This document discusses orthogeriatrics and focuses on elderly patients who sustain injuries. Some key points: - Elderly trauma patients, defined as over 70 years old, are more likely to die from their injuries regardless of severity due to decreased physiological reserves. - Common causes of falls in the elderly include osteoporosis, cardiovascular disease, dementia, and polypharmacy. Early surgery (within 48 hours) leads to better outcomes compared to delayed surgery. - Mortality rates after hip fractures are high, around 35% for men and 22% for women after 1 year. However, most hip fracture-associated deaths are due to preexisting medical conditions rather than the fracture itself. - Special

1. ORTHOGERIATRICS
Lt Col Rohit Vikas
Gd Spl (Ortho)26 Oct 2017

3. • Geriatric – No set Age
• 65 y – social and
statistical parameter
• Geriatric trauma patients
defined as > 70y
• Geriatrician view - > 75y

4. Older people who sustain
injuries are more likely to
die as a result of them,
regardless of the severity
of injury

5. ELDERLY FALLS
Osteoporosis is a ‘silent risk factor’ for
fractures, just as hypertension is for stroke.
Women  3 x more likely to suffer a hip fracture - Osteoporosis
Thin women  the incidence of hip fracture is 2 - 3 x higher
than in obese women – No ‘fat cushion’

6. • CVA / Ischemic heart disease
• Anaemia
• DM / HTN
• Osteoarthritis / Osteoporosis / Gait and balance
disturbances
• Visual impairment
• Depression / Parkinson’s disease / Dementia
• Polypharmacy

7.  Syncope, Dysrhythmias, Acute MI
 CVA, TIA, Seizure
 Acute renal failure
 Infection
 Hypoglycemia
 Abdominal Aortic Aneurysm
 New medications
 Dehydration
 Acute fractures
WHAT CAUSED THE FALL ?
Environmental factors

8. > 80% of patients with accidental fall are found to be on medications easily implicated in contributing to the fall
MEDICATIONS RELATED TO FALLS
• Psychotropic medications
(antidepressants, neuroleptics, sedatives)
• Antihypertensive (β-blockers, CCBs,
diuretics)
• Antiepileptic
• Glaucoma agents.
The presence of four or more chronic
medications seems to correlate well with an
increasing risk of falls
Nordell E, Jarnlo GB, Jetsen C, et al. Accidental falls and related fractures in 65–74 year olds:
a retrospective study of 332 patients. Acta Orthop Scand 2000;71:175–9.

9. 1-YR HIP FRACTURE MORTALITY AND MORBIDITY FOR SENIORS > 65 Y

10. MORTALITY FROM HIP FRACTURES IN ELDERLY
In-hospital mortality 2.3 - 13.9%
6-month mortality 12 - 23%.
Author Year Number of Patients In-Hospital Mortality, % Overall 1-Year Mortality, %;
Male/Female, %
White et al
29
1987 241 NS 22; M 34, F 18
Keene et al
23
1993 1000 15 33
Aharonoff et al
22
1997 612 4 12.7; M 20.7, F 10.7
Leibson et al
21
2002 312 NA NA
Elliot et al
20
2003 1780 NA 22; M 30.1, F 19.5
Richmond et al
58
2003 836 2.7 11.5; NA
Wehren et al
18
2003 794 NA 18.9; M 31.4, F 23.3
Roche et al
7
2005 2448 NA 33; NA
Haentjens et al
17
2007 170 6.5 18.8; NA
Rapp et al
16
2008 4342 NA M 58.3, F 44.8
Von Friesendorff et al
15
2008 163 NA 21; NA
Brauer et al
1
2009 786 717 NA M 32.5, F 21.9
Berry et al
14
2009 195 NA 39.5; M 53.5, F 35.6
Bentler et al
13
2009 495 3 26
Summary of Published Mortality Rates in Patients With Hip Fractures
For each 1-yr increase in age over 65, the odds of dying after trauma increases by over 6%
Grossman MD, Miller D, Scaff DW, et al. When is an elder old? Effect of preexisting conditions on
mortality in geriatric trauma. J Trauma 2002;52:242–6

11. MORTALITY FROM HIP FRACTURES
1-yr mortality 35% for men / 22% for women
Hommel A, Ulander K, Bjorkelund KB, Norrman PO, Wingstrand H,
Thorngren KG. Influence of optimised treatment of people with
hip fracture on time to operation, length of hospital stay,
reoperations and mortality within 1 year.
Injury. 2008 Oct; 39(10):1164-74.
Holt G, Smith R, Duncan K, Finlayson DF, Gregori A. Early mortality
after surgical fixation of hip fractures in the elderly: an analysis of
data from the scottish hip fracture audit.
JBJS Br. 2008 Oct; 90(10):1357-63.
Men present with a fracture at a younger age and are
likely to have more medical comorbidities. Men have a
significantly higher mortality rate at 30 and 120 days
Data from the Scottish Hip Fracture audit
Reason for this disparity in mortality between the sexes is unclear
Gender difference
Patients treated within a hip fracture clinical pathway

12.  3 in 4 hip fracture-
associated deaths related
to preexisting medical
conditions rather than the
fracture itself.
 Hip fracture destabilizes a
frail elderly with a high
burden of preexisting
morbidities.
 Acute conditions (stroke
and cardiac events) may
have also provoked falling
and thus hip fracture.
CAUSE OF MORTALITY FROM HIP FRACTURES
Young patients with trauma will often die within the first 24 h from the trauma itself,
whereas elderly patients often die later due to secondary complications
Preexisting medical conditions.

13. COMORBIDITES AFFECTING ELDERLY WITH TRAUMA

14. Cardiac functional reserve diminished.
Older patients  Lower cardiac output, decreased cardiac reserve, and
are less able to tolerate hemodynamic stress.
Decreased heart rate response to catecholamines
 Ageing of electrical conducting system
 β-blockers / Calcium blockers.
Elderly patients can have a blunted inotropic and chronotropic response
to trauma. Compensatory tachycardia, seen almost universally in young
patients in response to hypovolemia or shock, is frequently absent.
AGEING AND CARDIAC FUNCTION
• Heart failure - May further diminish cardiac output
• Heart block - further blunt the rate response to stress
• CAD - May manifest as demand ischemia during the stress of trauma.
Cardiac Comorbidities
The patient with a history of hypertension and a normal BP is unstable
until proven otherwise
 Less effective pump
 Minimal reserve
 Medication effects
 Ischaemia / hypoxia

15. HYPOPERFUSION
Heart rate inadequate to determine the stability of geriatric patients.
Patients who appear stable may have occult hypovolemia or impending
shock.
 ABG - May reveal an increased base deficit, or an elevated serum lactate.
 Any evidence of impaired perfusion  Aggressive monitoring and
resuscitation.
 Noninvasive hemodynamic monitoring using bioimpedance technology
 Repeat - Serum lactate or base deficit, 30 - 45 min.
Persistently high results  Ongoing hemorrhage, inadequate resuscitation,
or other complications such as compartment syndrome.
 Maintain core temperature using external warming devices.

16. OTHER ORGANS
Lungs
 Decreased elasticity, reduced alveolar number and function
 Increased chest wall rigidity, kyphosis.
 Increased bacterial colonization, decreased force of cough
Kidneys
 Decreased renal blood flow
 Loss of surface area
 Pregressive decline in filtration function.
CNS
 10% reduction in brain weight, loss of neurons, cerebral atrophy.

17. Lower basal metabolic
rate  Problems
maintaining core body
temperature when the
ambient air temperature
drops.
Acute and chronic medical
conditions predispose 
hypoglycemia,
hypothyroidism,
hypopituitarism,
hypoaldosteronism, sepsis,
and substance abuse.
A CVA or fall  Prolonged
exposure in a cold house
or room
Dementia.
ACCIDENTAL HYPOTHERMIA

18. Intracranial hmgh / SDH
Can result in elderly patients who sustain minor
head trauma (no loss of consciousness) and
who are neurologically intact on arrival to the
ED.
Further increased if the patient is taking
warfarin or other anticoagulants or antiplatelet
agents.
LIBERAL USE OF CT FOR ELDERLY
SDH in up to 70% of older adult patients
with mild to severe head trauma

19. Gregory JJ, Kostakopoulou K, Cool P, Ford DJ One-year outcome for elderly patients
with displaced intracapsular fractures of the femoral neck managed non-operatively.
Injury (2010) 41(12):1273–1276
Patients with hip fractures that are treated non-operatively, the reported 30-day mortality rate is significantly higher
(34 %) than the 30-day mortality rate of the patients treated operatively
Non-Operative vs Operative Intervention
Delaying the surgical intervention by > 48 h in hip fractures increases the risk of complications and corresponds to a
significant decrease in 1-yr survival.
Rapidly assessing and preparing these patients, in order to avoid the risks inherent to delays in the intervention and
immobility
 Bed sores
 Pneumonia, urinary sepsis
 Pulmonary thromboembolism, embolization of fat
 Muscle atrophy, osteopenia
Nonoperative approach for patients who are truly moribund or give informed refusal

20. Non-Operative vs Operative Intervention
Complications of Immobility

21. Suspension / Postponement of an emergency
surgical intervention does not eliminate the risk
of the intervention but, rather, it adds the risk
inherent to non-intervention or to the
postponement itself.
Waiting time for the intervention
Controlling the risk factors and scheduling the intervention under the best technical conditions possible
are highly desirable for reducing the risk among elderly patients.
In hip fractures in frail patients, this type of approach is often not possible or even desirable.

22. Guidelines established in New Zealand and Scottish Health Care System
Early surgery (within the first 24 h of the injury) for the reduction of postoperative
complications and mortality
British Orthopaedic Association guidelines “The Blue Book”
Surgery should not be delayed > 48 h unless there are clearly reversible medical conditions
New Zealand Guidelines Group (2003) Acute management and immediate
rehabilitation after hip fracture amongst people aged 65 years and over.
Wellington, NZ, guidelines/0007/Hip_Fracture_Management_Fulltext.pdf.
Accessed 11 Mar 2010
Scottish Intercollegiate Guideline Network (2009) Management of hip fracture
in older people. A national clinical guideline.
http://www.sign.ac.uk/guidelines/fulltext/111/index.html. Accessed 21 Jul 2009
Waiting time for the intervention
AAOS 2014 GUIDELINES - SURGICAL TIMING
Moderate evidence supports that hip fracture surgery within 48 h of admission
is associated with better outcomes

23. Al-Ani AN, Samuelsson B, Tidermark J, et al. Early operation on patients with a hip
fracture improved the ability to return to independent living: a prospective study of
850 patients.
JBJS (Am) 2008;90(7):1436–1442
Patients who had surgery < 36 h of admission experienced shorter hospital LOSs, fewer pressure ulcers, and greater
likelihood to return to independent living
Prospective study (850 patients)
A delay in surgery of 2 days or more from admission associated with a 17% increase in 30-day mortality
18 209 Medicare recipients who
underwent surgery for hip fracture
McGuire KJ, Bernstein J, Polsky D, Silber JH. The 2004 Marshall Urist award: delays until
surgery after hip fracture increases mortality.
Clin Orthop Relat Res. 2004 Nov; (428):294-301.
Surgery within 48 h of admission decrease minor and major complication rates
Lefaivre KA, Macadam SA, Davidson DJ, Gandhi R, Chan H, Broekhuyse HM. Length of
stay, mortality, morbidity and delay to surgery in hip fractures.
JBJS Br. 2009 Jul; 91(7):922-7.
Early operative intervention does improve outcomes, including morbidity (especially infections),
pressure sores, pain, and length of stay.
Effect of Timing of Surgical Intervention on Mortality
41 % increase in the 30-day mortality rate and a 32 % increase in the 1-yr mortality rate after delayed surgery for a
patient with a hip fracture
Meta-analysis
Shiga T, Wajima Z, Ohe Y Is operative delay associated with increased mortality of hip
fracture patients? Systematic review, meta-analysis, and meta-regression.
Can J Anaesth,2008, 55(3):146–154

24.  30-day mortality following surgery for a hip fracture was
9%.
 Patients with medical comorbidities that delayed surgery
had 2.5 x the risk of death within 30 days after the
surgery compared with patients without comorbidities that
delayed surgery.
 Mortality was not increased when the surgery was
delayed up to 4 days for patients who were otherwise fit
for hip fracture surgery.
 A delay of > 4 days significantly increased mortality.
Prospective, observational study (n = 2660) - Surgical treatment of a hip fracture
Moran CG, Wenn RT, Sikand M, Taylor AM. Early mortality after hip fracture: is
delay before surgery important? JBJS Am. 2005 Mar; 87(3):483-9.
Delay in Surgery due to Medical Comorbidities

25. Unnecessary delays in surgery result in the increased risk
of many negative outcomes
 Delirium / Pain
 Pneumonia / Urinary tract infections
 Pressure ulcers / Malnutrition
 Thromboembolism
 Deconditioning / Falls and additional injuries
 Patient, family, and staff dissatisfaction / Higher cost
 Increased mortality
Delay in Surgery
A Co-managed orthogeriatric unit may reduce the delays to surgery  Early optimisation of patient’s condition (e.g.
dealing with cardiovascular problems, anaemia, and electrolyte imbalance), earlier surgery, fewer complications, and shorter
length of hospital stay. Friedman SM, Mendelson DA, Bingham KW, Kates SL. Impact of a comanaged Geriatric Fracture
Center on short-term hip fracture outcomes. Arch Intern Med 2009;169:1712–7.

26. Oligoanalgesia
Barriers to timely and effective analgesia
• Failure to assess for pain
• Concerns about the use of analgesics in patients with cognitive
dysfunction or other comorbid illnesses.
• Physician misperception that pain is a natural and expected
consequence of aging.
• A dogma that pain should be expected after surgery.
PAIN RELIEF
 Delirium, or other impaired cognitive function,
 Decreased functional independence,
 Depression,
 Poorer clinical outcomes,
 Increased hospital length of stay, health care use and
overall costs
Inappropriate pain control 
Postoperative delirium 
Patients with delirium may also
receive inadequate analgesia

27. Fascia Iliaca Compartment Block / 3-in-1 femoral nerve block infiltrates the femoral nerve sheath then tracks
cranially and laterally anesthetizing the femoral and obturator nerves, lumbar plexus, and lateral cutaneous nerves
PAIN RELIEF
AAOS 2014 Guideline - PREOPERATIVE REGIONAL ANALGESIA
Strong evidence supports regional analgesia to improve preoperative pain control in patients with hip fracture.
0.5% bupivicaine 0.3 mL/kg, Max vol 20 mL
Fascia Iliaca Compartment Block

28. PAIN RELIEF
Orosz GM, Magaziner J, Hannan EL, Morrison RS, Koval K, Gilbert M, McLaughlin M, Halm
EA, Wang JJ, Litke A, Silberzweig SB, Siu AL Association of timing of surgery for hip fracture
and patient outcomes.
JAMA. 2004 Apr 14; 291(14):1738-43.
Surgery within 24 h had significantly fewer days of severe pain. Pain causes a stress reaction and subsequent insulin
resistance to accelerate the process of muscle loss and weakness, thereby delaying patient rehabilitation and
increasing the risk of delirium
Prospective cohort study of 1206 patients
Surgery is the best analgesia for a hip fracture

29. Chest infections (9%) and heart failure (5%) being the most common.
 Developing heart failure following a hip fracture
 Very poor prognosis - 30 day mortality 65% / 1-yr mortality of 92%
 Chest infections - 30 day mortality 43% / 1-yr mortality is 71%
POST-OPERATIVE COMPLICATIONS
Up to 20% of patients with hip fractures
 Preventing the development of these complications should be a priority
in units looking to improve mortality from hip fractures.
Medical complications more usual in patients in ASA class 3 and 4 than those in
ASA class 2
Donegan DJ, Gay AN, Baldwin K, Morales EE, Esterhai JL Jr, Mehta S. Use of medical comorbidities to
predict complications after hip fracture surgery in the elderly.
JBJS Am. 2010 Apr; 92(4):807-13

30. Post-Operative complications
Cognitive alterations 10%
Postoperative delirium 13.5 – 33% Preventive role of antipsychotics (haloperidol)
Arrhythmia / Heart failure /
Myocardial ischemia
35%-42% Restoration of fluid status to euvolemic. Beta-blockers if
necessary
DVT / PE 27 % / 1.4 -7.5 % VTE prophylaxis, Early mobilization
PPCs (exacerbation of chronic lung
disease, atelectasis, respiratory
failure, PE, ARDS)
4% Evaluation and care of patients with previous lung disease,
Adequate postoperative fluid balance and pain control
Hospital-acquired pneumonia 7% VTE prophylaxis, Timely diagnosis, adequate antibiotic
treatment and accurate monitoring
PGICs (dyspepsia, abdominal
distension, reflex ileum and
constipation)
5% Adequate postoperative fluid, diet, pain and medication
management
GI postop stress ulcer/ GI bleeding 1.9% GI bleeding prevention with pump inhibitors

31. Postoperative complications
Urinary retention / UTI 12 -61% Catheters should be taken out asap, preferably within 24 h.
Timely diagnosis and adequate antibiotic treatment.
Preventive identification of pre, peri or postoperative
medical or surgical risk factors.
AKI (prerenal, renal or postrenal) 11% Timely diagnosis, adequate treatment and accurate
monitoring
Anaemia 24%-44% Correct Hb to ≥ 10 g/dL before surgery
In anticoagulated patients, correct INR to ≤ 1.5
preoperatively.
Protein-caloric malnutrition 20%-70% Nutritional supplements in peroperative period
Diabetes 17% Maintain glucose levels between 100 and 180 mg/dL
Pressure scars 7 - 9% Early surgery fixation (within 24-48 h in stable patients).
Alternating pressure mattresses, pressure-relieving beds
and equipment, aggressive skin care and proper nutrition,
prevention-focused nursing.

32. Postoperative delirium may affect 1/3rd of elderly patients
Delirium
Multiple triggering factors:
• Hydroelectrolytic disorders (dehydration,
hypo/hypernatremia or hypercalcemia)
• Infections (urinary, resp, skin or soft-tissue)
• Toxicity due to medications
• Metabolic changes (hypoglycemia,
hypothyroidism, uremia or liver failure)
• Low cardiac output (shock, heart failure, MI)
• Hypoxemia.
• Preoperative medication (especial attention to
unrecognized benzodiazepine use), type of
anesthetic used during surgery, Environmental factors
 Loss of time and space references (lack of natural lighting, calendar or clock)
 Immobility (including use of physical containment);
 Use of bladder probe
 Sleep deprivation / Frequent changing of bedroom
 Being in an intensive care unit or chronic treatment unit.

33. 1-yr mortality rate of 28% of patients with severe dementia versus 12% without.
Delirium
Khan R, Fernandez C, Kashifl F, Shedden R, Diggory P. Combined orthogeriatric care in the management
of hip fractures: a prospective study.
Ann R Coll Surg Engl. 2002 Mar; 84(2):122-4.
2-y mortality rate of 26.4% in patients with dementia versus 6.5% with those without dementia.
376 patients with hip fractures Hershkovitz A, Polatov I, Beloosesky Y, Brill S. Factors affecting mortality of frail hip-fractured elderly
patients.
Arch Gerontol Geriatr. 2010 Sep-Oct; 51(2):113-6.
Hyperactive Hypoactive
Augmented psychomotor activity
(pressured speech, irritability and
uneasiness),
Exhibit quiet appearance, carelessness, reduced mobility and trouble to
answer simple questions about themselves and/or special-temporal
orientation.
May be misdiagnosed as depression or fatigue

34. Toxicity due to medications -
30% of the cases of delirium
• Antidepressants
• Antihistamines
• Antiparkinsonians
• Analgesics
• Anesthetics
• Sedatives, hypnotics
• Quinolone antibiotics.
Delirium
 Pain contributes to delirium  an adequate postoperative analgesia.
 Haloperidol at low doses (0.5 - 1.0 mg PO / IV / IM) may be used to control
agitation or psychotic symptoms, but on rare occasions, it may induce sedation
and hypotension.
 Atypical neuroleptics such as risperidone and olanzapine present fewer adverse
effects.
 Supplemental oxygen (3-4 L/min) for 48 h post op, or while patient’s oxygen
saturation is not ≥ 95% without oxygen, have proven to reduce delirium risk.
Dovjak P, Iglseder B, Mikosch P, Gosch M, Müller E, Pinter G, Pils K, Gerstofer I, Thaler H, Zmaritz
M, Weissenberger-Leduc M, Müller W. Treatment and prevention of postoperative complications
in hip fracture patients: infections and delirium.
Wien Med Wochenschr. 2013 Oct; 163(19-20):448-54.
Management

35. • Asymptomatic DVT - Up to 50% of all patients with hip fracture
• Fatal PE - Up to 10%
THROMBOEMBOLISM AFTER HIP FRACTURE
Zahn HR, Skinner JA, Porteous MJ. The preoperative prevalence of deep vein thrombosis in
patients with femoral neck fractures and delayed operation. Injury. 1999 Nov; 30(9):605-7.
Thrombosis involving the deep
veins of the leg may be
confined to the calf, but
15–25% of calf VTE propagate
and may extend into the
popliteal or proximal veins

36. Minimising VTE
Surgical delay appears to heighten the risk of VTE in hip fracture patients
Elder GM, Harvey EJ, Vaidya R, Guy P, Meek RN, Aebi M. The effectiveness of orthopaedic trauma
theatres in decreasing morbidity and mortality: a study of 701 displaced subcapital hip fractures in
two trauma centres. Injury. 2005;36:1060–6.
Parker MJ, Handoll HH, Griffiths R. Anaesthesia for hip fracture
surgery in adults. Cochrane Database Syst Rev. 2004 Oct 18;
(4):CD000521.
Incidence of VTE may be reduced with
spinal anesthesia
Zahn HR, Skinner JA, Porteous MJ. The preoperative prevalence of deep vein thrombosis in patients
with femoral neck fractures and delayed operation. Injury 1999; 30(9):605–607.
Active or passive mobilization
• Should begin on the 1st postop day.
• Adequate pain relief post op.
Adequate hydration
• Especially for immobilized patients.

37. Patients undergoing hip fracture surgery
Use of one of the following rather than no antithrombotic prophylaxis:
• LMWH / Fondaparinux / LDUH / Adjusted-dose VKA / Aspirin (all Grade 1B),
• Or an IPCD (Grade 1C) – 18h daily.
For a minimum of 10 to 14 days
American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines (9th ed)
VTE Prophylaxis
 LMWH - Starting either 12 h or more preoperatively or 12 h or more postoperatively rather than within 4 h or less
preoperatively or 4 h or less postoperatively (Grade 1B).
 In patients undergoing HFS, irrespective of the concomitant use of an IPCD or length of treatment, use of LMWH in
preference to the other agents recommended as alternatives: fondaparinux, LDUH (Grade 2B), adjusted-dose VKA, or
aspirin (all Grade 2C).
 Suggested extending thromboprophylaxis in the outpatient period for up to 35 days from the day of surgery rather
than for only 10 to 14 days (Grade 2B).
 Dual prophylaxis with an antithrombotic agent and an IPCD during the hospital stay (Grade 2C).

38. Patients undergoing hip fracture surgery
Patients with increased risk of bleeding  Use an IPCD
or no prophylaxis rather than pharmacologic treatment
(Grade 2C)
American College of Chest Physicians
Evidence-Based Clinical Practice Guidelines (9th ed)
VTE Prophylaxis
Who decline or are uncooperative with injections or
an IPCD  Use Apixaban or dabigatran (alternatively
rivaroxaban or adjusted-dose VKA if apixaban or
dabigatran are unavailable) rather than alternative
forms of prophylaxis (all Grade 1B).
For asymptomatic patients following major orthopedic surgery, recommend against Doppler US screening before
hospital discharge (Grade 1B).
Suggest no prophylaxis rather than pharmacologic thromboprophylaxis in patients with isolated lower-leg injuries
requiring leg immobilization (Grade 2C).

40. Mechanical Methods of VTE prophylaxis
IPCD
ACCP guidelines - Use of IPCD for least 18 h / day
• As an adjunct to chemoprophylaxis
• Or in patient with high risk of bleeding .
AAOS guidelines
• Use in patients with known bleeding disorders,
such as hemophilia or active liver disease
• As with chemoprophylaxis in patient with
previous VTE
Multicenter RCT – IPCD vs Enoxaparin
• IPCD was just as effective as enoxaparin in preventing proximal and distal DVT and PE events, but resulted in a much
lower bleeding risk (1.3 % IPCD vs 4.3 % LMWH).
• Disclosure - 1 or more of its authors or immediate family received benefits from the commercial party.
Colwell CW, Jr, Froimson MI, Mont MA, et al. Thrombosis prevention after total hip arthroplasty: a
prospective, randomized trial comparing a mobile compression device with low-molecular-weight
heparin. JBJS (Am) 2010.

41. Anti Embolic Stockings
Mechanical Methods of VTE prophylaxis

42. THROMBOEMBOLISM AFTER HIP FRACTURE
Post-Thrombotic Syndrome
• Most common complication of DVT.
• Chronic condition, develops in 20–50% of patients with symptomatic DVT, most cases occurring within 2 y.
• Pain, edema, skin hyperpigmentation, skin ulceration.

43. NUTRITION
Protein deficiency  Infections, bed sores, muscle weakness, poor respiratory function, myocardial hypertrophy and
death.
Biochemical indicators of malnutrition
 Anaemia
 Vitamin deficiency
 Low levels of pre-albumin, albumin, transferrin and cholesterol
 Low lymphocyte counts.
Proven clinical relevance as prognostic factors
 Albumin > 3.5 mg/dl
 Lymphocytes > 1800 mm3
 Involuntary weight loss < 10%.
Preop S. Albumin - Strong predictor of complications within the first 30 post-op days
AAOS 2014 GUIDELINE - NUTRITION
Moderate evidence supports that postoperative nutritional supplementation reduces mortality and improves
nutritional status in hip fracture patients

44. HIP Fractures in Patients on Clopidogrel
Clopidogrel
• Irreversibly binds to the platelet receptor ADP  Inhibits platelet
aggregation and thrombus formation.
• Affected platelets remain irreversibly inactivated and are replaced by new
platelets after 5 to 7 days.
• A complete recovery of platelet function 7 days after the last clopidogrel
dose
 Recent CVA, AMI / ACS and established PVD.
 Post PCI / coronary artery by-pass grafting.
No known method of reversing its antithrombotic effects acutely and the effectiveness of a fresh
platelet transfusion in the event of excessive bleeding is controversial

45. Increased bleeding risk of clopidogrel in patients
undergoing surgical procedures.
• Most of the studies relate to cardiac surgery  4-5 x increased
risk of haemorrhage-induced surgical re-exploration and 3 x
increased risk of blood transfusion post CABG.
• Limited reports to support this in orthopaedic literature.
• For patient on clopidogrel, surgery delayed for 5 - 7 days.
• Delay to surgery > 48 h independently associated with a higher
mortality rate at 30 days and 1 year.
Risks of delaying surgery in hip fracture patients
Risk of stopping clopidogrel in hip fracture patients
HIP Fractures in Patients on Clopidogrel
Fracture and surgery are Prothrombotic state.
Withholding clopidogrel  can induce a rebound effect and cause thromboembolic events  Stent thrombosis.
• Perioperative incidence of ACS of up to 20.2 % in patients with femoral neck fractures.
• In patients who have had stents inserted, cessation of clopidogrel during the first year is associated with a 20 % risk of AMI and
45 % mortality rate.
Rising concerns for patients with DES regarding the risk of late stent occlusion after cessation of clopidogrel - Dual-
antiplatelet therapy is prescribed on an empirical basis for 3-6 months after implantation, with life-long aspirin.

46. Lack of consensus about the best practice and safest approach
2007 – A survey of 139 UK orthopaedic departments
o 41 % stopped clopidogrel and operated immediately
o 19 % continued clopidogrel and operated immediately
o 21 % stopped clopidogrel for at least 5 days preoperatively
o 19 % had various alternative protocols
HIP Fractures in Patients on Clopidogrel
Christopher G. K. M. Soo, Paul K. Della Torre, Tristan J. Yolland, and Michael A. Shatwell. Clopidogrel and hip fractures,
is it safe? A systematic review and meta-analysis. BMC Musculoskelet Disord. 2016; 17: 136.
A systematic review and meta-analysis of the 14 comparative studies
Operating early on neck of femur patients who are on clopidogrel is safe and poses no
increased risk of bleeding when compared to patients not on clopidogrel.

47. HIP Fractures in Patients on Clopidogrel
AAOS 2014 GUIDELINE - ASPIRIN AND CLOPIDOGREL
Limited evidence supports not delaying hip fracture surgery for patients on aspirin
and/or clopidogrel.
• Aspirin should be withheld during inpatient stay unless indicated for unstable angina
or stroke.
• Clopidogrel  Do not delay surgery or have prophylactic platelets.
AAGBI suggests generally not stopping clopidogrel on admission especially in patients
with DES.
Anaesthetists of Great Britain and Ireland (AAGBI) guidelines regarding NOF surgery

48. POST FRACTURE HYPERGLYCEMIA
Karunakar MA, Staples KS. Does stress-induced hyperglycemia increase the risk
of perioperative infectious complications in orthopaedic trauma patients?
J Orthop Trauma. 2010 Dec; 24(12):752-6
Serum Glucose > 220 mg/dL  25% infection rate - Wound infections, pneumonia,
UTI, bacteremia or severe sepsis.
Hyperglycaemia is not a reason to delay surgery unless the patient is ketotic and/or
dehydrated.
Anaesthetists of Great Britain and Ireland (AAGBI) guidelines regarding NOF surgery

49. AAOS 2014 GUIDELINES - TRANSFUSION THRESHOLD
Strong evidence supports a blood transfusion threshold of no higher than 8g/dl
in asymptomatic postoperative hip fracture patients
TRANSFUSION
Anaesthetists of Great Britain and Ireland (AAGBI) guidelines regarding NOF surgery
• Use of a higher blood transfusion trigger in the elderly
• Hb < 9g/dL (or Hb < 10g/dL with a history of IHD)  02 units of blood should
be transfused
Platelet count < 80 x 109 /L is a relative contraindication to neuraxial anaesthesia.
Platelet count < 50 x 109 /L will usually need a platelet transfusion.

50. EARLY MOBILIZATION

51.  Early surgical fixation
 Good pain control perioperative
 Promotion of early mobilization
 Detection and management of delirium
 Anti-thromboembolic and anti-infective prophylaxis
 Correct urinary tract management
 Avoidance of malnutrition
 Vitamin D supplementation
 Osteoporosis treatment
 Falls prevention
Optimal care of hip fractured patients.

52. Increasing risk related to anesthesia/surgery versus
comorbidities
In young patients,
Elderly healthy patients (i.e., elderly patients with harmonious aging
process without significant comorbidities),
Geriatric patients (i.e., elderly patients with several comorbidities).
THE ORTHOGERIATRIC CONCEPT
4 designs of orthogeriatric cooperation proposed in the
literature with increasing participation of the geriatrician
and decreasing participation of the surgeon (from 1 to 4).
The Unit for PostOperative Geriatric (UPOG) care belongs
to the last one.

53. Australia “The Orthogeriatric Model of Care”  Emphasises the need for care of these patients by
an orthogeriatrician in an integrated service, and also early surgery within 24 h if the patient is medically
stable.
USA - Geriatric fracture centre where hip fracture patients are co-managed by geriatricians
and orthopaedic surgeons  Better outcomes in terms of shorter times to surgery, fewer post
operative infections, but showed no difference in in-hospital mortality.
Spain - Early multidisciplinary daily geriatric care  Reduces in-hospital mortality and medical
complications in elderly patients with hip fracture, but there is not a significant effect on length of hospital
stay or long-term functional recovery.
Orthogeriatric Services
UK - The best practice tariff for hip fractures: introduced in April 2010, this incentivizes individual trusts
financially for providing gold-standard care, defined by the following criteria:
 Time to theatre within 36 h
 Geriatrician review within 72 h
 Admitted under joint care and assessed using a joint protocol agreed by geriatricians, orthopaedic
surgeons, and anaesthetists
 Geriatrician led multiprofessional rehabilitation
 Falls and bone health assessment.

54. GERIATRIC FRACTURE CENTER
Co-management
Shared ownership, Shared decision making
Equal responsibility, Daily communication
Each discipline writes orders, write notes, and communicates
with the patient and care team.
True, interdisciplinary, fully coordinated co-management is the hallmark of the GFC model
GFC utilizes an interdisciplinary approach rather than multidisciplinary care
Evidence indicates that the only intervention presenting statistical significance in terms of mortality, for elderly with
hip fractures, is differentiated geriatric attention that includes multiprofessional participation.
In-hospital mortality rates are quite low at the GFC (< 2%)
Schnell S, Friedman SM, Mendelson DA, et al. The 1-year mortality of patientstreated in
a hip fracture program for elders. Geriatr Orthop Surg Rehabil 2010;1(1):6–14
1. Surgical stabilization
2. Optimization and Early surgery
3. Co-management
4. Standarised protocols
5. Discharge plan begins at the time of admission

55. Survival curves for mortality
for patients in the orthopedic
(solid line) and geriatric
(dotted line) cohorts. The
orthopedic cohort (n = 131)
was treated in an orthopedic
department without geriatric
cooperation. The geriatric
cohort (n = 203) was treated
in a dedicated Unit for
PostOperative Geriatric care.
Survival is adjusted for age,
sex, and Cumulative Illness
Rating Scale calculated with a
Cox regression analysis. P
values refer to log-rank test..
Boddaert et al. PLoS One 2014; 9:e83795.3
MINIMISING MORTALITY

56. Geriatric unit devoted to the
postoperative care of elderly patients
with hip fracture.
• Medical staff from the emergency
• Geriatrician
• Orthopedic surgeon
• Anesthesiology and critical care
• Nursing care
• Physiotherapist and Rehabilitation
department
• Equipment and facilities
NEED FOR AN ORTHO-GERIATRIC UNIT
Jacques Boddaert, Mathieu Raux, Frédéric Khiami, Bruno Riou. Perioperative Management of
Elderly Patients with Hip Fracture.
Anesthesiology 2014; 121:1336-41
Early sitting and walking, prevention of pressure ulcer, early identification of urinary retention and delirium may be the
most important management factors associated with survival improvement
A marked reduction in the risk of death at 6 months, a treatment effect is twice that observed with early surgery

57. NEED FOR AN ORTHO-GERIATRIC UNIT
 20 Bed Ward
 Bathroom with patient safety grab bars, anti-skid flooring and elevated commodes.
 Hospital beds with Air filled mattresses
 Oxygen delivery system / Oxygen concentrators
 Non invasive haemodynamic monitors
 ABG machine
 ECG machine
 Mechanical thrombo-prophylactic devices – IPCD / foot pumps for each bed
 Ambulatory aids / Wheel chairs
 External patient warming devices.
 Hand held Doppler device
 Portable bed side X-ray machine.
 Portable ultrasound machine
 STANDARISED PROTOCOLS FOR PRE AND POST OP EVALUATION AND THERAPY
Equipment
Co-management is true interdisciplinary care that results in a collaborative care environment in
which all team members maximize their contributions resulting in improved out-comes

58. FALL PREVENTION

59. FALL PREVENTION