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American Academy of Orthopaedic SurgeonsOrthopaedic Surgery2021advanced

Management of Hip Fractures in Older Adults

Published by American Academy of Orthopaedic Surgeons · GRADE Evidence-to-Decision Framework

16Recommendations
212References
2Tables
1Figures
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Summary

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This guideline offers evidence-based recommendations for the surgical and perioperative management of hip fractures in older adults. It focuses on aspects such as optimal surgical timing, venous thromboembolism prophylaxis, multimodal analgesia, surgical approaches, and the efficacy of interdisciplinary care programs in improving patient outcomes.

hip fractureAAOSorthopaedic surgeryguidelinesrecommendationsarthroplastycephalomedullary devicestranexamic acid

Key Takeaways

  • 1
    Preoperative traction should not routinely be used.
  • 2
    Surgery within 24-48 hours may lead to better outcomes.
  • 3
    VTE prophylaxis should be used for hip fracture patients.
  • 4
    Arthroplasty is recommended over fixation for unstable femoral neck fractures.
  • 5
    Cemented femoral stems should be used in patients undergoing arthroplasty.
  • 6
    Cephalomedullary devices are recommended for subtrochanteric, reverse obliquity, and unstable intertrochanteric fractures.
  • 7
    Tranexamic acid administration reduces blood loss and blood transfusion needs.
  • 8
    Multimodal analgesia with preoperative nerve blocks improves postoperative pain.
  • 9
    Interdisciplinary care programs should be utilized to decrease complications and improve outcomes.

What's New in This Version

This CPG replaces the 1st edition (2014). Key changes include the adoption of the GRADE Evidence-to-Decision Framework, assigning all observational studies a base appraisal of low-quality evidence, updating study appraisal methodology (coinciding with Cochrane, ROBINs, QUADAS, QUIPs), and mandating a sample size of >= 30 per comparison group with an average participant age of at least 65 years.

Key Recommendations

PREOPERATIVE TRACTION

  • 1

    Preoperative traction should not routinely be used for patients with a hip fracture.

    StrongEvidence: HighTreatment

SURGICAL TIMING

  • 2

    Hip fracture surgery within 24-48 hours of admission may be associated with better outcomes.

    ModerateEvidence: LowPerioperative Care

VENOUS THROMBOEMBOLISM PROPHYLAXIS

  • 3

    Venous thromboembolism (VTE) prophylaxis should be used in hip fracture patients.

    StrongEvidence: ModerateProphylaxis

ANESTHESIA

  • 4

    Either spinal or general anesthesia is appropriate for patients with a hip fracture.

    StrongEvidence: HighAnesthesia

UNSTABLE FEMORAL NECK FRACTURES – ARTHROPLASTY VS FIXATION

  • 5

    In patients with unstable (displaced) femoral neck fractures, arthroplasty is recommended over fixation.

    StrongEvidence: HighSurgical Management

UNIPOLAR/BIPOLAR HEMIARTHROPLASTY

  • 6

    In patients with unstable (displaced) femoral neck fractures, unipolar or bipolar hemiarthroplasty can be equally beneficial.

    ModerateEvidence: ModerateSurgical Management

UNSTABLE FEMORAL NECK FRACTURES – TOTAL ARTHROPLASTY vs HEMI ARTHROPLASTY

  • 7

    In properly selected patients with unstable (displaced) femoral neck fractures, there may be a functional benefit to total hip arthroplasty over hemi arthroplasty at the risk of increasing complications.

    ModerateEvidence: HighSurgical Management

CEMENTED FEMORAL STEMS

  • 8

    In patients undergoing arthroplasty for femoral neck fractures, the use of cemented femoral stems is recommended.

    StrongEvidence: HighSurgical Management

SURGICAL APPROACH

  • 9

    In patients undergoing treatment of femoral neck fractures with hip arthroplasty, evidence does not show a favored surgical approach.

    ModerateEvidence: ModerateSurgical Management

CEPHALOMEDULLARY DEVICE – STABLE INTERTROCHANTERIC FRACTURES

  • 10

    In patients with stable intertrochanteric fractures, use of either a sliding hip screw or a cephalomedullary device is recommended.

    StrongEvidence: HighSurgical Management

CEPHALOMEDULLARY DEVICE – SUBTROCHANTERIC/REVERSE OBLIQUITY FRACTURES

  • 11

    In patients with subtrochanteric or reverse obliquity fractures a cephalomedullary device is recommended.

    StrongEvidence: HighSurgical Management

CEPHALOMEDULLARY DEVICE – UNSTABLE INTERTROCHANTERIC FRACTURES

  • 12

    Patients with unstable intertrochanteric fractures should be treated with a cephalomedullary device.

    StrongEvidence: HighSurgical Management

TRANSFUSION

  • 13

    A blood transfusion threshold of no higher than 8g/dl is suggested in asymptomatic postoperative hip fracture patients.

    ModerateEvidence: ModeratePostoperative Care

MULTIMODAL ANALGESIA

  • 14

    Multimodal analgesia incorporating preoperative nerve block is recommended to treat pain after hip fracture.

    StrongEvidence: HighPain Management

TRANEXAMIC ACID

  • 15

    Tranexamic acid should be administered to reduce blood loss and blood transfusion in patients with hip fractures.

    StrongEvidence: HighPerioperative Care

INTERDISCIPLINARY CARE PROGRAMS

  • 16

    Interdisciplinary care programs should be used in the care of hip fracture patients to decrease complications and improve outcomes.

    StrongEvidence: HighCare Pathway

STABLE FEMORAL NECK FRACTURES

  • 17

    In patients with stable (impacted/non-displaced) femoral neck fractures, hemiarthroplasty, internal fixation or non-operative care may be considered.

    LimitedEvidence: ModerateTreatment Option

CEPHALOMEDULLARY DEVICE – PERTROCHANTERIC FRACTURES

  • 18

    In patients with pertrochanteric femur fractures, short or long cephalomedullary nail may be considered.

    LimitedEvidence: LowTreatment Option

WEIGHT BEARING

  • 19

    Following surgical treatment of hip fractures, immediate, full weight bearing to tolerance may be considered.

    LimitedEvidence: LowRehabilitation Option

Scope & Objectives

Clinical Topic

Hip Fractures

Objectives

To evaluate the current best evidence associated with the surgical treatment of hip fractures in older adults and provide recommendations to guide clinical practice.

Target Patient Population

Adults aged 65 years and older (with a lower limit of 55 years) diagnosed with a hip fracture.

Target Providers

Orthopaedic surgeonsAdult primary care physiciansGeriatriciansHospital based adult medicine specialistsPhysical therapistsOccupational therapistsNurse practitionersPhysician assistantsEmergency physicians

Patient Criteria & Setting

Therapeutic Area

Musculoskeletal Care

Guideline Scope

TreatmentSurgical ManagementPerioperative Care

Inclusion Criteria

  • Enrolled patients aged >=50 with a mean age >=65
  • Low-energy proximal femur fractures
  • Sample size >= 30 per group
  • Human studies
  • Published in English
  • Published in or after 2013 (or 1995 for new PICOs)

Exclusion Criteria

  • Acetabular/pelvic fractures
  • Oncological fractures
  • Atypical fractures
  • Periprosthetic fractures
  • High-energy fractures
  • Avascular necrosis
  • Retrospective non-comparative case series
  • Biomechanical or cadaver studies

Care Settings

HospitalsOperating RoomsEmergency DepartmentsInpatient Rehabilitation

Special Populations

Older adultsFrail elderlyNursing home residentsPatients with dementia or cognitive impairment

Evidence Grading

System: GRADE Evidence-to-Decision Framework

Evidence Distribution

3low_quality_count
11high_quality_count
5moderate_quality_count

Evidence Levels

LowEvidence from two or more 'Low' quality studies with consistent findings or evidence from a single 'Moderate' quality study recommending for or against the intervention.
HighEvidence from two or more 'High' quality studies with consistent findings recommending for or against the intervention.
ModerateEvidence from two or more 'Moderate' quality studies with consistent findings, or evidence from a single 'High' quality study recommending for or against the intervention.
Very Low / ConsensusEvidence from one 'Low' quality study, or no supporting evidence.

Recommendation Strength

StrongBased on High quality evidence, or upgraded using the EtD framework.
LimitedBased on Low quality evidence, or downgraded using the EtD framework.
ModerateBased on Moderate quality evidence, or upgraded/downgraded using the EtD framework.
ConsensusBased on Very Low quality evidence or Consensus, or downgraded using the EtD framework. Represents the guideline work group's clinical opinion.

Safety & Contraindications

Contraindications

  • Preoperative traction should not routinely be used.

Monitoring Guidance

A blood transfusion threshold of no higher than 8g/dl is suggested in asymptomatic postoperative hip fracture patients.

Authors & Contributors

Julie SwitzerMD; Mary O'ConnorMD; Daniel MendelsonMD; Thiru M. AnnaswamyMD; Thomas SpiegelMD; Nicholas BrownMD; Brian CulpMD; Zachary LumDO; Laura TosiMD; Michael MilshteynMD; Christine M. McDonoughPhDPT; Jennifer PierceMD; Pauline CamachoMD; Joel M. PostDO; Michael HuoMD; Mark D. NeumanMD

Guideline Features

Flowcharts includedBased on systematic reviewMultidisciplinary

Learning Context

Difficulty

advanced

Exam Relevance

Orthopaedic Surgery Board ExamsGeriatric Medicine Certifications

Learning Paths

Orthopaedic SurgeryGeriatric TraumaHip FractureSurgical ManagementPerioperative CarePain ManagementRehabilitation