With the aging of the population, the number of hip fractures in the elderly is gradually increasing, and hip fracture has become one of the main problems affecting the health of the elderly. It is an important factor to improve the quality of life of patients.
From June 2001 to February 2005, we operated on 217 elderly patients over 75 years old with hip fractures.
1. Clinical data and methods
1.1 General data: 217 cases of hip fracture, 219 hips (two cases of bilateral successive femoral neck fracture and intertrochanteric fracture). Among them, 86 cases were male and 131 cases were female. Age ranged from 75 to 99 years, mean age 82.3 years.
①Type of fracture: 121 hip femoral neck fractures and 98 hip intertrochanteric fractures.
Reason for injury: 95 hips were injured when walking on flat ground, 63 hips were injured when slipping and falling in the bath, 27 hips were injured when walking up and down the stairs, 22 hips were injured when walking in and out of the car, and 12 hips were injured in car accidents.
(③) Admission time: 2h~5d after injury, average 27h. The operation time is usually 48~72h after injury.
④Surgical methods: femoral neck fracture: 107 cases of artificial femoral head replacement and 14 cases of internal fixation treatment. Femoral trochanter fracture: 35 cases treated with internal fixation or external fixation brace, 63 cases with artificial femoral head replacement.
⑤Anesthesia methods: local anesthesia in 16 cases, epidural anesthesia in 47 cases, and general anesthesia in 156 cases.
1.2 Statistical analysis of combined diseases and postoperative complications: 137 cases (63.1%) had combined chronic diseases of brain, heart, lung, liver and kidney before fracture, 47 cases (21.7%) had 2 combined diseases, 26 cases (12.0%) had 3 combined diseases, and 10 cases (4.6%) had 4 or more combined diseases.
The cardiovascular diseases were mostly hypertension, various types of coronary heart disease, and arrhythmia; respiratory system diseases were senile bronchitis, emphysema, bronchiectasis, silicosis, and tuberculosis; endocrine diseases were diabetes mellitus, hyper- or hypothyroidism; digestive system diseases were mostly cholecystitis, pancreatitis, and hepatic insufficiency; urinary system diseases were urinary system infections and renal insufficiency; and neuropsychiatric system diseases: Parkinson’s disease The diseases of neuropsychiatric system: Parkinson’s disease, Alzheimer’s disease, cerebrovascular accident sequelae, etc., with hypertension, diabetes mellitus, old slow branch and cerebrovascular accident sequelae as the most common.
In some patients, traumatic hip fractures were accompanied by wrist fractures, ulnar hawk fractures and rib fractures.
A total of 30 cases of complications occurred in the early postoperative period in this group of cases, with an incidence rate of 13.7%. Infection-related complications accounted for 4.6%, including one case of joint infection (0.5%), four cases of lung infection (1.8%), five cases of incision infection or poor healing (2.3%); and two cases of emergency gastrointestinal ulcers (0.9%). There were 3 cases (1.4%) of deep vein thrombosis in the lower limbs, 2 cases (0.9%) of postoperative cerebral thrombosis recurrence, 7 cases (3.2%) of transient postoperative geriatric mental disorder, and 6 cases (2.7%) of early postoperative death.
1.3 Perioperative measures.
1.3.1 Preoperative general preparation: ask detailed medical history, understand the patient’s ability to live and mental status before injury from the patient and family members; understand the presence of medical diseases; improve preoperative routine examination: blood, urine routine, water-electrolyte and acid-base balance, liver and kidney function, blood glucose, chest X-ray, electrocardiogram and other examinations. If the patient is suspected of having respiratory insufficiency, perform respiratory function tests to fully understand the patient’s physical condition. The surgical risk is assessed according to the American Society of Anesthesiologists (ASA) score, and the anesthesia and surgical method are selected according to the characteristics of the patient’s condition.
1.3.2 Management of comorbid diseases: Consult the relevant departments to actively manage the comorbid diseases and adjust the patient’s condition to adapt to the surgery as soon as possible. For diabetic patients, control the diet and adjust the blood glucose by applying hypoglycemic drugs or insulin therapy according to the blood glucose before and after three meals and at bedtime, and control the fasting blood glucose between 5.6 and 9.4 mmol/L, with slightly higher than normal (6.4 mmol/L) as appropriate;
For patients with hypertension, apply antihypertensive drugs and control blood pressure at about 21.3/13.3KPa (160/100mmHg); for patients with combined respiratory and urinary tract infections and poor liver and kidney function, actively control infection and improve pulmonary ventilation, liver and kidney function. For patients with coronary artery disease and other cardiac disorders, preoperative assessment of cardiac function is performed to adjust the heart rate and improve cardiac function according to different conditions.
However, it is emphasized that the general condition of the patient should be improved as soon as possible, and the preparation time before surgery should be shortened as much as possible so that the patient’s various examination indexes reach or are close to normal levels and can tolerate anesthesia and surgery, and the preparation time before surgery should not be prolonged for reaching completely normal levels and missing the time for treatment.
The treatment of combined diseases after surgery is generally carried out with reference to the preoperative plan, while the treatment plan is adjusted according to the laboratory indexes of the reexamination. The changes of vital signs such as body temperature, blood pressure, pulse rate, respiration and oxygen saturation should be closely observed in elderly patients after surgery, and blood routine and blood biochemical indexes should be rechecked in time to guide treatment.
1.3.3 Intraoperative treatment: intraoperative anesthesiologists should pay attention to the general condition of the patient and changes in vital signs, and for patients with combined diabetes, hypertension, pulmonary disorders and other diseases, closely test blood sugar and observe changes in blood pressure, oxygen saturation and electrocardiogram, and communicate with the surgeon in a timely manner when problems are found; surgery should be minimally invasive and skillful, and the operating time should be shortened as much as possible so that the physiological interference of surgery on the organism is reduced to The operation should be minimally invasive and skillful, so as to minimize the physiological disturbance to the body and facilitate the recovery after surgery;
Intraoperative complications such as pulmonary embolism, hypotension, cardiovascular and cerebrovascular accidents during the process of cement placement in artificial arthroplasty or medullary expansion in internal fixation should be paid attention to; pressure sores and nerve injuries due to improper position; antibiotics should be applied during surgery to ensure effective antibiotic blood concentration; after the completion of surgery, thorough hemostasis, wound irrigation and drainage tubes should be placed to prevent tissue debris, blood accumulation, intraoperative bacterial Contamination leads to infection within the incision after surgery.
1.3.4 Prevention and treatment of postoperative complications: common complications include vascular embolic diseases, mainly deep vein thrombosis, followed by cerebral thrombosis, various infections, emergency ulcers, decubitus ulcers, etc.
The prevention and treatment measures of vascular embolic diseases mainly include: for patients with hypercoagulable blood or previous history of thrombosis, no coagulant drugs are used after surgery, and patients are encouraged to perform functional exercises of the limbs and active extension and flexion activities of the foot and ankle joints to promote venous reflux of the limbs and reduce swelling and thrombosis of the limbs. If the diagnosis of deep vein thrombosis is clear, take active measures such as braking the affected limb to prevent embolism, applying low molecular dextrose to reduce blood viscosity and low molecular weight heparin to dissolve the embolism.
Prevention and control of infection: apply antibiotics and take appropriate preventive measures for different infections that may occur at the same time.
①Incisional infection: Intraoperative minimally invasive operation, thorough hemostasis, rinsing before suturing and other measures are the basis for preventing infection; preoperative intraoperative application of antibiotics; postoperative negative pressure drainage of the incision, and removal of the drainage tube when the drainage flow is less than 50 ml/24h. Promptly change the medication and observe the wound condition. Routine blood count, blood sedimentation and C-reactive protein are the early indicators reflecting postoperative infection, which are usually rechecked 1, 3 and 7 days after surgery to observe their dynamic changes.
②Pulmonary infection: It is a common postoperative complication. Patients should be encouraged to change position or semi-sitting position, encouraged to breathe deeply and cough to expel sputum, assisted to tap the back to expel sputum, and given ultrasonic nebulized inhalation if necessary. After pneumonia occurs, select effective antibiotic treatment according to sputum bacterial drug sensitivity test.
Urinary tract infection: remove the catheter promptly after surgery and encourage patients to drink more water and urinate more often. Infections mostly occur in patients with previous urinary tract infections, prostatic hyperplasia and dyspareunia. After the occurrence, choose sensitive medication according to urine bacterial culture. In general, cephalosporin antibiotics are applied prophylactically within 7 days after surgery. The patient’s body temperature, wound condition, blood count, blood sedimentation, and C-reactive protein are used as indications for determining the presence or absence of infection and discontinuing antibiotics.
For the treatment of infectious complications, antibiotics should be selected according to bacterial culture and drug sensitivity test, and the indication for discontinuation should be judged according to bacterial culture results of chest X-ray, wound secretion and elimination (sputum and urine) in addition to the above indicators. In short, the dosage of antibiotics should not be too large and the time should not be too long to avoid secondary dysbiosis, resulting in aggravation of the disease or even death.
Emergency ulcer: 3-7d postoperative application of ranitidine type drugs for prevention. After ulceration occurs, actively rehydrate and transfuse blood to expand blood volume; apply hemostatic drugs to stop bleeding; apply H receptor or sodium-potassium pump inhibitors to inhibit gastric acid secretion; apply antibiotics appropriately to prevent infection. This group of patients with emergency ulcers was cured by the above measures.
Transient postoperative geriatric psychiatric disorder may be related to surgical and traumatic stimulation; application of sedative drugs for symptomatic treatment, and symptoms gradually relieved.
Decubitus ulcers: strengthening postoperative skin care, encouraging patients to change positions, and early movement to the floor are the keys to prevention, and for patients who have difficulty in early movement, air mattress beds are applied.
2.Results
In this group of cases, 63.1% of patients had preoperative medical comorbidities, 38.2% of patients had two or more comorbidities, ASA score: Grade I: 80 cases, Grade II: 108 cases, Grade III: 27 cases, Grade IV: 2 cases. All patients passed the operation period successfully. 30 cases of complications occurred in the early postoperative period, with an incidence rate of 13.7%.
There were 6 cases of death during hospitalization, with an incidence of 2.7%, including 2 cases of femoral neck fracture and 4 cases of femoral trochanter fracture, 1 case of emphysema, 2 cases of cerebrovascular accident sequelae and 3 cases of coronary heart disease combined with the patient before surgery. The cause of death was postoperative pulmonary infection induced brain, heart and kidney multi-system organ failure. Except for the fatal cases, other complications were cured. The mean operative time, mean blood loss and transfusion volume of different surgical procedures.
Postoperative follow-up ranged from 6 to 24 months, with an average of 13 months. The fractures with internal fixation were healed bony except for one case of non-union with joint replacement. Three cases were lost to follow-up. The efficacy of femoral neck fracture and femoral trochanter fracture was judged by the Harris score, and the efficacy rates of the two fractures were 86.3% and 78%, respectively, with an overall excellent rate of 82.7%.
3. Discussion:
There are no clear statistics on hip fractures in China; according to the United States, 250,000 hip fractures occur each year in the United States now, and by 2050, it is estimated that the number will be twice as high as it is now [2]. An increasing proportion of these patients are of advanced age. Although most elderly hip fracture patients have cardiac, pulmonary, cerebral, hepatic, renal and other organ insufficiencies and are at higher risk for surgery, they are not absolute contraindications to surgery.
Foreign literature reported that the mortality rate of hip fracture was 34% with conservative treatment and 17.5% with surgery, and the mortality rate of femoral rotor fracture was 3.6% with conservative treatment and 0.83% with surgery in Beijing Hospital, so early surgery is necessary [3].
Compared with other fracture patients, hip fracture population has the following characteristics: older age of onset, serious osteoporosis; higher proportion of combined chronic diseases, some chronic diseases are themselves risk factors for fracture, such as cerebral thrombosis patients with inflexible limbs, easy to fall; reduced function of the autoimmune system, weak resistance of the body; high blood viscosity, trauma and surgical stress leading to a hypercoagulable state of blood, trauma and postoperative limb activity is reduced. Patients with different types of combined diseases have corresponding abnormal examination indexes, such as hyperglycemia and abnormal electrocardiogram.
Therefore, they are prone to complications such as postoperative infection, thrombosis, and aggravation of comorbid diseases. Perioperative treatment is an important factor related to the success or failure of hip fracture surgery in the elderly, and several aspects should be noted.
Focus on adjusting the general condition, actively treating preoperative comorbidities, and operating as early as possible. Early surgery is of great importance, and the Zuckerman study showed that delayed surgery of hip fractures in the elderly for 3 d or more was associated with a 1-year increase in mortality after surgery [4]. Early surgery and early weight-bearing activities on the ground can significantly reduce pulmonary complications, deep venous and decubitus ulcers, and increase patients’ confidence in treating the disease, which is conducive to their recovery [5, 6] Age is not a decisive factor in the competence of elderly hip fracture patients for surgery, but preoperative assessment and improvement of the patient’s general health status are crucial, especially cardiopulmonary function.
Complication control is based on prevention, early detection, early and effective treatment, and emphasis on basic supportive therapy. Post-operative observation of the condition and treatment of fractures and co-morbidities should be paid attention to the prevention of complications. Seymour et al. reported that pulmonary disorders accounted for 40% of postoperative complications and 20% of preventable postoperative deaths in the elderly [7], and pneumonia was the main postoperative lethal factor. The present case is consistent with this.
The procedure should be based on the principles of minimal trauma, shortest operative time, minimal disturbance to the body, and best therapeutic outcome, and the appropriate surgical plan should be selected based on the type of fracture and the patient’s ASA score. The fracture of the femoral head is usually treated with internal fixation.
In the past, most of the fractures were treated by power hip screw (DHS) or proximal femoral intramedullary nail (PFN) fixation, but in the past 2 years, we applied the “femoral distance reconstruction” technique to the unstable femoral fracture and performed artificial femoral head replacement. This method is less invasive than DHS or PFN, with less blood loss and shorter operation time [8]. In patients with poor general condition, many medical disorders, and ASA grade III and above, conservative or local anesthesia reset external fixation brace fixation.
In elderly hip fractures, the surgical excellence rate is relatively lower than that of femoral neck fractures because patients with femoral trochanter fractures have a higher average age of onset than femoral neck fractures, tend to have more comorbid diseases, poor physical condition, and heavy fracture comminution.
Because general anesthesia with tracheal intubation has the advantages of effectively ensuring blood oxygen concentration, maintaining stable blood pressure, and facilitating resuscitation, patients with ASA scores who can tolerate general anesthesia are selected for surgery under general anesthesia. However, for patients with combined respiratory system diseases, intubation stimulation can increase tracheal secretions, respiratory depression after anesthesia, poor sputum excretion and other factors that can easily lead to pulmonary complications, so general anesthesia with tracheal intubation should not be selected, and local anesthesia or epidural anesthesia should be used.
Rehabilitation therapy is an important part of the perioperative treatment of hip fracture in the elderly, which plays an important role for patients to successfully pass the perioperative period and restore their preoperative living status. Rehabilitation therapy includes functional rehabilitation of the limbs and psychological rehabilitation. On the one hand, we should apply corresponding functional exercise measures to enable patients to get down to weight-bearing activities as soon as possible, restore joint function and resume self-care at a later stage. On the other hand, medical and nursing staff should cooperate with family members to make good ideological work of patients and help them adjust their mental state.
In conclusion, for elderly patients with hip fracture, active preoperative preparation, shortening the time of bed rest before surgery; minimally invasive operation during surgery, shortening the operation time; postoperative rehabilitation measures and attention to the prevention and treatment of combined diseases and complications, early movement to the ground and other measures can receive satisfactory treatment results.