An Update to Guidelines for Managing Hip Fractures in Older Adults
Over the past 7 years, new research has expanded our understanding of surgical care for patients who present with hip fractures.
In recognition of this, the American Academy of Orthopaedic Surgeons (AAOS) has issued the second edition of its Clinical Practice Guideline for Management of Hip Fractures in Older Adults, replacing the first edition released in 2014.
The new edition updates more than 80% of the evidence-based recommendations in the previous guideline to refine and improve treatment recommendations for hip fracture patients. It also encompasses younger patients: While the first edition addressed the management of patients age 65 and older, the new edition includes patients age 55 and older.
Timing of Surgery
One of the most significant changes to the guideline is the recommended time to surgery following a hip fracture. The 2014 guideline recommended that hip fracture surgery be performed within 48 hours of admission for better outcomes. This was supported by moderate evidence.
Recent data from high-volume centers with high-performance hip fracture programs have demonstrated improved outcomes when patients underwent surgery sooner, generally within 24 hours of the fracture. Taking into account that not all facilities have the same resources, the guideline now recommends surgery within 24 to 48 hours. This is based on strong evidence.
“Ideally the time to surgery should be as soon as safely possible based on variation in resources at the facility and the given surgical team,” said Mary O’Connor, MD, co-chair of the clinical practice guideline development group.
Interdisciplinary Care for All
The other significant change is the focus on the role of an interdisciplinary care program in decreasing complications and improving outcomes for all hip fracture patients. This approach to care supports many of the recommendations included in the guideline.
The 2014 edition strongly supported the use of interdisciplinary programs to improve functional outcomes for hip fracture patients with mild to moderate dementia. The new recommendation provides strong evidence that expanding this approach to care for all patients can decrease mortality and complications and result in improved outcomes.
“These 2 recommendations go hand in hand,” said Julie Switzer, MD, co-chair of the clinical practice guideline workgroup. “An interdisciplinary care program should begin the moment a patient is admitted to the hospital, as it is an essential part of driving efficiencies to get a patient into the operating room within 24 to 48 hours.
“Following surgery, this team, which can consist of geriatric, orthopaedic, nursing, dietary, and rehabilitation providers, are the key to driving good outcomes and helping patients navigate this sentinel event.”
Cemented femoral stems: The guideline cites strong evidence (updated from moderate) supporting the use of cemented femoral stems for patients undergoing arthroplasty for femoral neck fractures, as they may benefit from reduced periprosthetic fracture risk and improved short time outcomes.
However, the CPG does acknowledge that these data show a risk for increased surgical time and blood loss.
Surgical approach: In patients undergoing treatment of femoral neck fractures with hip arthroplasty, the work group found that moderate evidence demonstrates no clear difference in measured outcomes or risk based on the surgical approach – direct anterior, lateral, or posterior.
This marks a change from the 2014 guidance, in which the posterior surgical approach was not favored because of higher dislocation rates. However, research published since then does not support the superiority of one surgical approach over another.
The full Clinical Practice Guideline for Management of Hip Fractures in Older Adults is available here.