Is prescribed lower extremity weight-bearing status after geriatric lower extremity trauma associated with increased mortality?
Introduction
The geriatric population in the United States is growing rapidly. From 1980 to 1990 it increased by 21% [[1], [2]] and by 2040 more than 20% of the population will be older than 65 [[3], [4], [5], [6]]. The frequency of traumatic injury in geriatric patients, both low-energy and high-energy, is likewise expected to increase. It is clear that avoiding bedrest and encouraging early mobilization in hospitalized geriatric medical and critical care patients results in reduced decline in functional activities, reduction in new institutionalization, reduced incidence of medical complications such as pneumonia, blood clot and bedsores, and reduced mortality [[7], [8], [9], [10], [11], [12]]. Furthermore, it is becoming well established that surgical treatment within 24–48 h of hip fracture leads to improved outcomes related to mobility, pain, independence, readmission and mortality at 6 months [[13], [14]]. The survival benefit from early surgery is thought to be related to early mobilization in hip fracture patients. However, to our knowledge, the specific relationship between weight-bearing (rather than timing of surgery) and outcome in orthopaedic patients has not been studied. Despite this, many clinicians have extrapolated the data on timing of hip fracture management to advocate for minimizing weight-bearing restrictions after all fracture care in all older patients.
The aim of this study was to compare mortality after discharge between geriatric patients who were permitted to weight bear with that of patients whose weight-bearing was restricted, controlling for variables that are known to play a role in survival after traumatic injury in elderly patients including patient demographics and injury characteristics. We hypothesized that prescribed lower extremity weight-bearing status would be an independent predictor for long-term survival after traumatic injury.
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Patients and methods
After receiving study approval from the Institutional Review Board, we reviewed the prospectively collected trauma database at our urban level I trauma center. We identified 2004 patients 65 years and older who were admitted with lower extremity orthopaedic injuries from 2004 through 2014.
From January 2004 through December 2014, 2029 patients ≥65 years of age were admitted to our center with lower extremity injuries. We excluded forty-one patients who did not have social security numbers
Results
There were 1746 patients who met inclusion criteria. Baseline characteristics of the study population are shown in Table 1. Among all geriatric patients, those who were prescribed weight-bearing as tolerated on bilateral lower extremities, compared to those with restricted weight-bearing on one or both lower extremities were significantly older (p < 0.001), more female (p = 0.001), had a lower BMI (p < 0.001), had a higher Charlson Comorbidity Index (CCI) (p < 0.001), were more frequently
Discussion
The results of this study suggest that, contrary to our hypothesis, postoperative weight-bearing restriction, which is a modifiable variable frequently targeted in an attempt to improve outcome in geriatric fracture patients, was not associated with mortality at 1- or 5-years point when controlling for variables known to be related to mortality, such as age, Charlson Comorbidity Index, ISS and GCS. This was the case both in our larger patient cohort of 1746 geriatric trauma patients as well as
Funding
Funding for this study was provided by the AO North America Fellows Research Grant.
Conflict of interest
No authors have financial or personal relationships with other people or organizations that could inappropriately influence (bias) their work. Robert V. O’toole MD is a consultant for Smith and Newphew, unrelated to the present work. Marcus Sciadini MD is a consulstant for Stryker Orthopaedics and Globus Medical, unrelated to the present work.
References (27)
Time for critically ill patients to regain mobility after early mobilization in the intensive care unit and transition to a general inpatient floor
J Cri Care
(2015)Early physical medicine and rehabilitation for patients with acute respiratory failure: a quality improvement project
Arch Phys Med Rehabil
(2010)- et al.
How long should patients be kept non-weight bearing after ankle fracture fixation? A survey of OTA and AOFAS members
Injury
(2015) - et al.
Successful immediate weight-bearing of internal fixated ankle fractures in a general population
J Orthop Sci Off J Jpn Orthop Assoc
(2000) - et al.
Preventable complications and death from multiple organ failure among geriatric trauma victims
J Trauma
(1992) Morbidity and mortality in elderly trauma patients
J Trauma
(1999)- et al.
Polytrauma in the elderly
Clin Orthop
(1995) - et al.
Multiple trauma in the elderly: new management perspectives
J Orthop Trauma
(2011) - et al.
Trauma in the elderly: intensive care unit resource use and outcome
J Trauma
(2002) - United States Census Bureau. United States Census Bureau, Census 2000 Summary File 1: Matrcies P13 and PCT12 – Age...
Prevalence and outcomes of low mobility in hospitalized older patients
J Am Geriatr Soc
ICU early mobilization: from recommendation to implementation at three medical centers
Crit Care Med
Improving physical function during and after critical care
Curr Opin Crit Care
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