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Lifestyle Choices/co-Morbidities: Their Affects on Orthopedic Recovery

Lifestyle Choices/co-Morbidities: Their Affects on Orthopedic Recovery. Adam J Bakker, MD Hand and Upper Extremity Specialist Twin Cities Orthopedics. Disclosures. None. Background. Born: Seoul, South Korea Grew up: Walker, MN College: Concordia College, MN. Background.

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Lifestyle Choices/co-Morbidities: Their Affects on Orthopedic Recovery

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  1. Lifestyle Choices/co-Morbidities: Their Affects on Orthopedic Recovery Adam J Bakker, MD Hand and Upper Extremity Specialist Twin Cities Orthopedics

  2. Disclosures • None

  3. Background • Born: Seoul, South Korea • Grew up: Walker, MN • College: Concordia College, MN

  4. Background • MD: University of Minnesota • Orthopedic Residency: University of Washington • Hand Fellowship: Mayo Clinic • Twin Cities Orthopedics, Edina

  5. Overview • Case Report • Medical Co-morbidities • Life Style Choices

  6. Case Report • Pt: 67 yo Male • CC: Distal radius fracture and ulna • HPI: DOI 5 days ago GLF while intoxicated • Outside ER: 2 days after fall…splinted • Left AMA-removed splint & fell again • Finally came back to ER due to increase pain & “something” sticking out of skin

  7. Case Report • PMHx: DM2, HTN, HLD, liver failure • Social Hx: 18-24 beers, 2 PPD smoker, unknown disability, & lives alone • Labs: INR 1.6 (No Hx Coumadin use)

  8. Medical Comorbidities • Age >75 • Osteoporosis: Associated fragility fractures • Distal radius • Hip • Cardiac: • Congestive Heart Failure • Afib& Cardiac stents…anticoagulation • Renal: Renal failure

  9. Medical Comorbidities • Hepatic: Coagulopathies • Infectious: Activated inflammatory cascade • Respiratory: • COPD • Pneumonia • Neurological: • Dementia • Parkinson

  10. Inpatient Orthopedics Surgeries: Rates of & Risk Factors Mortality • 3 yr. analysis of all inpatient surgeries • 1995-1997 • 43,215 Orthopedic Inpatients • Overall Mortality rates (inpatient): 1% Bhattacharyya, JBJS 2002

  11. Inpatient Orthopedics Surgeries: Mortality • Overall: 1% • Hip Fractures: 3.1 % • Without Hip Fractures: 0.5% • None of the “Big 5” Critical Risk factors 0.25% Bhattacharyya, JBJS 2002

  12. Inpatient Orthopedics Surgeries: Mortality by Specialties • Low • Adult Recon (0.29%) • Sports, Peds, & Shoulder • Average • Trauma & Spine • HAND: Considered very safe…Abscesses (0.86%) • High • Tumor (5.1%) • Hip Fractures (3.1%)

  13. Inpatient Mortality Rates: 5 Independent Risk Factors • Chronic Renal Failure • Congestive Heart Failure • COPD • Hip Fractures • >75 yrs. of age Bhattacharyya, JBJS 2002

  14. Hip Fractures:Elderly (>65 yrs.) • Cost $10.3 to $15.2 billion in US • Lifetime risk 17.5% women & 6% men • 310, 000 Pts. hospitalized in 2003 • 87% to 96% hip fractures occur pts. >65 yrs. Walker, UpToDate 2013

  15. Hip Fractures:Elderly (>65 yrs.) • 30 day mortality rate • 9% without acute medical condition • 17% acute medical condition • 1 yr. Postoperative Mortality: 27.3% (12-37%) • 3x Risk of Mortality Pts. with Hip Fxs BMC Musculoskeletal Disorders 2011 AAOS 2013

  16. Distal Radius Fractures • 150,000-200,00 per year • Aging population: 50% increase 2030 • 50% increase in risk for hip fracture • Men 2x more likely to die and 2x as fast • No difference in overall medical comorbidities • Did not look at social support Rozental, J Hand Surg Am 2002

  17. Patient’s Medical Risk FactorsFragility Fractures • Osteoporosis (Greater in women vs. men) • 1.5 million osteoporotic/yr. USA • Falls • 30% to 60% community-dwelling fall each year • 90% hip fractures occur fall from standing BMC Musculoskeletal Disorders 2011

  18. Fall PreventionEvidence • Exercise: focus on balance most effective • Environment/assistive technology • Most effective when delivered by OT • Therapy • Strength • Balance Kiel, UpToDate 2013

  19. Fall PreventionEvidence: Lacking • Vision assessment & correction • Education alone (w/o OT/PT) • Medication modification • Assistive Devices (w/o OT/PT) • Hip Protectors Kiel, UpToDate 2013

  20. Lifestyle Choices • Smoking • Alcohol • Recreational Drug Use • Marital Status/Family • Poverty • Location from Surgeon • Noncompliant/Difficult Patients

  21. Smoking (Nicotine) • Devastating to Bones • Review 20 clinical studies • 6,480 patients (1,457 smokers & 5,023 nonsmokers) with long bone fxs AAOS 2013

  22. Smoking (Nicotine) • Longer Healing times: 6 weeks longer • Increased Nonunions: 15% • Higher rates of wound complication • Superficial: 2x • Deep: 3x AAOS 2013

  23. Nicotine: Multifactorial Mechanism • Vasoconstriction • Inhibition RBCs • Decrease Oxygen levels in blood • Osteoblasts (bone making cells) • Inhibited • Longer to heal & Weaker bone

  24. Alcohol • Chronic & Heavy Use • >100 grams EtOH/day=7 drinks • Lower bone mass • Decrease bone formation • Mechanism: • Suppresses Osteoblast activity • Decreases rates of bone remodeling Chakkalakal, Alcohol ClimExp Res 2005

  25. Alcohol • Generates “Liquid Courage” • Ignore Sxs • Masks Sxs • Falls

  26. Recreational Drugs • Marijuana: (Actually Study) Slows bone healing • Meth: Driving 100 mph wrong lane • Cocaine: Vasoconstriction & 100 mph wrong lane • IVDU: Infections Nogueira-Filho. Implant Dent 2008

  27. Marital Status/Family • Married people healthier • Most striking in 18-44 yo population • Married adults but particularly men higher obesity • Never married least obese Schoenborn, Advance Data CDC 2004

  28. Marital Status/Family • “Hispanic Paradox” • Waiting room effect • Will to live

  29. Poverty • Trauma is disease of poverty • Car safety • Number of passengers • Resources • Health maintenance • Time off • Healthy options • Fast food • Substance abuse

  30. Distance From Surgeon • Mayo Clinic • Closure to Rochester, MN…better outcomes • International Pts.…worse outcomes • Alaskan Fisherman • Appropriate Hand & Physical Therapy • Communication • Accessibility • Availability

  31. Difficult Patients… • Noncompliant with weight bearing restrictions • Removal of splints • No shows in clinic • Must follow up on • Increase rates of medical lawsuits AAOS 2013

  32. Difficult Patients…Surgeons • Cardiac Surgeon…POD 1 returned to OR s/p carpal tunnel release • Hand Surgeon…Patella fracture…treated non operatively • Removal of splint • Noncompliant with ROM • Missed zero days from work

  33. Case Report • Underwent serial irrigation & debridement • ORIF of distal radius • Prolonged immobilization • Removed cast x2 • Prolonged Healing • Despite smoking & chronic alcohol abuse

  34. Thank You Adam J Bakker, MD Hand and Upper Extremity Specialist Twin Cities Orthopedics

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