In the Older Patient — It’s not just a question of orthopaedic expertise
By Ali R. Jamali, MD, FACS, Sports Medicine & Orthopaedic Center

According to the Centers for Disease Control, at least 250,000 older Americans (defined as 65 and older) are hospitalized for hip fractures every year.  The chances of a senior sustaining a hip fracture increase with every year of life, so much so that the National Institutes of Health predicts the number of hip fractures in the United States could total 840,000 by the year 2040.

Three-quarters of those fractures will occur in women, in part because of their increased risk for osteoporosis.  Eight million American women have osteoporosis, which weakens bones and makes them more likely to break.  In fact, the National Osteoporosis Foundation claims a osteoporotic woman’s risk of breaking her hip is equal to her combined risk of breast, uterine and ovarian cancer.

Unfortunately, the most troubling statistic comes from a study funded by the the National Institutes of Health and published in the Archives of Internal Medicine:  women ages 65–69 who break a hip are five times more likely to die within a year than women of the same age who don’t break a hip.

The problem lies not so much with the hip fracture itself, but with the sequelae of the trauma.  When the body responds to such a trauma, it goes through a transformation and begins to excrete proteins and hormones that affect all of the organs in the body, the endocrine system, the gastrointestinal system, and the inflammatory and immune responses.

It is this multiple-organ pathological response to trauma that we need to take into consideration when we care for older patients, over and above correcting the original fracture, because elderly patients are often already suffering medical problems and diseases associated with age.  For instance, diabetic patients may suddenly have trouble regulating their blood sugar after a hip fracture.  A thyroid patient may have a similar experience with thyroid hormone.  A patient with a queasy stomach may see that turn into an ulcer because of excess acid production.  In short, many chronic conditions can be exacerbated by the trauma.

Surgery for the elderly patient.
When surgery is indicated for such patients, the type of procedure will depend on the nature and extent of the fracture, whether intertrochanteric, subtrochanteric or subcapital.  No matter what the procedure, I consider it essential to have the safest possible anesthesia for my elderly patients, which is most often a spinal or a regional block –  and I want the patient anesthetized for the shortest possible period of time.  It can sometimes take an older patient a few days to shake off the effects of anesthesia, and we watch them very carefully during their post-op recovery.

These older patients are especially vulnerable, and they face a long road ahead as other medical issues resulting from the trauma may impair their ability to heal and recover hip function.  But paying attention to the whole patient, not just the fracture, can make all the difference.

Ali R. Jamali, MD joined SMOC in January 2016.  He completed medical school at Tabriz University Medical School in Tabriz, Iran.  He took post-graduate training in London, England and Seattle, Washington, and completed a combined orthopaedic residency training program at EVMS affiliate Children’s Hospital, Richmond, Virginia.  smoc-pt.com