Early Orthogeriatric Treatment of Trauma in the Elderly

Abstract

Background

More than 125 000 hip fractures occur in Germany every year, with a one-year mortality of about 25%. To improve treatment outcomes, models of cooperation between trauma surgery and geriatrics have been developed. Their benefit has not yet been unequivocally demonstrated.

Methods

We systematically searched the Medline database and the Cochrane Library for prospective randomized controlled trials in which the treatment of elderly patients with fractures by the trauma surgery service alone was compared with preoperatively initiated collaborative treatment by the trauma surgery and geriatric services (“orthogeriatric” treatment). We investigated three treatment outcome variables—length of hospital stay, in-hospital mortality, and one-year mortality—in a metaanalysis.

Results

The five trials of hip fracture treatment that met the selection criteria all had relatively small study populations and a high risk of bias. The outcomes with respect to hospital stay differed greatly among trials (I²: 88.5%), and geriatric intervention was not found to have any statistically significant effect (0.06 days, 95% confidence interval [CI]: –3.74 to 3.62 days). The relative risk of dying in the hospital was 0.66 for orthogeriatric treatment (95% CI: 0.28–1.55, p = 0.34), and the hazard ratio for one-year mortality was 0.79 in favor of orthogeriatric treatment (95% CI: 0.57 to 1.10, p = 0.17). A metaanalysis of functional outcomes was not possible.

Conclusion

Only a few randomized controlled trials of early orthogeriatric treatment have been performed, and these trials are of limited quality. Due to low case numbers, a benefit from interdisciplinary orthogeriatric treatment could not clearly be demonstrated. Further trials are needed.

As a result of demographic change, with the number of elderly persons in industrialized countries rising, the number of fractures in geriatric patients is also increasing.

Typical geriatric fractures are fractures of the proximal femur, the proximal humerus, the distal radius, vertebral bodies, and the pelvis, and increasingly also periprosthetic fractures (1). These fractures, which are associated with osteoporosis and falls, pose great challenges to treating physicians. On the one hand, altered bone structure complicates surgical care, and on the other comorbidities often lead to complications (2).

The most significant socio-economic factor in this setting is proximal femoral fractures. These are fractures of the neck of the femur and pertrochanteric and subtrochanteric fractures (ICD-10 S72.0 to S72.2 [3]). In 2009 more than 125 000 patients over the age of 70 years received inpatient treatment for the principal diagnosis proximal femoral fracture in Germany alone (4). Despite great advances in surgical care, treatment outcomes remain disappointing (5). One-year mortality for proximal femoral fractures is approximately 25% (6), and around one-third of patients lose their independence within the same period (7). The direct annual costs of illness are estimated at €2.5 billion in Germany alone (8). Clearly, then, optimum patient care is important. In order to be able to deal better with these patients’ multimorbidity, various models for collaborative orthogeriatric care of patients with proximal femoral fractures have been developed worldwide in recent years (9). To date it has only been shown that patients with proximal femoral fractures benefit from orthogeriatric care during rehabilitation (10). It has not yet been possible to provide unambiguous evidence of an advantage for interdisciplinary orthogeriatric care begun perioperatively, although individual studies have been published, some of the results of which are promising (9).

This systematic review and metaanalysis is intended to represent the current state of scientific knowledge on the possible benefit for patients with typical geriatric fractures of orthogeriatric care begun perioperatively.

Methods

The first stage in the compilation of this article was a systematic review of Medline and the Cochrane Library performed by two reviewers. Next, a metaanalysis of the various outcome parameters was performed, to the extent that this was possible. Both these steps were performed in line with the PRISMA Statement (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) (11). The search terms “fragility fracture,” “geriatric fracture,” “osteoporotic fracture,” “hip fracture,” “femur fracture,” “femoral fracture,” “humerus fracture,” “humeral fracture, “periprosthetic fracture,” and “vertebral fracture” combined with “multidisciplinary,” “comanagement,” “co-management,” “interdisciplinary,” “comprehensive care,” and the terms “ortho-geriatric” and “orthogeriatric” were used to identify studies which investigated orthogeriatric care begun perioperatively for geriatric trauma patients (Figure 1). Study inclusion criteria were selected on the basis of the PICOS (Patient Group, Intervention, Control Intervention, Outcome, Study Design) question (Table 1), and risk of bias was evaluated using the criteria shown in Table 2. In a second stage, metaanalysis was performed on the studies identified during the review of the literature using the random effects model.

Figure 1.

Study selection procedure used in literature search

Table 1. Study inclusion criteria for metaanalysis.

Population	Geriatric patients with one of the following: Proximal femoral fracture Proximal humeral fracture Periprosthetic fracture Fracture of the vertebral body
Intervention	Orthogeriatric treatment begun perioperatively
Control	Trauma surgery only
Outcome	Time from hospital admission to surgery Length of hospital stay Functional level Independence/living situation Complication rate Quality of life Mortality
Study design	Randomized controlled trials

Table 2. Risk of bias in analyzed studies.

Study	Type of randomization	Concealment of allocation	Blinding	Handling of data loss	ITT*1 analysis	Risk of bias*2
Naglie et al. (2002) CMAJ (20)	Computerized block randomization (stratification by age and living situation)	+	Investigator blinding	ND	ND	High
Stenvall et al. (2007) J Rehabil Med (15)	Envelopes (stratification by operating method)	+	–	ND	+	High
Shyu et al. (2010) JAGS (18)	ND	ND	Patient blinding	Generalized estimating equations, multiple imputation	+	High
Vidán et al. (2005) JAGS (12)	ND (stratification by ADL)	ND	–	ND	ND	High
Uy et al. (2008) Australas J Ageing (13)	Envelopes	ND	Investigator blinding	ND	ND	High

^*1ITT: intention to treat; ND: no data; ADL: activities of daily living

^*2Risk of bias was low or high. Low risk of bias required precise information on adequate randomization (e.g. computerized list), concealment of allocation, adequate blinding (patients and investigators), and handling of data loss. It also required ITT analysis

Results

Study selection

The above-mentioned search terms identified 558 citations, 49 of which were literature citations (39 original articles and 10 reviews) that met the inclusion criteria and of which the full text was available (Figure 1). Manual searches of the bibliographies of the selected original articles did not identify any further publications. Patients with proximal femoral fractures were investigated in all the selected literature citations.

Of the 39 identified original articles, 10 were randomized controlled trials (eTable 1). However, closer examination revealed that the articles by Shyu et al. (16– 19, 21) and Stenvall et al. (14, 15) were based on one study or one study cohort each. These were included only once each. The metaanalysis therefore included a final total of five studies, involving 970 patients altogether (482 intervention, 488 control).

eTable 1. Prospective randomized trials; trials included in the metaanalysis appear in bold.

Study	Country	Pioli collaboration model*	Inclusion criteria	Exclusion criteria	No. of patients (intervention/control)	Follow-up period
Naglie et al. (2002) CMAJ (20)	Canada	2	Proximal femoral fracture Age ≥70 years Surgery	Fractures occurring in hospital Pathological fractures Multiple injuries Prior operation on injured hip Life expectancy <6 months institutionalization and immobility before accident technical complications during surgery postoperative admission to intensive care unit if no bed available in interdisciplinary unit	279 (141/138)	6 months
Stenvall et al. (2007) J Rehabil Med (15)	Sweden	3	Fracture of the neck of the femur Age ≥70 years	Severe osteoarthritis Severe rheumatoid arthritis Pathological fractures Severe renal insufficiency Bedbound	199 (102/97)	12 months
Stenvall et al. (2007) Osteoporos Int (14)	Sweden	3	Fracture of the neck of the ‧femur Age ≥70 years	Severe osteoarthritis Severe rheumatoid arthritis Pathological fractures Severe renal insufficiency Bedbound	199 (102/97)	Hospital stay
Shyu et al. (2005) JAGS (16)	Taiwan	4	Unilateral proximal femoral fracture caused by fall Age ≥60 years Prosthesis or osteosynthesis Full range of motion against gravity, some resistance Chinese Barthel index at least 70 before fracture	Chinese mini-mental state examination <10 terminal illness	159 (72/87)	3 months after hospital discharge
Shyu et al. (2008) Journal of Gerontology (17)	Taiwan	4	Unilateral proximal femoral fracture caused by fall Age ≥60 years Prosthesis or osteosynthesis Full range of motion against gravity, some resistance Chinese Barthel index at least 70 before fracture	Chinese mini-mental state examination <10 terminal illness	162 (80/82)	12 months after hospital discharge
Shyu et al. (2010) JAGS (18)	Taiwan	4	Unilateral proximal femoral fracture caused by fall Age ≥60 years Prosthesis or osteosynthesis Full range of motion against gravity, some resistance Chinese Barthel index at least 70 before fracture	Chinese mini-mental state examination <10 terminal illness	162 (80/82)	24 months after hospital discharge
Shyu et al. (2010) BMC Musculoskeletal Disorders (21)	Taiwan	4	Unilateral proximal femoral fracture caused by fall Age ≥60 years Prosthesis or osteosynthesis Full range of motion against gravity, some resistance Chinese Barthel index at least 70 before fracture	Chinese mini-mental state examination <10 terminal illness	162 (80/82)	12 months after hospital discharge
Shyu et al. (2012) Int J Geriatr Psychiatry (19)	Taiwan	4	Unilateral proximal femoral fracture caused by fall Age ≥60 years Prosthesis or osteosynthesis Full range of motion against gravity, some resistance Chinese Barthel index at least 70 before fracture	Chinese mini-mental state examination <10 terminal illness	160 (79/81)	24 months after hospital discharge
Vidán et al. (2005) JAGS (12)	Spain	4	Fresh proximal femoral fracture Age ≥65 years	Inability to walk before injury Dependence for all ADLs Pathological fractures Terminal illness (life expectancy <12 months)	319 (155/164)	12 months
Uy et al. (2008) Australes J Ageing (13)	Australia	4	Women Resident in care home Ability to walk before injury Ability to follow instructions		10 (4/7)	4 months

^*Four different models of orthogeriatric collaboration were distinguished, in line with Pioli et al. (30):

Model 1: treatment by trauma surgeons able to consult a geriatrician, followed by geriatric rehabilitation

Model 2: model 1 plus visits by geriatrician every weekday\

Model 3: treatment in a geriatric unit and consultation with the trauma surgeon

Model 4: collaborative orthogeriatric treatment from admission to discharge

ADL, activities of daily living

Risk of bias

All the studies included in the metaanalysis were shown to have a high risk of bias (Table 2).

Study results

Some of the parameters examined varied between studies, so metaanalysis was performed only on length of hospital stay, hospital mortality, and long-term mortality (eTable 2).

eTable 2. Results of collated studies.

Study	Length of preoperative hospital stay		Length of hospital stay (days)		Hospital mortality		Complication rate			Long-term mortality		Functional outcome
	I	C	I	C	I	C	I		C	I	C	I		C
Naglie et al. (2002) CMAJ (20)	1.3 days	1.4 days	20.9*	29.2*	5.0%	9.4%				12.1	15.2	39.7% survived with no deterioration in mobility, transfer, or living situation		34.1% survived with no deterioration in mobility, transfer, or living situation
Stenvall et al. (2007) J Rehabil Med (15)	24.5 hours	24.8 hours	30*	40*	5.9%	7.2%	Lower rate of postoperative delirium*, urinary tract infections*, nutrition problems*, sleep disorders*, and decubitus ulcers* in the intervention group			15.7	18.6	62% recovery of preinjury walking ability 58%* recovery of ADL		53% recovery of preinjury walking ability 36%* recovery of ADL
Stenvall et al. (2007) Osteoporos Int (14)			28*	38*	5.9%	7.2%	Lower rate of postoperative delirium*, urinary tract infections*, nutrition problems*, sleep disorders*, and decubitus ulcers* in the intervention group					12 patients fell*		26 patients fell*
							No repeat fractures		4 repeat fractures
Shyu et al. (2005) JAGS (16)			10.07	10.23	1.4%	0%				0%	1.6%	78.1%* recovery of preinjury walking ability		62.7%* recovery of preinjury walking ability
												89.76* Chinese Barthel index		79.28* Chinese Barthel index
Shyu et al. (2008) Journal of Gerontology (17)	35% operation within 24 hours	43% operation within 24 hours	10.1	9.72	0%	0%				16.3%	18.3%	84%* recovery of walking ability 90.53% Chinese Barthel index		66%* recovery of walking ability 84.36% Chinese Barthel index
Shyu et al. (2010) JAGS (18)	35% operation within 24 hours	43% operation within 24 hours	10.12	9.63						11.2%	15.9%	75% recovery of previous walking ability		58% recovery of previous walking ability
												Improved ADL, health-related quality of life (physical component of SF-36), and hip mobility*
Shyu et al. (2010) BMC Musculoskeletal Disorders (21)	35% operation within 24 hours	43% operation within 24 hours	10.12	9.63						5.0%	7.3%	Improved health-related quality of life in the intervention group*
Shyu et al. (2012) Int J Geriatr Psychiatry (19)										11.4%	16.0%	Improved hip mobility, ADL, recovery of walking ability in intervention group*
Vidán et al. (2005) JAGS (12)	75.8 hours	78.5 hours	16	18	0.6%*	5.5%*	45.2*		61.7*	18.1	25.3	47% recovery of ADL and mobility		39% recovery of ADL and mobility
Uy et al. (2008) Australes J Ageing (13)					25%	0%				25%	0%	28 Barthel index		68 Barthel index

Studies included in metaanalysis appear in bold; ^*p <0.05

I = Intervention group; C = Control group; ADL = Activities of daily living

Length of hospital stay

Metaanalysis of length of hospital stay revealed very high heterogeneity (I²: 88.5%) and a difference of –0.06 days (95% confidence interval [CI]: –3.74 to 3.62), meaning that the length of hospital stay in the intervention group was not significantly shorter (p = 0.97; Figure 2).

Figure 2.

Length of hospital stay (days): forest plot of the effect of orthogeriatric treatment

n, number; x, mean value; SD, standard deviation; 95% CI, 95% confidence interval; NA, not available

Hospital mortality

This parameter, too, yielded heterogeneous results (I²: 31.6%). Only Vidán et al. found a significant decrease in hospital mortality as a result of geriatric intervention (12). Overall, analysis showed a relative risk of 0.66 in favor of the intervention, which was statistically insignificant (95% CI: 0.28 to 1.55; p = 0.34; Figure 3).

Figure 3.

Hospital mortality: forest plot of the effect of orthogeriatric treatment

95% CI, 95% confidence interval

Long-term mortality

These results were more homogeneous than those for the other parameters (I²: 0%). Only the small study by Uy et al. showed a higher mortality rate in the intervention group (13). In the other four studies, more patients died in the control groups. With a hazard ratio (HR) of 0.79 (95% CI: 0.57 to 1.10), metaanalysis did not show significantly lower mortality as a result of geriatric intervention (p = 0.17; Figure 4).

Figure 4.

Long-term mortality: forest plot of the effect of orthogeriatric treatment

95% CI, 95% confidence interval

Other study results

For the other outcome parameters, Stenvall et al. showed a significant decrease in the rate of complications during hospital stay; this was also true of patients who fell during the same period (14). At the same time, in this group of patients preoperative length of hospital stay was lower than in the other studies; however, there were no major differences between the two patient groups within studies. The rate of patients who recovered their preinjury walking ability or preinjury activity level was higher in the intervention group (15) (eTable 2). Shyu et al. found that at various points during the research the functional outcome in the intervention group was better than in the control group (16– 19). Nevertheless, not all of the results were significant, as shown by those of Naglie et al. (20), Vidán et al. (12), and Uy et al. (13) (eTable 2). Because methods of assessment varied and the parameters chosen were heterogenous, we did not perform a metaanalysis on functional outcome. Only Shyu et al. investigated health-related quality of life (HRQoL). They found higher HRQoL in the intervention group (21).

Discussion

This systematic review and metaanalysis are intended to investigate whether interdisciplinary orthogeriatric care begun perioperatively is more beneficial than trauma surgery alone. Only five studies could be included. All five studies investigated patients with proximal femoral fractures. Interdisciplinary care led to a decrease in hospital mortality and one-year mortality, but these decreases were not statistically significant.

Study selection

The selected search terms identified a number of potentially eligible studies. All the studies investigated patients with proximal femoral fractures. This highlights the worldwide significance of these fractures due to their frequency, their high treatment costs, and their lasting effect on patients’ quality of life, but also as a tracer diagnosis for suitable treatment of fragility fractures. However, in this setting it is doubtful whether findings on treatment of patients with proximal femoral fractures can be extrapolated to to patients with other fragility fractures without further information.

Most of the identified studies on proximal femoral fractures were nonrandomized studies (Figure 1). Although most of the results of these studies were promising (22– 29) they were not included in our metaanalysis because they were nonrandomized.

The five included studies, which were conducted in various countries, investigated various models of collaboration described in Pioli (30). Inclusion and exclusion criteria also differed between the included studies (eTable 1). This explains the observed heterogeneity of the studies’ results—however, the results cannot be simply extrapolated to the German health-care system. The control groups received trauma surgery only. Only a few studies compared individual models, so the models cannot be evaluated. Mazzola et al. only found earlier mobilization with interdisciplinary treatment directly after hospital admission versus interdisciplinary treatment begun postoperatively. However, this was an observational study in which patient characteristics differed between the two patient groups (33). In our opinion, local circumstances must be taken into account when developing an interdisciplinary treatment approach.

Other studies showed that patients with proximal femoral fractures, some without concomitant treatment by a geriatrician, benefited from structured, multidisciplinary, multiprofessional treatment according to treatment pathways (27, 34– 37). Among other things, these approaches include early surgery; early mobilization with full weight bearing postoperatively; internal guidelines covering common problems in orthogeriatric patients such as delirium, malnutrition, coagulation management, and pain; and finally structured discharge management.

This metaanalysis was therefore only able to investigate whether early interdisciplinary orthogeriatric treatment of various types was superior to conventional trauma surgery.

Length of hospital stay

Length of hospital stay was approximately the same in both treatment groups (Figure 2). It was therefore impossible to determine whether length of hospital stay was affected by the different treatment models. The study by Naglie et al. was noteworthy for its significantly longer length of stay, 29.2 days, in the intervention group (control: 20.9 days) (20). One explanation for this might be that the study included only one geriatric internist visit, which may have prolonged inpatient stay. Length of inpatient hospital stay in this study was significantly above the mean length of acute medical hospitalization in Germany, which is currently 15.5 days (median: 13 days) (31). Other studies not included in the metaanalysis also yielded heterogeneous results regarding length of hospital stay (9). Differences in the length of hospital stay may be the result of differences in different countries’ health care systems and the features of local structures as a quality criterion in the treatment of orthogeriatric patients. Length of hospital stay in the same framework conditions would itself be problematic as a quality criterion for patient care, as it does not provide any information on quality of treatment.

Hospital mortality

The relative risk was 0.66 (95% CI: 0.28 to 1.55) in favor of interdisciplinary treatment versus trauma surgery alone, and there was no significant decrease in hospital mortality (Figure 3). Vidán et al. explain their significant reduction in mortality (0.6% versus 5.5%) by prevention or better management of systemic complications in the intervention group. In the study by Vidán et al. the rate of major systemic complications was significantly lower in the intervention group (45.2% versus 61.7%) (12). As Vidán et al. investigated Pioli’s fourth model, joint interdisciplinary orthogeriatric care from admission to discharge, the figures might provide evidence that intensive interdisciplinary care offers patients the most benefits. Astonishingly, only one of 162 patients (0.6%) died in the study by Shyu et al. (18). In contrast, the most recent mortality rate in Germany was 5.2% (31). This can be explained by the study’s exclusion criteria of terminal diseases and major cognitive impairment, which are associated with higher mortality.

Long-term mortality

As described in other studies, proximal femoral fractures are associated with considerable long-term mortality. According to a current review of the literature, one-year mortality is approximately 25% (6). Mortality in the studies included in our metaanalysis was significantly lower: an average of 15%. However, in one study the follow-up period was only six months, and in another only four months. Although the data from both studies were included in the metaanalysis using Perneger’s method (32), the varying follow-up times are a limitation. No significant reduction in one-year mortality was shown for the intervention group versus the control group (Figure 4). However, it should be remembered that the studies in this metaanalysis included only a small number of cases. In our opinion, the one-year mortality figures are evidence of a lasting effect of early interdisciplinary care that should be investigated in more detail in further studies. Bachmann et al. also included studies that concentrated on rehabilitation in a metaanalysis and were able to corroborate the positive effect of collaborative orthogeriatric care on one-year mortality (10).

Further outcome parameters

Functional improvement in patients in the intervention group was achieved in most studies. These included, among others, a reduced rate of falls (14) and more frequent recovery of preinjury walking ability (15, 18), preinjury mobility (12, 20), or preinjury ADL (activities of daily living) (12, 15) (eTable 2). Because of differing measurement tools and outcome parameters, these could not be included in metaanalysis, although the recovery of independence associated with functional status is itself of great importance to patients. Only Shyu et al. investigated patients’ health-related quality of life. They found that it was significantly positively affected by interdisciplinary treatment (21). The studies analyzed here examined only length of hospital stay, in view of the costs incurred. Treatment problems are already emerging in orthogeriatric care. For example, in a survey for 2009, 37% of hospitals reported problems in follow-up care of patients with proximal femoral fractures (38). The various models of interdisciplinary collaboration may help to reduce these treatment problems. If these models improve quality of care and therefore also functional outcome, there may also be financial advantages for all those providing funding, as a result of a reduction in the demand for care. This means that health economic evaluation of interdisciplinary care versus conventional treatment approaches is essential to overall assessment.

Risk of bias

The power of this metaanalysis is limited by the high risk of bias of all the studies it included (Table 2). In addition, there is a risk of bias across studies as a result of publication bias or selective reporting in individual studies. Although we did not perform analysis of publication bias because of the small number of studies and the high risk of bias within studies, we do not believe that there are good-quality and therefore expensive studies on this important subject that have not been published. Selective reporting, on the other hand, is more likely in our opinion. A further limitation is the fact that the literature search involved only two databases.

Conclusion

In the literature overall there is a variety of evidence that early orthogeriatric collaboration leads to improved outcomes for orthogeriatric patients. The small number of randomized controlled trials, which had small case numbers and were of limited quality, did not allow this benefit to be demonstrated with certainty in our metaanalysis. Randomized controlled trials with sufficient patient numbers should therefore be conducted, investigating functional parameters, quality of life, and financial issues.

Key Messages.

• A systematic review of the literature on orthogeriatric collaboration begun perioperatively in elderly trauma patients identified only five randomized controlled trials on proximal femoral fractures.

• Despite promising outcomes, metaanalysis showed no significant decrease in hospital mortality or long-term mortality.

• Length of hospital stay was not affected by interdisciplinary treatment.

• The high risk of bias, high heterogeneity, and low case numbers in the trials limit the power of the metaanalysis.

• Extrapolating the results to the German health care system seems problematic. High-quality studies on this subject must therefore also be conducted in Germany.