Surgery for Hip Fractures in the Elderly

Published in Panorama


SURGERY TO TREAT HIP FRACTURES IN THE ELDERLY … A MUST

70 year old Ramesh woke up, past midnight, to attend nature’s call. He tripped on the edge of the doormat at the entrance to the washroom and fell. As a result, he fractured his right hip.

Yes, fall and consequent fractures, is one of the commonest problems faced by the old and elderly, reveals Dr. H.P.C.Khincha, Director and Head of the Department Orthopedics, Specialist in Joint Replacement, Arthroscopic Surgery & Sports Medicine, Sagar Apollo Hospital, Bangalore.

The most common areas where these individuals fall are on wet surfaces, particularly in bathrooms, uneven pathways and roads, by tripping on edges of carpets and rugs at home, by tripping on toys which children leave around on the floor after playing. The problem is further compounded by the fact that many of these people have poor eyesight.

But the heartening fact is in majority of these cases, the fractures can be very successfully treated and managed with surgery, contrary to popular belief, emphasizes Dr.Khincha. “I have performed surgery on patients up to 108 years of age!” Unless there is some underlying systemic disorder, fractures in the elderly are neither life-threatening, nor are they inoperable! In fact, it is a myth that the elderly with fractures, cannot be operated, that if they suffer from cardiac problems or diabetes, they cannot be surgically treated.

Again it is a myth that following surgery, these individuals will suffer from stiff leg and not be able to walk or that they will need life long support with sticks, walkers, et al and that recovery from surgery is painful, requiring lengthy hospitalization.

Dr.Khincha cautions, “The fact is, there are more risks from not operating these persons than the risk from surgery itself! If you do not operate on them, the following can result:

1. The fractures may not unite at all or unite wrongly.
2. The commonest and most debilitating and painful effects of not operating, are bedsores.
3. Prolonged bed rest may lead to deep vein thrombosis and pneumonia.
4. The patient may go into severe depression and mental agony because he/she is now dependent on others even to perform simple routine chores, being confined to bed.
5. There is disruption of routine of family members on whom the patient is now dependent.
6. Financial burden of hospitalization is no mean cause for concern.

If a fall is one leading risk factor in fractures, osteoporosis (a condition where the bones become brittle or hard with advancing age and therefore have a tendency to break easily) is the other major cause of fractures in the elderly. While the common sites of fractures in these individuals are the hips, shoulders, wrists, spine, knees and ankles, globally, hip followed by the wrist are the commonest fracture sites in the elderly, reveals Dr.Khincha. “This is because, when people fall, they have to take support of their bottoms which endangers the hips; else, they may have to put their hands down in which case the wrists bear the entire weight of the fall and in the process get fractured. Also, osteoporosis is more marked in the hips and wrists.”

Is there any gender bias to fractures? Osteoporosis is commoner and more gross in females because of hormonal problems. Hence the female population of hip fractures anywhere in the world is far higher than the make population, reveals Dr.Khincha.

Can it be said that some elderly people are prone to fractures?
While there is nothing like a prone-ness to fractures, elderly people who suffer from osteoporosis are at risk, explains Dr.Khincha. “Many times we hear people say that they were walking when they heard a click in the hip region and then they fell down. This means that the person has broken an osteoporotic bone and then fallen. A second group of ‘at-risk’ elderly, are the males with prostatic problem. These people may wake up frequently at night, to urinate. They can trip and fall in the darkness or from sleep. This is compounded by the fact that most of them have vision problems.”

Once a fracture is diagnosed, surgical treatment is the best option in most instances, says Dr.Khincha. “In fact, more the age of the patient, greater is the indication for surgery, unless medically contra-indicated.”

What does a hip surgery involve? Depending on the level of fracture and its exact location, Intracapsular or Extracapsular surgery is performed. That is when the fracture is within the hip joint, intracapsular surgery is performed. This involves replacing the hip with a new, artificial hip which is made of medical steel and very rarely, from titanium. This steel is medically tested and is found to be bio-compatible with the tissues of the body. That is, it is non-allergic, non-infective and non-irritant, in majority of people. A very small minority of people may be allergic to medical steel in which case, titanium implants are used, explains Dr.Khincha.

Before deciding on surgery, the patients go through a pre-operative examination of their heart, lungs, teeth and urinary tract. Once these are in order, surgery is carried out. If the fracture is not very much into bits and pieces, on the 2nd day of surgery, the patients can walk with the full weight of the leg, with the help of a walker. Within 3 days of surgery, they can be back to carry out simple chores independently like getting out of bed, sitting at a dining table for meals, using a commode, doing their shaving et al. They can even climb a few steps by the 6th day and between one to two weeks, get discharged from the hospital, depending on their home environment, assures Dr.Khincha. In 3 months following surgery, the patients return to complete normalcy.

The extra capsular procedure is done when patients have a fracture outside the hip joint and the fracture is fixed using plates and screws or other devices, which are once again bio-compatible.

What are the complications that may arise during the surgery? Surgical techniques today are increasingly technology-driven, conditions of performing vastly improved with sterile theatre conditions. Yet we cannot rule out the possibility of infection, though this is very rare, says Dr.Khincha reassuringly. The only other situation which could cause concern is when the person’s bones are very, very osteoporotic. In this situation, the fixation of the implants are not very tight. It is like putting a screw in some wet cement which can be easily pulled out. So the fixation can fail. But there are techniques to overcome these problems also, concludes Dr.Khincha.


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