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    Guidelines from AAOS Address Hip Fracture in Older Patients

    Evidence-based recommendations for diagnosing and treating hip fractures in patients age 65 years and older are the subject of a clinical practice guideline (CPG) from the American Academy of Orthopaedic Surgeons. [1]

    The CPG, entitled Management of Hip Fractures in the Elderly, addresses “a global health care challenge, as the occurrence of hip fractures is increasing related to the aging of the population and current prevalence of osteoporosis,” a progressive disease causing bone loss and hip fractures, said Karl Roberts, MD, vice chair of the hip fracture CPG work group.

    Many of the recommendations in the CPG have the ultimate goal of reducing delirium in hip fracture patients, according to W. Timothy Brox, MD, chair of the hip fracture CPG work group. Delirium is common among hip fracture patients. Multiple studies have found that patients with postoperative delirium are less likely to return to their pre-injury level of function, are more frequently placed in nursing homes, and have an increased rate of mortality.

    “The more you can reduce the incidence of delirium, the faster and more effectively the patient will recover,” Dr. Brox said.

    Most notably, the CPG includes a “strong” recommendation for preoperative regional analgesia to reduce pain in hip fracture patients, a practice that is not standard of care in all hospital settings.

    The hip fracture CPG also recommends:

    • Hip fracture surgery within 48 hours of hospital admission.
    • Intensive physical therapy following hospital discharge to improve functional outcomes.
    • An osteoporosis evaluation, as well as vitamin D and calcium supplements, for patients following a hip fracture.

    The recommendations in the CPG are meant to be used as an educational tool to augment the clinical judgment of healthcare providers and patient preferences and values when making clinical decisions regarding these conditions.

    Interestingly, a study recently published in the journal Medical Care showed that similar guidelines launched in 2007 in England have resulted in a substantial increase in early surgery for hip fracture patients age 60 years and older, as well as a dramatic decrease in deaths at 30, 60, and 365 days after the fracture. The UK National Hip Fracture Database is a collaboration between the British Orthopaedic Association and British Geriatrics Society.

    The CPG from the AAOS has been widely endorsed by other organizations in the U.S., including the United States Bone and Joint Initiative, the Orthopaedic Trauma Association, the American Association of Clinical Endocrinologists, The Hip Society. the American Academy of Physical Medicine and Rehabilitation, the American Society for Bone and Mineral Research, the Orthopaedic Rehabilitation Association, and the American Geriatrics Society.

    References

    1. Brox WT, Roberts KC, Takasali S, et al. The American Academy of Orthopaedic Surgeons Evidence-Based Guideline on Management of Hip Fractures in the Elderly. J Bone Joint Surg Am, 2015 Jul 15; 97(14):1196-1199.
    2. Neuburger J, Currie C, Wakeman R, Tsang C, Plant F, De Stavola B, Cromwell DA, van der Meulen J.The impact of a national clinician-led audit initiative on care and mortality after hip fracture in England: An External Evaluation using Time Trends in Non-audit Data. Med Care. 2015 Aug;53(8):686-691.