Epidemiology - PowerPoint Presentation

Slide1

Epidemiology, Diagnosis, Prevention and Management of Osteoporotic FracturesHassan R. Mir, MD, MBA, FACSAssociate Professor

Created

March 2004;

Kenneth

Egol

, MD

Revised

February

2010; Revised May 2015Slide2

Population is AgingDemographics

WORLD

USASlide3

Initial EvaluationThorough H&PFocus on:PMHMedsPSH and ResponseDNR / DNIFunctional Status Pre-OpSocial HistorySlide4

Co-Morbid Conditions Cardiac, PulmonaryDiabetesWound Infection, Delayed HealingPVDDecubitus UlcersInfection RiskNutritionSlide5

Initial EvaluationPhysical ExaminationSkin/Soft TissuesVascularityLabs, CXR, EKGFilms – Bone QualityConsent – Competent?Goals of CareSlide6

Treatment GoalsRestore Pre-Injury Level of FunctionSocial Assistance Post-opSlide7

Non-Operative Care?Consider when:Moribund/Terminal PatientRefusal of ConsentFutility of SurgeryPatient Would Not Survive ProcedureSlide8

Medical ClearanceBased on StabilityPatient OptimizedTesting Required?Perioperative CareType of Anesthesia Slide9

Fleisher LA, et al.2014 ACC/AHA Perioperative Guideline

Published with permission

J Am Coll Cardiol

. 2014;64(22):e77-e137Slide10

Cardiac Testing

253 Patients

35 (15%) had

Preop

Cardiac Testing

Stress Thallium or Echo

Testing Due to New Dx (EKG, CHF) in 16 Patients Slide11

Cardiac Testing

Conclusions

Preop

Cardiac Testing

In 48% Did Not Lead to New Medical

Tx

. In 52%, Recommendations were only made for Medical Management of Previously Known Cardiac Disease. No changes in Perioperative Orthopaedic or Medical Management Significant Delay to Surgery. (3.3 vs 1.9 days, p<0.001) Extrapolated to 250,000 US Annual Hip FxsPreop Cardiac Testing of 15% Would Cost nearly $47,000,000 annually. Slide12

ASA ClassificationPhysical StatusDescription1Normal healthy patient2Patient with mild systemic disease3Patient with severe systemic disease that is limiting but not incapacitating4Patient with incapacitating disease which is a constant threat to life5Moribund patient not expected to live more than 24 hours

6

A declared brain-dead patient whose organs are being removed for donor purposes

*Add E for emergency

proceduresSlide13

ASA ScoreASA SurvivalClass 1 – 8.5yClass 2 – 5.6yClass 3 – 3.5yClass 4 – 1.6ySlide14

ASA ScoreASA LOS 1 ASA : 2.053 DaysASA Cost 1 ASA : $9300Slide15

Patients on AnticoagulationASA/PlavixOk to Operate with No Delay Slide16

Patients on AnticoagulationCoumadinIV Vit K vs FFP Depends on Comorbidities and ResponseMay need bridging with LMWHSlide17

Patients on AnticoagulationDirect Thrombin InhibitorDabigatranFactor Xa InhibitorsRivaroxabanApixabanDifficult to Monitor/Reverse Currents Tests are Surrogates OnlyNo AntidotesHighly Variable Strategies Currently Wait Out (48-72 Hrs) if not Emergent Slide18

Cognitive FunctionDementia Afflicts > 5 million AmericansMost secondary to AD followed by Multi-InfarctPrevalence 60-65 years ~ 1/100>90 years ~ 50/100Ability to Consent, Rehab, Comply Fall RiskSlide19

Clinical Ramifications of Cognitive DeclineHigher Incidence of DeliriumHigher Mortality and Morbidity

Morrison: JAMA July 5,

2000

Copyright ©2000 American Medical Association. All rights reserved.Slide20

Osteoporosis - Scope of the Problem50% Caucasian Women will FractureMost Serious Outcome - Hip Fracture10-20% Excess Mortality at 1 year25% Long Term NH CareOnly 1/3 Regain Independence Psychological and Social Issues Quality of LifeSlide21

DefinitionsInsufficiency Fracture Bone Fails with Normal WBFragility FractureFall from a Standing Height or LessSlide22

Diagnosis - DEXA BMDRelationship (SD) to NormsT-Score - Reference StandardComparison to “young normal” adult same sexZ-ScoreComparison to age matched adult same sexSlide23

Orthopaedic Diagnosis - OsteoporosisClinical Presentation Presence of Insufficiency or Fragility FractureBone Mineral Density (BMD) 2.5 SD Below the Young Adult Average Value (T)Slide24

Further Diagnosis - OsteoporosisLabs Can Help R/O Secondary CausesCMP, Serum Thyrotropin, Protein Electrophoresis, PTH, Vitamin D, Urine Calcium, CortisolClinical Utility of Biochemical Markers still Not ProvenSlide25

FRAXDeveloped by WHOIncorporates Risk Factors + BMDAge, Sex, Ht, Wt, Family Hx, Previous Fx, Steroids, Smoking, EtOH, Secondary Causes, RA10-yr Fracture Risk (%)Hip Other Major Fracture

Online Tool

Published with permission

Osteoporosis International 2008

Vol

19 Issue 10 pp 1395-1408 Slide26

Pathophysiology - OsteoporosisImbalance in Removal/Replacement of CaNot an Organic Matrix or Mineralization Defect Loss of Trabecular Plates, Cortical ThinningStructural Weakening “Mechanical Problem”Slide27

Surgical Issues - OsteoporosisDifficult Fracture FixationPoor Screw PurchaseExcessive Bowing (Distal Nail Penetration)Immobilization or Minimal WB Bone LossAutogenous Bone Graft Not as UsefulSlide28

Surgical TimingConflicting Results Regarding M/M being Increased or Unaffected by Delaying SurgeryEarly Surgery <48 Hrs Reduces Hospital StayMay also Reduce Complications and MortalitySlide29

Surgical Timing92 PatientsDelay Greater than 4 days Increases the 6-month and 1-year Mortality Risks versus <48 Hours to SurgerySlide30

Surgical TimingDifferent Story in PolytraumaElderly Patient with 3 or More Comorbid Conditions have a Worse Survival Rate if Treated within 24 HrsNeed to Individualize Treatment PlanPre-Existing Activity, Disease, Reserve, Injuries Slide31

High Energy Trauma6 x Greater Mortality for Elderly Polytrauma>65 yo Patient has 50% Mortality with ISS>2024 - 44yo Patient has 50% Mortality with ISS>40Slide32

Choice of AnesthesiaLiterature Search of Pubmed and Cochrane (1967-2010)56 references, covering 18,715 patients with hip fractureSlide33

Choice of AnesthesiaConclusions:Spinal Anesthesia Significantly Reduced Early Mortality, Fewer DVT, Less Acute Postop Confusion, Fewer MI, Fewer Pneumonia, Fewer Fatal PE, Less Postop Hypoxia. General Anesthesia Less Hypotension, Fewer CVAData suggests that Regional Anesthesia is preferred, but the limited evidence does not permit definitive conclusion for mortality or other outcomes. Slide34

Surgical Treatment PrinciplesPlan for Possible Future Surgeries IncisionsImplantsReductionGentleIndirect Impaction - ↑ StabilitySlide35

Surgical Treatment Principles - OsteoporosisFixationLength IM Nails, Long platesAugmentation Biologic Cements, Graft, Struts Angular StabilityLocked screws with plates/nailsArthroplastyShoulder, Elbow, Hip, KneeAllow WB if PossibleSlide36

Recognition - OsteoporosisOrtho Often the First to SeeAssure All at Risk Patients Have F/UDevelop a System in Your Hospital Synthes Geriatric ProgramAOA Own the BoneSlide37

Fractures Beget FracturesRisk of future fractures increases 1.5 - 9.5 fold following initial fractureHistory of fragility fracture is more predictive of future fracture than bone densitySlide38

Treatment - OsteoporosisPatientsSlide39

Treatment - OsteoporosisAddress Risk FactorsAvoid EtOH and TobEnsure Nutrition Ca (1200mg)600 mg po BID Vitamin D (>1500 IU)Other Nutrients MagnesiumSiliconVitamin K

Boron Slide40

Exercise and RehabImprove Strength, Endurance, PostureMaintain Bone DensityPrevent Falls30 Minutes Moderate Intensity DailyPost Fracture Rehab May Reduce Future FractureSlide41

Fall PreventionDiscuss with FamilyMedicationsBalance and Strength TrainingCorrect VisionWalking AidsFall Proofing the HomePoor LightingThrow RugsPetsSlide42

Treatment - OsteoporosisIndication for Pharmacologic InterventionT-score < -2.5 without other Risk FactorsT-score < -1.0 – 2.5 with other Risk FactorsFragility FxFRAX Score Hip Fx 10-yr Risk >3% FRAX Score Other Major Fx 10-yr Risk >20%Slide43

Pharmacological TherapyAnti-Resorptive DrugsHormonal Replacement Therapy: Estrogen/ProgestinBisphosphonates: Alendronate, Ibandronate,

Risendronate

,

Raloxifene

,

Zoledronic

AcidSelective Estrogen Receptor Modulators: RaloxifeneCalcitoninBone Forming DrugsTeriparatideRecombinant Parathyroid HormoneSlide44

BisphosphonatesLong T1/2Side-EffectsGIJaw Osteonecrosis (Rare)Atypical FracturesRisk with Long term useAssess Both femursDifficult to healMust weigh risks of use against huge benefits of other

Fx

Prevention

Hip, wrist, spineSlide45

ConclusionsOsteoporosis: Prevalence – Recognition is KeyNeed Effective Tx to  Fx RateNutrition ExerciseFall PreventionMedicationsAssure Follow UpSurgical Improvements HelpSlide46

ConclusionsCareful Consideration of Pre-op, Intra-op, and Post-op Factors Unique to Geriatric Population Necessary to Obtain Goal of Long Term Functional Recovery