Improving Patients' Outcomes After Osteoporotic Fractures

Rozalia Dimitriou; Giorgio Maria Calori; Peter V Giannoudis

Disclosures

Int J Clin Rheumatol. 2012;7(1):109-124. 

In This Article

Specific Considerations to Improve Patients' Outcomes Based on the Fracture Site

Hip Fractures

Hip fractures have been characterized as the 'international barometer' of osteoporosis, as they are strongly related to low BMD, they are almost always treated in hospital and are more costly, they are associated with major morbidity, loss of independence, and even increased mortality than other common types of osteoporotic fractures.[4,34] Mortality following hip fracture is mainly attributed to complications such as deep vein thrombosis, pulmonary embolism, pneumonia, deconditioning and poor rehabilitation.[76] Mortality rates increase with patient age (4% for each patient year), the time required to have the hip repaired (<2 days, 4%; >4 days, 6.1%), and comorbid conditions at admission (10-year mortality rate for chronic obstructive pulmonary disease, 27%; congestive heart failure, 40%).[77–79] Mortality rates have also been found to be higher in men compared with women.[80] In a recent systematic literature review, it has been shown that patients with osteoporotic hip fracture are at considerable excess risk for death compared with nonhip fracture/community control populations ranging from 8.4 to 36% for the first year after fracture, and that the increased mortality risk may persist for several years thereafter.[9] Overall, there is an increased relative risk for mortality following hip fracture that was at least double that for the age-matched control population, which however, becomes less pronounced with advancing age and is highest in the days and weeks following the index fracture.[9]

Even though an initial hip fracture was found to be associated with an increased risk for subsequent osteoporotic fracture up to sixfold,[81] which is associated with poorer prognosis than the first one,[82] current postfracture care for these cases remains problematic, with only 5–25% of patients being discharged with prescriptions for osteoporosis treatment.[35] Furthermore, hip fracture patients may experience a second hip fracture, especially within the first year.[83] Therefore, it is essential to implement and adhere to clinical strategies immediately after the first hip fracture to lower the risk of subsequent fractures.[34,84]

Regarding the effect of surgical timing in patients with osteoporotic hip fracture, most studies focus on mortality with conflicting findings.[85–90] Such discrepancies on the effect of surgical delay on outcomes among studies may be due to the diversity of the reasons of delay or a differential effect on patient risk subgroups, as a recent prospective study of 2250 elderly patients with hip fracture has shown that the reported association between late surgery and higher morbidity and mortality in patients with hip fracture is mostly explained by medical reasons for surgical delay.[88] Nevertheless, even if the timing of the operation remains controversial and potential residual medical and nonmedical confounding factors may limit definitive conclusions, operative delay beyond 48 h after admission may increase the odds of all-cause mortality.[87] Additionally, a delay of more than 4 days was found to increase mortality even more.[89] Conversely, a recent study has shown that although a 1-week delay in the surgical treatment of elderly patients with hip fractures increased the incidence of postoperative complications, it did not increase the mortality rate or prolong the period of recovery.[90]

Regarding the functional outcome, Orosz et al. investigated the association of timing of surgical repair of hip fracture with function and other outcomes in osteoporotic patients, and found that early surgery was not associated with improved function or mortality.[86] Nevertheless, it was associated with reduced pain, length of stay and probably with major complications among medically stable patients. Overall, further research is required in this field, but meanwhile medically stable patients with hip fractures should receive early surgery when possible,[86] to improve the short-term clinical outcome including the ability to return to independent living, shorten length of stay and reduce risk for development of pressure ulcers, and possibly to minimize overall mortality rates and postoperative complications.[91] The aim is to shorten the period of higher levels of pain and avoid prolonged delay and fasting period, which may aggravate the postfracture catabolic phase.[91] Obviously, important factors such as patient's medical and cognitive status as well as preinjury walking ability and activities of daily living should also be considered when evaluating patient's outcome and time to surgery in patients with osteoporotic hip fractures. The availability of operating rooms and support services needs to be optimum to avoid system-related causes of a delay of surgery.

The Role of Postoperative Management After a Hip Fracture

The postoperative management after a hip fracture in older patients is fundamental for the final outcome, since optimal management can minimize potential perioperative causes of morbidity and mortality. In summary, important parameters to be considered during postoperative management include appropriate pharmacologic treatment with monitoring and adjustment of medications, as well as physiotherapy (as appropriate including chest physiotherapy).[12] Regarding the pharmacologic treatment, medications prescribed depend on the type of fracture treated and they may include thromboprophylaxis to prevent deep vein thrombosis, antibiotics to prevent infection and analgesics to control pain.[12] Adequate analgesia in particular during the early postoperative period, is particularly important for facilitating physical therapy sessions and mobilization, but narcotic use should be carefully monitored as they may increase adverse events and the risk for falls. However, it has been reported that postoperative pain is often inadequately managed,[92] and this can persist not only for the early postoperative period, but also for a short period after discharge, ranging from discomfort to more severe pain associated with movement.[93] In a recent systematic review on the efficacy and safety of pharmacologic and nonpharmacologic interventions for managing pain after a hip fracture including nerve blockade, spinal anesthesia, systemic analgesia (narcotics, NSAIDs), multimodal pain management, transcutaneous electrical neurostimulation and complementary and alternative medicine, it has been shown that nerve blockades are effective in reducing acute pain after hip fracture; however, evidence was insufficient on the benefits and harms of most interventions in managing acute pain.[94]

Nerve blockade has also been found to be effective in reducing postoperative delirium,[95] which constitutes a common and troublesome complication in older patients with hip fractures.[95] Its incidence during hospitalization varies from 13%[96] up to 34%[95] even in patients cognitively intact at admission. Risk factors for development of delirium are older age, more than four prescribed drugs at admission, cognitive dysfunction as well as pain intensity.[95,96] The latter highlights the need for adequate pain management pre- and post-operatively. Furthermore, it has been shown that the implementation of a multifactorial program with intensified prehospital and perioperative treatment and care could reduce the incidence of delirium during hospitalization by 35%.[96]

Finally, the role of orthogeriatrics for an efficacious postoperative management should also be affirmed, since older patients with hip fracture often have complex comorbid conditions or develop severe complications during hospitalization. Therefore, timely and high-quality care must be provided with continuous orthogeriatric input to prevent and address these complex problems.[97,98] It has been demonstrated that daily comanagement of these patients by geriatricians and orthopedic surgeons leads to improved outcomes including shorter times to surgery, shorter length of stay, fewer cardiac complications and fewer cases of thromboembolism, delirium and infection, although no difference in in-hospital mortality or readmission rate was noted.[97] Overall, different models have been implemented and evaluated to improve ortho-geriatric services.[99] Although the best model is yet to be elucidated, there is a trend toward an integrated approach including a geriatrician in the trauma unit, a multidisciplinary team, prioritization of the geriatric fracture patients and development of guidelines to improve outcomes of older patients with hip fracture.[99]

Osteoporotic Vertebral Fractures

A considerable proportion of osteoporotic vertebral fractures escape clinical diagnosis and severe vertebral deformities alone produce symptoms that lead to diagnosis, with less than 10% of fractures necessitating admission to hospital.[4] This implies that many patients with an osteoporotic vertebral fracture seldom receive preventive osteoporotic treatment.[100] However, it is essential to identify the occurrence of one vertebral osteoporotic fracture, even an asymptomatic one detected incidentally on a routine radiograph, as it increases the likelihood of additional fractures by at least fourfold.[101] Early recognition of these fractures will allow prompt initiation of osteoporotic treatment and secondary prevention to reduce future fracture risk.

Moreover, as most osteoporotic vertebral fractures are precipitated by routine everyday activities (e.g., bending or lifting light objects) and only a quarter of them result from falls,[4] it is important to investigate the spine for such fractures in patients who already sustained a fragility fracture and complain of back pain, even if there is no history of trauma, in order to provide appropriate treatment. Such fractures are regarded as prima facie evidence of osteoporosis and their incidence rises rapidly with age in both sexes.[4] After the age of 60 years, women have approximately a two- to three-fold greater incidence of vertebral fractures than men.[4,102]

In general, acute osteoporotic vertebral compression fractures are treated conservatively with bracing, analgesics and functional restoration, whereas open surgical management with decompression and stabilization is reserved for the rare patient with neural compression and progressive deformity with neurologic deficits.[102] Percutaneous vertebral body augmentation (vertebroplasty or balloon tamp reduction) is indicated in patients with chronic pain in nonsurgically treated patients who fail to improve over 8–12 weeks after fracture, in an effort to improve pain and function, but the exact indications remain unclear.[102] Newer materials for augmentation may provide more favorable clinical results and may be used in the future for prophylactic vertebral augmentation with biologic agents that locally improve bone density and strength, offering long-term functional improvement in treated patients.[103]

Recently, clinical practice guidelines approved by the American Academy of Orthopaedic Surgeons (AAOS) on the treatment of symptomatic osteoporotic spinal compression fractures have been published,[103] aiming to help physicians in their clinical decision-making and improve patient outcome. In summary, the use of vertebroplasty for the treatment of these fractures is not recommended (strong recommendation) as it has not shown any significantly improved outcome, whereas the use of calcitonin for 4 weeks following the onset of fracture is recommended for pain reduction (moderate recommendation). Also, for the prevention of additional symptomatic fractures, ibandronate and strontium ranelate can be administered, and for pain management, the use of L2 nerve root blocks to treat the pain associated with L3 or L4 fractures is recommended. Finally, kyphoplasty can be performed to improve pain in patients, who are neurologically intact, with subacute or chronic symptomatic fractures (weak recommendations). Insufficient evidence exists to support the use of bracing or the implementation of an exercise program for patients who present with an osteoporotic spinal compression fracture. Future research is required to determine the effectiveness of modalities such as bracing, physical therapy/exercise and kyphoplasty in the treatment of these fractures.[103]

Distal Radius Fractures

Although distal radius fractures have no impact on mortality rate and have minimal morbidity compared with other osteoporotic fractures,[12,104] the history of prior wrist fracture may represent a risk factor for recurrent osteoporotic fractures, especially in men.[105] However, the risk of recurrent fractures was found to be substantially lower than that following other osteoporotic fractures, but significantly higher than for those who no previous fracture.[106] Therefore, patients with osteoporotic wrist fractures should be evaluated as candidates for preventive measures. A recent diagnostic meta-analysis of the ability of distal radius to predict a future hip fracture has shown low sensitivity and high specificity for predicting future fragility fracture.[107]

Among the clinical practice guidelines recently published on the treatment of distal radius fractures in adults,[108] there is inconclusive evidence to recommend for or against surgical treatment of older people (>55 years) patients with distal radius fractures. The available evidence could not demonstrate any statistically significant difference regarding pain and overall mental or physical outcomes between casting and surgical fixation in these patients. On the other hand, adjuvant treatment of distal radius fractures with vitamin C is recommended to prevent disproportionate pain and improve functional recovery (moderate recommendation).[107]

Osteoporotic Pelvic & Acetabular Fractures

Even though osteoporotic pelvic fractures, including pubic rami and sacral fractures, are less frequent fragility fractures, an increase in their incidence has been observed.[108] In general, osteoporotic pelvic fractures requiring initial hospitalization share most characteristics of hip fracture with high morbidity and mortality and loss of autonomy in terms of outcome.[109] Although the vast majority of osteoporotic pelvic fractures are classified as stable injuries and their management involves conservative treatment and pain management, the pain-related immobility and the long healing period that is often required may lead to a possible increased risk of morbidity and mortality especially in patients with severe pre-existing comorbidities.[109,110] Recently, operative treatment in certain cases with reconstruction of the pelvic ring using external fixation with supra-acetabular screw positioning was found to reduce the pain and allow an earliest possible rehabilitation without prolonged immobilization or secondary pelvic insufficiency instability.[111] Finally, a high rate of vitamin D deficiency associated with a secondary hyperparathyroidism has been observed among patients with osteoporotic pelvic fractures[109] and therefore it should be treated to improve outcome.

Regarding the acetabular fractures in older individuals with severe osteoporosis, the outcome can be improved by aggressive operative treatment if the physiological status of the patient allows it. Techniques common to revision of failed acetabular components can be used to reconstruct the osteoporotic acetabular fracture in combination with total hip replacement with satisfactory outcome similar to those achieved for reconstruction of osteoarthritis and early mobilization.[112]

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