Hip Fractures

Episode 23 - Hip Fractures

[00:00:00] Dr. Chehab: Welcome to IBJI's OrthoInform, where we talk all things orthopedics to help you move better, live better. I'm your host, Dr. Eric Chehab. With OrthoInform, our goal is to provide you with an in depth resource about common orthopedic procedures that we perform every day. Today, it's my pleasure to welcome Dr.

Evan Dougherty, who will be speaking about hip fractures. Dr. Dougherty hails from Colorado, where he grew up in the mountains outside of Denver. After graduation from Evergreen High School, he attended Colorado College in Colorado Springs. As a linebacker, he was named Freshman Defensive Player of the Year for the Colorado College Tigers football team.

Unfortunately, a series of injuries kept him from the field during his sophomore year, but it was at that time that he began to focus his extracurricular time on injury diagnosis and recovery. Working as a student athletic trainer for Division III athletes. He majored in biology and minored in Spanish, and he graduated with honors, becoming a member of the Blue Key Honor Society.

Thereafter, Dr. Dougherty worked at the internationally renowned National Jewish Medical Center in Denver, Colorado, known for their work in allergy, Immunology and pulmonary disease, he researched free radical effect and smoking effect on bone health and fracture healing. He then matriculated to West Virginia University, starting his medical school education in Morgantown, West Virginia in 2005.

After his wife's graduation from law school, they moved to Charleston, West Virginia. where he performed his clinical rotations. He trained at the only two level one trauma centers within the entire state of West Virginia, where he was initially introduced to the care of severely injured patients. He graduated from medical school in 2009 as a member of Alpha Omega Alpha, the country's top medical school honor society.

He and his wife then moved to the suburbs outside of Chicago, with his wife continuing her career in finance and business operations, and his working as a resident in orthopedic surgery at Loyola University Medical Center, Illinois only American College of Surgeons certified Level 1 trauma center.

Additionally, he was able to work with veterans at Heinz VA Hospital and children with congenital and traumatic maladies at Shriners Hospital for Children. Finally, he spent a year on orthopedic trauma fellowship at the Metro Health Medical Center in Cleveland, Ohio, where he worked with the preeminent orthopedic traumatologist from Case Western Medical Center and the Cleveland Clinic.

Since 2015, he has worked at Hinsdale Orthopedic Associates, a part of Illinois Bone and Joint Institute, where he has delivered the highest level of subspecialty orthopedic trauma expertise within the southwest suburbs. He has been awarded top doctor billing by Chicago Magazine and Castle Connelly since 2021 for the care that he provides to pediatric, adult, and elderly patients.

Dr. Dougherty has treated thousands of patients with traumatic injuries. Evan, welcome to OrthoInform and thanks so much for joining us.

[00:02:46] Dr. Dougherty: I appreciate the opportunity.

[00:02:48] Dr. Chehab: So we're going to be talking about hip fractures today, which are devastating injuries for young and old people alike, but for vastly different reasons.

And, you know, when we say hip fracture. What really are we talking about?

[00:03:01] Dr. Dougherty: Certainly, people come in and they'll always ask, Is it a fracture or is it a break? And they say, Well, I thought it was a hip fracture. You just told me that I broke my femur. So, the hip is a joint itself. The common term, the lay term, is hip fracture.

But we really speak about femurs in general, and specifically the top part of the femur, where it meets the pelvis at the hip socket. These fractures are varied in their

descriptions, but we can generally say a hip fracture is one that is very close to the hip itself, that it involves the neck of the femur, which is just below the ball in the ball and socket, or it involves an area just below that in the inner trochanteric region where you can feel the side of your hip, that bump on the side of your hip.

So these are fractures about that area.

[00:03:52] Dr. Chehab: So fractures at the very top of the femur. Right near the ball area are what we tend to think about as hip fractures. Socket side is sort of its own set of fractures that we're not really going to get into today and carry a different set of circumstances, but seems like this part of the femur, for whatever reason, is really prone to Bad things that can happen down the road.

[00:04:13] Dr. Dougherty: Correct. We'll, we'll aside the hip sockets. Those can be even worse, but these are, these are injuries that are very common. We see them in kind of two levels high energy trauma in young patients or the more, you know, simple slip and fall episodes in the older population that lead to this type of injury.

[00:04:31] Dr. Chehab: Yeah. And, and when people have this injury, how do they present to you? What are, what are some of their signs and symptoms?

[00:04:38] Dr. Dougherty: Certainly, the vast majority of patients who sustain a hip fracture don't get up off the ground. They have an inability to step, stand, or walk. They have a sense that they have some pain around the hip.

Sometimes, these fractures are grossly displaced and the patient obviously sees that. Their leg is shortened. It may be externally rotated. Their foot may be pointing outwards. And they can tell that they can't lift their leg off the ground. Sometimes they think that it is a problem more close to the foot because their foot looks odd but it has, you know, a destabilization of the top of the femur.

Some patients can get back up, whether it's with family members or by themselves. You'll see this in patients who are at home or in nursing homes. There's a fall, whether it's out of bed or a chair or from standing. And they can get assistance back up. Sometimes they'll call EMS, the EMS will come to their house and help them.

It's, you know, they, it's a routine thing that occurs. Oh, they need help getting back up. The fire department came and helped them. They get them back in bed or they get them into a chair and then two hours later they realize they can't get out of the chair or they can't get out of bed. So they come usually via, you know, emergency medical services through an emergency department.

Occasionally, patients will get to their PCP, their primary care physician, and say, my hip or my knee hurts, and they'll get an x ray in the office that proves that they have a hip fracture. But the majority of these patients are brought in, you know, via ambulance to the emergency department where they have this obvious...

Shortening of their limb. They have an obvious disability. They can be subtle. These fractures can be non displaced. They can be stable fractures, but still can be at risk for displacement. And so, you know, the initial diagnosis is an x ray or a clinical exam with an obvious deformity.

[00:06:24] Dr. Chehab: You mentioned knee pain.

Why is that? Why would someone with a hip fracture present with knee pain? Correct.

[00:06:28] Dr. Dougherty: So you know, we, we see this in kids as well, in pediatric patients. You can present with knee pain through a referral of pain pattern. You can have an injury about the hip, and for some reason we don't sense that it is a hip injury, but rather there's some referred pain from the hip down to the knee.

I had a gentleman, this is, you know, One term of hip fracture was an acetabular fracture, the hip socket fracture. He had fallen. He had assistance getting back up and over a five day period of time had worsening knee pain. He went to his PCP did a knee x ray. Knee x ray was normal. Right. They sent him back home.

And so then his family just didn't know what to do. He was worsening condition. They took him to an immediate care clinic. Two days later, they all of a sudden get a Pelvis picture and they noticed that he had a really bad acetabular fracture. Yeah. So then, you know, unfortunately he's now six or seven days out by the time he gets to the actual hospital, but knee pain is a common complaint.

[00:07:20] Dr. Chehab: Yeah. Okay. And so so just to summarize, when a patient presents with a hip fracture, they'll usually have some deformity of their leg. They'll be a little bit shorter. They'll be rotated out to the side with their foot pointing outward. They'll probably have difficulty elevating their leg or walking on their leg.

Sometimes, if the fracture lends itself to it, patients can put some weight on the leg, but that's more the exception than the rule, and and when patients present with knee pain after a fall and an inability to walk, it's important to think about the hip.

[00:07:50] Dr. Dougherty: Correct. The, you know, every situation, family wants to do what's best for their family member.

Sometimes they don't want to be too pushy with physicians or medical personnel but if you have that sense that there's something wrong with the extremity, that it's rotated getting a pelvis picture is a, is a very easy way to diagnose a great number of injuries.

[00:08:14] Dr. Chehab: And so the majority of patients with a hip fracture will present to the emergency department, whether they're a young patient in a high energy environment.

Injury, a mechanism or an older patient who's had a fall from standing and can't get up and can't move. So what's the sequence of events typically in the emergency room that a hip fracture patient will experience?

[00:08:33] Dr. Dougherty: So the, the goal nationally through a number of programs is to expedite care with hip fractures.

We know that these patients need early diagnosis. We need to optimize their conditions and we need to get into the or as quickly as we can. So, you know, we talked about the simple ways, an X-ray. Shows us the vast majority of these injuries. On occasion, a patient will have significant pain that is aligned with a hip fracture but it is not visible on an x ray.

An MRI may be indicated at that point, or CT, but MRI can pick up even more subtle injuries. And you can see swelling patterns within the bone. That can show you that the patient has sustained an injury that is non displaced and is at risk for... propagation or further displacement with activity. So you know, majority of patients will only require an x ray.

Occasionally we will have diagnosed that picture, or sorry, diagnose that fracture on the initial x ray. Sometimes a traction x ray is indicated, and so although we know that it's broken the practitioner may desire a specific x ray where there's some traction pulled through the limb. It provides a greater level of understanding as to the fracture planes and fracture obliquities and fracture associations to know what is the most appropriate way to treat it.

And 99 percent of the time. A hip fracture is an operative condition. I generally tell patients that the 1 percent are the patients who fell out of their deathbed, the patients who do not step, stand, or walk routinely, the patients who are not ambulatory. But even patients on hospice, even patients with, you know, severe medical conditions, the majority are operative because it provides pain control and the ability to get out of bed.

Even if it's just a transfer to a chair, that can be a very drastic improvement from their, you know, baseline, you know, laying in bed for the rest of their life, so to speak. And so Some of the initial diagnosis may be a wrist fracture, so some patients will fall, break their hip, and simultaneously have some wrist pain.

So they may get associated, you know, pain in their other joints, so x rays of other areas is important. And then, as I said before, it's the optimization of the patient. So, a lot of patients come in, they're very concerned, they have had history of heart attack, they've had history of other issues, they have diabetes, all these different things.

We know that we want to not disregard those, but certainly understand and optimize their conditions. But a lot of patients don't require a lot of subspecialty evaluations. Cardiology evaluations, pulmonology evaluations, nephrology evaluations, all of these separate consults that can come from this usually just delay the patient to the OR.

So, these protocols or these hip fracture protocols in the emergency department are meant to diagnose, optimize, and then get the patient to the next step, which would be the OR. Yeah,

[00:11:20] Dr. Chehab: there's been an evolution, obviously, in hip fracture care from when I was in training to now, where we were sort of on a 72 hour timeline to get patients.

So, we brought patients into the operating room with the idea that we would optimize their medical conditions, since many of the patients were elderly and frail and had multiple medical comorbidities, and we wanted to minimize the risk of the procedure from that. But the data really demonstrates that doing that may actually cause more harm than good, and that delaying the operative care for the hip.

Is, is not what we want to do. And what's, what's a timeframe that's generally considered standard of care at this point?

[00:11:58] Dr. Dougherty: So the, as you said, the 72 hour mark is by no means inappropriate in today's literature, but there are increasing studies, number of studies that push, you know, 48 hours and even into 24 hours.

And what we, what we do know very clear through the literature is that the things that delay us to the OR are frequently the things that have no outcome, you know, difference. We do know patients come in with significant comorbidities, but they don't have an optimizable condition if they have a fixed.

Lesion in their heart, they, they know that they have some coronary disease, they know that they have pulmonary disease, and so we can't dramatically change those risks. We know that they enter the OR, so to speak, with an increased level of risk, and anesthesia understands that, medicine understands that, and we can always have different consultants weigh in with relation to their post surgical care, because that can be very important, but there is very little that needs to change you know, through Pre operative optimization by getting all these other consultants involved.

The time spent in bed... Just one day additive, you know, to each day really decreases a patient's reserve. It saps them of their energy. You can get fairly significant muscle atrophy within a short period of time in these older patients. You can have bed rest related complications. So, certainly, immobility lends itself to pneumonia.

It lends itself to blood clots within the legs. Those blood clots can ultimately travel. So, you know, the diagnosis of the blood clot in the leg. That isn't the worst thing, but ultimately their presence can mean that they can travel to the heart and lungs, and those can be fatal. So getting patients up and moving is very important.

People get skin ulcers or skin sores from being in bed for too long, and we know that by minimizing time before surgery, we're going to minimize those problems. Yeah.

[00:13:53] Dr. Chehab: So, So, just again, to sort of go over this ground, we want to get to the, we want to get the patients to the operating room as quickly as reasonably possible.

It's not that they hit the emergency room and the double doors fly open and the patients are going straight to the operating room. There is some deliberation and understanding what their medical comorbidities are, but once those are sort of Recognized and optimized to the degree that they can be.

Getting patients to the operating room really pays dividends for the patients in the sense that they get mobile much more quickly and avoid many of the complications of being immobile. Correct,

[00:14:29] Dr. Dougherty: correct. There are some optimizable conditions that we don't gloss over. So patients will usually have a a chemistry set.

You know, take and they'll get a BMP or a CMP. It's kind of looking at your overall levels of function within your body. Patients can come in with a significant dip in their sodium levels and correction of sodium prior to surgery is an important way to reduce anesthetic risk and physiologic risk during a big procedure.

[00:14:56] Dr. Chehab: And that's relatively quick

[00:14:58] Dr. Dougherty: too, correct? It can be, yeah. So I have patients, unfortunately, it can be a slow correction. Most patients who come in low Live low, but there are some conditions that, that really drop patients sodium pretty quickly, and they do require that. Improvement in their sodium before being able to go to the operating room.

Other patients may have diabetes with significantly elevated glucose. And you can get kind of a general acute marker for how high their glucose has been compared to more chronic markers. We know that we're not going to make a big change if they've been chronically elevated. We certainly want to work.

Post operatively with that patient to, to minimize their glucose levels or not minimize, but appropriatize them, get them to the right range. But excessively high acute glucose levels are affiliated with, you know, associated with increasing risk of infection, wound site issues. And so it is important that we see that there are specific things that can be acutely optimized, acutely improved to improve the patients entering the OR and exiting.

[00:15:58] Dr. Chehab: Yeah. So it, so it sounds like a balance of being able to get patients. It's cared for expeditiously and quickly, but it's also a deliberate process where things that we can recognize and correct, that we take some of the time to do that, and then weighing the risks and benefits of maybe delaying a procedure to optimize glucose or sodium or some of the imbalances that can occur as patients age, and then to address the fracture so that patients can get better.

Okay, so let's now talk about, you've got the patient in the emergency room, we've diagnosed the hip fracture, we have the imaging, which most often is an x ray being sufficient, but maybe some other imaging such as MRI or CT that you mentioned. And there are different types of hip fractures that dictate the care.

So let's go through those. One by one, wherever

[00:16:53] Dr. Dougherty: you'd like to start. You got it. We will not touch on acetabular fractures. They are their own... The socket side fractures. Correct. They're their own beast. Okay. A number of fractures that go through that area, they do involve the socket itself, but they're low within the socket, and they're more pelvic fractures.

Those are ones that are truly non surgical. Acetabular fractures are big surgical issues, but the ones that we're going to really touch on today are... Femoral neck fractures, again that's a break at the neck below the ball or below the head of the femur. Those fractures are within the hip capsule itself.

And they act very differently than fractures outside of the hip capsule. The capsule is kind of the strong ligaments that hold the joint together. The capsule is filled with a little bit of fluid at baseline. Obviously when we break that bone, that bone will bleed and fill up. Because it is intracapsular, it is very difficult to heal through normal healing mechanisms.

There are a number of ways that bone decides to heal itself, and one primary way is that it builds additional layering of bone onto an existing fracture surface or bone surface. If it's within a capsule, that cannot happen. The synovial fluid within the joint will wash away that effect, and so your available fracture healing mechanisms are reduced and to worsen that, there's a very fickle blood supply to the femoral head that can become injured acutely and then that blood supply never recovers.

So you can end up having an issue where you just don't have healing potential because the blood supply is not there, it's been injured, and additionally, any healing that is trying to occur is being washed away.

[00:18:34] Dr. Chehab: Hmm. But there are some femoral neck fractures that Can heal. So which ones

[00:18:38] Dr. Dougherty: are those?

Correct. They're, again, the patients who sometimes can get up, can sometimes step stand and walk afterwards. Mm-Hmm. , they may be diagnosed with a non-displaced femoral neck fracture or a, a minimally angulated femoral neck fracture, usually termed valgus, but it's where that's, it's kind of smushed itself into a more stable alignment.

Those are patients that can successfully, you know, recover with treatment that would include fixing the fracture. Mm-Hmm. . The ones that are grossly displaced, the ones that don't stay aligned, those are the ones that usually require some type of replacement in the elderly population or older population, a replacement as opposed to any attempt to fix the bone, because again, it's hard to heal this bone or this region of bone.

And so instead of trying to get it to heal in the older population, we get rid of the bad part and then we give them a new

[00:19:30] Dr. Chehab: good part. Okay. So let's talk about fixing that. That valgus impacted, smushed fracture that's stable, how do you do that and, and what are some of the risks of that procedure and what are some of the benefits of doing that type of procedure?

You got it.

[00:19:45] Dr. Dougherty: The, the usual the historical treatment which is still very active today and very appropriate is called screw fixation. It's usually termed percutaneous or sometimes open, it, it, it does require incisions and screws will be placed across the top of the femur. And they will span from the outside bump that you can feel on the side of your hip across the fracture itself and into the ball.

The usual alignment would be three screws. They are performed in a specific array to maximize the stability of the construct. But we do know that bone health... And bone strength reduces over time and isn't it in this geriatric population they break because the bone is weaker So sometimes screws are just not adequate to provide that support and stability There are some newer implants that involve a small plate that sits on the side of the bone But they're meant to stabilize this type of pattern.

They're meant to Prevent this pattern from destabilizing and trying to keep it from worsening alignment with the goal of the fracture surface that is impacted or compressed against itself, that it's able to heal because it still has that intact compressed surface. There's no gap.

[00:20:55] Dr. Chehab: No fluid washing away the healing components.

Got it. And so the screw fixation is meant to stabilize a fracture that's already relatively stable, almost provide reinforcement or rebar into the bone and then prevent it from moving and becoming unstable. And sometimes if the bone is It's not amenable if it's a little bit osteoporotic, maybe a different type of implant with a side plate and, and screw to use that as reinforcement.

Obviously, that's a technical issue for the surgeon to decide what's best. But in general, these are done through very small incisions. And pretty safe for that patient. Correct. Not a lot of blood loss involved with this.

[00:21:34] Dr. Dougherty: Correct. Yeah. So we didn't touch on it with regard to optimization. Mm-Hmm. A lot of patients will come in on blood thinners.

Oh, right, right. So there's a, a great deal of increasing literature that states that a lot of these hip fractures can be treated through their blood thinners. That we don't have to stop a blood thinner for 48 hours or 72 hours, which you would normally do for an elective type procedure. That we can usually proceed within 12 or 24 hours without any significant risk to the patient.

But blood loss is always a consideration. So, percutaneous or small incisions lend themselves to lower levels of blood loss. Certainly, lower risks for infection. The larger an incision, the longer that an incision is open. The, the greater number of times that a surgeon's hands or instruments are entering the incision or exiting, increase risk for infection.

So, these are the lowest risk for infection. They're the lowest risk for blood loss. But they can be the higher risk for some secondary failures if the bone truly isn't strong enough, if it is osteoporotic. So you can see some, what we would term, failure of fixation. You can see secondary displacements, and it usually is, is secondary to a bone being truly that weak.

And, and not the rebar, although the rebar is strong, the concrete around the rebar is still, wants to crack and crumble

[00:22:46] Dr. Chehab: more. Yeah. Okay. So let's move to the displaced femoral neck fracture. What is the standard or typical treatment? Obviously it varies patient to patient, but what's the range of, of treatment options for a patient who just, who sustains a displaced intracapsular

[00:23:01] Dr. Dougherty: femoral neck fracture?

Young patients will get fixed. So we, we really try in a physiologically appropriate. Older individual who has great healing potential. They're super active. You might give them the option to have it fixed. But the majority of these patients are older, elderly, geriatric. They're going to get a replacement instead of an attempt to fix the bone.

And so that replacement will remove the ball itself from the socket. That ball is no longer good to us, so to speak. And so we want to put something in that is very strong that can't crumble. And we have to keep that ball stable. By attaching it to a stem, which sits inside the top of the femur. So, a lot of patients will have had a either personally or a family member or friend have a hip replacement.

The hip replacement usually replaces the socket itself. The majority of hip fracture patients who have a femoral neck fracture who are older or geriatric won't require that socket to be replaced. They won't have enough arthritis to require replacement of the socket or they just don't have that physiologic demand.

So they'll get what is termed a hemi arthroplasty, hemi being half. So, half of the hip is replaced, and that's truly the ball is removed, a new metal ball is placed, and that metal ball sits upon a stem, the stem sits down inside the top of the femur, and it's a very stable construct for immediate weight bearing, for immediate, you know, function.

[00:24:21] Dr. Chehab: Okay, so again, the younger patient, you'll try and fix, and retention of the bone and, and hoping that it, it heals. We'll probably be long run better for the patient and, and, and reduce complications. But for the older patient, they're typically getting that ball replaced. And they're not getting the hip replacement that perhaps, you know, someone else would get in their 50s and 60s from a degenerative hip condition.

They're getting half the hip replacement on the ball side. And, and, and that typically works very, very well for the geriatric, geriatric patient with a displaced. Intracapsular femoral neck fracture. So what are the circumstances where you might actually do a full hip replacement in a femoral neck fracture that's displaced?

[00:25:01] Dr. Dougherty: Yeah. So it could be a really highly functional patient. 75 year old who rides their bike every day, falls off their bike, and you notice that they have no arthritis, but they are truly that functional. They're doing miles on a bike each day, or the. Patient who loves walking, right? They'll walk three to five miles a day.

That patient is indicated to have a total hip replacement over a hemiarthroplasty. And the reason is we know that there will be secondary wear within the hip socket if that hip socket has not been replaced. If there's that metal ball inside the socket. The wear rates are low for patients who are, you know, I'm going to the store.

I'm walking up and down the aisles Compared to I'm walking miles a day. So that patient who's very active can be indicated for a total hip replacement Additionally patients who come in they break their femoral neck and you look at the x ray and they have bad existing hip arthritis You should be doing a total hip replacement on those patients or they should receive that as opposed to just a hemiarthroplasty because they will have Automatically at baseline, worsening wear conditions within their hips.

So you want to give them the bearing surface that will give them the longitudinal, you know,

[00:26:05] Dr. Chehab: the benefit. Best outcome. Yeah. Okay. And then so, so let's shift gears just a little bit. We've been talking about the intracapsular hip fractures. Let's go extracapsular and talk about some of the the, the treatments, surgical treatments for the extra capsular hip

[00:26:19] Dr. Dougherty: fractures.

They can present the same way. Again, you can have that same workup. You can have that same optimization. It's blood thinning. It's all these different things, but then you're going to the operating room with the idea that you're going to be fixing this bone. This is one that again has better healing rates, better blood supply, far less risk for that.

Blood supply issue and so we expect that these heal. There are conditions that we haven't spoken about that can reduce healing potential. So patients who come in chronically smoking, patients who come in with, you know, frequent alcohol, patients who come in with an immunocompromised state, they've had transplants in the past, they've had other conditions, skin conditions, rheumatologic conditions that require steroids, those patients will have reduced healing.

So these are the conversations you have with this patient. If we're going to go and fix this bone, these are the things we have to do to optimize your healing potential. We're also going to try to reduce this. It's smoking, we've got to really cut back on that. Alcohol use, we've got to cut back on that.

You discuss, you know, these conditions with these patients, and that's the risk factor. Healing or not healing for these intertrochanteric fractures. Again, you said extra capsule or outside the hip capsule. And intertrochanteric is a big word, right? These are the ones that really involve the bump that you can feel on the side of your hip.

They're usually within that region or within just an inch or two below that area. And they are obviously surgical because they are grossly unstable in the majority. And that surgery over time has evolved, kind of as the femoral neck has. The usual treatment was a plate and screws to fixate this bone.

And then we've realized that there are really two distinct patterns. We're going to call them stable and unstable. Kind of like with the femoral neck. Stable ones make it screws. Unstable ones probably get replacement. In these instances, if you have a stable intertrochanteric fracture, a plate and screw construct is indicated, but you can also use a nail or a rod construct instead that goes inside the bone, as opposed to a plate that's applied to the outside of the bone.

But in the truly unstable intertrochanteric fractures a plate and screw construct is inappropriate. It, it is not adequate to provide initial stability or ongoing stability. You'll see a lot of secondary displacements or... Compression or, you know, malalignments that come from that. So a rod or nail placed inside the bone, kind of like a chopstick being slid down inside of a drinking straw, that's the initial part of the construct, that provides a better biomechanic benefit and stability.

So those patients are obviously having surgery, but it's a different... Implant that's used and kind of a different surgical tactic. Okay, so

[00:28:57] Dr. Chehab: just again to summarize, so the extracapsular intertrochanteric hip fractures typically have high potential for healing and those are the ones where we fix it, either with a plate and screw construct in certain types of fractures or a rod and screw construct for, which is something that can be used for many of the intertrochanteric hip fractures.

And the goal is to basically maintain the alignment of that part of the femur, not so that it gets... Malaligned or squished, but to try and just keep it as it was before it was broken, presumably to optimize the outcome on the other end.

[00:29:31] Dr. Dougherty: You got it. And again, the degrees of displacement, the number of pieces produced those increasing, you know, complexities with the fracture, they can lead to some levels of displacement over time, or some levels of compression over time, or some levels of malalignment.

Some of those cannot be avoided, truly. It's not that you had a bad surgeon, it's the fracture itself is going to lend itself to some, we'll call it, controlled compression. Right. But it's a little bit of collapse of the fracture so that it can stabilize, that it's pressing against itself and that that compression helps to heal.

So

[00:30:02] Dr. Chehab: now let's just change gears a little bit now to the recovery side. And when, when patients have a hip fracture and let's say they have fixation of it where the bones are retained or they have replacement of the bone with the hemi arthroplasty, it, it's not like, again, the hip replaced patient who has arthritis, who's basically at the bottom of their function, and then they get their hip replaced and they start climbing upward and getting better Right from that moment.

You know, when patients come with a hip fracture, they were functioning totally normally and now they really can't function at all, and they're dug into a very deep hole. And, and what's that recovery like coming out of that hole?

[00:30:38] Dr. Dougherty: Certainly. So, the, the understanding their medical conditions coming in to a surgery, it's equally important to understand what their baseline activity is.

Day to day, what are they doing? Are they getting out of bed by themselves? Are they requiring assistance? Are they using any type of assist device before they fell? Do they occasionally use a cane if they're outside the house? Do they use a walker for all of their mobility? Do they always have their arm around a family member because they don't feel good with balance?

So why is that so important? Those pre existing issues with balance, with strength, with function will be acutely worsened With this hip fracture scenario the patients, you know, hospitalized, they have this is getting into even beyond physical issues, right? It's the, it's the mental part of, of health dementia, some level of delirium that can happen, but these patients, As you said, usually are functioning at their level, right?

And that level may be really tip top. It may be kind of bottom of the barrel and understanding that before going in for the surgery, you have an understanding. You can educate the patient and the family and the nursing staff, right? As to how this patient. It can mobilize following surgery. What level of assistance will they require?

And it is. It's a, it's a, it's a wake up. These patients come in. They say, well, I, I, my sister just had her hip replaced, and she said she was up and walking the next day, and she walked the, the, the lap around the hospital twice. I was only able to take two steps. And so it's, it's certainly a lot of education.

It's discussing the differences between somebody coming in and having their hip replaced for an arthritic issue. Thank you. Compared to this acute fracture issue, which, which really decreases their abilities to bounce back quickly.

[00:32:16] Dr. Chehab: What are coming up the rules of thumb? I, again, going back to my residency, which now, oh my god, it's decades ago.

There are you know, we would say patients would lose a level of function on average. So what

[00:32:27] Dr. Dougherty: does that mean? Yeah, so patient who requires nothing from an assist device standpoint, they haven't used a cane or a walker at all. After surgery, they're going to be using a walker initially, but they're going to get back usually to using a cane and hopefully back to using nothing.

They might be an occasional, you know, cane person. Somebody who is using a cane for every activity may ultimately, if they don't get back all their levels of function, have to use a walker. For the rest of their life. Patients who are using a walker really well, we'll usually get back to that walker without any issue, but patients who really struggle to get around, and this is their baseline function, their baseline issue they can require a wheelchair for a fair amount of time.

And obviously the goal is to not Not take that information and, and relegate that patient into that patient population to say you're going to have to be on a wheelchair or, you know, all these different things. You still motivate the patient. And by aligning your goals with the patient goals and getting PT and OT involved and really understanding what the capabilities are and getting them into the OR quickly, we have been able to reduce those big secondary problems and levels of function decline.

[00:33:31] Dr. Chehab: And, and. Again, I don't think it's very well understood just how morbid and lethal a hip fracture can be. So can you review some of those statistics, the 30 day mortality, the one year mortality for untreated and treated

[00:33:51] Dr. Dougherty: hip fractures? You got it. So some patients come in and You'll diagnose their hip fracture, you'll start to discuss this with them or their family members, and you'll say you have a hip fracture, and you can see some patients almost, they think that it is a death sentence right away.

They had a family member, they had somebody else who, who expired within some period of time after a hip fracture. You know, historical numbers, 25. 30 percent of patients may have their hip fracture occur and then they die within one year of that hip fracture. Those numbers have reduced or have been decreased through their early optimization pathways, right?

That we can reduce this number of patients who acutely suffer this hip fracture from ultimately dying. But the 30 day mortality rates, the 30 day morbidity rates, you know, 30 day or 100 day mortality rates, the one year mortality rates, they can be quite sizable. What we have to educate patients on is those patients who have a lot of those secondary issues that they re hospitalized, that they re admitted, they have other, you know, medical conditions that they ultimately die within one year.

They are the sicker patients. They're the patients who come in with a lot of those other comorbidities that we discussed, but still the pathways that we've created over the past 10 or 15 years have decreased those morbidity rates have decreased those mortality rates. And so, you know, I would say that.

So, currently you could expect that, you know, 10 to 20 percent of the sick, the sick subset you know, they're the ones who are most at risk. 10 to 20 percent may still have a mortality event, right? They may die within one

[00:35:28] Dr. Chehab: year. Sure. Okay. So, again, with hip fractures, what, what, what's the Timeline for recovery.

You know, we talked about a little bit about the degenerative replaced hip, walking around the ward, you know, two laps the first day. It's a much different timeline for the hip, hip fracture patient. So in general, what can patients expect over the first. Week, six weeks, three months. Six months.

[00:35:54] Dr. Dougherty: You got it.

So day one, the hope is that we get 'em out of bed, that we can stand, that we can work on Standing balance. We can shift some weight back and forth that they're able to. Mobilize or ambulate upwards of 6 to 10 to 20 feet. Maybe we get them to the chair. Maybe we get them to the bathroom. Maybe we get them to the door, to the hallway.

There are some patients who truly do better than that. That's fine. But at the minimum, getting them into a chair getting their, their joints mobilized, moving their feet, moving their ankles, moving their knees, just being frequent in their activities, even if they're not walking long distances, that reduces their blood clot risk.

That's very important. At, you know, two weeks when patients are coming back to see me in the office, I certainly hope that they're coming in with an ambulatory assist device and not a wheelchair, but I have patients who come back in a wheelchair, largely because they're coming back from a facility. The facility transports them to us in a metacar with a wheelchair there.

But we're assessing their level of, of ambulation seeing how far they can walk are they walking from the waiting area into the, into the, the office into the exam room? Are they getting to and from x ray? Are they able to get on and off the x ray table? Most FIP fracture patients will be able to do that with some level of assistance and certainly they might not be ambulating.

200 feet at that point, but they're routinely going 50 feet, 100 feet, 150 feet, that type, that type of activity at six weeks. The majority of my patients are coming back. They have a cane at that point. They might still be using a walker. They're walking more freely. They feel more confident. Their balance has improved again.

Their strength has certainly picked up. We've been focusing on their nutrition, patients who come in really, you know, malnourished and so they have better levels of energy. They have hopefully not been that subset of population that was readmitted. Again, there is that, that subset where patients will have exacerbations of other medical conditions.

They can have anemia related to existing blood level issues, and then they acutely lose blood. They need a transfusion. So those are the patients that sometimes I'm, you know, following them up. They're still in rehab. It's you know, coming back at six weeks, still in rehab. Those are the patients who are generally a lot sicker at the outset.

There are other subset of populations. Patients that go home right after a hip fracture. They have either a, the perfect setup. They live in a ranch home. There are no steps, or they have an apartment with an elevator. There are no steps. They can Get home more quickly, whether that's acutely from the hospital or having gone to a rehab, you know, for some period of time, maybe 10 days, maybe two weeks.

And then the other subset of patients who come in, they live in a house that was built in the 1920s. The stairs are very steep. They're, you know, each rise is high and each step is very, very, You know, narrow, so to speak. They just don't have the ideal setup. Their doorways are very small. They can't fit their walker between their toilet and their tub.

Those are patients, if they're not going to be moving into a different environment, they may be in rehab for a longer period of time. They're still functioning well. They're still walking well, but they can't fit their assist device. Within their, their home, they could be in a rehab facility for a longer period of time.

Three months is the last, so three months, not even three months, ten weeks for me is usually the last scheduled visit for all these patients. We'll see that their fracture is healed, or is, is on the path of healing where we don't need additional x rays. If they've had a replacement, you know, we've already seen that they have a stable replacement.

We see that they're functioning really well. We see that they've returned to some of their activities, right? Some of them have started a garden again. Some of them are walking routinely outside. Some of them are bicycling. And then, you know, as with any subset of injury, you'll have patients who just never recover but again, those patients are usually patients who have significant medical comorbidities, other issues that have been bubbling under the surface, but were undiagnosed.

All of a sudden, they're in the hospital, and with all of these subspecialists here, They get, you know, the evaluations that are required. We find out that they really do have a significant amount of cardiac disease. That was just, they were doing fine. And then all of a sudden they need a secondary cardiac procedure.

Right. Patients with significant diabetic issues, again, they're the ones at risk for getting, you know, heel ulcerations while they're laying in bed. Patients who don't have good sensation, they have some level of neuropathy, they don't sense that their heel's hurting them because it's laying in one position for a long period of time.

So those are the patients, again, their recovery is lengthened because additional issues. have popped up that may not have been present or understood.

[00:40:27] Dr. Chehab: Yeah, or just sort of simmering below this, simmering below the surface and then percolate to the top of the surface after a devastating injury like a hip fracture.

It's amazing, we didn't discuss this, but the fact that patients can walk Right out of surgery, really, the constructs that have been developed are so strong and stable that it can reinforce the bone that even after it breaks, that reinforcement can allow patients to walk right away. And that's one of the goals of the surgery is to get people moving right away and able to put their weight on the leg right away.

[00:40:57] Dr. Dougherty: Correct. There are you have to have Confidence behind the construct. You need to be able to give these older populations the ability to put weight through their limb. And there are some truly devastating injuries that no matter what we do, we still decide we've got to limit weight bearing to a degree, so that we don't see that catastrophic collapse right away.

Truly osteoporotic bone. Truly comminuted or many many pieces produced. Yeah, but the constructs today are very advanced the ability to have multiple Screws that go up and within the ball in the head the ability to secondarily inject cement Through the implant into the ball itself so that that screw that's in the ball is parked within hard cement as opposed to with an osteoporotic bone.

But my goal is always to give patients full weight bearing allowance. I'll still say they should use a walker, the balance issues, the strength issues, but you have to be able to put weight through this limb because if you can't and I make you sit in bed or sit in a wheelchair for another six weeks.

The devastating effect of, you know, muscle atrophy is there. Yeah.

[00:42:02] Dr. Chehab: So what do you see in the future? Are there any future developments, scenarios that you see playing out that can continue to reduce the morbidity and mortality of hip

[00:42:12] Dr. Dougherty: fractures? Yeah, so we didn't touch on, you know, the treatments of osteoporosis and whatnot.

There's another subset of hip fractures which are very peculiar in their presentation. It's a patient who Breaks their femur while they're standing just from standing and the weight on the femur and you'll get that Scenario, the patient says, I was standing in the doorway, and the next thing I know, I was on the ground.

And I think my, my hip broke before I hit the ground. And that can happen. So we talk about osteoporosis, we talk about treatment of osteoporosis, and the reduction of fractures. A lot of patients who have been on osteoporotic medications for a number of years, it's the, the class called bisphosphonates those patients, unfortunately, can be in the subset of patients, the complications that come from any medication.

And although their overall skeleton is benefited by being on a bisphosphonate or an anti osteoporosis medication, and the strength within the bone is improving, these medications change how bone repairs itself as well. The goal is to not lose bone, it doesn't necessarily build bone, but the remodeling capacity and the healing capacity is somewhat altered and the patient can weaken their femur and break their femur and have the same type of surgical need.

Those patients have this atypical presentation. The recovery is going to be similar, but we may be changing their medications afterwards. To eliminate that previous bisphosphonate medication, give them a different medication to help their bones heal, those types of things. The patients who comes in, who comes in with a standard fall, I fell and then I broke my hip.

You're trying to maximize their bone health afterwards. You're trying to minimize their future fracture risk by setting them up with either their primary or endocrine rheumatology to reduce fracture risk, those types of things. There are a number of new advancements that come through from an implant standpoint.

But I think it's the hip fracture protocols. That will continue to advance, you know, through the community hospitals that will benefit these patients the most in that It's you're not at a level in trauma center. That's okay You you know, hope that you have landed in a facility that has more of hip fracture protocol that There's a pathway to recovery.

So,

[00:44:29] Dr. Chehab: Prevention, you mentioned with treatment of osteoporosis is important. I mean, that may be the biggest impact we can have on hip fracture outcomes is preventing it in the first place. And then, thankfully, the hardware and development of designs has improved. And then standardizing these pathways that have proved beneficial.

at reducing morbidity and mortality. These are some of the things that are most likely going to continue to help reduce the impact of a hip fracture on elderly populations. Okay. Any other parting

[00:45:01] Dr. Dougherty: thoughts? Yeah. So I love my patients. Trauma is a, is an amazing field. Again, touched on, I treat kids, I treat adults, I treat geriatric, geriatric patients.

One thing you have to, to be ready to discuss with your surgeon is. Is it time to move from the environment from which I fell, right? It's a conversation that you should have with family members. I have a lot of conversations with my patients with relation to... Appropriateness of their home living environment and secondarily there are some patients who don't get surgery, right?

There are some patients who I said they fell out of their deathbed, they're on hospice, and you have to have that conversation really early on with the patient. I have, you know, this 1 percent subset of population and patients who don't have surgery. And the family members who sometimes have to make that call for their mom or dad their mom or dad has significant dementia.

They're not decisional. They don't have the capacity. And so daughter, son, family, whomever, a circuit decision maker is trying to make that decision for what, what is right for their family member. A lot of education goes into it. And sometimes the decision is, is we're not going to perform a surgery. We could tell that mom wouldn't want this.

She's already been kind of declining. Right. And so Having those conversations with the surgeon, really letting the surgeon and the medical team know what you want for your family member. If you're making those decisions for your family member is, is, it's key. It's crucial. We don't want to be treating patients just because they have a fracture.

We need to treat the patient as a whole and understand how they're coming in, what their associated issues are, and in those patients that are, that are truly debilitated from a functional standpoint, and they have that component of dementia, delirium, sometimes surgery is, is the right call, but sometimes it isn't, and so you can, you know Help the family understand that you can have palliative care consultations.

You can have hospice consultations and you can still usually facilitate those within 24 to 36 hours to help that family member make that right call for their patient or their family member.

[00:47:04] Dr. Chehab: Our guest today on IBGI's OrthoInform is Dr. Evan Daugherty. Evan, thanks so much for being here.

[00:47:09] Dr. Dougherty: I truly appreciate the opportunity.

Thank you.