The American Academy of Orthopaedic Surgeons (AAOS) issued an update to the Clinical Practice Guideline (CPG) for Management of Hip Fractures in Older Adults (age 55 years and older), replacing the 1st edition released in 2014, which initially covered a patient population of 65 years and older.
This edition of the guideline updates over 80% of the evidence-based recommendations included in the previous guideline to refine and improve treatment recommendations for hip fracture patients. Notably, the CPG highlights the important role an interdisciplinary care program plays in decreasing complications and improving outcomes for all hip fracture patients and how this approach to care is an integral component to support many of the recommendations included in this CPG.
The time to surgery following a hip fracture and implementing a multidisciplinary approach to patient care are two significant updates to the recommendations in this guideline. While moderate evidence in 2014 supported the recommendation that hip fracture surgery occurring within 48 hours of admission is associated with better outcomes, recent data from high volume centers with high performance hip fracture programs showed improved outcomes with surgery within 24 hours. The committee provided strong evidence to recommend surgery within 24 to 48 hours to recognize differences in resources available to support surgical care at various facilities.
Interdisciplinary programs that involve providers from multiple disciplines to co-manage individuals with hip fractures were strongly supported in the 2014 edition to improve functional outcomes for patients with mild to moderate dementia. The new recommendation provides strong evidence that expanding this approach to care for all patients with an interdisciplinary approach can decrease mortality and complications and result in improved outcomes.
Additional highlights of the CPG include:
- 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.
- While this CPG evaluates 19 recommendations specifically related to surgical care for hip fractures, the development group did not review current literature or issue recommendations in regard important pre-and post-operative considerations such as preventative measures, bone health and osteoporosis. However, this omission should not imply that this information is not critical to the overall health of hip fracture patients.
- Development of this CPG was a collaborative effort prepared by the AAOS Hip Fracture in Older Adults Guideline physician development group (clinical experts) with the assistance of the AAOS Clinical Quality and Value (CQV) Department (methodologists).
CPGs are not meant to be stand-alone documents, but rather serve as a point of reference and educational tool for both orthopaedic surgeons and healthcare professionals managing patients with hip fractures. CPGs recommend accepted approaches to treatment and/or diagnosis and are not intended to be a fixed protocol for treatment or diagnosis. Patient care and treatment should always be based on a clinician’s independent medical judgment, giving the individual patient’s specific clinical circumstances.