Walking Can Begin Immediately After Hip Fracture Surgery
Health care for seniors is taking a decided turn in other countries. In Italy, for example, hospitals that focus on the care of older adults are being developed. With the special needs of this population being addressed, problems like hip fracture can be treated with a geriatric-orthopedic multidisciplinary approach. This article reports on efforts to use an immediate weight-bearing early ambulation (IWB-EA) program after surgery to repair a hip fracture.
Immediate weight-bearing after surgery for hip fracture has been proven safe and effective in several studies. But as a general protocol, the medical practice of getting people up and walking again right away has not been adopted universally. There is still a general idea and belief that older adults need time to recover from surgery and should rest in bed for a couple of days before beginning an ambulation program with the physical therapist. And there's been some thought that older adults with memory or cognitive problems will have a harder time remembering to put weight on the involved leg.
To test out these ideas, surgeons at the Genoa Galliera Hospital in Liguria, Italy studied a group of older adults with hip fracture. Everyone in the study was 70 years old or older and had surgery to stabilize a proximal femur fracture (break at the top of the thigh bone). Before the hip fracture occurred, these patients were all still walking independently without assistance from a walker, crutches, or person assisting them.
The type of surgical stabilization performed depended on the location and severity of the fracture. Some patients only needed to have the bone repaired with metal plates and screws or a long intramedullary pin (down the inside of the bone). Others had to have a partial or complete hip replacement.
Everyone was up and instructed in walking with weight through the involved leg the day after surgery called postoperative day 1 or POD1. A physical therapist supervised the daily (Monday through Saturday) rehab program. Each patient was instructed by the therapist to put as much weight on the involved leg as was comfortable or tolerable. A walker was used for support and stability and the distance walked was increased daily. By the fourth day, patients were started on stairs and progressed to crutches whenever possible. A program of strength and balance training was also incorporated right from the start. Range-of-motion exercises were included with some movement restrictions for the patients who had a hip replacement.
Data collected on the patients included information about themselves (age, sex, living situation, physical and cognitive function) as well as information about their hospitalization (length of stay, type of surgery, day of surgery, destination at discharge such as home or step-down/transition unit). The therapists and nurses also charted how soon after surgery the patients put weight on the leg. They had to stand on the leg for at least two minutes for it to count. When the patient could walk forward at least 15 feet, they were credited with having successfully ambulated.
Those patients who could put weight on the leg and walk (ambulate) within 48 hours of the surgery were labeled compliant or adherent to the immediate weight-bearing early ambulation (IWB-EA) protocol. This was the weight-bearing (WB) group. Anyone who did not achieve this weight-bearing status was considered nonweight-bearing (NWB).
Analysis of the data showed that 78 per cent of the patients could weight-bear and ambulate within 48 hours (most achieved this in the first 24 hours). About half of the remaining 22 per cent (the nonweight-bearing group) eventually made the goal of weight-bearing and ambulation before being discharged from the hospital. Was there any particular reason or individual patient factor that could explain the difference between the weight-bearing and nonweight-bearing patients?
The authors found that it wasn't their age or cognitive function that made a difference in weight-bearing outcomes. It was the day of the week the surgery was done. Patients who had surgery done on Friday or the day before a holiday were much more likely to end up in the nonweight-bearing group. This finding is important because more patients in the weight-bearing group went directly home from the hospital and much sooner than the nonweight-bearing group.
If early ambulation after surgery for hip fracture can reduce costs associated with this procedure and more patients are able to go directly home from the hospital, then it's worth looking at staffing patterns in hospitals where these patients are treated. Reduced numbers of physical therapists and nurses and the absence of physicians in the hospitals on weekends and holidays appear to make a difference in how patients progress after surgical stabilization of hip fractures.
The authors suggest that if, as they showed in their study, the model of care for early in-hospital rehab of older adults with hip fractures can reduce the time of functional recovery, then results (especially long-term results) should be explored further. Data of this type may help move more hospitals toward a pattern of earlier recovery through immediate weight-bearing.
Antonella Barone, MD, et al. Factors Associated with an Immediate Weight-Bearing and Early Ambulation Program for Older Adults After Hip Fracture Repair. In Archives of Physical Medicine and Rehabilitation. September 2009. Vol. 90. No. 9. Pp. 1495-1498.