1.8 Postoperative surgical management
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1 Introduction
The postoperative period has not been a primary focus for many surgeons, at least not to the same degree as the intraoperative one. As long as wound healing is progressing normally and postoperative x-rays are satisfactory, little attention is usually paid to other important issues that impact postsurgical recovery, rehabilitation, and overall functional outcomes. The communication between surgeons, staff nurses, and physiotherapists regarding common postoperative recovery is often poor.
This is partly due to the lack of availability and application of tools that focus on functional outcomes of individual patients. In addition, surgical and medical providers may not know how to best influence the rehabilitation progress.
Postoperative management seems as important as surgical treatment in producing optimal outcomes. Surgeons’ advice has an enormous influence on the patient, relatives, nurses, and physiotherapists, and can positively influence the quality of care in these areas. In this chapter we will focus on the importance of early mobility and rehabilitation, wound and skin management, and the prevention and treatment of pressure sores.
2 The impact of immobilization
2.1 Loss of muscle mass
Loss of muscle mass and muscle strength is common in older adults and is highly associated with frailty, functional decline, immobility, and falls ( Fig 1.8-1 ) [1]. This age-related decline of human muscle mass and strength is known as sarcopenia (see chapter 1.11 Sarcopenia, malnutrition, frailty, and falls) and may be exacerbated by short periods of immobilization [2]:
Wall et al [3] have generated pilot data from eight older adults demonstrating that 5 days of limb immobilization leads to a 1.5% loss of quadriceps cross-sectional area. When extrapolating this to a whole-body level, merely 5 days of bed rest would result in the loss of roughly 1 kg of muscle tissue.
Skeletal muscle atrophy is caused by a variety of stressors including decreased external loading and neural activation (ie, disuse), inflammatory cytokines and glucocorticoids, and malnutrition [2]. A combination of unloading and reduced neural activity occurs frequently in clinical settings following limb immobilization, bed rest, spinal cord injury and partial/complete peripheral nerve damage, resulting in significant loss of muscle mass and force production [2].
Older adults display a marked reduction in their ability to regain lost muscle tissue following a period of disuse, even with an intensive, supervised, resistance-type exercise training schedule [4–6].
Substantial muscle atrophy occurs during short-term disuse, with higher rates of muscle loss during more prolonged disuse. This suggests that the mechanisms responsible for the early loss of muscle during disuse differ from those occurring in prolonged disuse [3].
Older adults reduce their normal daily activity following a period of bed rest. Even with structured, supervised training, older adults spend the majority of their day completely inactive [7].
Structured and prolonged resistance training is effective for muscle mass gain in older adults [8, 9] and should be considered vital to their recovery. Most current clinical practice does not mandate such a rehabilitation program following a period of immobility, and older adults generally show low adherence to nonsupervised, structured resistance-type exercise training [10–12].
Composition of the slow, oxidative muscle fibers (type 1) and the fast, glycolytic muscle fibers (type 2) changes with age. Due to a natural loss of type 2 fibers, older adults are unable to react adequately to an unforeseen situation and fall easily. Both walking speed and coordination are decreased, which results in increased risk of falling and fracture. During immobilization, this process continues and the loss of fast twitch fibers progresses. Both the number and the volume of the fibers diminish.
Since there is a direct relation between muscle mass and muscle strength, this loss of muscle mass represents an independent risk factor for new falls and fractures. Restoration of muscle mass will improve performance during mobilization after fracture treatment [13].
There is clear evidence that considerable muscle atrophy occurs during the early phase of immobilization and is attributed to a rapid increase in muscle protein breakdown accompanied by a decline in muscle protein synthesis [3]. A persistent catabolic state hampers the improvement of this situation, so nutritional intake (1.25–1.5 mg of protein per kilogram of body weight per day) together with active mobilization is essential to regain muscle power and coordination. Both are a challenge in older adults.
Early mobilization by itself is not sufficient to prevent a decline in function. There is increasing evidence that strength training for the frail geriatric patient is an effective way to restore muscle function and to eliminate muscle strength asymmetry after surgery within 3 months [1].
In order to regain prefracture level of function and independence, early active mobilization with resistance exercises and adequate protein intake is essential.
3 Rehabilitation
Each surgical intervention in fragility fractures should enable the patient to make immediate use of the injured extremity. Undertaking the risk of surgery while still being restricted in postoperative range of motion or active mobilization often results in unacceptable overall functional outcomes.
Why are we afraid that we might overload our fracture/implant construct? Biomechanical studies show that constructs fail at distinct levels typically above physiological loads, even in cadaveric bone without soft tissue and active muscles to support the construct. We have an incomplete understanding of the in vivo forces during partial, full, and non-weight bearing as well as of forces emerging with upper extremity movements.
Surprisingly, forces in the hip joint measured in patients lying in bed and lifting their buttocks are higher than in the same hip joint during full weight bearing (FWB), using two crutches [14]. In light of these biomechanical and clinical realities, immediate weight bearing as tolerated (WBAT) using support should be promoted.
The same reasoning applies, if nonoperative treatment is chosen.
Some general remarks:
Patients usually enjoy mobilization and use of their extremities. It makes them less dependent on help and reduces frustration noted with activity restrictions.
Patients may be afraid of pain. It is always helpful if the surgeon assists in the early postoperative phase with moving joints, sitting and standing in front of the bed, to reassure patients about the safety of mobilization during pain.
Walking exercises should be supervised by the surgeon to enable him/her to interpret utterances and questions with regard to pain. Never rely on reports from other healthcare providers. There is no way around a personal visit and observation of the patient.
Giving patients individually tailored tips and tricks to safely improve mobilization may give them emotional support and be extremely helpful.
Talking to the patients, touching their hands, and answering concerns may also help and encourage them.
Pain management is critical. Timing, drug selection and dosage all influence patients’ ability and willingness to get mobilized and to cooperate.
Patients should feel comfortable while being mobilized, and different walking aids should be offered. Canes or walking sticks are usually more difficult to use and require arm force and coordination. A walker with or without wheels may be easier to use at the beginning or even permanently but may not allow for enough independence.
3.1 Lower extremity
Based on traditional teaching, anecdotal information and fear of loss of reduction, many surgeons are hesitant to permit FWB after reduction and stable fixation of fractures of the pelvis and/or lower limb.
No or limited weight bearing for some time is supposed to limit forces on the reconstructed bone and fixation material and to prevent loosening, hardware failure and secondary displacement of the fracture and implant. Of course, if such an event occurs, it is a disaster for patient and physician. Traditionally, limited weight bearing only is allowed for a time span of 6, 8 or 12 weeks after surgery.
One origin of this time-based protocol for weight bearing is the AO Principles of Fracture Management by Müller et al [15] that advocates a limited weight-bearing recommendation with 3 months of 5–10 kg load for hip fractures, unfortunately without any support from evidence-based literature. It is remarkable that these classic protocols are still in use, while at least some evidence promoting a less restricted weight-bearing protocol has existed since the end of the last century.
Failures of fixation are mostly associated with biomechanical flaws including suboptimal reduction and/or fixation.
3.1.1 Partial weight bearing is not an option
In the authors’ opinions, immediate postoperative WBAT is the only reasonable option in geriatric patients with lower extremity injuries. This applies to all kinds of fixations and joint replacements. Biomechanically sound constructs and close observation of the patient are prerequisite for this regimen.
If a fixation is deemed to be ‘not stable enough’, it could mean weeks to months of bed rest and/or partial weight bearing (PWB) until fracture healing has taken place. Usually, bone resorption at the fracture site renders the stability of the bone-implant-construct even weaker in the first weeks.
Even though high-level evidence is lacking, the authors list a few thoughts:
Failures typically occur between the 2nd and 3rd months after surgery, and there is no evidence that they occur more often in patients with weight-bearing permission.
Restriction of weight bearing inflicts a significant physiological burden on the older patient. The energy expenditure for ambulation without FWB increases fourfold, which leads to rapid exhaustion [16].
Most fragility fracture patients (FFPs) are not physically able to perform PWB due to sarcopenia, lack of proprioception and arm weakness. Many have preexisting impaired function of the upper and lower extremities which prevents them from using crutches or walkers in a way that effectively and safely spares the affected lower extremity. This makes implementation of a nonweight-bearing or PWB protocol impossible and forces the patient to prolonged bed rest and its well-known negative ramifications, predominantly a rapid loss of muscle mass. In addition, it makes non-weight bearing risky and increases the likelihood for another injury.
Patient motivation may drop due to fear and anxiety of failure to make functional progress.
The altered gait mechanism can lead to complaints of overload or low back pain.
Many FFPs have cognitive impairment, and may not understand or remember weight-bearing instructions.
Partial weight-bearing protocols are not evidence-based.
Even in the presence of appropriate doses of pain medication, pain will guide the patient to bear weight safely and appropriately. Patients with severely impaired cognitive function typically have the same self-protective mechanisms as cognitively intact patients.
Early weight bearing can promote fracture healing and union of the fracture without increasing loss of fixation [17–19].
There is no evidence that PWB after operative treatment of fractures of the pelvis and lower extremity has any advantages for the patient over FWB. Since there are many advantages of immediate full WBAT, this should be the standard approach. It may help to diminish adverse effects of sustaining a fracture such as loss of independence, less sarcopenia, less fear of falling and is expected to lead to a better outcome.
3.1.2 Recommendations
The following recommendations regarding weight bearing should serve to produce optimal outcomes for typical FFPs:
Surgical treatment should be adapted and extended to make fixation as safe as possible. Additional implant augmentation, the use of long, splinting constructs with relative stability, and joint replacement instead of an unstable osteosynthesis requiring PWB are examples.
Patients should be mobilized with WBAT as soon as possible after surgery. Usually, bedside sitting and standing in front of the bed with equal weight on both legs should be the initial approach.
Use a walker to assist with WBAT. More specific walkers with support for both upper extremities and the upper part of the body make patients feel safe with regard to falling or becoming so weak that walking is no longer possible.
Create a safe environment to improve patient confidence and reduce the risk of falling.
Stress body awareness to help patients identify situations where overload may occur.
For most intraarticular fractures reduced and fixed with an implant, there is no need to restrict weight bearing. Even though cartilage is damaged, anatomy is restored. Axial loading helps circulation in the joint and the cartilage and facilitates joint healing and strength.
Surgeons should intermittently observe the postoperative patient during mobilization and ambulation and pay special attention to any barriers to rehabilitation. Little remarks, tips and encouragement from the surgeon can be extremely important for optimal outcomes.
3.1.3 Evidence
Literature review indicates that WBAT is safe for most post-fixation FFPs.
Koval et al [17] demonstrated that older adults encouraged to perform FWB initiated PWB up to 50% in the first week and increased up to 87% in 3 months without any loss of fixation if they were allowed to bear weight as tolerated from day 1.
The use of bathroom scales to instruct the patient with a biofeedback system is useful for standing but not for walking [20].
We do not know the actual amount of axial load delivered to the implant-bone construct. We know that patient compliance to follow precise instructions is fairly low and implant constructs rarely fail. So why employ a restricted weight-bearing protocol and not shift to a protocol for weight bearing as tolerated?
There is no solid proof for an earlier onset of osteoarthritis in general, and it is hardly an issue in this population. It is not the timing of weight bearing, but inadequate articular reduction that predicts the outcome. The few studies of early weight bearing in geriatric acetabular fracture patients showed results similar to nonweight-bearing studies with no secondary loss of reduction [21]. One should realize that in acetabular fractures most forces are exerted posteriorly during transfers and sitting while axial compression during walking transmits force to the acetabular roof which is relatively robust even in severe osteoporosis. Even nonoperatively treated acetabular fractures patients can tolerate weight bearing ( Fig 1.8-2 ).
Similar principles apply to fractures of the tibial plateau. After adequate reduction and plate fixation early weight bearing does not predict malunion or nonunion. Some physicians use locked plates and/or postoperative braces, but superiority for these have not been proven yet [22–24].
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