AAOS Updates Clinical Practice Guideline for Management of Hip Fractures in Older Adults

ROSEMONT, Ill. (December 15, 2021)—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.

“Hip fractures are a very serious public health issue, specifically for our seniors,” said Mary O’Connor, MD, FAAOS, co-chair of the clinical practice guideline development group. “For this patient population, a hip fracture can become a life-altering event that requires surgery and may result in a decreased quality of life, increased morbidities and a higher rate of mortality within one year after surgery. Due to the increased prevalence of hip fractures in older U.S. adults, I commend the AAOS for recognizing the importance of funding this CPG to update guidance based on the latest research and best available evidence to improve patient care.”

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.

“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,” added Dr. O’Connor.

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.

“These two recommendations go hand in hand,” said Julie Switzer, MD, FAAOS, 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 24-48 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.”

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.
 
The full Clinical Practice Guideline for Management of Hip Fractures in Older Adults is intended for reference by orthopaedic surgeons and other physicians, and available through AAOS’ OrthoGuidelines website and free mobile app. For more information on the development process for AAOS clinical practice guidelines, please view the Clinical Practice Guideline Methodology.

About the AAOS
With more than 39,000 members, the American Academy of Orthopaedic Surgeons is the world’s largest medical association of musculoskeletal specialists. The AAOS is the trusted leader in advancing musculoskeletal health. It provides the highest quality, most comprehensive education to help orthopaedic surgeons and allied health professionals at every career level best treat patients in their daily practices. The AAOS is the source for information on bone and joint conditions, treatments, and related musculoskeletal health care issues and it leads the health care discussion on advancing quality.

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