Management of Hip Fractures in the Elderly
Endorsed by: OTA, AGS, AAPM&R, ASBMR, USBJI, The Hip Society, AACE, ORA
Advanced Imaging
Moderate evidence supports MRI as the advanced imaging of choice for diagnosis of presumed hip fracture not apparent on initial radiographs.
Moderate Evidence Moderate Evidence
Five low strength studies evaluated the use of MRI to assess for hip fractures in patients with a clinical history consistent with fracture but negative plain films. The included studies demonstrated the ability of MRI to identify fractures, especially in older patients (Chana et al 1). The studies also noted that MRI was able to demonstrate causes of hip pain other than fracture (Harrmati et al2, Kirby et al3, Lim et al 4, and Pandey et al 5).  Only one low strength study (Lee et al 6) was available that evaluated the sensitivity of bone scan in detecting occult hip fractures. Rizzo et al. 7 noted equivalent accuracy when comparing MRI to bone scan in this setting; however, MRI was found to provide a diagnosis earlier (Rizzo et al. 7) than bone scan, with better spatial resolution.  In this study, MRI was obtained within 24 hours of admission and bone scan within 72 hours.  For situations in which MRI is not immediately available, bone scan can be considered (Rizzo et al). 7  In addressing issues of cost and patient discomfort,, three studies showed that a “limited” MRI of the hip could identify occult hip fractures (Lim et al 4, Iwata et al 8, Quinn et al 9); these limited scans were obtained with lower cost and shorter duration that standard MRIs. 

Limited, small studies have examined the use of CT scan in the diagnosis of occult hip fractures.  Due to the quality of existing literature, as well as potential harm with radiation exposure related to use of CT in this setting, this modality was not recommended for evaluation of occult hip fracture.

Risks and Harms of Implementing this Recommendation
There are no specific harms associated with this recommendation.
 
Future Research
Additional research is needed to clarify the role, if any, as well as accuracy and timing, of bone scan in identifying occult hip fractures. Studies are also needed to clarify the role, if any, of CT in this situation, and the relative accuracy and safety of bone scan vs CT vs MRI for the diagnosis of occult hip fractures.  There needs to be further clarification of the technique and relative accuracy of “limited” MRIs in the diagnosis of occult hip fractures.  
 
 
Preoperative Regional Analgesia
Strong evidence supports regional analgesia to improve preoperative pain control in patients with hip fracture.
Strong Evidence Strong Evidence
Six high strength studies (Fletcher et al 10, Foss et al 11, Haddad et al 12, Monzon et al 13, Mouzopoulos et al 14, and Yun et al 15) and one moderate strength study (Matot, 2003 16) showed beneficial outcomes. Six studies inclusive of 593 patients used a prospective randomized clinical trial design to assess the effect of regional analgesia in reducing preoperative pain after hip fracture upon presentation to the emergency department (Fletcher et al 10, Foss et al 11, Haddad et al 12, Monzon et al 13, Mouzopoulos et al, and Yun et al 15).  These studies all used a technique of administration of a local anesthetic that results in temporary loss of nerve function in the fascia iliaca or femoral compartment of the injured hip.  In each study the patients who received this agent reported significant reduction in reported preoperative pain on a visual analog scale.  One of these studies reported improved reported pain at time of administering spinal anesthesia.
 
The administration of regional analgesia in these six studies was performed by a different group of providers in each study including: emergency physicians, anesthesiologists, and orthopaedic surgeons (Fletcher et al 10, Foss et al 11, Haddad et al 12, Monzon et al 13, Mouzopoulos et al 14, and Yun et al 15).  All the providers who were administering the analgesia were trained in performance of the specific technique before the study began.  One study found the technique for this type of regional analgesia administration can be successfully taught to medical providers who were inexperienced in these skills (Fletcher et al 10). 
 
In all of these trials pain recorded with a visual analog score is a reported outcome (Fletcher et al 10, Foss et al 11, Haddad et al 12, Matot, et al 16, Monzon et al 13, Mouzopoulos et al 14, and Yun et al 15).  Reported outcomes in five of the trials were limited to the preoperative episode of care for the studies patients (Fletcher et al 10, Foss et al 11, Haddad et al 12, Monzon et al 13, and Yun et al15). 
 
Two trials reported effects beyond this initial preoperative period.   One trial reported a reduction in the incidence of postoperative delirium in addition to a reduction in preoperative pain levels in the population who received regional analgesia. Incidence of delirium with the regional analgesia group was 11% (11/102) and 24% (25/105) in the control group [relative risk 0.45, 95% CI 0.23-0.87] (Mouzopoulos et al 14).   The seventh study reported the use of epidural anesthesia administered preoperatively in hip fracture patients with known cardiac disease or who were at high risk for cardiac disease was associated with reduction of preoperative myocardial ischemia events; Adverse preoperative cardiac events occurred in 7 of 34 patients in the control group and 0 of 34 patients in the treatment group [p = 0.01] (Matot et al 16).  
 
No complications were reported in these studies using a technique of administration of a numbing agent that results in temporary loss of nerve function in the femoral compartment of the injured hip. However, the consideration of standard risks and benefits of these techniques should be considered when implementing this recommendation.

Risks and Harms of Implementing this Recommendation
Risks are equal to those of any regional anesthesia technique.

Future Research
The studies available to date report improved pain scores preoperatively.  Future research should focus on the impact of early regional analgesic technique on patient outcome.  Several important outcomes need to be studied: assessment of total opioid usage pre- and post-op, incidence of delirium during hospital stay, and length of stay; There may be others.  

 
Preoperative Traction
Moderate evidence does not support routine use of preoperative traction for patients with a hip fracture.
Moderate Evidence Moderate Evidence
Seven moderate strength studies (Anderson et al 17, Finsen et al 18, Needoff et al 19, Resch et al 20, Rosen et al 21, Saygi et al 22, Yip et al 23) compared skin traction to no traction. There was no difference noted between the two groups with regard to decreased pain or decreased doses of analgesia administered. A meta-analysis of the data showed that preoperative traction offered no benefit to hip fracture patients.
 
One high strength study (Resch et al 24) showed no difference in pain alleviation and number of analgesics administered when comparing skeletal traction to skin traction in hip fracture patients. However, half of the patients in the skeletal traction group found the application of skeletal traction to be painful.
 
Risks and Harms of Implementing this Recommendation
There are no known harms of implementing this recommendation.
 
Future Research
Future research regarding preoperative modalities to minimize patient pain should be continued to be investigated.
 
Surgical Timing
Moderate evidence supports that hip fracture surgery within 48 hours of admission is associated with better outcomes.
Moderate Evidence Moderate Evidence
Nine moderate strength studies evaluated patient outcomes in relation to timing of hip fracture surgery (Elliot et al 25, Fox et al 26, McGuire et al 27, Moran et al 28, Novack et al 29, Orosz et al 30, Parker et al 31, Radcliff et al 32, Siegmeth et al 33). In many of these studies the presence of increased comorbidities represented a confounding effect, and therefore delays for medical reasons were often excluded.
 
The majority of studies favored improved outcomes in regards to mortality, pain, complications, or length of stay (Elliot et al 25, McGuire et al 27, Novack et al 29, Orosz et al 30, Parker et al 31, and Siegmeth et al 33). Although several studies showed a benefit of surgery within 48 hours, one study showed no harm with a delay up to four days for patients fit for surgery who were not delayed for medical reasons (Moran et al 28). Patients delayed due to medical reasons had the highest mortality and it is this subset of patients that could potentially benefit the most from earlier surgery.
 
Risks and Harms of Implementing this Recommendation
There are no known harms associated with implementing this recommendation.
 
Future Research
Future research improving controls for bias relating to increased medical severity of patients delayed for surgery is needed to better identify critical timing related issues regarding patient specific populations.
 
Aspirin and Clopidogrel
Limited evidence supports not delaying hip fracture surgery for patients on aspirin and/or clopidogrel.
Limited Evidence Limited Evidence
Six low-strength studies (Chechik et al34; Maheshwari et al 35; Manning et al 36; Thaler et al 37; Hossain et al 38) showed either no difference in outcome or favored not delaying hip fracture surgery in patients on antiplatelet (clopidogrel and/or aspirin) therapy. Previously, some surgeons have delayed surgery for hip fracture patients on Aspirin and / or clopidogrel. This systematic review suggests at worse that there is no advantage to this practice or that in fact the advantage is for patients where surgery is not delayed. The benefit of implementing this recommendation is preventing an unnecessary (unhelpful) delay in performing hip fracture surgery.
 
Risks and Harms of Implementing this Recommendation
As with all surgical procedures, there are potential risks and complications, including, but not limited to, the possibility of bleeding. There is no data suggesting patient outcome harms will occur with implementation of this recommendation.
 
Future Research
Future research with regard to risks and benefits of delayed surgery should include patient oriented outcome measures such as death, return to prior living situation and treatment complications such as transfusions, wound infections and return to operating room. Some of these factors may be addressed with treatment registries. It is also appropriate to address the risks and benefits of delayed surgery for patients on antiplatelet medication specific to this patient population and to quantify risks of those who are on these medicines (e.g. bleeding, transfusions, etc). Appropriately targeted randomized trials would be helpful.
 
Anesthesia
Strong evidence supports similar outcomes for general or spinal anesthesia for patients undergoing hip fracture surgery.
Strong Evidence Strong Evidence
Two high strength (Casati et al39, Davis et al40) and seven moderate strength (De Visme et al 41, Honkonen et al42, Koval et al43, Koval et al44, McKenzie et al45, Sutcliffe et al46, and Valentin et al47) studies compared spinal anesthesia to general anesthesia in patients undergoing hip fracture surgery.
 
Meta-analysis showed no difference in mortality. McKenzie et al 45 demonstrated a decreased mortality rate at two weeks post operatively in the spinal anesthesia group; however, this difference did not persist at two months.  Valentin et al47, Sutcliffe et al 46, Davis et al 40 and Koval et al 43 did not demonstrate a difference in mortality between the two groups. De Visme et al 41 and Casati et al 39 found no differences in postoperative confusion.
 
Casati et al 39, McKenzie et al 45, and Valentin et al47, demonstrated decreased blood loss in those patients receiving spinal anesthesia..  Finally, Koval et al43, Valentin et al47, Sutcliffe et al46, McKenzie et al45, and Casati et al39 all did not demonstrate a difference in hospital length of stay. 
 
The work group recognizes that anesthetic techniques described in several of these articles which were published decades ago may have changed when compared with modern methods.  In addition, there was significant heterogeneity in the patient populations studied, including multiple studies in which patients were not randomized.

Risks and Harms of Implementing this Recommendation
Both general anesthesia and spinal anesthesia carry risks and benefits, which should be assessed on an individual basis. Because both forms of anesthesia appear to have similar mortality profiles, providers can consider specific circumstances that would favor one form or the other for their particular patient.

Future Research
Future research involving appropriately randomized patients may yet delineate which anesthesia technique is more appropriate in this patient population.

 
Stable Femoral Neck Fractures
Moderate evidence supports operative fixation for patients with stable (non-displaced) femoral neck fractures.
Moderate Evidence Moderate Evidence
One high strength article compared operative to nonoperative treatment for non-displaced femoral neck fractures (Cserhati et al48). The major risk factor for non-operative treatment is displacement. It is unclear if this will lead to a more involved treatment such as arthroplasty with higher risks and if the risk- benefit curve favors this approach. There is unique difficulty in determining a truly non-displaced fracture and what patient will benefit from non-operative treatment. Operative treatment typically provides reproducible results with low risk, earlier mobilization and fewer complications.
 
Risks and Harms of Implementing this Recommendation
Higher morbidity, mortality, and longer hospital stays have been shown to be associated with non-operative treatment. The benefit of avoiding surgery and anesthesia was contrasted with a failure rate of approximately 20% in the non-operative treatment group that required surgery.
 
Future Research
Given high failure rates with non-operative treatment, clinical equipoise is lacking, making a study on non-operative treatment of hip fractures unethical. While there are clearly hip fracture patients with end of life issues who may be appropriate for non-operative treatment, surgical fixation may decrease pain, facilitate hygiene and nursing, and improve mobilization for end of life comfort. 
 
Special consideration for end of life issues, risks and limited benefits of surgery and the balancing of surgical goals with patient and family wishes.
 
 
Displaced Femoral Neck Fractures
Strong evidence supports arthroplasty for patients with unstable (displaced) femoral neck fractures.
Strong Evidence Strong Evidence
Six high strength (Davison et al 49, Keating et al 50, Johansson et al 51, Bray et al 52, Frihagen et al 53, and Sikorski et al 54) and 19 moderate-strength studies (Ravikumar et al 55, Rogmark et al 56, Tidermark et al 57, Chammout et al 58, Bacharach-Lindstrom et al 59, Calder et al 60, El-Abed et al 61, Johansson  et al 62, Johansson et al 63, Jonsson et al 64, Mouzopoulos et al 65, Neander et al 66, Parker et al 67, Parker et al 68, Parker et al 69, Roden et al 70, Skinner et al 71, Van Dortmont et al 72,  Waaler Bjornelv et al 73) directly compared arthroplasty (hemi- and/or total hip arthroplasty) to internal fixation for the treatment of unstable/displaced (Garden III and IV) femoral neck fractures in elderly patients. These studies consistently reported better outcomes (reoperation rate, pain scores, functional status, and/or complication rate) for patients in whom internal fixation was avoided as the treatment of choice.  A decreased rate of reoperation among patients treated with arthroplasty was the most consistent finding across the studies. A meta-analysis on patients treated with hemiarthroplasty demonstrated no statistically significant difference in mortality (Figure 4).
 
Risks and Harms of Implementing this Recommendation
The benefit of implementing this recommendation will be the avoidance of reoperations in this frail patient population.  This has implications on cost savings to society.

Future Research
Future studies should help to identify patient populations who may benefit from less invasive treatment.

 
Unipolar versus Bipolar
Moderate evidence supports that the outcomes of unipolar and bipolar hemiarthroplasty for unstable (displaced) femoral neck fractures are similar.
Moderate Evidence Moderate Evidence
One high strength study (Davison et al 49) and seven moderate strength (Raia et al 74, Cornell et al 75, Jeffcote et al 76, Calder et al 60, Calder et al 77, Hedbeck et al 78, Kenzora et al 79) Kenzora studies compared unipolar and bipolar hemiarthroplasty for the treatment of displaced femoral neck fractures.  All of the included studies showed equivalence in functional and radiographic outcomes, suggesting no significant benefit for bipolar articulation over unipolar hemiarthroplasty for displaced femoral neck fracture. A meta-analysis of mortality at six months and one year show no significant differences between unipolar and bipolar hemiarthroplasty.
 
Risks and Harms of Implementing this Recommendation
The majority of the reviewed studies reported that that unipolar heads were acknowledged as being significantly less expensive than the bipolar heads without any accompanying clinical difference recognized. 
There is no apparent harm associated with implementing this recommendation and cost savings represent a direct economic benefit from the preferential use of unipolar articulations.

Future Research
None needed

 
Hemi Versus Total Hip Arthroplasty
Moderate evidence supports a benefit to total hip arthroplasty in properly selected patients with unstable (displaced) femoral neck fractures.
Moderate Evidence Moderate Evidence
One high strength (Keating et al 50) and four moderate strength studies (Blomfeldt et al 80, Hedbeck et al 81, Macaulay et al 82, van den Bekerom et al 83) examined this question.  Though various methodologic issues preclude strong recommendations, the evidence on this question generally demonstrates a benefit to patients who received total hip arthroplasty (Hedbeck et al 81, Macaulay et al 82).  This benefit was largely manifest in lower pain related scores and lower revision rates for acetabular wear.  Mortality rates and infection rates were largely unaffected within the first 4 years after treatment.

However, patient exclusion criteria in some of these studies also reflects the general bias amongst surgeons towards performing total hip arthroplasty in patients who are higher functioning and more likely to be independent community ambulators (Macaulay et al 82). Cautious decision making for lower functioning patients may be justified; studies also demonstrate a higher dislocation rate among total hip arthroplasty patients (van den Bekerom et al 83).

Risks and Harms of Implementing this Recommendation
Implementing this recommendation does not result in additional harm in the patient beyond that conferred by usual surgical risk. The choice of appropriate treatment requires discussion of risk and benefit with patients and families.  This may help determine which patients stand to benefit from the superior pain relief and lower likelihood of revision surgery conferred by total hip arthroplasty, and which patients whose preoperative function does not justify a surgical procedure involving greater risks.

Future Research
Further areas of investigation include whether potential delays in surgery occur when total hip arthroplasty is the chosen treatment, and whether this has an effect on postoperative morbidity. Another important but unanswered question is whether the demand for total hip arthroplasty following fracture can be met by surgeons who currently employ hemiarthroplasty, or if the increasing use of total hip arthroplasty by less experienced surgeons will offset potential benefits seen in previous studies.
 
Cemented Femoral Stems
Moderate evidence supports the preferential use of cemented femoral stems in patients undergoing arthroplasty for femoral neck fractures.
Moderate Evidence Moderate Evidence
Eight moderate strength (Deangelis et al 84, Figved et al 85, Taylor et al 86,Santini et al87, Lennox et al88, Parker et al 89, Sonne-Holm et al 90, Singh et al 91) studies address the question of cemented or press fit arthroplasty in the elderly. Randomized controlled trials have largely failed to demonstrate differences (Deangelis et al 84, Figved et al 85), with the exception of fracture risk, which appears to be higher in press fit stems (Taylor et al 86). This remains an infrequent event in other studies.  In general, both approaches yielded acceptable functional results with low complication rates.

Risks and Harms of Implementing this Recommendation
As with all surgical procedures, there are potential risks and benefits which are unlikely to be affected by this recommendation.

Future Research
Long term studies designed specifically to elucidate potential differences in postoperative fracture risk between cemented or press fit stems are needed.
 
Stable Intertrochanteric Fractures
Moderate evidence supports the use of either a sliding hip screw or a cephalomedullary device in patients with stable intertrochanteric fractures.
Moderate Evidence Moderate Evidence
One high quality (Ahrengart et al94) and two moderate strength (Utrilla et al 95, Varela et al96) studies compared the use of an extramedullary sliding hip screw device with a cephalomedullary device for stable intertrochanteric fractures.  The high strength study compared a cephalomedullary device and sliding hip screw in both stable and unstable intertrochanteric fractures (Ahrengart et al 94).  Subgroup evaluation of the stable fractures favored the use of a sliding hip screw with respect to operative time and blood loss. One moderate strength study (Utrilla et al 95) found no difference in walking ability with either a sliding hip screw or cephalomedullary nail for the stable intertrochanteric fractures. The other moderate strength study (Varela et al96) found no difference in functional outcome, hospital stay, fracture collapse, or mortality between a cephalomedullary nail and an extramedullary sliding hip screw and plate device that offers two points of fixation into the femoral head. 
 
Risks and Harms of Implementing this Recommendation

There are no known harms associated with implementing this recommendation.
 
Future Research
Randomized, prospective trials comparing modern cephalomedullary nails with extramedullary devices in a large cohort of patients with only stable intertrochanteric fractures (OTA 31.A1) should specifically assess functional outcomes, radiographic parameters, complications, and cost. These studies should control for patient demographics as well as quality of fracture reduction and placement of fixation (tip-to-apex distance). The potential difficulty with conversion to total hip arthroplasty for failed fracture treatment also should be considered when comparing fixation methods.
 
Surgical Approach
Moderate evidence supports higher dislocation rates with a posterior approach in the treatment of displaced femoral neck fractures with hip arthroplasty.
Moderate Evidence Moderate Evidence
Two moderate strength articles (Biber et al 92 and Skoldenberg et al93) compared the posterior approach to the direct lateral approach for arthroplasty in femoral neck fracture surgery.   Alternative nomenclature for the posterior approach to the hip identified in the literature includes the Southern, the posterior, the Moore or the dorsal approach.  Similarly, the direct lateral approach can also be called the anterolateral, the transgluteal or more commonly the Modified Hardinge approach.  While neither of the included studies specifically addressed any functional outcomes, they both demonstrated statistically significant differences in dislocation rates, favoring the Modified Hardinge approach.  
 
Risks and Harms of Implementing this Recommendation
There is no inherent harm in either approach or any associated complications other than the primary outcome of dislocation of the prosthesis postoperatively. This information should be considered in the context of both patient and surgeon specific factors when deciding on a surgical approach.
 
Future Research
The existing evidence only compares posterior and lateral approaches and only allows comparison of dislocation as the primary end point.  Future well designed RCTs should include a comparison of the increasingly popular anterior approach with either the posterior and/or the lateral approach.  Any future studies related to surgical approach should also include functional data associated with the approaches.  This may have important implications for patient selection and recovery needs such as assistive devices or therapy needs.
 
 
Subtrochanteric or Reverse Obliquity Fractures
Strong evidence supports using a cephalomedullary device for the treatment of patients with subtrochanteric or reverse obliquity fractures.
Strong Evidence Strong Evidence
There were 3 high (Sadowski et al 97, Zhang et al 98, Schipper et al 99), and 2 moderate strength (Miedel et al 100, Hardy et al 101) studies evaluating the use of cephalomedullary devices in the treatment of unstable intertrochanteric and subtrochanteric fractures. Although many comparative studies have been done, the variability of fracture classification systems and implants used makes interpretation of the literature challenging.  Evaluation of these studies shows an apparent treatment benefit with cephalomedullary devices for unstable peritrochanteric fractures.
 
One high strength study (Sadowski et al 97) that  specifically evaluated reverse oblique and transverse intertrochanteric fractures (OTA 31.A3) found lower failure rates, blood loss, and operating room time in the cephalomedullary nail cohort versus a 95º fixed-angle device with no difference in functional results.  Two high strength comparative studies showed similar results and outcomes between different cephalomedullary devices in unstable fractures (Zhang et al 98, Schipper et al 99).
 
A moderate strength study (Miedel et al 100) demonstrated a lower complication rate with use of a cephalomedullary versus an extramedullary device in treatment of unstable intertrochanteric and subtrochanteric fractures.  Another moderate strength study (Hardy et al 101) showed improved mobility and decreased limb shortening in unstable intertrochanteric fractures treated with a cephalomedullary device versus a sliding hip screw.
 
Risk and Harms of Implementing this Recommendation
There are no known harms associated with implementing this recommendation
 
Future Research
Continued comparative studies between modern cephalomedullary and extramedullary devices in unstable subtrochanteric and reverse obliquity fractures (OTA 31.A3) which control for fracture reduction and implant position (specifically tip-to-apex distance) may further clarify the utility of cephalomedullary devices for this fracture cohort.

 
Unstable Intertrochanteric Fractures
Moderate evidence supports using a cephalomedullary device for the treatment of patients with unstable intertrochanteric fractures.
Moderate Evidence Moderate Evidence
Five moderate (Adams et al 102, Knobe et al 103, Papasimos 2005 104,Utrilla et al 95, Leung et al 105) and one high strength (Verettas et al 106)  studies evaluated the use of cephalomedullary devices in unstable intertrochanteric fractures with a separate lesser trochanteric fragment but no subtrochanteric involvement (OTA 31.A2).   Although many studies have been done, the variability of fracture classification systems and implants used makes interpretation of the literature challenging.    Evaluation of these studies shows moderate strength evidence supporting the treatment benefit of cephalomedullary devices for unstable intertrochanteric fractures.  
 
Two moderate strength studies (Utrilla et al 95; Leung et al 105) recommended a cephalomedullary device over sliding hip screw. Utrilla et al 95 found improved postoperative walking ability and fewer blood transfusions in the cephalomedullary group. Leung et al. 105 showed no difference in mortality or ultimate hip function but did show a shorter convalescence in the cephalomedullary cohort.  A high strength study (Verettas et al 106) found no difference in pain and the systemic physiologic responses (O2 requirement, mental status, hematocrit) between treatment with a either sliding hip screw or a cephalomedullary device for this fracture pattern.  Similarly, a moderate strength study (Knobe et al 103) found similar mortality and functional results between an extramedullary and a cephalomedullary device. Papasimos et al 104 conducted a moderate strength study evaluating treatment with a sliding hip screw and two different cephalomedullary devices showing no difference between devices with respect to ultimate fracture consolidation and a return to pre-fracture level of function.  Adams et al 102 conducted a moderate strength comparative study evaluating a cephalomedullary device to an extramedullary plate and screw including 31.A1, 31.A2 and 31.A3 fractures and found the use of an intramedullary device in the treatment of intertrochanteric femoral fractures is associated with a higher but nonsignificant risk of postoperative complications.  By controlling for TAD, there was found to be no statistical difference in the performance of the implants when looking at fracture stability.
 
Risks and Harms of Implementing this Recommendation
There are no known harms associated with implementing this recommendation
 
Future Research
The current trend for increasing use of cephalomedullary devices in the treatment of intertrochanteric fractures (Yli-Kyyny, Injury 2012; 2008, Jeffery Anglen, JBJS) in the absence of strong supporting evidence as well as the recent concerns regarding increased complication rates with conversion of failed cephalomedullary implants to total hip arthroplasty (Pui et al JOA 2013) warrants caution and further investigation.  High level trials comparing modern cephalomedullary devices with sliding hip screws in a large cohort of patients with intertrochanteric fractures classified as OTA 31.A2 should specifically assess functional outcomes, radiographic outcomes, complications, and cost. These studies should control for patient demographics, quality of fracture reduction, hardware placement (specifically tip-to-apex distance) and the changing experience of practicing surgeons. 
VTE Prophylaxis
Moderate evidence supports use of venous thromboembolism prophylaxis (VTE) in hip fracture patients.
Moderate Evidence Moderate Evidence
One high strength study (PE Prevention Trial Collaborative Group107), three moderate strength studies (Moskovits et al167; Xabregas et al168; Morris et al169), and eight low strength studies (Chatanaphutiet al 108; Sasaki et al109; Sasaki et al110; Checketts et al111; Jorgensen et al112; Lahnborg et al113; Kew et al114; Eskeland et al115) were identified comparing various pharmacological prophylaxis interventions to placebo. One moderate strength study (Stranks et al115) compared mechanical prophylaxis to a group that received no mechanical prophylaxis.  These studies show the risk of DVT/VTE/PE complications is significantly less with VTE prophylaxis than control. Most general complications were not significantly different between treatment groups, with the exception of Lahnborg et al113 which found hematoma complications were higher in pharmacological prophylaxis groups. There was no difference in hospital stay and there is some evidence that mortality is less with prophylaxis.
 
Given the significant established risk factors for VTE present in this patient population including age, presence of hip fracture, major surgery, delays to surgery,  and the potential serious consequences of failure to provide prophylaxis in the hip fracture population,  it is the recommendation of the workgroup that VTE prophylaxis be used
 
Risks and Harms of Implementing this Recommendation
Patients with hip fracture are at high risk for deep venous thrombosis and pulmonary embolism. The consequences of symptomatic VTE are significant and include both increased morbidity and mortality. The harms associated with this recommendation include those associated with VTE prophylaxis, bleeding and thrombotic complications.
 
Future Research
The issue of VTE prophylaxis in patients who have sustained a hip fracture is complex. There are many unanswered questions that have the potential to have a significant impact on clinical outcomes for this patient population. A multi-armed randomized controlled study would be optimal. Such a study would potentially need to evaluate the comparative effectiveness of a multitude of chemical agents, at different dosages, with multiple time points (such as pre and post-op), and include assorted durations of therapy, while utilizing contemporary diagnostic methodologies. Barriers to such a study include the low incidence of the complication implicating a requirement for a substantially large sample size. Furthermore, such a study carries ethical concerns given the potential risks associated with under-treatment. Potentially, well organized patient outcome registries may ultimately help improve our knowledge in this area.

 
Transfusion Threshold
Strong evidence supports a blood transfusion threshold of no higher than 8g/dl in asymptomatic postoperative hip fracture patients.
Strong Evidence Strong Evidence
Two high strength studies (Carson et al 116 and Carson et al 117) support this recommendation. Carson et al 116  (FOCUS trial) is the largest (n=2016) and most robust study to address transfusion threshold in hip fracture patients. FOCUS considered patient-centered and clinically important outcomes in a prospective, randomized, multicenter, controlled trial. This study showed that a restrictive transfusion threshold of hemoglobin 8g/dl in asymptomatic hip fracture patients with cardiovascular disease or risk factors resulted in no significant difference in primary or secondary outcomes at 30 or 60 days including mortality, independent walking ability, residence, other functional outcomes, cardiovascular events, or length of stay. Carson’s 1998 trial 117 was also a high strength study and was the pilot study that led to FOCUS. Symptoms or signs that were considered indicative of anemia appropriate for transfusion were chest pain that was deemed to be cardiac in origin, congestive heart failure, and unexplained tachycardia or hypotension unresponsive to fluid replacement.
 
Risks and Harms of Implementing this Recommendation
Implementation of this recommendation is likely to result in lower transfusion associated complications and cost. There is risk that cognitively impaired patients cannot report symptoms, so special attention to these individuals may be warranted; FOCUS automatically transfused significantly demented patients below hemoglobin 8mg/dl.
 
Future Research
Confirmatory studies by other authors would strengthen evidence. Additional studies could further risk stratify and refine transfusion thresholds in subpopulations.
 
Occupational and Physical Therapy
Moderate evidence supports supervised occupational and physical therapy across the continuum of care, including home, to improve functional outcomes and fall prevention.
Moderate Evidence Moderate Evidence
Two high-strength studies (Ziden et al 118, Crotty et al 119) and five moderate-strength studies (Binder et al 120, Hagsten et al 121, Hagsten et al 122, Tsauo et al 123, Bischoff-Ferrari et al 124) support that rehabilitative therapies delivered across the continuum of care have been shown to be effective in improving functional outcomes in the elderly patient with hip fracture, post-surgery. Binder et al 120 demonstrated a supervised home-based Physical Therapy (PT) program to be superior to conventional care in improving physical functioning and mobility. Hagsten et al’s studies121;122) were moderate strength studies that similarly demonstrated utility of Occupational Therapy (OT) (initiated during hospital stay and continued at home) in improving functional outcomes as measured by Activities of Daily Living (ADL), Instrumental Activities of Daily Living (IADL) and Health-Related Quality of Life (HRQOL).
 
Four studies including one high strength (Ziden et al 118) and three  moderate strength (Tsauo et al 123; Bischoff-Ferrari et al 124; Ziden et al 125) studies establish the beneficial effects of home-based PT on functional outcomes such as physical and social functioning, ADLs, mobility, HRQOL and patient satisfaction. In addition, Bischoff-Ferrari’s et al 119 study showed reduction in falls although Crotty’s study showed no change in fall rates; however, they demonstrated that accelerated discharge to home-based PT improved level of independence and physical functioning at same levels as hospital-based rehabilitation.

Risks and Harms of Implementing These Recommendations
The delivery and implementation of this therapy vary, but the benefits of rehabilitative services are demonstrated in a variety of settings and across the continuum of care. There is no harm associated with implementing this recommendation.

Future Research
Further studies to establish more precise dosages and durations of rehabilitative therapies, as well as to determine the most appropriate settings would be beneficial. Further nutritional research needs to elucidate which type of protein supplementation is most beneficial and should clarify risks associated with malnutrition and benefits of supplementation, especially in diabetic patients.  
 
Intensive Physical Therapy
Strong evidence supports intensive home physical therapy to improve functional outcomes.
Strong Evidence Strong Evidence
Two high strength (Mangione et al 126; Sylliaas et al 127) and two moderate strength (Allegrante et al 128; Ryan et al 129) studies evaluated benefits of intensive exercise training in elderly patients with hip fracture. Studies support that intensive exercise training administered by physical therapy to patients after discharge from hospital care, improves functional outcomes, leg strength and health status. Sylliaas et al127 found that a 3-month leg-muscle strength-training program, performed at 70-80% 1-Repetition Maximum, administered at an outpatient rehabilitation clinic, showed improvement in balance, mobility and instrumental ADLs in home-dwelling hip fracture patients post-surgery. Mangione et al126 found improved leg muscle strength, gait speed, 6-minute walk distance and physical performance scores with intensive leg strengthening exercise training performed by community-dwelling elderly patients, 6-month post hip fracture. Allegrante et al 128 found that high-intensity strength training along with motivational video and peer support, in addition to usual postoperative care, significantly improved SF-36 scores in the role-physical domain functional performance and social functioning. Ryan et al129 found no significant difference in anxiety/depression scores of recently discharged postoperative hip fracture patients, with augmented in-home therapy compared to conventional care.

Risks and Harms of Implementing These Recommendations
The delivery and implementation of this therapy vary, but the benefits of rehabilitative services are demonstrated in a variety of settings and across the continuum of care. There is no harm associated with implementing this recommendation.

Future Research
Further studies to establish more precise dosages and durations of rehabilitative therapies, as well as to determine the most appropriate settings would be beneficial. Further nutritional research needs to elucidate which type of protein supplementation is most beneficial and should clarify risks associated with malnutrition and benefits of supplementation, especially in diabetic patients.  
Nutrition
Moderate evidence supports that nutritional supplementation in patients with underlying deficiency improves functional outcomes and reduces mortality; therefore nutritional status should be assessed.
Moderate Evidence Moderate Evidence
One high strength (Duncan et al)130 and 2 low strength (Eneroth et al)131 and Espaulella et al 132 studies were used to evaluate the relationship between nutritional supplementation and outcomes in elderly patients with hip fractures. These studies report that protein energy malnutrition is an important determinant of outcome in older patients with hip fracture. Use of a dietary assistant decreased death acutely 2.5 times (Duncan et al 130) and at 4 months by half. Duncan et al is the largest randomized control study of nutritional support following hip fracture and the first that includes patients with cognitive impairment (57%). Energy intake in the intervention group (IV x 3d and PO x 7d) provided by supplements (Eneroth et al 131) was optimal in 100% of patients in the intervention group vs. 54% in the control group. Fracture related complication rate was 15% (intervention group) vs. 70% (control group).Greater than 58% of the patients in each group were malnourished on admission. A 20g protein supplement daily with 800mg of calcium did not decrease mortality or increase functional status but significantly decreased complications within the hospital (odds ratio 1.88 in-hospital and overall 1.94 after discharge (Espaulella et al 132).
 
Risks and Harms of Implementing these Recommendations
The delivery and implementation of this therapy vary, but the benefits of rehabilitative services are demonstrated in a variety of settings and across the continuum of care. There is no harm associated with implementing this recommendation.
 
Future Research
Further studies to establish more precise dosages and durations of rehabilitative therapies, as well as to determine the most appropriate settings would be beneficial. Further nutritional research needs to elucidate which type of protein supplementation is most beneficial and should clarify risks associated with malnutrition and benefits of supplementation, especially in diabetic patients.  
 
 
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.
Strong Evidence Strong Evidence
Two high strength (Berggren et al133 and Marcantonio et al 134), and seven moderate strength (Huusko et al 135; Huusko et al 136; Krichbaum et al 137; Shyu et al138-140; Stenvall et al 141), studies found that an interdisciplinary rehabilitative program achieved better functional outcomes and fall prevention in post-surgical hip fracture patients. The most differences were found in the group of patients having mild to moderate dementia (Huusko et al 135; and Shyu et al 138-140).

The elements of the interdisciplinary rehabilitative programs varied minimally in the studies reviewed. For example, Shyu et al’s study140 included geriatric consultation, rehabilitative services, discharge planning and post-hospital services, while Berggren et al’s 133 study included geriatric assessment, rehabilitation and active detection, prevention and treatment of fall risk factors.

Risks and Harms of Implementing these Recommendations
The delivery and implementation of this therapy vary, but the benefits of rehabilitative services are demonstrated in a variety of settings and across the continuum of care. There is no harm associated with implementing this recommendation.
 
Future Research
Further studies to establish more precise dosages and durations of rehabilitative therapies, as well as to determine the most appropriate settings would be beneficial. Further nutritional research needs to elucidate which type of protein supplementation is most beneficial and should clarify risks associated with malnutrition and benefits of supplementation, especially in diabetic patients.  
Postoperative MultiModal Analgesia
Strong evidence supports multimodal pain management after hip fracture surgery.
Strong Evidence Strong Evidence
Five high strength (Mouzopoulos et al 14, Matot et al  16, Lamb et al  142, Kang et al  143, Gorodetskyi et al 144) and five moderate strength (Bech et al 145, Foss et al 146, Ogilvie-Harris et al 147, Spansberg et al 148, Tuncer et al 149) studies support this recommendation. Neurostimulation, local anesthetics, regional anesthetics, epidural anesthetics, relaxation, combination techniques, and pain protocols have been shown to reduce pain as well as improve satisfaction, improve function, reduce complications, reduce nausea and vomiting, reduce delirium, decrease cardiovascular events, and reduce opiate utilization. There are a large variety of techniques that result in modest but significant positive improvements in many clinical and patient-centered domains with minimal significant adverse outcomes noted. While no particular technique is recommended, using an array of pain management modalities is appropriate.
 
Risks and Harms of Implementing this Recommendation
Potential risks include medication risks and those associated with the particular procedures or techniques.
 
Future Research
Further study is necessary to define which modalities offer the most benefit at the lowest cost and risk. Further study is necessary to determine which combinations offer the most synergy. Additional study is necessary to determine if any particular modality improves functional and system outcomes as well as pain and satisfaction.
 
Calcium and Vitamin D
Moderate evidence supports use of supplemental vitamin D and calcium in patients following hip fracture surgery.
Moderate Evidence Moderate Evidence
Four moderate strength studies (Bischoff-Ferrari et al 150, Prince et al151, Harwood et al152, and Chapuy et al153) show benefits of either supplemental calcium, vitamin D or both to reduce fall risk and prevent fractures in the elderly.   There is a high prevalence of vitamin D deficiency among hip fracture patients (Bischoff-Ferrari et al150) and hip fracture patients have a 5-10x increased risk of a second hip fracture and other fragility fractures (Harwood et al152).  In a moderate strength double-blinded study in elderly women with hip fractures  (Bischoff-Ferrari et al), 98% of patients were found to be vitamin D deficient (<30 ng/ml) and hospital readmission rates were decreased by 39% in patients treated with daily supplementation of 2000 IU versus 800 IU vitamin D.  In a moderate strength randomized clinical trial in 3,270 elderly women, Chapuy et al153 showed that supplemental calcium and 800 IU vitamin D reduced the risk of hip fractures by 43% and non-spine fractures by 32% over 18 months.  Another moderate strength 5 year double-blind placebo-controlled study (Prince et al151) showed a reduction in fractures in the elderly population with supplemental calcium carbonate (1200mg/d), but the results were limited due to poor long term compliance.  A randomized controlled trial of hip fracture patients (Harwood et al152) showed vitamin D supplementation either orally or by injection increased bone mineral density and reduced the incidence of falls, with calcium co-supplementation having a positive effect.
 
Risks and Harms of Implementing this Recommendation
Calcium and vitamin D supplements are generally safe with few side effects. Some studies show that supplemental calcium in adults aged 65 or older is associated with an increased risk of constipation or nephrolithiasis. 

Future Research
Further placebo controlled randomized clinical trials controlling for non-compliance are needed to clarify benefits and risks of calcium and vitamin D supplementation in patients 65 and older, as well as to identify target levels to achieve optimal benefits as there appears to be a dose dependent relationship in outcomes.  Measurement of the serum calcium, albumin, 25-hydoxyvitamin D, and creatinine levels may reveal secondary causes of osteoporosis (e.g. hyperparathyroidism, malignancy, vitamin D  deficiency or chronic kidney disease) and could guide use of calcium, vitamin D, or nutritional supplements which may improve outcomes.
 
Screening
Limited evidence supports preoperative assessment of serum levels of albumin and creatinine for risk assessment of hip fracture patients.
Limited Evidence Limited Evidence
There was one moderate strength (Mosfeldt el al156) and four low strength prognostic studies assessing the effect of albumin levels on patient outcomes after hip fracture surgey (Burness et al154, Forminga et al155, Ozturk et al157 and Lieberman et al158). Low albumin levels had a statistically significant positive correlation with mortality in three studies (Burness et al154, Mosfeldt et al156, Ozturk et al157). Lieberman et al found that a 1 g/DL increase in serum albumin at discharge was associated with an 8.4% improvement on the Functional Independence Measure after rehabiliatation was complete. Finally, Forminga et al155 found that low albumin levels were associated with a higher risk of nosocomial infection and pressure ulcers. 

Three low strength prognostic studies assessed the effect of patient creatinine levels on outcomes after hip fracture surgery (Talsnes et al159, Bjorkelund et al160, Mosfeldt et al156). Talsnes et al159 found elevated creatinine levels on the 1 post-op day significantly increased the odds of mortality, but pre-op levels and day 4 post-op levels were not significant predictors of death. Finally Bjorkelund et al160 did not find creatinine levels of > 100 g/L to be signicantly associated with post-op confusion, in-hospital complications or length of hospitals stay beyond 10 days. 

Risks and Harms of Implementing this Recommendation
There are no risks associated with this recommendation. 

Future Research
Further studies are needed to evaluate the importance of pre-op assessment to risk stratify and optimize elderly patients with hip fractures. Measurement of the serum calcium, albumin, 25-hydoxyvitamin D, and creatinine levels may reveal secondary causes of osteoporosis (e.g. hyperparathyroidism, malignancy, vitamin D deficiency or chronic kidney disease) and could guide use of calcium, vitamin D, or nutritional supplements which may improve outcomes. 

 
Osteoporosis Evaluation and Treatment
Moderate evidence supports that patients be evaluated and treated for osteoporosis after sustaining a hip fracture.
Moderate Evidence Moderate Evidence
There were two moderate strength studies (Lyles et al161 and Majumdar et al162) and one low strength studies (Gardner et al163) that support this recommendation. Lyles et al161 studied the effectiveness of zoledronic acid versus placebo combined with pre-treatment vitamin D repletion and found that the treatment group exhibited statistically significant reductions in mortality rates, rates of any new fractures, rates of new non-vertebral fractures, or the rates of new vertebral fractures.All participants who had very low 25-hydroxyvitamin D levels or no blood level available  received 50,000 to 125,000 units of vitamin D2 or D3 (orally or intramuscularly) 14 days before the treatment intervention.  All participants then received supplemental calcium and vitamin D daily. Majumdar et al162 was upgraded from a low strength study to a moderate strength study due to a large effect size. Majumdar, et al studied the effectiveness of an osteoporosis case manager for post-discharge hip fracture care.  In this study, those patients who received the intervention had increased chance of osteoporosis evaluation by bone mineral density testing and osteoporosis-specific treatment with bisphosphonates. The Gardner et al163study found no significant differences in mortality or osteoporosis addressed with bone density scan and/or bisphosphonate therapy between the group who received a discussion regarding osteoporosis risks post-surgery and the group who received a fall prevention pamphlet. Hip fractures are a sign (symptom) of osteoporosis, but most patients with hip fractures are not currently evaluated and treated for their underlying osteoporosis.
  
 
Risks and Harms of Implementing this Recommendation
A hip fracture is a sign of osteoporosis, but most patients with hip fractures are not currently evaluated and treated for their underlying osteoporosis. Patients who have fractured a hip are at high risk for subsequent fracture and increased mortality. There are very effective osteoporosis therapies that lower the risk of fractures. There are potential benefits for identification of secondary causes of osteoporosis with no known harm associated with this osteoporosis evaluation. There is the potential for “atypical femur fractures” that may be associated with prolonged bisphosphonate therapy. All medications including osteoporosis therapies have potential harms.
 
Future Research
Cost-effectiveness research on use of a fracture liaison service in open health care systems would be helpful for evaluation and treatment of osteoporosis and to test whether a fracture liaison service reduces the risk of hip fracture readmission rates after a hip fracture.  Further investigations of the long term patient specific outcomes of bisphosphonate therapies are also appropriate, including assessment of alternative osteoporosis treatments. In addition, the relative roles of the orthopaedic surgeon and the patient's primary care provider in evaluating and treating low bone mass after hip fracture, and how these compare to the use of a fracture liaison service, should be studied.

 
Long Cephalomedullary Nails
The following companion consensus statement was developed by panels nominated by the Orthopaedic Trauma Association (OTA) and has been approved by the Orthopaedic Trauma Association's Board of Directors. In the absence of reliable evidence, OTA recommends that long cephalomedullary nails be used for subtrochanteric and reverse obliquity fractures.
Consensus Consensus
N/A
Negative Plain Films and Exam
The following companion consensus statement was developed by panels nominated by the Orthopaedic Trauma Association (OTA) and has been approved by the Orthopaedic Trauma Association's Board of Directors. In the absence of reliable evidence, OTA recommends that patients with a negative physical examination and negative plain films should be evaluated for other causes of symptoms.
Consensus Consensus
N/A
Initial Patient Evaluation
The following companion consensus statement was developed by panels nominated by the Orthopaedic Trauma Association (OTA) and has been approved by the Orthopaedic Trauma Association's Board of Directors. In the absence of reliable evidence, OTA recommends that patients with a presumed hip fracture be initially evaluated with radiographs to include an AP of the pelvis and hip and a cross table lateral of the hip.
Consensus Consensus
N/A

ACKNOWLEDGEMENTS

Guideline Work Group:
W. Timothy Brox, MD, Chair
Karl C. Roberts, MD, Vice-Chair
Sudeep Taksali, MD
Douglas G. Wright, MD
John J. Wixted, MD
Creighton C. Tubb, MD
Joshua C. Patt, MD
Kimberly J. Templeton, MD
Eitan Dickman, MD
Robert A. Adler MD
William B. Macaulay, MD
James M. Jackman, DO
Thiru Annaswamy, MD
Alan M. Adelman MD, MS
Catherine G. Hawthorne MD
Steven A. Olson, MD
Daniel Ari Mendelson, MD
Meryl S. LeBoff, MD
Pauline A. Camacho, MD, MACE

AAOS Guidelines Oversight Chair:
David Jevsevar, MD, MBA

AAOS Clinical Practice Guidelines Section Leader:
Kevin Shea, MD

AAOS Council on Research and Quality Chair:
Kevin J. Bozic, MD, MBA

 
Additional Contributing Members:
C. Conrad Johnston, MD
Frederick E. Sieber, MD
 
AAOS Staff:
William Shaffer, MD, AAOS Medical Director
Deborah Cummins, PhD, Director of Research and Scientific Affairs
Jayson N. Murray, MA, Manager, Clinical Practice Guidelines
Peter Shores, MPH, Statistician
Patrick Donnelly, MA, Lead Research Analyst
Anne Woznica, MLS, Medical Librarian
Yasseline Martinez, Administrative Coordinator
Kaitlyn Sevarino, Evidence-Based Quality and Value Coordinator
 
Former Staff:
Leeaht Gross, MPH
Catherine Boone
 

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