Break, Rattle, and Fall
When bones turn porous or joints become creaky and painful with every move, what treatment choices do the elderly have?
Rowena thought her golden years were idyllic. A retired schoolteacher who now alternates her schedule between household chores and church activities, Rowena never thought that her routine would be broken by one fatal fall. Until the accident, Rowena's only health problem had been asthma which she has had since childhood. The slightest change in weather, a thick miasma of smoke, or a bout of upper respiratory tract infection or pneumonia would usually send her wheezing. Maintained on beta agonists and steroids, little did she know that her chronic steroid use on top of her postmenopausal status and heavy frame would make her prone to a hip fracture.
The orthopedic surgeon she consulted noted that her fracture was not displaced and a conservative treatment approach was done. However, her doctor warned her that she might need a hip replacement in the future because the femoral head might undergo avascular necrosis. This finding was complicated by osteoporosis brought about by her chronic steroid use, postmenopausal status, and poor calcium intake.
Rowena also suffered from degenerative osteoarthritis (DOA), a joint disease known to affect mainly the elderly but made worse in her case by obesity. To take care of her osteoporosis, her doctor put her on a high calcium diet, calcitonin, and selective estrogen-receptor modulators (SERMs). She was also referred to a pulmonologist for assessment of whether she can go on beta-2 agonists alone, to a physiatrist for rehabilitation, and to a dietician for nutritional and weight management.
Breaking News
According to 2001 data from the United States Centers for Disease Control and Prevention (CDC), falls were the leading cause of death in persons 65 years and older. Also, nearly 300,000 elderly suffer from fall-related hip fractures yearly, making it the most serious of all fall-related injuries in the age group. Almost half of those who suffer from a hip fracture do not fully recover and have difficulty with their activities of daily living (ADLs).
"We try to preserve the femoral head as
much as possible, but if it is a completely displaced fracture and the femoral
head ends up with avascular necrosis, or in cases when the damage to the hip
including the acetabulum is extensive, a total joint replacement is warranted."
-Dr. Bernardo |
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The geriatric population is besieged by medical problems that affect strength, mobility, endurance, and balance. Dr. Peter Bernardo, clinical associate professor of orthopedics and head of the arthroplasty unit at the University of the Philippines-Philippine General Hospital (UP-PGH), says that, more than any other condition, osteoporosis predisposes the elderly to fractures. A slight fall or minor trauma that to a younger individual might just cause contusion, may-to one whose bones have become brittle-lead to a fracture.
Bernardo says the hip is the most common site of fracture in the elderly, followed by distal radial, then spine. The 1996 Far Eastern Osteoporosis Study attests to this. It found that hip fractures are the most serious outcome of osteoporosis, and women above 50 years of age have a higher risk for hip fractures than developing breast, uterine, and ovarian cancer combined.
Hip fractures usually involve the femoral neck or the intertrochanteric area and commonly result from sliding or slipping that causes elderly individuals to land on their buttocks. A 1998 PGH study located 45 to 50 percent of hip fractures among 170 males and females at the intertrochanteric area, 35 to 40 percent at the femoral neck.
Treatment for hip fractures involves either partial hip replacement or pinning, where the femoral head is fixed to the femoral neck using metal implants and pins embedded into the bone. This procedure tries to preserve the femoral head.
A total hip replacement may be necessary when the head is deemed unsalvageable. "We try to preserve the femoral head as much as possible, but if it is a completely displaced fracture and the femoral head ends up with avascular necrosis, or in cases when the damage to the hip including the acetabulum is extensive, a total joint replacement is warranted," Bernardo points out.
To lower the incidence of hip fractures, the Philippine Hip and Knee Society (PHKS) emphasizes prevention of osteoporosis. Postmenopausal women who are most likely to suffer hip fractures secondary to osteoporosis can benefit from hormone replacement therapy with estrogen. But Bernardo warns that long-term HRT use is now being dissuaded because of its association with breast or uterine cancer. Other available drugs like bisphosphonates, calcitonin, SERMs, glucosamine sulfate, along with calcium supplementation, help prevent bone loss.
Creaky and Crepitant
Joint replacement in the elderly is not only beneficial in cases of hip fractures secondary to osteoporosis. It is also an important treatment option for severe cases of rheumatoid arthritis and DOA-two health problems that greatly affect the quality of life of the elderly. Bernardo points out that the most common reason for a joint replacement in the country [and the world] is pain from DOA. The main indications are for pain relief, joint deformities, and limitation of the range of motion of the affected joint.
In its early stages, DOA is managed conservatively through nonsurgical means like pain relievers, exercises, and physical therapy. Braces are sometimes applied to
provide some joint stability. Joint replacement is only indicated for moderate to severe cases of joint pain that is correlated with radiologic findings where erosion of the joint surface or cartilage has worsened. Says Bernardo: "When disease process progresses to the severe stage, no matter how much medication or therapy you give [to the patient] these will not be enough to alleviate the pain. So this is where joint replacement surgery comes in."
Bernardo cites another reason why arthroplasty is not
offered as first-line treatment. If the implant is put in early, there is a
possibility that-over time and with constant use of the joint-it would
loosen, particularly in young and active patients.
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IN BLACK AND WHITE: X-ray pictures don't
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Joint replacement-whether a hip or knee-often becomes necessary because of posttraumatic arthritis or avascular necrosis of the femoral head. Avascular necrosis though is seen more in relatively younger patients than in the older age groups. Bernardo says avascular necrosis results more from chronic steroid and alcohol intake and rarely congenital dislocations or trauma. This would also explain why patients on long-term steroid medication, like asthmatics and those suffering from connective tissue disorders like lupus, often develop avascular necrosis. At its later stage, avascular necrosis usually leads to collapse of the femoral head and involvement of the acetabular portion, requiring no other option but arthroplasty.
Bernardo notes that fewer than a thousand hip and knee arthroplasty are performed each year in the Philippines, way below those of other Asian countries like Thailand, which has around 5,000 cases a year, or the US where about 250,000 joint replacements are performed annually.
Bernardo says the prohibitive cost of the implant and the surgical procedure is a major constraint. "We see a lot of patients who need a joint replacement but their problem is the financial aspect. In other countries where medical insurance is readily available, the patient does not have a problem obtaining the implants and undergoing the surgery."
For indigent patients, some form of assistance comes from organizations like the Philippine Charity Sweepstakes Office while training hospitals like PGH perform the surgery without charge. Bernardo says that contrary to what many think, joint replacement surgery and the implants used for these surgeries are very much available in the Philippines. Orthopedic International, Surgicare, and Unimed sell hip and knee implants in the country.
Bone Dry
Bernardo says prognosis has improved tremendously since the first joint replacement surgery was done in England in 1968. Up to 90 percent of implants could last up to 20 to 25 years.
In his private practice, Bernardo advises patients needing arthroplasty of their options, the reasons they might require joint replacement. If the DOA is still mild to moderate conservative management could be tried. But if surgery is a must, the patient is told of what the procedure entails, what will be expected before and after surgery, the role of physical therapy before and after the surgery, and the precautions that the patient should take.
Bernardo says the PHKS, of which he is treasurer, laid the groundwork for putting up a joint registry two years ago. The project aims to monitor the number of cases of joint replacements done in the country yearly. At present their estimates for knee arthroplasty is about 350 cases a year and 430 for total hip replacement. Bernardo notes that the number has been growing. The PHKS is a subspecialty organization of the Philippine Orthopedic Association (POA).
The PHKS, however, faces difficulties in its task. Records of hip and knee replacements since 1976 when the first hip replacement was performed in the country are hard to come by.
Notes Bernardo: "In some hospitals the medical record keeping is not that good, and even the X-rays that are two or three years old are difficult to retrieve. So we have to start going forward. For instance in our hospital (PGH) we now get the complete data from all patients undergoing any form of joint replacement. We get all the X-rays and file all these so we can easily trace and retrieve the films."
Meantime, the PHKS has started distributing forms to different Philippine hospitals doing joint replacement surgery and recruited people to collate the data.
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