lifestyle choices/co-morbidities: their affects on orthopedic recovery adam j bakker, md hand and...
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Lifestyle Choices/co-Morbidities: Their Affects on Orthopedic Recovery
Adam J Bakker, MDHand and Upper Extremity Specialist
Twin Cities Orthopedics
Background
• MD: University of Minnesota• Orthopedic Residency: University of
Washington• Hand Fellowship: Mayo Clinic• Twin Cities Orthopedics, Edina
Case Report
• Pt: 67 yo Male• CC: Distal radius fracture and ulna• HPI: DOI 5 days ago GLF while intoxicated– Outside ER: 2 days after fall…splinted– Left AMA-removed splint & fell again– Finally came back to ER due to increase pain &
“something” sticking out of skin
Case Report
• PMHx: DM2, HTN, HLD, liver failure• Social Hx: 18-24 beers, 2 PPD smoker,
unknown disability, & lives alone• Labs: INR 1.6 (No Hx Coumadin use)
Medical Comorbidities
• Age >75• Osteoporosis: Associated fragility fractures– Distal radius– Hip
• Cardiac:– Congestive Heart Failure– Afib & Cardiac stents…anticoagulation
• Renal: Renal failure
Medical Comorbidities
• Hepatic: Coagulopathies• Infectious: Activated inflammatory cascade• Respiratory: – COPD– Pneumonia
• Neurological:– Dementia– Parkinson
Inpatient Orthopedics Surgeries: Rates of & Risk Factors Mortality
• 3 yr. analysis of all inpatient surgeries– 1995-1997– 43,215 Orthopedic Inpatients
• Overall Mortality rates (inpatient): 1%
Bhattacharyya, JBJS 2002
Inpatient Orthopedics Surgeries: Mortality
• Overall: 1%• Hip Fractures: 3.1 %• Without Hip Fractures: 0.5%• None of the “Big 5” Critical Risk factors 0.25%
Bhattacharyya, JBJS 2002
Inpatient Orthopedics Surgeries: Mortality by Specialties
• Low– Adult Recon (0.29%)– Sports, Peds, & Shoulder
• Average– Trauma & Spine– HAND: Considered very safe…Abscesses (0.86%)
• High– Tumor (5.1%)– Hip Fractures (3.1%)
Inpatient Mortality Rates: 5 Independent Risk Factors
1. Chronic Renal Failure2. Congestive Heart Failure3. COPD4. Hip Fractures5. >75 yrs. of age
Bhattacharyya, JBJS 2002
Hip Fractures:Elderly (>65 yrs.)
• Cost $10.3 to $15.2 billion in US• Lifetime risk 17.5% women & 6% men• 310, 000 Pts. hospitalized in 2003• 87% to 96% hip fractures occur pts. >65 yrs.
Walker, UpToDate 2013
Hip Fractures:Elderly (>65 yrs.)
• 30 day mortality rate– 9% without acute medical condition– 17% acute medical condition
• 1 yr. Postoperative Mortality: 27.3% (12-37%)• 3x Risk of Mortality Pts. with Hip Fxs
AAOS 2013 BMC Musculoskeletal Disorders 2011
Distal Radius Fractures
• 150,000-200,00 per year • Aging population: 50% increase 2030• 50% increase in risk for hip fracture• Men 2x more likely to die and 2x as fast– No difference in overall medical comorbidities– Did not look at social support
Rozental, J Hand Surg Am 2002
Patient’s Medical Risk FactorsFragility Fractures
• Osteoporosis (Greater in women vs. men)– 1.5 million osteoporotic/yr. USA
• Falls– 30% to 60% community-dwelling fall each year– 90% hip fractures occur fall from standing
BMC Musculoskeletal Disorders 2011
Fall PreventionEvidence
• Exercise: focus on balance most effective• Environment/assistive technology– Most effective when delivered by OT
• Therapy– Strength– Balance
Kiel, UpToDate 2013
Fall PreventionEvidence: Lacking
• Vision assessment & correction• Education alone (w/o OT/PT)• Medication modification• Assistive Devices (w/o OT/PT)• Hip Protectors
Kiel, UpToDate 2013
Lifestyle Choices
• Smoking• Alcohol• Recreational Drug Use• Marital Status/Family• Poverty• Location from Surgeon• Noncompliant/Difficult Patients
Smoking (Nicotine)
• Devastating to Bones• Review 20 clinical studies• 6,480 patients (1,457 smokers & 5,023
nonsmokers) with long bone fxs
AAOS 2013
Smoking (Nicotine)
• Longer Healing times: 6 weeks longer• Increased Nonunions: 15%• Higher rates of wound complication– Superficial: 2x – Deep: 3x
AAOS 2013
Nicotine: Multifactorial Mechanism
• Vasoconstriction• Inhibition RBCs• Decrease Oxygen levels in blood• Osteoblasts (bone making cells)– Inhibited– Longer to heal & Weaker bone
Alcohol
• Chronic & Heavy Use • >100 grams EtOH/day=7 drinks– Lower bone mass– Decrease bone formation
• Mechanism: – Suppresses Osteoblast activity– Decreases rates of bone remodeling
Chakkalakal, Alcohol Clim Exp Res 2005
Recreational Drugs
• Marijuana: (Actually Study) Slows bone healing
• Meth: Driving 100 mph wrong lane• Cocaine: Vasoconstriction & 100 mph wrong
lane• IVDU: Infections
Nogueira-Filho. Implant Dent 2008
Marital Status/Family
• Married people healthier • Most striking in 18-44 yo population• Married adults but particularly men higher
obesity• Never married least obese
Schoenborn, Advance Data CDC 2004
Poverty
• Trauma is disease of poverty– Car safety– Number of passengers
• Resources– Health maintenance – Time off
• Healthy options– Fast food– Substance abuse
Distance From Surgeon
• Mayo Clinic– Closure to Rochester, MN…better outcomes– International Pts.…worse outcomes
• Alaskan Fisherman• Appropriate Hand & Physical Therapy• Communication– Accessibility– Availability
Difficult Patients…
• Noncompliant with weight bearing restrictions• Removal of splints• No shows in clinic– Must follow up on– Increase rates of medical lawsuits
AAOS 2013
Difficult Patients…Surgeons
• Cardiac Surgeon…POD 1 returned to OR s/p carpal tunnel release
• Hand Surgeon…Patella fracture…treated non operatively– Removal of splint– Noncompliant with ROM– Missed zero days from work
Case Report
• Underwent serial irrigation & debridement• ORIF of distal radius• Prolonged immobilization– Removed cast x2
• Prolonged Healing– Despite smoking & chronic alcohol abuse