Abstract
[Purpose] We report the case of an 81-year-old woman with a femoral neck fracture whose gait function improved with in-hospital physical therapy prior to surgery. [Participants and Methods] The patient’s planned bipolar hip arthroplasty was postponed due to suspected metal allergy, and she commenced rehabilitation on hospital day 4. [Results] On day 7, the patient stood and was transferred with assistance. Subsequently, owing to pain, she only left her bed during rehabilitation. On day 10, the fracture was externally fixed using a soft-conforming lumbar immobilization orthosis, which relieved the pain. The patient was allowed to stand and was transferred under supervision. On day 22, surgery was scheduled after obtaining a negative metal patch test result. On day 23, the patient was able to walk 25 m using a walker. Bipolar hip arthroplasty was performed on day 28. On day 30, she walked 10 m using a walker with light assistance. On day 52, the patient walked independently using a cane. The patient was discharged on day 63. [Conclusion] External lumbar immobilization bandages effectively reduced motion-related fracture pain. The high frequency of rehabilitation while waiting for surgery effectively prevented perioperative complications and promoted early postoperative walking recovery.
Keywords: Femoral neck fracture, Physical therapy, Preoperative
INTRODUCTION
In Japan, surgery is the treatment of choice for 95.4% of patients with hip fractures. In 2014, the average preoperative surgical waiting time was 4.5 days1). A longer waiting time for surgery increases mortality and the frequency of complications2), and surgery is recommended as soon as possible after hospitalization3).
In postoperative rehabilitation for patients with hip fractures, early mobilization is recommended. Early initiation of gait practice accelerates the recovery of walking function4), and patients can be discharged home within a shorter timeframe5). Patients who had high pre-fracture function and underwent surgery without delay are more likely to be able to walk independently one week after surgery6). However, few studies concerning gait function progression in patients with hip fractures and prolonged surgical waiting times have been reported.
Although prolonged waiting periods for surgery are rare, a 71-year-old man with a history of polio who had a 4-week waiting period for surgery was reported7). Before the fracture, the patient was able to walk with a walking aid, but after the fracture, he was treated only with analgesics and no rehabilitation. The patient was in severe pain and had difficulty walking. Total hip replacement was performed, and rehabilitation was started on the second day after surgery. However, it took 6 weeks after surgery for the patient to regain some of his previous walking ability, and it was not until three months after the surgery that he was able to return to a normal life. In other words, we believed that preoperative rehabilitation was important because a longer waiting period for surgery could be predicted to take longer to recover gait function and affect the postoperative course of the patient.
In this case report, a patient with a femoral neck fracture was scheduled to undergo a bipolar hip arthroplasty. However, a 27-day waiting period was required to await the results of a test for suspected metal allergy. During this prolonged waiting period, the patient was expected to practice standing on the floor and sitting in the wheelchair but was not expected to practice walking. We considered that recovery of gait function postoperatively would take time and that early discharge to home would be difficult. However, a physical therapist identified a method of external fixation of the fracture site that reduced pain during movement, enabling our patient to walk using a walker while awaiting surgery. The patient’s postoperative course was good; she walked independently at an early stage and was discharged.
Typically, conservative treatment for fractures comprises closed reduction followed by external fixation using traction or braces. External fixation using braces is based on the principle of splint and is an additional procedure used to stabilize the fracture site and limit the range of motion of the joint8). Stabilizing the fracture site promotes bone healing and relieves pain8). However, restricting hip joint movement with a brace impedes basic movements, walking, and other activities. Skin traction is sometimes performed for pain relief for hip fractures before surgery, but skin traction does not significantly decrease pain or analgesia use9). Moreover, skin traction restricts even bedside exercise. In other words, the brace used needed to stabilize the fracture site and not impede activity.
Here, we report on the effective management of the fracture site to reduce pain during the prolonged surgical waiting time and on the patient’s walking function progress during hospitalization.
This case report was conducted in accordance with the principles of the Declaration of Helsinki. The purpose and content of this case report were explained orally to the patient, who provided informed consent to publish this case report.
CASE PRESENTATION
Prior to injury, a woman in her 80s had performed all activities of daily living independently and walked without a cane. She lived with her husband, worked as a massage therapist, had no cognitive deficits, and had a past history of lumbar compression fracture. She was admitted to our hospital following a right femoral neck fracture resulting from a fall (degree of fracture dislocation, Garden classification Stage IV; Fig. 1). Following a surgical conference held by her orthopedic surgeon, a bipolar hip arthroplasty was planned; however, surgery was postponed because of a suspected metal allergy. While waiting for surgery, pain management medication comprised regular acetaminophen administration (four times/day) after every meal and before bedtime (Table 1).
Fig. 1.
Plain radiographic images of the femoral neck fracture.
(a) Immediately after fracture on hospital day 1; (b) Preoperatively on day 22; and (c) Postoperatively on day 28 (POD 0)
POD: postoperative day.
Table 1. Medical treatment and rehabilitation timeline.
| Date | Medical treatment course | Rehabilitation course |
| Day 1 | Hospitalized. Rx: acetaminophen, 4 times/day | Physical and occupational therapy prescribed |
| Day 4 | Physical and occupational therapy started in bed | |
| Day 5 | Standing exercises started | |
| Day 10 | Metal patch test performed | Started wearing a lumbar immobilization bandage |
| Day 14 | Practiced walking using a walker | |
| Day 22 | Negative metal patch test confirmed | |
| Day 28 (POD 0) | Surgery (bipolar hip arthroplasty) | |
| Day 29 (POD 1) | Standing exercises started | |
| Day 30 (POD 2) | Practiced walking using a walker. | |
| Day 42 (POD 14) | Acetaminophen administration switched to an abortive dose | |
| Day 43 (POD 15) | Practiced walking with a cane | |
| Day 63 (POD 35) | Discharged to home |
POD: postoperative day, Rx: prescription.
Rehabilitation was initiated on hospital admission day 1. However, owing to the in-hospital prevalence of COVID-19, rehabilitation intervention was suspended and then re-started on day 4. In consultation with the patient’s physician, a physiotherapist planned an aggressive rehabilitation program that aimed to prevent complications and disuse owing to the possibility of a prolonged preoperative period, with no restrictions on body weight. The orthopedic surgeon noted that the risk of fracture displacement with weight-bearing activity was acceptable to prevent the risk of secondary complications from immobilization, such as disuse syndrome, deep vein thrombosis, and pneumonia. On hospital day 5, the patient stood up with the help of two assistants (The patient was very happy to be out of bed for the first time in a long time. She hoped that the surgery could be performed soon.). On day 7, she stood and transferred with the help of one assistant. However, owing to pain, it was difficult for her to leave the bed, except for rehabilitation (The patient was aware that her mobility was improving and was feeling positive, but the timing of surgery was not clear, and she was anxious.). On day 10, her fractured hip was compressed externally using a soft, confirming lumbar immobilization orthosis (Fig. 2), which resulted in pain relief and enabled the patient to stand and transfer with monitoring (Table 2).
Fig. 2.
Simple fracture fixation using a lumbar immobilization orthosis.
(a) Frontal plane, (b) Sagittal plane
A lumbar immobilization orthosis is commonly used in orthopedics to treat patients with low back pain. This orthosis comprises an elasticized immobilization bandage with an auxiliary belt, with two metal supports inserted into the material posteriorly.
A lumbar immobilization orthosis was applied to the hip joint on the affected side to provide external compression over the fracture site. Velcro is used fixed both ends of the immobilizing hip orthosis across the anterior surface of the non-fractured hip joint. The patient’s subjective assessment: wearing the device improved hip stability and decreased pain.
Table 2. Using a lumbar immobilization bandage and the degree of pain (hospital day 10).
| No lumbar immobilization bandage | Using a lumbar immobilization bandage | ||
| FRS | At rest | 2 | 2 |
| In motion | 5 | 3 |
FRS: face rating scale.
The impetus for using confirming lumbar immobilization orthosis was inspired by a situation in which the patient was assisted in basic activities during a physical therapy intervention. When the physical therapist assisted the patient in such a way that the physical therapist’s hand was placed on the outside of the hip joint, and the physical therapist’s hand became a stabilizing splint for the fracture, pain at the fracture site was reduced. The patient asked that the physical therapist’s hands support the hip all the time because it makes it easier to move. Therefore, we used confirming lumbar immobilization orthosis as a familiar alternative to the physical therapist’s hands without undue restriction of hip motion (After using the confirming lumbar immobilization orthosis, the patient felt improved hip stability and reduced pain). On day 14, she walked 3 m using a walker under supervision (Patients were more motivated for rehabilitation because they had less pain when walking). On day 22, the metal patch test result was negative, and surgery was scheduled (The patient was relieved that the surgery had been scheduled). On day 23, she walked 25 m with a walker under supervision. The average rehabilitation session time (combined physical and occupational therapy) while awaiting surgery was 86.6 ± 43.3 min/day. A bipolar hip arthroplasty was performed on day 28 (Fig. 1). On day 30 (postoperative day [POD] 2), the patient walked 10 m using a walker (The patient was pleased that the surgery was a success. After the surgery, she began to think about being discharged home). On day 32 (POD 4), she walked around the hospital room using a walker under supervision. On day 38 (POD 10), she walked independently in the ward using a walker. On day 52 (POD 24), she walked independently in the ward using a cane (Day by day, the patient felt that her walking ability and lower limbs became easier to move). On day 63 (POD 35), she was discharged from the hospital (discharged to home) (Patient was able to walk again and was happy to be discharged home). Post-discharge, she underwent home-visit rehabilitation. The average duration of postoperative rehabilitation sessions was 97.8 ± 27.8 min/day. Preoperative and post-discharge walking are shown in Fig. 3. The progress of gait function (functional ambulation categories) during hospitalization is shown in Fig. 4. Table 3 shows the trends in gait function and lower limb muscle strength.
Fig. 3.
Walking scene.
(a) Preoperative walking on hospital day 22, (b) walking prior to discharge on day 62 (POD 34).
POD: postoperative day.
Fig. 4.
Functional ambulation categories and Continuous walking distance.
FAC: functional ambulation categories; POD: postoperative day.
Table 3. Progress in gait function and lower extremity muscle strength and pain.
| Day 5 | Day 27 | POD 1 | POD 2 | POD 29 | POD 35 | |
| 10-m maximum walking speed (m/s) | - | 0.20 | - | 0.18 | 0.68 | - |
| Timed up & go test (s) | - | 88.4 | - | - | 12.4 | - |
| Isometric knee extensor strength right/left (kgf) | - | 5.9/12.1 | 5.1/13.3 | - | 12.1/14.7 | - |
| Maximum Numerical Rating Scale (point) | 10 | 8 | - | 8 | 3 | 0 |
POD: postoperative day; kgf: kilogram-force.
DISCUSSION
The patient underwent a planned bipolar hip arthroplasty for a femoral neck fracture, but a 27-day waiting period for surgery was needed to await test results for a suspected metal allergy. Rehabilitation was initiated on admission with no restrictions on body weight. The patient was able to initiate rehabilitation soon after admission, which was deemed the best manner in which to maintain her preoperative physical function. In Japan, only approximately 50%10) of patients with hip fractures undergo rehabilitation during the waiting period for surgery, and a typical rehabilitation program for such patients involves 20–30 min of physical therapy at the bedside10). However, in this case, rehabilitation was performed during the waiting period for surgery at an average of 86.6 min/day. When nonoperative treatment is chosen for older adult patients with hip fractures, the probability of gaining ambulation 6 months post-injury is only 9.6%11). Our patient was able to walk during the waiting period for surgery (on day 14) and could walk at an early stage postoperatively, which was atypical of patients her age.
Preoperative rehabilitation after hip fracture has been shown to result in better FIM motor scores than no preoperative rehabilitation10). Early mobilization after hip fracture surgery reduced 30-day mortality and complication rates compared12). It has been shown that high-frequency (daily) in-hospital physical therapy should be provided after surgery for elderly patients with hip fractures13). To date, there is no clear evidence regarding preoperative physical therapy for patients with a long waiting period for surgery, but we felt that in elderly patients with hip fractures, preoperative management should promote early and high-frequency physical therapy as well as postoperative management.
In other words, preoperative rehabilitation is effective in restoring function early after surgery. Furthermore, if preoperative rehabilitation is implemented, there is no consensus as to when weight bearing should begin, but we suspect that the sooner a patient can resume walking after a fracture, the sooner they will be able to regain walking function.
The benefits of preoperative rehabilitation include minimizing the effects of secondary complications such as pneumonia, deep vein thrombosis, and disuse syndrome associated with being bedridden, maintaining ambulatory function, and reducing patients’ emotional distress. Conversely, possible drawbacks of preoperative rehabilitation include the possibility that pain may decrease the patient’s motivation for rehabilitation and increase psychological distress. The risk of falls is unavoidable; this dislocation of the fracture site may cause secondary damage to the surrounding soft tissues, and the surgical plan may have to be changed due to the dislocation of the fracture site. Thus, such interventions require careful patient selection and monitoring.
Our patient was able to walk while awaiting surgery with the use of a soft, conforming lumbar immobilization orthosis, which reduced motion pain. The mechanism of post-fracture pain is that even normal innocuous movements and loads are perceived as adverse events when mechanosensitive nerve fibers innervating the periosteum, bone calcification, and bone marrow are mechanically stimulated14). Considering this mechanism, external fixation with a soft, conforming lumbar immobilization orthosis may have worked to reduce the mechanical stimulation applied to the fracture site. Perhaps the conforming lumbar immobilization orthosis played the role of the principle of splint for fracture fixation8). Conforming lumbar immobilization orthosis, which combined moderate immobilization force and mobility, was effective in this case because it led to pain relief without excessively restricting movement. Furthermore, we consider that this is analogous to pain in patients with hip osteoarthritis and decreased hip range of motion and a reduction in pain15, 16) when wearing a hip orthosis. It is also possible that the sensory stimulation of pressure and contact while wearing the lumbar immobilization orthosis resulted in desensitization and reduced pain. A rigid hip orthosis works to mechanically stabilize the hip joint; however, the weight and stiffness of the orthosis can be uncomfortable for some patients16). In contrast, the use of a soft, conforming lumbar immobilization orthosis is a simple external fixation technique as the material has moderate elasticity and supportive properties, and pressure can be adjusted. Moreover, this soft orthosis is easily contoured to fit the shape of the pelvis. The femoral neck and fracture site experience strain (physiological loading) during walking and activity17,18,19). This strain is dependent on the amount of loading during activity and decreases with low-intensity activities compared with high-intensity activities18, 19). Decreasing body weight loading also reduces hip extension and adduction moments during walking20). We consider that the use of a walker to reduce weight-bearing was also effective in reducing our patient’s pain. Body weight-supported devices may be considered for use when upper extremity support is weak, and when weight bearing cannot be reduced. Plain radiographs taken prior to surgery (on day 22) showed little evidence of dislocation of the fracture site when compared with those taken on admission. Therefore, rehabilitation during the waiting period for surgery was performed with minimal strain at the fracture site.
This case report has some limitations. The high-frequency rehabilitation during the waiting period for surgery was possible because physicians provided sufficient informed consent to the patient, who understood and agreed on the significance of rehabilitation during the waiting period for surgery. Our hospital has a well-staffed physical and occupational therapist workforce, which enables us to provide a high level of preoperative care. Our patient had good physical and cognitive function prior to the injury and no medical complications, which we consider to be a Good Baseline. Therefore, the patient’s postoperative functional recovery may have been good. The treatment and rehabilitation program might not be applicable to patients with a poor general health status for whom nonoperative treatment is the treatment of choice. We consider the absence of depression or perioperative complications while awaiting surgery to have a significant effect on the course of treatment for this patient. Although the use of the conforming lumbar immobilization orthosis reduced pain during weight bearing, the influence of analgesics and the placebo effect cannot be denied. Finally, this is a single case report and may not be generalizable. Early surgery is recommended for patients with hip fractures, so the waiting period for surgery is generally short, and there is a lack of randomized controlled trials on preoperative rehabilitation for hip fractures. As it is unlikely that a large number of similar cases will be reported in the future, it is necessary to conduct single case studies and examine effective rehabilitation methods.
In conclusion, external fixation with a soft, conforming lumbar immobilization orthosis effectively reduced pain during a prolonged preoperative period. Our patient’s gains in terms of ambulation are likely to provide useful information for the rehabilitation of patients with hip fractures who are forced to wait longer for surgery or for patients in good general condition who have to choose nonoperative treatment for some reason.
Conference presentation
Some of this report’s content was presented at the 51st Annual Meeting of the Japanese Hip Society.
Conflicts of interest
The authors declare no conflicts of interest.
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