbidities. All the co morbidities were properly managed and treatment given thereby ensuring functional independence to the elderly [4].

Conclusion:

Based on our experience and literature review:

  • We do not recommend denying surgery based on preoperative co morbidity or delayed presentation.
  • When co morbidities dictate, delay appropriately to optimize does not increase Preoperative mortality. Multi- disciplinary approach is needed for care in elderly.
  • Early surgery, mobilization and bed sore prevention yield good results. Dedicated pain management , standard catheterization and infection control, through protocols suitable for for the grand elderly, should be followed.
  • Mechanical DVT prophylaxis is a safer option in elderly patients with hip fractures.

References:

[1] U.S. Census Bureau, 2012 Population Estimates, 2012 National Projections, and International Data Base. http://www.census.gov/prod/2014pubs/p25-1140.pdf.

[2]G S Shanth , B Krishnaswamy “risk factor for falls in elderly” journal of Indian academy of geriatrics, 2005; 2 : 57-60.

[3] E.L.Hannan, J.Magaziner, J. J. Wang, E . A. Eastwood, S .B . Silberzweig, M.Gilbert, R. S. Morrison, M. A. McLaughlin, G. M. Orosz and A. L. Siu, ” mortality and locomotion 6 months after hospitilisation for hip fracture: risk factors and risk- adjusted hospital outcomes”. JAMA. Vol. 285, (2001), pp. 2736-2742.

[4]Jong Won Kang; Kap Jung Kim; Sang Ki Lee; Jin Kim; Sang Wook Jeung; Han Gyul Choi “Predictors of Mortality in Patients with Hip Fractures for Persons Aging More Than 65 Years Old” International Journal of Bio-Science & Bio-Technology;Apr2013, Vol. 5 Issue 2, p27.

chockalingam

Dr. S. Chockalingam

Senior Consultant – Orthopaedic Surgeon

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