Elsevier

Injury

Volume 49, Issue 2, February 2018, Pages 404-408
Injury

Is prescribed lower extremity weight-bearing status after geriatric lower extremity trauma associated with increased mortality?

https://doi.org/10.1016/j.injury.2017.12.012Get rights and content

Abstract

Objectives

Evaluate whether mortality after discharge is elevated in geriatric fracture patients whose lower extremity weight-bearing is restricted.

Setting

Urban Level 1 trauma center

Patients/participants

1746 patients >65 years of age

Intervention

Post-operative lower extremity weight-bearing status

Main outcome measure

Mortality, as determined by the Social Security Death Index

Results

Univariate analysis demonstrated that patients who were weight-bearing as tolerated on bilateral lower extremities (BLE) had significantly higher 5-year mortality compared to patients with restricted weight-bearing on one lower extremity and restricted weight-bearing on BLE (30%, 21% and 22% respectively, p < 0.001). Cox regression analysis controlling for variables including age, Charlson Comorbidity Index, Injury Severity Scale, combined UE/LE injury, injury mechanism (high vs low), sex, BMI and GCS demonstrated that, in comparison to patients who were weight bearing as tolerated on BLE, restricted weight-bearing on one lower extremity had a hazard ratio (HR) of 0.97 (95% confidence interval 0.78 to 1.20, p = 0.76) and restricted weight-bearing in BLE had a HR of 0.91 (95% confidence interval 0.60 to 1.36, p = 0.73).

Conclusions

In geriatric patients, prescribed weight-bearing status did not have a statistically significant association with mortality after discharge, when controlling for age, sex, body mass index, medical comorbidities, Injury Severity Scale (ISS), mechanism of injury, nonoperative treatment and admission GCS. This remained true in when the analysis was restricted to operative injuries only.

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.

Section snippets

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.

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