Management of Hip Fractures in the Elderly

521 Pages·2015·7.71 MB·English

by  Jayson Murray

MANAGEMENT OF HIP FRACTURES IN THE
ELDERLY

EVIDENCE- BASED CLINICAL PRACTICE
GUIDELINE

Adopted by the American Academy of Orthopaedic Surgeons
Board of Directors
September 5, 2014

This Guideline has been endorsed by the following organizations:
Disclaimer
This Clinical Practice Guideline was developed by an AAOS physician volunteer Work
Group based on a systematic review of the current scientific and clinical information and
accepted approaches to treatment and/or diagnosis. This Clinical Practice Guideline is not
intended to be a fixed protocol, as some patients may require more or less treatment or
different means of diagnosis. Clinical patients may not necessarily be the same as those
found in a clinical trial. Patient care and treatment should always be based on a
clinician’s independent medical judgment, given the individual patient’s clinical
circumstances.
Disclosure Requirement
In accordance with AAOS policy, all individuals whose names appear as authors or
contributors to Clinical Practice Guideline filed a disclosure statement as part of the
submission process. All panel members provided full disclosure of potential conflicts of
interest prior to voting on the recommendations contained within this Clinical Practice
Guidelines.
Funding Source
This Clinical Practice Guideline was funded exclusively by the American Academy of
Orthopaedic Surgeons who received no funding from outside commercial sources to
support the development of this document.
FDA Clearance
Some drugs or medical devices referenced or described in this Clinical Practice Guideline
may not have been cleared by the Food and Drug Administration (FDA) or may have
been cleared for a specific use only. The FDA has stated that it is the responsibility of the
physician to determine the FDA clearance status of each drug or device he or she wishes
to use in clinical practice.
Copyright
All rights reserved. No part of this Clinical Practice Guideline may be reproduced, stored
in a retrieval system, or transmitted, in any form, or by any means, electronic,
mechanical, photocopying, recording, or otherwise, without prior written permission
from the AAOS.
Published 2014 by the American Academy of Orthopaedic Surgeons
6300 North River Road
Rosemont, IL 60018
First Edition
Copyright 2014 by the American Academy of Orthopaedic Surgeons
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I. SUMMARY OF RECOMMENDATIONS
The following is a summary of the recommendations of the AAOS Clinical Practice
Guideline on the Management of Hip Fractures in the Elderly. All readers of this
summary are strongly urged to consult the full guideline and evidence report for this
information. We are confident that those who read the full guideline and evidence report
will see that the recommendations were developed using systematic evidence-based
processes designed to combat bias, enhance transparency, and promote reproducibility.
This summary of recommendations is not intended to stand alone. Treatment decisions
should be made in light of all circumstances presented by the patient. Treatments and
procedures applicable to the individual patient rely on mutual communication between
patient, physician, and other healthcare practitioners.
Strength of Recommendation Descriptions
Overall
Strength Strength of Description of Evidence Strength
Evidence Strength Visual
Evidence from two or more “High” strength
Strong Strong studies with consistent findings for
recommending for or against the intervention.
Evidence from two or more “Moderate” strength
studies with consistent findings, or evidence
Moderate Moderate
from a single “High” quality study for

recommending for or against the intervention.
Evidence from one or more “Low” strength
studies with consistent findings or evidence
Low Strength
from a single moderate strength study for
Evidence or
Limited recommending for or against the intervention or
Conflicting
diagnostic test or the evidence is insufficient or
Evidence
conflicting and does not allow a
recommendation for or against the intervention.
There is no supporting evidence. In the absence
of reliable evidence, the work group is making a
recommendation based on their clinical opinion.
Consensus No Evidence
Consensus recommendations can only be

created when not establishing a recommendation
could have catastrophic consequences.

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ADVANCED IMAGING
Moderate evidence supports MRI as the advanced imaging of choice for diagnosis of
presumed hip fracture not apparent on initial radiographs.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
PREOPERATIVE REGIONAL ANALGESIA
Strong evidence supports regional analgesia to improve preoperative pain control in
patients with hip fracture.
Strength of Recommendation: Strong
Description: Evidence from two or more “High” strength studies with consistent findings for
recommending for or against the intervention.
PREOPERATIVE TRACTION
Moderate evidence does not support routine use of preoperative traction for patients with
a hip fracture.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
SURGICAL TIMING
Moderate evidence supports that hip fracture surgery within 48 hours of admission is
associated with better outcomes.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
ASPIRIN AND CLOPIDOGREL
Limited evidence supports not delaying hip fracture surgery for patients on aspirin and/or
clopidogrel.
Strength of Recommendation: Limited
Description: Evidence from two or more “Low” strength studies with consistent findings or evidence from
a single study for recommending for or against the intervention or diagnostic test or the evidence is
insufficient or conflicting and does not allow a recommendation for or against the intervention.

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ANESTHESIA
Strong evidence supports similar outcomes for general or spinal anesthesia for patients
undergoing hip fracture surgery.
Strength of Recommendation: Strong
Description: Evidence from two or more “High” strength studies with consistent findings for
recommending for or against the intervention.
STABLE FEMORAL NECK FRACTURES
Moderate evidence supports operative fixation for patients with stable (non-displaced)
femoral neck fractures.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
DISPLACED FEMORAL NECK FRACTURES
Strong evidence supports arthroplasty for patients with unstable (displaced) femoral neck
fractures.
Strength of Recommendation: Strong
Description: Evidence from two or more “High” strength studies with consistent findings for
recommending for or against the intervention.
UNIPOLAR VERSUS BIPOLAR
Moderate evidence supports that the outcomes of unipolar and bipolar hemiarthroplasty
for unstable (displaced) femoral neck fractures are similar.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
HEMI VS. TOTAL HIP ARTHROPLASTY
Moderate evidence supports a benefit to total hip arthroplasty in properly selected
patients with unstable (displaced) femoral neck fractures.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
CEMENTED FEMORAL STEMS
Moderate evidence supports the preferential use of cemented femoral stems in patients
undergoing arthroplasty for femoral neck fractures.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
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SURGICAL APPROACH
Moderate evidence supports higher dislocation rates with a posterior approach in the
treatment of displaced femoral neck fractures with hip arthroplasty.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
STABLE INTERTROCHANTERIC FRACTURES
Moderate evidence supports the use of either a sliding hip screw or a cephalomedullary
device in patients with stable intertrochanteric fractures.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
SUBTROCHANTERIC OR REVERSE OBLIQUITY FRACTURES
Strong evidence supports using a cephalomedullary device for the treatment of patients
with subtrochanteric or reverse obliquity fractures.
Strength of Recommendation: Strong
Description: Evidence from two or more “High” strength studies with consistent findings for
recommending for or against the intervention.
UNSTABLE INTERTROCHANTERIC FRACTURES
Moderate evidence supports using a cephalomedullary device for the treatment of
patients with unstable intertrochanteric fractures.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
VTE PROPHYLAXIS
Moderate evidence supports use of venous thromboembolism prophylaxis (VTE) in hip
fracture patients.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
TRANSFUSION THRESHOLD
Strong evidence supports a blood transfusion threshold of no higher than 8g/dl in
asymptomatic postoperative hip fracture patients.
Strength of Recommendation: Strong
Description: Evidence from two or more “High” strength studies with consistent findings for
recommending for or against the intervention.
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OCCUPATIONAL AND PHYSICAL THERAPY
Moderate evidence supports that supervised occupational and physical therapy across the
continuum of care, including home, improves functional outcomes and fall prevention.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
INTENSIVE PHYSICAL THERAPY
Strong evidence supports intensive physical therapy post-discharge to improve functional
outcomes in hip fracture patients.
Strength of Recommendation: Strong
Description: Evidence from two or more “High” strength studies with consistent findings for
recommending for or against the intervention.
NUTRITION
Moderate evidence supports that postoperative nutritional supplementation reduces
mortality and improves nutritional status in hip fracture patients.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
INTERDISCIPLINARY CARE PROGRAM
Strong evidence supports use of an interdisciplinary care program in those patients with
mild to moderate dementia who have sustained a hip fracture to improve functional
outcomes.
Strength of Recommendation: Strong
Description: Evidence from two or more “High” strength studies with consistent findings for
recommending for or against the intervention.
POSTOPERATIVE MULTIMODAL ANALGESIA
Strong evidence supports multimodal pain management after hip fracture surgery.
Strength of Recommendation: Strong
Description: Evidence from two or more “High” strength studies with consistent findings for
recommending for or against the intervention.
CALCIUM AND VITAMIN D
Moderate evidence supports use of supplemental vitamin D and calcium in patients
following hip fracture surgery.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
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SCREENING
Limited evidence supports preoperative assessment of serum levels of albumin and
creatinine for risk assessment of hip fracture patients.
Strength of Recommendation: Limited
Description: Evidence from two or more “Low” strength studies with consistent findings or evidence from
a single study for recommending for or against the intervention or diagnostic test or the evidence is
insufficient or conflicting and does not allow a recommendation for or against the intervention.
OSTEOPOROSIS EVALUATION AND TREATMENT
Moderate evidence supports that patients be evaluated and treated for osteoporosis after
sustaining a hip fracture.
Strength of Recommendation: Moderate
Description: Evidence from two or more “Moderate” strength studies with consistent findings, or evidence
from a single “High” quality study for recommending for or against the intervention.
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TABLE OF CONTENTS
I. Summary of Recommendations .................................................................................. 3
Advanced Imaging .......................................................................................................... 4
Preoperative Regional Analgesia .................................................................................... 4
Preoperative Traction ...................................................................................................... 4
Surgical Timing .............................................................................................................. 4
Aspirin and Clopidogrel .................................................................................................. 4
Anesthesia ....................................................................................................................... 5
Stable Femoral Neck Fractures ....................................................................................... 5
Displaced Femoral Neck Fractures ................................................................................. 5
Unipolar Versus Bipolar ................................................................................................. 5
Hemi vs. Total Hip Arthroplasty .................................................................................... 5
Cemented Femoral Stems ............................................................................................... 5
Surgical Approach .......................................................................................................... 6
Stable Intertrochanteric Fractures ................................................................................... 6
Subtrochanteric or Reverse Obliquity Fractures ............................................................. 6
Unstable Intertrochanteric Fractures ............................................................................... 6
VTE Prophylaxis ............................................................................................................. 6
Transfusion Threshold .................................................................................................... 6
Occupational and Physical Therapy ................................................................................ 7
Intensive Physical Therapy ............................................................................................. 7
Nutrition .......................................................................................................................... 7
Interdisciplinary Care Program ....................................................................................... 7
Postoperative MultiModal Analgesia ............................................................................. 7
Calcium and Vitamin D .................................................................................................. 7
Screening......................................................................................................................... 8
Osteoporosis Evaluation and Treatment ......................................................................... 8
Table of Contents ............................................................................................................ 9
List of Tables ................................................................................................................ 14
Table of Figures ............................................................................................................ 18
II. Introduction ............................................................................................................... 19
Overview ....................................................................................................................... 19
Goals and Rationale ...................................................................................................... 19
Intended Users .............................................................................................................. 19
Patient Population ......................................................................................................... 20
Burden of Disease ......................................................................................................... 20
Etiology ......................................................................................................................... 20
Incidence and Prevalence .............................................................................................. 20
Risk Factors .................................................................................................................. 21
Emotional and Physical Impact .................................................................................... 21
Potential Benefits, Harms, and Contraindications ........................................................ 21
Future Research ............................................................................................................ 21
III. Methods................................................................................................................. 23
Formulating Preliminary Recommendations ................................................................ 24
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Study Selection Criteria ................................................................................................ 24
Best Evidence Synthesis ............................................................................................... 25
Minimally Clinically Important Improvement.............................................................. 25
Literature Searches........................................................................................................ 26
Methods for Evaluating Evidence ................................................................................. 26
Studies of Intervention/Prevention ........................................................................... 26
Studies of Screening and Diagnostic Tests ............................................................... 28
Studies of Prognostics ............................................................................................... 30
Final Strength of Evidence........................................................................................ 31
Defining the Strength of the Recommendations ........................................................... 31
Wording of the Final Recommendations ...................................................................... 32
Applying the Recommendations to Clinical Practice ................................................... 33
Voting on the Recommendations .................................................................................. 33
Statistical Methods ........................................................................................................ 34
Peer Review .................................................................................................................. 35
Public Commentary ...................................................................................................... 36
The AAOS Guideline Approval Process ...................................................................... 36
Revision Plans ............................................................................................................... 36
Guideline Dissemination Plans ..................................................................................... 36
IV. Recommendations ................................................................................................. 38
Overview of Articles by Recommendation ................................................................... 38
Advanced Imaging ........................................................................................................ 39
Rationale ................................................................................................................... 39
Risks and Harms of Implementing this Recommendation ....................................... 39
Future Research ........................................................................................................ 39
Results ....................................................................................................................... 40
Preoperative Regional Analgesia .................................................................................. 45
Rationale ................................................................................................................... 45
Risks and Harms of Implementing this Recommendation ....................................... 46
Future Research ........................................................................................................ 46
Results ....................................................................................................................... 47
Preoperative Traction .................................................................................................... 56
Rationale ................................................................................................................... 56
Risks and Harms of Implementing this Recommendation ....................................... 56
Future Research ........................................................................................................ 56
Results ....................................................................................................................... 57
Surgical Timing ............................................................................................................ 66
Rationale ................................................................................................................... 66
Risks and Harms of Implementing this Recommendation ....................................... 66
Future Research ........................................................................................................ 66
Results ....................................................................................................................... 67
Aspirin and Clopidogrel ................................................................................................ 75
Rationale ................................................................................................................... 75
Risks and Harms of Implementing this Recommendation ....................................... 75
Future Research ........................................................................................................ 75
Results ....................................................................................................................... 76
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