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Melanie Cole (Host): The population of older adults is increasing all around the world. But as a result of that, so are the number of hip fractures. My guest today is Dr. Drew Brady. He’s an orthopedic surgeon at Christiana Care. Dr. Brady, tell us about the current state of hip fractures. What’s the prevalence and what are you seeing as this generation becomes so much older and you’re seeing things like osteoporosis and risk of falls? What are you seeing as the prevalence of hip fractures?

Drew A. Brady, MD (Guest): So, far the prevalence of hip fractures from recent reports we have, is about 300,000 hip fractures per year that we are seeing here in the US. Those numbers are expected to increase to about 500,000 per year by the year 2050, probably related to the fact that our population is aging. We are keeping people around a lot longer which is a good thing. But they also develop things like osteoporosis and impaired mobility and decreased balance, so they tend to fall, and we see more and more hip fractures as time goes on.

Host: So, you mentioned because the population is getting older and osteoporosis was one of the things you mentioned. What other types of conditions can cause that hip joint to break down and become weak enough that it can be more easily broken or fractured?

Dr. Brady: I think by far we see mostly – most of these hip fractures are caused because of osteoporosis from older ages, however, you can get certain secondary causes of osteoporosis or weakening of your bones from other systemic illnesses. Things that we think about are for instance, patients who have significant pulmonary disease who may need to be on steroids for a long period of time and we know steroids can cause some weakening of the bone. Some patients who have some cancer diagnoses, those types of things can decrease the bones and unfortunately some people who are just generally malnourished and don’t have the best diet can have some issues with turning over their bone as time goes on and they can be more prone to having hip fractures.

Host: Well then along those lines Dr. Brady, as we speak about the risk for hip fractures, what is that link between those things you’re mentioning, the older population and osteoporosis and include for us risk of falls because while osteoporosis and these things contribute to the fracture; it’s really something that happens to the person, correct? I mean they fall and break their hip.

Dr. Brady: Correct. So, most of the time, when you have a hip fracture, it’s from some form of a trauma. We do see some hip fractures from high energy trauma; motor vehicle crashes and things like that that happen in a younger population. But most of the hip fractures that we are actually talking about happen in an older population who have brittle bones and it happens from low energy trauma such as a fall just from a standing height or off of a single step or off of a step stool. And we really want to make sure that we have a population of people who have less chance of falling and things that can help to prevent you from falling are good activity, good exercise, good muscle tone. And that requires you keeping yourself healthy and active throughout your life.

Host: Dr. Brady, I have a 95 year old father, so I’m always concerned because he’s a pretty healthy guy, that he’s going to fall and that’s going to take him out as it will. What about that link we’ve heard about for so many years between mortality and broken or fractured hips? Is that a myth?

Dr. Brady: It’s not a myth. I think unfortunately we see that if you have or develop a hip fracture that requires admission to the hospital and surgery from a traumatic event; that there is somewhere on the order of sometimes upwards of 25-30% mortality in the next year. Part of that is probably because it’s not the hip fracture that is ultimately killing you; but it’s the fact that you have underlying medical comorbidities and other underlying medical problems that become unmasked when you have a hip fracture.

Host: That’s interesting. So, really, it can be very scary for caregivers when they are caring for loved ones. Should we know or would we know if someone has osteoporosis? Is that just women, again, is that a myth? Tell us a little bit about osteoporosis as that is something that contributes to hip fractures which we are discussing today.

Dr. Brady: So, osteoporosis can happen in men and women. It’s not just limited to women. It is sometimes a part of aging however, when it becomes pathologic or problematic; it’s when you lose more bone than you’d be expected to lose for people who are in your normal age group. We know the bones are a dynamic tissue. They turn over from the day we are born to the day we die. And they remodel themselves over time. As we get older, the remodeling process sometimes slows down. In order for a bone to remodel; your body has a process where it takes away bone or resorbs bone and then the bone that it takes away, it replaces with new bone.

What osteoporosis is, is there is a mismatch in that where you body takes away more bone than it puts down so that your bone looks like relatively normal architecture; it’s just less of it. so, it’s not as dense. That’s a normal part of aging. However, in certain people, that normal part of aging speeds up a little bit or you don’t have enough rebuilding of bone after your bone is first taken down to remodel that they become weak. We can’t completely reverse osteoporosis, but we can do some things to try to slow it down.

Host: Well, before we talk about some of those things, because I do want to ask you about calcium, vitamin D, smoking, things that can breakdown that density of the bone mineral mass; what about a screening tool. Do you advise that people of a certain age get screened for osteoporosis so that they can find out if they have osteopenia, the softening or if they are on their way towards full blown osteoporosis? What do you advise?

Dr. Brady: So, generally as part of just your general medical work up and your primary care physician or some GYN physicians can talk with patients about it. But usually it comes through the primary care physician and it comes through the orthopedic surgeon mainly as secondary screening when we see a problem. But usually somewhere around 65 or 70 years of age, you could have a DEXA scan which is basically a high tech x-ray that can quantify how much bone mass you have and then we’ll take the amount of bone mass or bone density that you have as an individual and compare that against a reference control and that will give us an idea of whether you actually have osteoporosis.

When patients get a DEXA scan they’ll either get a diagnosis of normal bone mass, they can get a diagnosis of osteopenia which is slightly decreased bone mass, or you can get a diagnosis of osteoporosis which is significantly decreased bone mass which they quantify or measure as two and a half standard deviations of bone mass less than what a normal reference control individual would have.

In those cases, we probably need to talk about treatment. The other thing that can happen when you have a bone mineral density test or a DEXA scan to look at osteoporosis; is that you can also do a FRAX score, F-R-A-X or a vertebral fracture assessment score which can look at some of your underlying medical problems and give you a risk score on what your likelihood or probability is of having either a vertebral fracture so a fracture in your spine or another type of fracture within the next ten years.

Host: As someone who has had one of those DEXA scans, I can tell the listeners it’s really an easy screening and it gives you a lot of information. If we are told that you’re headed towards that direction; what do you advise for preventing osteoporosis as we get into the fractures? Does calcium, vitamin D; do those things help doctor?

Dr. Brady: So, I think calcium and vitamin D definitely help. So, in order to rebuild bone, you need the building blocks to build that bone and that’s where the calcium and vitamin D come into play. And if you are in an at risk position for bone loss, meaning say you are a postmenopausal woman or you’re a man who has some underlying pulmonary disease and needs to be on steroids, or if you had that DEXA scan and it says that you are low normal, or you have osteopenia; then you definitely need to have a diet that’s high in calcium and vitamin D so that you can have the appropriate building blocks to build bone. And if you don’t have a diet high enough in those building blocks; then you may need to supplement with a medication.

Host: So, now on to the actual fracture itself. If someone falls Dr. Brady, would they automatically know if they fractured their hip or do some people, they don’t feel it quite like if you broke your leg.

Dr. Brady: So, most people when they fall, will know that they have something wrong that prompts them to seek urgent medical care. We do see some patients who have stress fractures in their hip or who are just tough individuals who can break their hip and somehow get up and still walk around on it for a few days to sometimes a few weeks. But in general, if you fall down and you break your hip; you’ll have pain in your groin, you’ll have pain sometimes in your upper buttocks area or your upper thigh area and you will not be able to bear weight or if you can bear weight, it will be extremely painful.

Host: And then what happens? So, you go to the Emergency Room or you get your loved one to the Emergency Room. How are fractures treated and what’s the first line of defense that you would use? Is it automatically necessary that surgery becomes the option?

Dr. Brady: So, surgery is not an automatic option for hip fractures, but it depends on what type of hip fracture you have. In general, if you have a displace fracture of your femoral neck of the intertrochanteric region or the subtrochanteric region; these are all areas that are at the top of the thigh bone. If you have a break in those areas; generally surgery will be recommended because that’s the best in terms of ongoing long-term pain control as well as ongoing long-term functional recovery.

Host: That’s so interesting that the different types don’t necessarily have the same treatment options. So, what about hip replacements. Where do they fit into this picture? If you have a fracture, people think in their minds a pin, or something to hold it together. What do you think of when you are doing these types of treatments with people, whether they are going to get a full on replacement or whether it’s something that you can repair?

Dr. Brady: So, of the general types of hip fractures that we talked about; intertrochanteric hip fractures we can generally repair. However, fractures that occur in the femoral neck which is where the ball goes into the socket; in an older population, are not usually able to be repaired or if they can be repaired; they have a high likelihood of going on to either nonunion, meaning it doesn’t heal or late failure or collapse.

So, most femoral neck fractures are recommended to be treated with some form of arthroplasty or replacement, where we replace either just the broken ball itself or we replace both the ball and the socket depending upon patient factors.

Host: Tell us about that then, the replacement and what types of hip replacement do you perform?

Dr. Brady: So, the general type of hip replacement that is done for the majority of fractured hips or femoral neck fractures is what we call a hemiarthroplasty or a partial replacement. A femoral neck fracture causes the ball to break off. That ball is then removed from the body and replaced with a metal and plastic prosthesis.

Occasionally, if a person has either underlying arthritis or if they are very healthy and very active; then we will plan to treat that with a full total hip replacement where we replace not only the broken ball, but we also replace the socket. The benefit of replacing both the ball and the socket, is that that can help us to get more complete pain control. However, it is a more extensive operation that has some other potential surgical complications that go along with it so not every orthopedic surgeon either recommends or is comfortable doing that particular procedure.

Host: People hear in the media now about anterior hip replacement. What is that and is this becoming a standard of care or was it kind of something that came and went a little bit?

Dr. Brady: So, anterior total hip replacements have been around for probably just as long as standard lateral or posterior hip replacements have been around. Now there’s a recent buzz on doing anterior replacements and they have become more commonplace again. It’s important to know however, that a total hip replacement can be done either from an anterior, a posterior or a lateral approach. And as long as the surgery is done appropriately; patients are going to do very well.

Some of the benefits of doing anterior hip replacement surgery is that it tends to be a little bit more of a muscle and tendon sparing procedure which can hopefully mobilize the patient a little bit quicker and can also allow them to have some better pain control and functional recovery in the immediate timeframe after they’ve had their surgery.

In terms of anterior versus posterior hip replacement for hip fractures; hip fractures can be treated in either way, if they are a fracture that you would normal do a replacement for. And so can just standard arthritis problems can be addressed with either anterior or posterior hip replacements.

Host: That’s really a fascinating field of study. Dr. Brady, tell us a little bit about the implants. What’s exciting in the world of hip replacement these days? What are the implants like?

Dr. Brady: I think there’s not much on my side that’s very new or exciting about the implants. The implant that we use is going to be dependent upon the patient’s bone quality and bone morphology or shape. And different types of implants can be done through both anterior or posterior approaches. In general, in the United States, for implants for arthroplasty or replacement around the time of a hip fracture; we usually use what’s called Press-Fit implants which means that the implant is made in size to your size of bone and then the way that it gets fixation in your bone is by wedging it into the bone.

Occasionally if patients have very poor bone quality, where we are worried about fractures around the hip if we put in a prosthetic implant, then we can use cemented implants. But the standard of care in the United States these days generally is for Press-Fit implants for hip replacement surgery.

Host: How long do they last, and do they still set off the metal detectors at airports? And people want to know about the after effects of a hip replacement compared to say a knee or a shoulder. What is the hip replacement like for a patient?

Dr. Brady: So, we get asked very often about whether the implants are going to set off the metal detectors and yes, they will or at least they have the potential to set off the metal detectors. So, this is metal, it’s titanium going into your body and it’s a pretty good sized hunk of metal. So, it will potentially set off metal detectors. What I found anecdotally is that people tend to set off metal detectors more if they have to go into the courthouse for jury duty than if they have to go through an airplane metal detector. But either one, can set off metal detectors.

And in terms of how long your implants will last for replacement surgery; we hope that they last a good 20-30 years if they are put in correctly and you have no other complications with it. So, they can theoretically last your lifetime once you get them.

Host: And then what’s life like? What is the rehab like? If someone fractures their hip, is the rehabilitation different if you repair that hip Dr. Brady versus doing a replacement? Tell us about sort of compare and contrast that for us and what it would be like and when you tell the patient, well I can repair this, or we can do a replacement; what questions do they ask you about what they can expect?

Dr. Brady: So, the general rehabilitation after a hip fracture is that we want out patients to be able to get up on a sturdy hip and be able to mobilize and fully weight bear immediately after surgery. If we have a femoral neck fracture that we choose to treat without replacement; then we may have to limit how much weight bearing that patient does immediately after surgery.

So, if we have a patient who breaks their hip and they are on a cusp of age where we may consider internal fixation meaning we fix the bone rather than replacing the bone; if we fix their bone with plates and screws or pins; then we may have to limit the weight bearing on that patient and they may need to stay on a walker for a longer period of time which is not what we want to do.

So, in general, if we think we’re going to have to limit weight bearing after a hip fracture; we will tend to go along the route of doing a replacement so that we can have them weight bear immediately, the day of or at least the day after surgery. Generally, within 24 hours after having surgery for a repair or a replacement of a hip fracture; we like to have our patients out of bed, up on a walker and participating in physical therapy so that they can get on the road to recovery right away.

Host: When they ask you for ballpark of when they can return to physical activity; I suppose it depends on what their level of fitness was before the fracture. But what do you generally tell them as a timeframe for physical therapy and being able to do things like drive a car or go back to work?

Dr. Brady: So, as we said before, we’ll start physical therapy immediately after surgery if we can. The rest of how long it takes you to get back to normal activities will depend upon your physical functioning before you had your hip fracture. Unfortunately, what we see is that most people usually lose one level of physical functioning for at least the first six months to a year after an unexpected hip fracture.

So, what I like to tell my patients is that you weren’t expecting to wake up today and end up in the hospital getting a hip fracture repaired so you’re not prepared for getting back into life right away. For our patients who we’re scheduling an elective joint replacement surgery; they’ve had some times months to get their affairs in order and to get meals cooked at home and to arrange for care for their animals and arrange for care for their house. So, they are prepared for what’s going to happen after surgery and they are generally a fitter population who is kind of ready to go as soon as their surgery is done.

For somebody who happened to just slip over the curb when they were on their way into the restaurant for breakfast this morning and ends up with a hip replacement later on that night or internal fixation for a hip fracture later that night; they weren’t prepared for life after that. So, it’s going to take them a little bit longer to get back into normal functioning. If somebody was a very healthy, active person that never needed to use a walker or a cane or anything; generally for the first six months or so after surgery; they may have to use a cane for long distance walking.

If you are a person who relied on a cane all the time prior to having your hip fracture; and then you have a hip fracture, you are likely going to need to rely on a walker for the first three to six months and then you’ll get back to your cane. For patients who were relying on a walker; it’s unlikely they are going to get off of the walker, however, we still do surgery to repair their broken hip because that will help with their overall pain control and their ability to take care of themselves after the surgery is performed.

Host: That’s a great point Dr. Brady and people do have to kind of think about that but as you say, there’s no way to tell in advance that you’re going to fall. So, let’s talk about falls. What do you advise as an orthopedic surgeon about preventing falls, because that seems to be one of the biggest risks for older people and because they are afraid of falling; sometimes they will move less because they are afraid of falling. What do you advise for fall prevention?

Dr. Brady: So, unfortunately, oftentimes after I see the patient or by the time, I see the patient they’ve already had their fall. However, we can certainly advise them on what to do so that you can prevent future falls. What I harp on constantly through this is that good weightbearing exercise and good muscle tone. So, it’s always good. Get out and take a walk around the block or take a walk in the park. Whether you need to use a walker or a cane. Do some aerobic exercise so you make sure you keep your joints mobile. Have a good diet so that you have the good correct building blocks to build good strong muscles.

One of the things that we oftentimes don’t think about on the orthopedic side is vision. A lot of our patients fall because they can’t see where they are going. So, if you need glasses, wear your glasses. If you need to get your vision checked, get your vision checked. Oftentimes I have patients who are very reluctant to use a cane or a walker when they are out in public because they think it makes them look old. However, I try to stress to them that you’d rather use a cane or a walker, it doesn’t make you look old because I have plenty of 25-year-old trauma patients who have to use canes and walkers for several months. And if that’s what helps prevent you from falling and getting a hip fracture; it’s much better to use a cane or a walker than to end up having a hip fracture that requires you to be in the hospital and have surgery.

Host: I agree completely. Sometimes you’re right, people are embarrassed or afraid to use a cane or a walker as you say, it might make them look old or feel like they look old; but it also can help prevent a fall. And as far as keeping healthy hips in general, as an orthopedic surgeon, what do you recommend. Give us your best advise as we wrap up this really interesting segment about hip fractures. What do you want us to know about keeping healthy hips and healthy bones in general?

Dr. Brady: I think unfortunately, we are not going to be able to prevent all hip fractures. However, we want to try to prevent as many as we can. People should look around their homes, make sure they don’t have extra throw rugs or uneven areas in their home that’s going to cause them to fall. We always want to make sure that people are very healthy and active so that even if unfortunately you do fall, and you develop a hit fracture; that after surgery, you have yourself poised to be able to return home and to return back to normal function as soon as possible.

And then if unfortunately you do have a hip fracture, we want to make sure that you follow up with a bone density scan within a few months after your surgery to make sure that we identify whether you have truly osteoporosis or not and that you follow the recommendations of your orthopedic surgeon and your primary care physician in terms of maintaining a healthy diet, getting on calcium and vitamin D supplementation if you need it and if you truly have osteoporosis, following the recommendations of any other medications that are prescribed for osteoporosis such as a bisphosphonate or Forteo or Prolia injection.

Host: Tell us about your team Dr. Brady and your multidisciplinary approach to care at Christiana Care.

Dr. Brady: There are going to be many people who impact and interact with the patient who has a hip fracture when they come into the hospital. So, our team includes the Emergency Department staff who initially sees the patient and makes the provisional diagnosis. It will be the orthopedic staff which is both the orthopedic surgeon as well as the orthopedic physician assistants who help us get patients ready for surgery.

A very important member of that team is the medical hospitalist who helps get the patient optimized for surgery. And the social work team and case management team who helps us to make provisions for that patient after surgery trying to either get them back to home with home physical therapy services or if they need to go to a nursing facility for a short time of recovery.

Physical therapists are very important in that as they help us to mobilize our patients right away. They help to instruct patients on fall prevention techniques and show them how to move around with their walker or cane effectively after surgery. Occupational therapists help to show you how to manage your normal activities of daily living such as dressing yourself, feeding yourself, in a time when you have just recently had surgery because you may not be able to dress yourself as easily, so you may need some extra aides. And the case management team is very, very important in terms of helping patients transition out of the hospital and back to normal life.

Host: That’s great information. Thank you so much Dr. Brady, for telling us about your team and what people can expect and the many providers that are involved if someone does suffer a hip fracture and you’ve given us such great information on preventing falls and even osteoporosis which can contribute to those fractures. Thank you again for joining us and sharing your expertise. This is Christiana Care’s Moving Freely Podcast Series. To learn more about programs and services for prevention and treatment of hip fractures please visit www.christianacare.org/boneandjoint, that’s www.christiancare.org/boneandjoint. I’m Melanie Cole. Thanks so much for tuning in.