CPGs contain practice-altering recommendations
One way or another, we as orthopaedic surgeons all practice EBM. The question for each of us is whether the "E" represents Evidence-based or Experience-based Medicine.
Some of us may be dogmatic in our approach, rigidly adhering to experienced-based medicine; others of us are neophytes looking for guidance. Regardless of our personal situation, familiarity with clinical practice guidelines (CPGs) and appropriate use criteria (AUCs) can benefit us as surgeons and our patients as well. I ask my veteran colleagues to recognize that individual experience can be confounded by bias.
To highlight areas in which AAOS CPGs can bridge the divide between evidence and experience, the Committee on Evidence-Based Quality and Value recently produced "Impactful Statements." These statements call out the strong and moderate recommendations of each CPG that have the potential to impact patient care. They, as well as the CPGs and AUCs developed by the AAOS, can be found online at www.orthoguidelines.org.
Hip fractures are a major public health issue and considerable variability can be found in the management of hip fractures in the elderly. The degree of variability is such that patient outcomes can be improved if all treating physicians followed evidence-based care guidelines.
For women older than age 65, the incidence of hip fracture is almost 1 in 100. As the aging population increases, the occurrence of hip fractures is expected to increase, with an estimated 6.3 million hip fractures predicted worldwide by 2050. Given the high morbidity and mortality associated with these fractures, it is imperative that we standardize care for these patients to achieve the best outcomes possible.
In 2014, the AAOS released a CPG on Management of Hip Fractures in the Elderly, based on an evaluation of the most recent research. The guideline summarized the best evidence-based practices to guide clinical treatment. From that document, we can all agree on the following:
- Traction prior to surgery no longer has a role (moderate evidence).
- Regional analgesia with fascia iliaca blocks can improve preoperative pain (strong evidence).
- Timing of surgery is important; improved outcomes are seen if surgery can be performed within 24 to 48 hours (moderate evidence).
- Multimodal pain control in the elderly can minimize delirium, improve patient satisfaction, decrease complications, and improve early mobility (strong evidence).
- A restrictive transfusion threshold of hemoglobin no greater than 8g/dL can safely reduce transfusions (strong evidence).
- Bipolar heads do not appear to provide any advantage, so using unipolar heads is a good value-based recommendation unless costs are comparable (moderate evidence).
- As orthopaedic surgeons, we are not as good at diagnosing, managing, and treating osteoporosis in the episode of care as we should be, but no one doubts the importance of this in preventing second fractures. We recognize there is room for improvement in this regard, and have initiated programs such as Own the Bone to lead the way (moderate evidence).
But, if we look at the trends in utilization of press-fit stems in arthroplasty for treatment of displaced femoral neck fractures, we find a wide gap between evidence and application. The use of press-fit stems is increasing, contrary to the guideline recommendations.
If the question is what is best for population health, given all patients and all surgeons, the evidence is clear. We should use cement when performing arthroplasty in elderly hip fracture patients (moderate evidence). This recommendation is consistent across numerous evidenced-based CPGs, including those issued by the United Kingdom's National Institute for Clinical Excellence, the Cochrane Review, and the AAOS. Using cemented stems results in decreased fracture risk, fewer implant-related complications, and trends toward better function and mobility. Some high-level studies showed no difference; this is best exemplified by the study conducted by Figved et al and published in Clinical Orthopaedics and Related Research in 2009. However, a 5-year follow-up study of the same patients showed considerably lower risk of periprosthetic fracture in the cemented group.
Let evidence be your guide
Let us take a leap of faith and, when evidence is available, allow it to guide our practice. Let us use cemented stems when we treat displaced femoral neck fractures to improve outcomes.
Certainly, there will always be outlier situations in which the uniqueness of the patient and the experience of the surgeon will lead away from the evidence. CPGs are not meant to override good clinical judgment. If we recognize that evidence and experience are complementary, we may improve the value of care by truly practicing EBM and using CPGs and AUCs to guide our treatment decisions and develop care pathways.
When I am 80 years old and sustain a displaced femoral neck fracture, I want a cemented unipolar hemiarthroplasty. If I am still in good health and able to walk the golf course, a cemented total hip arthroplasty with an experienced surgeon would be great!
Karl C. Roberts, MD, is vice-chair of the AAOS Clinical Practice Guidelines Management of Hip Fractures in the Elderly and a member of the AAOS Committee on Evidence-Based Quality and Value.