A collaborative approach using the AAOS Clinical Practice Guideline can help ensure better outcomes

Care in the medically complex patient with a hip fracture can be difficult to organize, inefficient, and fraught with risks of complications. By creating a framework and a collaborative approach guided by the AAOS evidence-based Clinical Practice Guideline (CPG), providers can avoid pitfalls in the care of these challenging cases.

A 65-year-old female was referred to her hematologist with profound anemia, hypercalcemia, and a protein gap on serum protein electrophoresis. The patient had a preliminary diagnosis of multiple myeloma, and chemotherapy was initiated urgently. That day, as she attempted to get out of her car, she felt a painful, ominous “crack” and was unable to stand. She went to the emergency department, and her fears were confirmed: She had sustained a hip fracture. Things could have gotten even worse, but the interdisciplinary approach to her optimization and surgical management over the next 24 hours may have prevented the situation from escalating. After diagnosing her injury—a displaced subcapital femoral neck fracture (Fig. 1A)—the orthopaedic resident on call admitted her and initiated the institution’s protocol for the management of hip fractures in older patients with compromised bone quality due to osteoporosis or other disease. The protocol included a multimodal pain medication regimen and interdisciplinary preoperative work-up, both of which are supported by strong evidence in the AAOS CPG. The protocol also outlined prompt surgical treatment, within 48 hours of admission, to minimize complications associated with immobilization, as supported by both a moderate-strength recommendation and an AAOS performance measure.

The hospitalist service evaluated and risk-stratified the patient, initiated a blood transfusion, and corrected the patient’s electrolyte abnormalities. The hematology service recommended a modified perioperative chemotherapy regimen that would balance her elevated risk of postsurgical wound complications with the need to adequately suppress her bone marrow in anticipation of eventual transplantation. The anesthesiologist recommended a regional block to minimize perioperative anesthetic risks and optimize pain control, as supported by strong evidence. Acknowledging that not all femoral neck fractures are equal, the attending orthopaedic traumatologist discussed treatment options with his orthopaedic oncology and adult reconstruction colleagues.

Within 16 hours of the patient’s initial presentation, at least seven attending physicians had collaborated in her care before she was taken to the operating room with the adult reconstruction service. Multiple patient factors resulted in the selection of an uncemented bipolar hemiarthroplasty as the implant of choice (Fig. 1B), and the procedure was performed without complication. The patient mobilized out of bed the same day with physical therapy, and she was discharged home on the second postoperative day.

Consistent with the institution’s collaborative approach to fragility fracture prevention, the patient also was referred to endocrinology in the early postoperative period for optimization of her bone health. At her most recent six-month follow-up, the patient was walking without pain and approaching bone marrow transplantation.

Unfortunately, hip fractures are common in some of our most medically fragile patients. AAOS has provided a CPG for the management of hip fractures in older patients and those with compromised bone quality, which includes evidence-based support for interdisciplinary care, early surgical treatment, regional anesthesia, and multimodal regimens to control pain.

This case highlights one institution’s collaborative, personalized approach to the application of the CPG to the medically complex patient with a hip fracture to optimize outcomes and minimize complications. When providers are faced with complicated patients, practicing evidence-based medicine may help them avoid pitfalls, even when caring for the most challenging patients.

References

1. AAOS: Management of hip fracture in the elderly: evidence-based clinical practice guideline. Available at: https://www.aaos.org/research/guidelines/HipFxGuideline_rev.pdf. Accessed August 14, 2018.
2. AAOS: Management of hip fractures in the elderly: timing of surgical intervention performance measure. Available at: https://www.aaos.org/uploadedFiles/PreProduction/Quality/Measures/Hip%20Fx%20Timing%20Measure%20Technical%20Report.pdf. Accessed August 14, 2018.

Andrew Campbell, MD, is a chief resident in the Department of Orthopaedics at the Ohio State University Wexner Medical Center.

Thuan Ly, MD, is an associate professor and director of Orthopaedic Trauma at the Ohio State University Wexner Medical Center.

Andrew Glassman, MD, MS, is a professor, Frank J. Kloenne Chair of Orthopaedics, and chief of adult reconstructive surgery at the Ohio State University Wexner Medical Center.