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Post-operative Management

  • Giulio PioliEmail author
  • Chiara Bendini
  • Paolo Pignedoli
Chapter
  • 951 Downloads
Part of the Practical Issues in Geriatrics book series (PIG)

Abstract

The management of hip fracture in older adults in the postoperative setting requires a multidisciplinary approach and geriatric competencies. The main goals of the post-operative phase are early mobilisation and prevention of complications. Achieving the goal of early mobilisation requires a stable surgical repair – allowing the patient to bear weight as tolerated – effective pain control and fluid management protocols that ensure volume adequacy and avoid orthostatic hypotension. Due to age-associated decline in physiological reserve and function across multi-organ systems, hip fracture patients are at risk of multiple complications. Almost every organ is vulnerable, though cognitive dysfunction, cardiac complications and infections are the most frequent and clinically significant. A systematic approach to management, with check lists for each professional and shared protocols for the most common conditions, is an established way to improve the quality of the intervention and reduce postoperative complications. The susceptibility to complications of hip fracture elderly patients may last several days after surgical repair, thus discharge planning based on discharge needs is a crucial point in the acute management.

Keywords

Pressure Ulcer Early Mobilisation Regional Nerve Block Geriatric Consultant Fluid Management Protocol 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

References

  1. 1.
    Pioli G, Giusti A, Barone A (2008) Orthogeriatric care for the elderly with hip fractures: where are we? Aging Clin Exp Res 20(2):113–122CrossRefPubMedGoogle Scholar
  2. 2.
    Giusti A, Barone A, Razzano M, Pizzonia M, Pioli G (2011) Optimal setting and care organization in the management of older adults with hip fracture. Eur J Phys Rehabil Med 47(2):281–296PubMedGoogle Scholar
  3. 3.
    Vidán M, Serra JA, Moreno C, Riquelme G, Ortiz J (2005) Efficacy of a comprehensive geriatric intervention in older patients hospitalized for hip fracture: a randomized, controlled trial. J Am Geriatr Soc 53(9):1476–1482CrossRefPubMedGoogle Scholar
  4. 4.
    Khasraghi FA, Christmas C, Lee EJ, Mears SC, Wenz JF Sr (2005) Effectiveness of a multidisciplinary team approach to hip fracture management. J Surg Orthop Adv 14(1):27–31PubMedGoogle Scholar
  5. 5.
    Friedman SM, Mendelson DA, Bingham KW, Kates SL (2009) Impact of a comanaged geriatric fracture center on short-term hip fracture outcomes. Arch Intern Med 169(18):1712–1717CrossRefPubMedGoogle Scholar
  6. 6.
    Miura LN, DiPiero AR, Homer LD (2009) Effects of a geriatrician-led hip fracture program: improvements in clinical and economic outcomes. J Am Geriatr Soc 57(1):159–167CrossRefPubMedGoogle Scholar
  7. 7.
    Adunsky A, Arad M, Levi R, Blankstein A, Zeilig G, Mizrachi E (2005) Five-year experience with the ‘Sheba’ model of comprehensive orthogeriatric care for elderly hip fracture. Disabil Rehabil 27(18–19):1123–1127CrossRefPubMedGoogle Scholar
  8. 8.
    Prestmo A, Hagen G, Sletvold O, Helbostad JL, Thingstad P, Taraldsen K et al (2015) Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial. Lancet 385(9978):1623–1633CrossRefPubMedGoogle Scholar
  9. 9.
    Boddaert J, Cohen-Bittan J, Khiami F, Le Manach Y, Raux M, Beinis JY, Verny M, Riou B (2014) Postoperative admission to a dedicated geriatric unit decreases mortality in elderly patients with hip fracture. PLoS One 9(1):e83795. doi: 10.1371/journal.pone.0083795.eCollection2014 CrossRefPubMedPubMedCentralGoogle Scholar
  10. 10.
    Foss NB, Kristensen MT, Kehlet H (2006) Prediction of postoperative morbidity, mortality and rehabilitation in hip fracture patients: the cumulated ambulation score. Clin Rehabil 20(8):701–708CrossRefPubMedGoogle Scholar
  11. 11.
    Hulsbæk S, Larsen RF, Troelsen A (2015) Predictors of not regaining basic mobility after hip fracture surgery. Disabil Rehabil 37(19):1739–1744CrossRefPubMedGoogle Scholar
  12. 12.
    Barone A, Giusti A, Pizzonia M, Razzano M, Oliveri M, Palummeri E, Pioli G (2009) Factors associated with an immediate weight-bearing and early ambulation program for older adults after hip fracture repair. Arch Phys Med Rehabil 90(9):1495–1498CrossRefPubMedGoogle Scholar
  13. 13.
    Abou-Setta AM, Beaupre LA, Rashiq S, Dryden DM, Hamm MP, Sadowski CA et al (2011) Comparative effectiveness of pain management interventions for hip fracture: a systematic review. Ann Intern Med 155(4):234–245CrossRefPubMedGoogle Scholar
  14. 14.
    Wong SS, Irwin MG (2016) Peri-operative cardiac protection for non-cardiac surgery. Anaesthesia 71(Suppl 1):29–39CrossRefPubMedGoogle Scholar
  15. 15.
    Moppett IK, Rowlands M, Mannings A, Moran CG, Wiles MD, NOTTS Investigators (2015) LiDCO-based fluid management in patients undergoing hip fracture surgery under spinal anaesthesia: a randomized trial and systematic review. Br J Anaesth 114(3):444–459CrossRefPubMedGoogle Scholar
  16. 16.
    Roche JJ, Wenn RT, Sahota O, Moran CG (2005) Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study. BMJ 331(7529):1374CrossRefPubMedPubMedCentralGoogle Scholar
  17. 17.
    Belmont PJ Jr, Garcia EJ, Romano D, Bader JO, Nelson KJ, Schoenfeld AJ (2014) Risk factors for complications and in-hospital mortality following hip fractures: a study using the National Trauma Data Bank. Arch Orthop Trauma Surg 134(5):597–604CrossRefPubMedGoogle Scholar
  18. 18.
    Khan MA, Hossain FS, Ahmed I, Muthukumar N, Mohsen A (2013) Predictors of early mortality after hip fracture surgery. Int Orthop 37(11):2119–2124CrossRefPubMedPubMedCentralGoogle Scholar
  19. 19.
    Pioli G, Barone A, Giusti A, Oliveri M, Pizzonia M, Razzano M, Palummeri E (2006) Predictors of mortality after hip fracture: results from 1-year follow-up. Aging Clin Exp Res 18(5):381–387CrossRefPubMedGoogle Scholar
  20. 20.
    Simunovic N, Devereaux PJ, Sprague S, Guyatt GH, Schemitsch E, Debeer J, Bhandari M (2010) Effect of early surgery after hip fracture on mortality and complications: systematic review and meta-analysis. CMAJ 182(15):1609–1616CrossRefPubMedPubMedCentralGoogle Scholar
  21. 21.
    Pioli G, Lauretani F, Davoli ML, Martini E, Frondini C, Pellicciotti F et al (2012) Older people with hip fracture and IADL disability require earlier surgery. J Gerontol A Biol Sci Med Sci 67(11):1272–1277CrossRefPubMedGoogle Scholar
  22. 22.
    Goisser S, Schrader E, Singler K, Bertsch T, Gefeller O, Biber R et al (2015) Low postoperative dietary intake is associated with worse functional course in geriatric patients up to 6 months after hip fracture. Br J Nutr 113(12):1940–1950CrossRefPubMedGoogle Scholar
  23. 23.
    Avenell A, Handoll HH (2010) Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev (1):CD001880. doi: 10.1002/14651858.CD001880.pub5
  24. 24.
    Liu M, Yang J, Yu X, Huang X, Vaidya S, Huang F, Xiang Z (2015) The role of perioperative oral nutritional supplementation in elderly patients after hip surgery. Clin Interv Aging 10:849–858PubMedPubMedCentralGoogle Scholar
  25. 25.
    Botella-Carretero JI, Iglesias B, Balsa JA, Arrieta F, Zamarrón I, Vázquez C (2010) Perioperative oral nutritional supplements in normally or mildly undernourished geriatric patients submitted to surgery for hip fracture: a randomized clinical trial. Clin Nutr 29(5):574–579CrossRefPubMedGoogle Scholar
  26. 26.
    Carson JL, Sieber F, Cook DR, Hoover DR, Noveck H, Chaitman BR et al (2015) Liberal versus restrictive blood transfusion strategy: 3-year survival and cause of death results from the FOCUS randomised controlled trial. Lancet 385(9974):1183–1189CrossRefPubMedGoogle Scholar
  27. 27.
    Marik PE, Corwin HL (2008) Efficacy of red blood cell transfusion in the critically ill: a systematic review of the literature. Crit Care Med 36(9):2667–2674CrossRefPubMedGoogle Scholar
  28. 28.
    Gregersen M, Damsgaard EM, Borris LC (2015) Blood transfusion and risk of infection in frail elderly after hip fracture surgery: the TRIFE randomized controlled trial. Eur J Orthop Surg Traumatol 25(6):1031–1038CrossRefPubMedGoogle Scholar
  29. 29.
    Lauretani F, Frondini C, Davoli ML, Martini E, Pellicciotti F, Zagatti A et al (2012) Vitamin D supplementation is required to normalize serum level of 25OH-vitamin D in older adults: an observational study of 974 hip fracture inpatients. J Endocrinol Invest 35(10):921–924PubMedGoogle Scholar
  30. 30.
    Fakler JK, Grafe A, Dinger J, Josten C, Aust G (2016) Perioperative risk factors in patients with a femoral neck fracture - influence of 25-hydroxyvitamin D and C-reactive protein on postoperative medical complications and 1-year mortality. BMC Musculoskelet Disord 17(1):51CrossRefPubMedPubMedCentralGoogle Scholar
  31. 31.
    Pioli G, Lauretani F, Pellicciotti F, Pignedoli P, Bendini C, Davoli ML et al (2016) Modifiable and non-modifiable risk factors affecting walking recovery after hip fracture. Osteoporos Int 27(6):2009–2016CrossRefPubMedGoogle Scholar
  32. 32.
    Gottschalk A, Hubbs J, Vikani AR, Gottschalk LB, Sieber FE (2015) The impact of incident postoperative delirium on survival of elderly patients after surgery for Hip fracture repair. Anesth Analg 121(5):1336–1343CrossRefPubMedGoogle Scholar
  33. 33.
    Oh ES, Li M, Fafowora TM, Inouye SK, Chen CH, Rosman LM, Lyketsos CG et al (2015) Preoperative risk factors for postoperative delirium following hip fracture repair: a systematic review. Int J Geriatr Psychiatry 30(9):900–910CrossRefPubMedGoogle Scholar
  34. 34.
    Hshieh TT, Yue J, Oh E, Puelle M, Dowal S, Travison T, Inouye SK (2015) Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis. JAMA Intern Med 175(4):512–520CrossRefPubMedPubMedCentralGoogle Scholar
  35. 35.
    Akunne A, Davis S, Westby M, Young J (2014) The cost-effectiveness of multi-component interventions to prevent delirium in older people undergoing surgical repair of hip fracture. Eur J Orthop Surg Traumatol 24(2):187–195CrossRefPubMedGoogle Scholar
  36. 36.
    Orena EF, King AB, Hughes CG (2016) The role of anesthesia in the prevention of postoperative delirium: a systematic review. Minerva Anestesiol 82(6):669–683PubMedGoogle Scholar
  37. 37.
    Fok MC, Sepehry AA, Frisch L, Sztramko R, van der Burg BL B et al (2015) Do antipsychotics prevent postoperative delirium? a systematic review and meta-analysis. Int J Geriatr Psychiatry 30(4):333–344CrossRefPubMedGoogle Scholar
  38. 38.
    Shoair OA, Grasso Ii MP, Lahaye LA, Daniel R, Biddle CJ, Slattum PW (2015) Incidence and risk factors for postoperative cognitive dysfunction in older adults undergoing major noncardiac surgery: a prospective study. J Anaesthesiol Clin Pharmacol 31(1):30–36CrossRefPubMedPubMedCentralGoogle Scholar
  39. 39.
    Chatterton BD, Moores TS, Ahmad S, Cattell A, Roberts PJ (2015) Cause of death and factors associated with early in-hospital mortality after hip fracture. Bone Joint J 97-B(2):246–251CrossRefPubMedGoogle Scholar
  40. 40.
    Sathiyakumar V, Avilucea FR, Whiting PS, Jahangir AA, Mir HR, Obremskey WT, Sethi MK (2016) Risk factors for adverse cardiac events in hip fracture patients: an analysis of NSQIP data. Int Orthop 40(3):439–445CrossRefPubMedGoogle Scholar
  41. 41.
    Hietala P, Strandberg M, Kiviniemi T, Strandberg N, Airaksinen KE (2014) Usefulness of troponin T to predict short-term and long-term mortality in patients after hip fracture. Am J Cardiol 114(2):193–197CrossRefPubMedGoogle Scholar
  42. 42.
    Nordling P, Kiviniemi T, Strandberg M, Strandberg N, Airaksinen J (2016) Predicting the outcome of hip fracture patients by using N-terminal fragment of pro-B-type natriuretic peptide. BMJ Open 6(2):e009416. doi: 10.1136/bmjopen-2015-009416 CrossRefPubMedPubMedCentralGoogle Scholar
  43. 43.
    Gupta BP, Steckelberg RC, Gullerud RE, Huddleston PM, Kirkland LL, Wright RS, Huddleston JM (2015) Incidence and 1-year outcomes of perioperative atrial arrhythmia in elderly adults after Hip fracture surgery. J Am Geriatr Soc 63(11):2269–2274CrossRefPubMedGoogle Scholar
  44. 44.
    Lesperance R, Lehman R, Lesperance K, Cronk D, Martin M (2011) Early postoperative fever and the “routine” fever work-up: results of a prospective study. J Surg Res 171(1):245–250CrossRefPubMedGoogle Scholar
  45. 45.
    Sivakumar B, Vijaysegaran P, Ottley M, Crawford R, Coulter C (2012) Blood cultures for evaluation of early postoperative fever after femoral neck fracture surgery. J Orthop Surg (Hong Kong) 20(3):336–340Google Scholar
  46. 46.
    Hunziker S, Hügle T, Schuchardt K, Groeschl I, Schuetz P, Mueller B et al (2010) The value of serum procalcitonin level for differentiation of infectious from noninfectious causes of fever after orthopaedic surgery. J Bone Joint Surg Am 92(1):138–148CrossRefPubMedGoogle Scholar
  47. 47.
    Kamel HK (2005) The frequency and factors linked to a urinary tract infection coding in patients undergoing hip fracture surgery. J Am Med Dir Assoc 6(5):316–320CrossRefPubMedGoogle Scholar
  48. 48.
    Martin ET, Kaye KS, Knott C, Nguyen H, Santarossa M, Evans R et al (2016) Diabetes and risk of surgical site infection: a systematic review and meta-analysis. Infect Control Hosp Epidemiol 37(1):88–99CrossRefPubMedGoogle Scholar
  49. 49.
    Karunakar MA, Staples KS (2010) Does stress-induced hyperglycemia increase the risk of perioperative infectious complications in orthopaedic trauma patients? J Orthop Trauma 24(12):752–756CrossRefPubMedGoogle Scholar
  50. 50.
    Ulucay C, Eren Z, Kaspar EC, Ozler T, Yuksel K, Kantarci G, Altintas F (2012) Risk factors for acute kidney injury after hip fracture surgery in the elderly individuals. Geriatr Orthop Surg Rehabil 3(4):150–156CrossRefPubMedPubMedCentralGoogle Scholar
  51. 51.
    Tobu S, Noguchi M, Hashikawa T, Uozumi J (2014) Risk factors of postoperative urinary retention after hip surgery for femoral neck fracture in elderly women. Geriatr Gerontol Int 14(3):636–639CrossRefPubMedGoogle Scholar
  52. 52.
    Fisher L, Fisher A, Pavli P, Davis M (2007) Perioperative acute upper gastrointestinal haemorrhage in older patients with hip fracture: incidence, risk factors and prevention. Aliment Pharmacol Ther 25(3):297–308CrossRefPubMedGoogle Scholar
  53. 53.
    Grigoryan KV, Javedan H, Rudolph JL (2014) Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis. J Orthop Trauma 28(3):e49–e55CrossRefPubMedPubMedCentralGoogle Scholar
  54. 54.
    Nordström P, Gustafson Y, Michaëlsson K, Nordström A (2015) Length of hospital stay after hip fracture and short term risk of death after discharge: a total cohort study in Sweden. BMJ 350:h696. doi: 10.1136/bmj.h696 CrossRefPubMedPubMedCentralGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  1. 1.Geriatric UnitArcispedale Santa Maria Nuova-IRCCSReggio EmiliaItaly
  2. 2.Orthopaedic UnitArcispedale Santa Maria Nuova-IRCCSReggio EmiliaItaly

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