Orthogeriatric co-management: differences in outcome between major and minor fractures

On average, 2.7 million fragility fractures occur annually in Europe alone, while increasing numbers of these fractures increase the burden on health care systems and health care providers [1]. The orthogeriatric patient requires a more complex treatment approach than a younger patient in the trauma unit [2]. Multimorbidities, frailty, cognitive impairment, immobility, reduced capacity for self-care, and organizational issues (e.g., a change of accommodation) are some of the main issues driving these patients’ complex needs [2]. To address these and provide complementary treatment for orthogeriatric patients, orthogeriatric co-management was established [2‐5]. It involves a multi-professional team of geriatric and orthopedic specialists, physio- and ergotherapists, and social helpers that build the foundation of a multidimensional approach [3]. Several studies have already shown that orthogeriatric co-management improves patients’ mortality and recovery of function as well as socioeconomic aspects such as place of residence, the need for care, and retention of accommodation [6‐10]. These outcome parameters have consequently been evaluated for hip fracture patients as hip fractures are the most common fragility fractures associated with age. Nevertheless, in a more holistic view of today’s orthogeriatric treatment, a multitude of injuries, including forearm, humeral, vertebral, rib, and pelvic fractures are of concern. Although some investigations examine these other fragility fractures of the elderly [11, 12], the literature is still lacking an adequate overview of co-management’s impact on them and a comparison of major and minor fractures according to their immobilizing or non-immobilizing character, respectively.

In this investigation, a 2 year follow-up was performed, focusing on orthogeriatric patients who received co-management. The causes of admission were stratified into two groups, major and minor injuries. Fracture-independent and -dependent functions, socioeconomic outcomes, and survival were evaluated. Our objective was to examine, on one hand, the importance of orthogeriatric co-management for the mentioned outcome parameters and, on the other hand, whether outcomes in this context differ between major and minor fractures.

An entire cohort of patients treated on a co-managed orthogeriatric ward during 1 year was assessed, from February 2014 to January 2015. The institutional review board in charge approved of this study (7/11192) and the patients and/or their legal guardians gave their informed consent. The patients were treated for different fragility fractures. Those admitted for non-fracture-associated causes were excluded. An in-house score was used for screening admission adequacy to the orthogeriatric ward: one point each for age greater than 75 years, auditory impairment, visual impairment, polypharmacy (≥ 5 medications), dementia, frequent falling, and sarcopenia. Two points were given for impaired mobility or the need for aids like crutches or wheeled walkers. A total of four or more points qualified patients for admission. The exclusion criteria were immobility and severe dementia (determined by Mini-Mental State Exam scores of < 10 points and individual assessment).

Each patient’s injury and therapy were recorded. Several assessments and socioeconomic parameters were included.

Included data:

A total of 740 patients suffering from major or minor fractures, as shown in Fig. 1, were assessed during the in-hospital period.

Of these, 584 patients (78.9%) were included in the follow-up and the mean follow-up time was 617.7 ± 187.16 days. Although major fractures exhibited a subtly higher loss to follow-up than minor fractures did, the difference was insignificant (p = 0.380) (Tables 3, 4). 229 patients were deceased after 2 years, leaving 355 cases for the evaluation of further parameters. Due to isolated deficits in the documentation of several assessment items, further assessment rate losses occurred, as stated in the supplemental material for each variable.

In this study, 574 major and 166 minor injuries were assessed. The patients’ mean age was 84.5 ± 6.59 years. It did not differ much nor significantly between the major (84.5 ± 6.67) and minor (84.6 ± 6.33) groups (p = 0.950). There was no significant difference in the gender distribution between the groups; 562 women and 178 men were treated in total (p = 0.918). The CCI distribution showed a significantly higher proportion of patients with a CCI > 4 in the major fracture group (Table 1) (p < 0.001). The mean length of stay (LOS) overall was 15.8 ± 7.78 days. The LOS was significantly lower for those with minor fractures, at a mean duration of 13.3 ± 7.99 days, than for those with major fractures, at a mean duration of 16.6 ± 7.56 days (p < 0.001). Significantly more patients in the major group received CEGH (51.0%) than in the minor group (36.2%) (p = 0.002). Nevertheless, after linear regression, we still observed a significant prolonged stay of 1.8 ± 0.64 days after major fractures.

Overall, we found a significant recovery of the activities of daily living but a slight, significant decline in mobility. Also, approximately one-third of all patients were classified as being in higher need of care and approximately one-fifth of the home dwellers had to leave their homes.

By comparing major and minor injuries, no significant differences were found between groups concerning changes in function, accommodation, domestic help, and 2-year-mortality. As the only remarkable differences, LOS and the need for care at follow-up were significantly higher and patients’ and relatives’ subjective satisfaction were significantly lower after major fractures. Although in-house and 1-year-mortality was significantly higher for major fractures, this difference vanished after 2 years. Notably, significantly more patients in the major group had higher morbidity scores than those in the minor group, which suggests even more comparable outcomes, all else being equal.

Mobility and the activities of daily living are two of the major outcome parameters worth evaluating in geriatric patients who have experienced trauma [16].

The regain and preservation of function are major aspects of orthogeriatric treatment. Stenvall et al. and Prestmo et al. have shown superior development of functionality and mobility after multidisciplinary treatment compared with conventional treatment in randomized, controlled studies [17, 18]. In our study, the increased BI score, as a marker of functional regain, was remarkable, although we must respect that the initial baseline was assessed directly after admission and the fracture event.

The amelioration of BI from discharge to follow-up was comparable to the initial change from admission to discharge. This supports the profound importance of acute rehabilitation during the in-hospital course, as well as the necessity of further rehabilitation after discharge. In the context of orthogeriatric treatment, Neuerburg et al. also described significant improvements in the activities of daily living for hip-fracture patients after 1 year [9]. Gosch et al. describe significant increases in BI for their long-term care residents independent of fracture from day 5 to a 3 month follow-up [7]. Another study supports these findings, reporting an average increase of BI from discharge to 1 year follow-up of 23.42 points (hip fracture patients that underwent inpatient rehabilitation after acute treatment) or 13.03 points (hip fracture patients that did not undergo inpatient rehabilitation after acute treatment), further underlining the importance of inpatient rehabilitation to ameliorate ADL in the long term [19].

Mobility scores at follow-up were compared to the pre-hospital scores; we observed a decent but not dramatic decline for both fracture groups.

There were neither significant nor tendentious differences between the major and minor groups concerning functional outcomes. Although minor non-immobilizing fractures were associated with a higher total BI at any time, no significantly different changes in BI or PMS were recorded from admission to follow-up. Immobilizing injuries were thus not associated with poorer functional outcomes. Gosch et al. showed comparable results, having observed a slight decline of PMS and a regain of BI without significant differences between hip-fracture and non-hip-fracture patients [7].

The length of stay was, on average 3.3 days longer after major than minor fractures, which is partially explained by the higher proportion of patients in this group receiving the total length of early inpatient rehabilitation (CEGH) of at least 16 days. The difference remains significant after correction for this confounding variable. This aligns with the clinical experience that lower extremity fractures require a more prolonged acute hospital stay consisting of rehabilitation and the organization of further social provisions than upper extremity fractures and thus supposedly were more often recommended for CEGH. As previously mentioned, the rehabilitative and therapeutic strategies were not different for non-CEGH patients. That the change in functional outcome parameters was not different between major and minor fractures confirms the value of a longer LOS after major fractures. Likewise, the literature reports a lower LOS to treat humeral fractures in geriatric patients [20, 21] and a higher LOS to treat hip fractures [9, 22].

The readmission rates were also comparable to reports in the literature [9]. Again, no difference was found between major or minor fractures, including for readmissions due to falls, which is interesting as one would suppose a lower extremity fracture would more strongly predispose for frequent falling than an upper extremity fracture would. This suggests that a fracture event, independent of the fracture site, is more of an indicator of general fall susceptibility. Furthermore, minor fractures can also cause immobility. Upper extremity fractures could result in unsteadiness in walking as the majority of geriatric patients cannot walk sufficiently and safely without aids like wheeled walkers. Additionally, even after rib fractures, a significant loss of self-care capacity and consequences like pneumonia or a predisposition for further falls or readmissions are conceivable [23, 24].

These observations assume that the primary goal for any injured patient (major or minor) should be the preservation of their daily living activities and mobility, which can more reliably be achieved with a multidisciplinary approach. This affirms that patients suffering from minor fractures should receive orthogeriatric co-management no less than those suffering from major fractures.

Care level and place of residence can be seen as surrogate parameters for, on one hand, the patient’s need for care and, on the other hand, socioeconomic elements. More than one-third of all patients were assessed at a higher care level at follow-up than before, with the minor group experiencing this to a significantly lower extent than the major group. Nevertheless, almost 30% of patients suffering from minor fractures experienced an upgrade in care levels, which is not a negligible proportion. This once again emphasizes the relevance of any fracture event to a patient’s self-support capability and its impact on health care systems.

This is also supported by the POR data, as almost one-fifth of all patients had to move (or leave their homes) permanently by the follow-up, with a tendentious, insignificantly lower rate in the minor fracture group. Additionally, about half of all patients that still lived at home needed more assistance from either family or care providers.

The personal evaluation of the situation at follow-up displays almost a normal distribution for all patients. Our results suggest better perceived conditions after minor fractures than after major ones.

Compared with our major group, Neuerburg et al. included only hip fractures and observed a similar distribution in their analogous assessment of the patient’s perceived “status of health” after orthogeriatric treatment. The results of a control group that was conventionally treated were significantly worse [9]. Shyu et al. also showed a significantly better “health-related quality of life” after interdisciplinary treatment of patients with fractured hips [25]. The literature provides some evidence in the field of hip fractures; a comparison or examination of other fragility fractures has not yet occurred. In this study, the major group included significantly more multimorbid individuals than the minor group, which could have exerted a nonnegligible confounding effect on the perceived evaluation. Consequently, we emphasize again the importance of understanding that minor fractures are not trivial events. Furthermore, by including the results from the literature, the relevance of orthogeriatric treatment for improvements in self-perceived health status is supported.

Concerning mortality, in-house and 1-year-mortality were significantly higher after major injuries than after minor; we observed no deaths in the minor group during the in-hospital course. Nevertheless, after 2 years, the significant difference in mortality had vanished. The persisting group-dependent difference might be further mitigated as the major group has a higher proportion of multimorbid patients. As previously mentioned in discussing the functionality data, this contradicts the presumption of overall higher death rates after major injuries (hip, thoracolumbar vertebral, pelvic, and other lower extremity fractures) than after minor injuries (upper extremity, cervical spine, and rib fractures). This is relevant to the comparison of any other outcome parameter assessed at follow-up, because higher mortality in one of the groups after 2 years could create a mortality bias, which our analysis did not discover. In summary, even mortality underlines a certain equality of outcomes with increasing observation time. Accordingly, Gosch et al. found no significant differences in mortality after hip and non-hip fractures for long-term care residents [7]. Contrarily, Center et al. describe remarkably higher survival rates after minor injuries. We must consider that patients in the mentioned study were included at the age of 60 and minor and major fractures were classified differently than in our study [26]. Bliuc et al., on the other hand, describe a relevant association of “nonhip nonvertebral fractures” and increased mortality [27]. As already mentioned, pain and immobility due to the inability to use aids might play a role in these results. Also, a general fracture event, whether major or minor, may be considered more of an overall indicator of higher morbidity and a higher probability for death, as a previous publication posited.

In general, the literature confirms that orthogeriatric treatment leads to improved survival after hip fractures compared with conventional treatment [6, 8, 9], and randomized, controlled trials for minor fractures could reveal similar results, as our observations suggest.

In this prospective 2 year follow-up on orthogeriatric co-management, we observed comparable outcomes for the functional and socioeconomic aspects of major and minor injuries.

These results underline the importance of orthogeriatric care in the treatment of fragility fractures and highlight the equal severity of any injury. Minor fractures should receive multidisciplinary care to the same extent as major fractures and their severity should not be underestimated. Upcoming investigations in the orthogeriatric field should assess more than just hip fractures so the most common and more rare fragility fractures can be analyzed analogously to either support or relativize our findings.