The ongoing magnitude of hip fracture as a clinical challenge led to the development of a clinical practice guideline (CPG) on the “Management of Hip Fractures in the Elderly.” The resulting document includes 25 recommendations (Table 1), more than any previous CPG. Notably, 8 recommendations are supported by Strong evidence and 15 by Moderate evidence, indicating that relatively compelling research can guide clinical practice in this area (Table 2).

“We had a lot of strong evidence, which led to strong recommendations,” said W. Timothy Brox, MD, of Kaiser Permanente in Fresno, Calif., chair of the work group for the hip fracture CPG.

“What’s important about this guideline is that it emphasizes the concept of hip fracture care as a team endeavor,” said Dr. Brox. “Twenty years ago, if a patient had a hip fracture, the emergency doctor would call the orthopaedic surgeon, the operating room team would ask what implant the surgeon planned to use, and the surgeon would individually need to handle things that are now considered more routine—attention to preoperative analgesia, appropriate medical optimization, surgical timing, implant considerations, peri-operative osteoporosis evaluation, and multidisciplinary rehab.

“Today,” he continued, “we as orthopaedic surgeons lead a team and we are getting better at working together. As surgeons, we must continue to pay attention to the complexities involved in the management of hip fractures to deliver better patient care. This is reflected in guideline recommendations covering treatment throughout the continuum of care, including regional analgesia, intensive physical therapy, interdisciplinary care, and postoperative multimodal analgesia.”

Potential changes in practice
For example, one recommendation cites Strong evidence supporting the use of preoperative regional analgesia to improve preoperative pain control in patients with hip fracture (administration of a local anesthetic that results in temporary loss of nerve function in the fascia iliaca or femoral compartment of the injured hip). “This practice is not standard in all hospital settings and will be a change for some people,” said Dr. Brox.

Another Strong-level recommendation supports multimodal pain management after surgery for postoperative pain control.

With regard to anesthesia, the guideline states that Strong evidence supports either general or spinal anesthesia administration. “This may be an issue with anesthesia providers,” Dr. Brox said. “Some anesthesiologists have a bias that spinal anesthesia is better, based on supporting data from the 1980s. However, current evidence does not support that conclusion.”

The recommendation for prophylaxis for venous thromboembolism (VTE) carries a Moderate label, which reflects the somewhat limited evidence available specific to hip fracture patients, rather than the probable effectiveness and benefit of such therapy.

“Most of the literature on VTE prophylaxis focuses on arthroplasty surgery; very little was specific to hip fracture patients. As a result, we had to exclude many studies,” Dr. Brox said. “This was a challenge for members of the work group, who strongly believed that VTE prophylaxis should not be ignored. But the way the evidence was presented in the literature presented a challenge to the methodology used to prepare this guideline.”

Another recommendation, characterized as Strong in evidence, will effect change in the use of blood transfusions. It supports a transfusion threshold of hemoglobin no greater than 8 g/dL in asymptomatic postoperative hip fracture patients.

“A low transfusion threshold is relatively new,” Dr. Brox said. “We now recognize that we don’t need to be transfusing at the levels we previously did. Transfusion triggers are going down, which is a good thing due to the associated risks and cost of transfusion.”

Other recommendations in the CPG include the following:

• Surgical timing: Moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes.
• Intensive physical therapy: Strong evidence supports intensive home physical therapy to improve functional outcomes.
• Osteoporosis: Moderate evidence supports that patients be evaluated and treated for osteoporosis after sustaining a hip fracture. Moderate evidence supports use of supplemental vitamin D and calcium in patients following hip fracture surgery.

The CPG also gives Moderate endorsement to the use of cemented femoral stems in patients undergoing arthroplasty for femoral neck fractures. For unstable femoral neck fractures, it states, both unipolar and bipolar hemiarthroplasty yield similar outcomes. “Often surgeons are still using bipolar implants,” Dr. Brox noted.

The recommendation addressing hemiarthroplasty versus total hip arthroplasty (THA) cites Moderate evidence in support of THA in “properly selected patients” with unstable femoral neck fractures.

“This is a very nuanced recommendation,” Dr. Brox said. “The big words are ‘properly selected patients.’ Patients and surgeons should know that, in certain situations, a THA instead of partial arthroplasty is an option—if the surgeon is experienced with the procedure and the patient is a suitable candidate. However, the potential for increased complications and the risks of performing a more complex procedure are concerns.”

Reducing delirium
Running through this newly issued CPG is a clinical goal of reducing delirium in hip fracture patients. “If this document is followed, patients will experience less delirium,” noted Dr. Brox. “If they experience less delirium, treatment of their fractured hips will improve. There is no recommendation that says ‘avoid delirium.’ However, the recommendation on the use of preoperative regional analgesia is designed to avoid delirium, as are those on the timing of surgery, nutrition, postoperative multimodal analgesia to minimize opioids, and an interdisciplinary approach including intensive physical therapy.”

Dr. Brox said this CPG provides practical recommendations for improving the care of patients with hip fractures. “This is not a document that should sit on the shelf,” he said. “This needs to get out there so people can think about it and even argue about it. Constructive discourse can be positive, because care is being discussed. If clinicians are thinking about and evaluating new ways to do things better, patient care will continue to evolve.

“We are making progress in research,” he continued. “We have moved from a time of expert-opinion–based research—when highly regarded surgeons gave opinions based on their individual experience—to a time of evidence-based research with people in leadership being asked to evaluate and provide evidence of outcomes. This is reflected in the types of studies being done. It is why granting agencies give money. Researchers are now concentrating on how to ask a question, how to answer it, and how to make sure the answer will withstand scrutiny. It is a huge step forward.”

The CPG on the “Management of Hip Fractures in the Elderly” carries the endorsement of the Orthopaedic Trauma Association, the Hip Society, the American Association of Clinical Endocrinologists, and the United States Bone and Joint Initiative. The complete guideline is available at www.aaos.org/guidelines

Terry Stanton is a senior science writer for AAOS Now. He can be reached at tstanton@aaos.org