Lifestyle Choices/co-Morbidities: Their Affects on Orthopedic Recovery

Adam J Bakker, MDHand and Upper Extremity Specialist

Twin Cities Orthopedics

Disclosures

• None

Background

• Born: Seoul, South Korea• Grew up: Walker, MN• College: Concordia College, MN

Background

• MD: University of Minnesota• Orthopedic Residency: University of

Washington• Hand Fellowship: Mayo Clinic• Twin Cities Orthopedics, Edina

Overview

• Case Report• Medical Co-morbidities• Life Style Choices

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

Alcohol

• Generates “Liquid Courage”• Ignore Sxs• Masks Sxs• Falls

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

Marital Status/Family

• “Hispanic Paradox”• Waiting room effect• Will to live

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

Thank You

Adam J Bakker, MDHand and Upper Extremity Specialist

Twin Cities Orthopedics