Published 5/29/2024
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Stephen L. Kates, MD, FAAOS, FAOA
The population of older adults is growing rapidly and staying active as they age. There will be a predictable increase in hip fractures accompanying this demographic shift. This increase in case volume offers practicing orthopaedic surgeons an opportunity to “up their game” in care of hip fractures.
Fortunately, AAOS has a clinically useful and thorough set of Clinical Practice Guidelines (CPGs) and Appropriate Use Criteria on the topic of hip fracture management in older adults, which can be found at OrthoGuidelines. The intention of this article is to emphasize and bring attention to the need to implement these evidence-based guidelines into routine clinical care of hip fracture patients.
A logical beginning for improving the hospital-based care episode is to establish an organized multidisciplinary geriatric hip fracture care program at each hospital. This program consists of mutually agreed upon pathways and standard order sets in the electronic medical record, as well as agreement to prioritize hip fracture care as an urgent surgery to be accomplished within 24 to 48 hours on a medically stable patient.
Such an organized program is essential and yields many benefits, including better outcomes, shortened length of stay, and improved collegiality among the care team. An organized program also allows for a standard approach to analgesia, with a multimodal approach and surgical anesthesia with either a spinal or general anesthetic based on patient needs.
When preparing patients for surgery, it is also critical to have a cohesive team approach to patient preoperative optimization that engages hospital medicine and primary care physicians or geriatricians. Patient preoperative optimization includes managing fluids (usually hydration) and medications (e.g., stopping harmful medications); establishing goals of care; and taking steps to prevent delirium, which has a deleterious effect on patient outcomes during and after hospitalization. An organized program also offers the opportunity to collect data for quality improvement to assess the outcomes of the program itself.
All hip fracture patients should be allowed to bear weight as tolerated after surgery, and the specific surgical procedure chosen should permit this. All procedures should be “single-shot” surgeries, as reoperation is associated with poor patient outcomes. Reoperation can be best avoided by accurate fracture reduction prior to fixation, correct choice of procedure or implant, and gentle handling of the bone and soft tissues during surgery.
Multiple opportunities to standardize surgical interventions are offered by the AAOS CPG on the Management of Hip Fractures in Older Adults. These include the use of a cephalomedullary nail for fixation of most peritrochanteric fractures, especially for fractures with an unstable pattern. Displaced intracapsular femoral neck fractures should be managed with cemented arthroplasty. Additionally, varus
impacted subcapital hip fractures require arthroplasty.
Total hip arthroplasty is a valuable tool for highly functional older adult patients or those with pre-existing arthritis. Hemiarthroplasty should remain the procedure of choice for patients with cognitive impairment and lower functional levels and those who are institutionalized. The specific surgical approach should be the surgeon’s choice and allow for rapid recovery. The use of tranexamic acid during surgery is recommended to reduce blood loss. Postoperatively, the use of anticoagulation is essential to prevent venous thromboembolic events.
Hip fracture is a sentinel event for the diagnosis of osteoporosis. It is also an opportunity to educate the patient and family on the need to prevent a secondary fracture by improving bone health.
Physicians should use this teachable moment to explain the diagnosis of osteoporosis and the fact that a low-energy hip fracture establishes this diagnosis regardless of previous dual-energy X-ray absorptiometry scan results. Physicians should also emphasize the need for treatment to improve bone health and the efficacy of osteoporosis treatment.
Additionally, physicians can refer the patient for treatment to an organized program such as an American Orthopaedic Association’s Own the Bone program or other fracture liaison service. (To read more about the Own the Bone program, see the article “Why Orthopaedic Surgeons Should All ‘Own the Bone’ This May” on page 1). Better yet, physicians can start Own the Bone programs at their centers. Osteoporosis treatment does not diminish fracture healing, so early referral and treatment are essential.
In summary, adherence to the evidence-based CPGs established by AAOS and use of the American Orthopaedic Association’s Own the Bone program after discharge will help orthopaedic surgeons provide the best care for older patients who experience a hip fracture.
Stephen L. Kates, MD, FAAOS, FAOA, is a member of the Own the Bone Steering Committee.