Laurie Barclay, MD
The American Academy of Orthopaedic Surgeons issued a new, evidence-based Clinical Practice Guideline (CPG) on hip fracture diagnosis and treatment in patients aged 65 years and older. This CPG, published online September 5, includes a strong recommendation for preoperative regional analgesia to achieve pain control without increasing the risk for delirium, which is not currently the standard of care in all hospital settings.
“The more you can reduce the incidence of delirium, the faster and more effectively the patient will recover,” CPG chair W. Timothy Brox, MD, said in a news release.
Many elderly patients with hip fracture develop delirium, or acute confusion, which increases their risk for nursing home care and mortality, and reduces the likelihood they will resume their preinjury level of function. Therefore, many of the new recommendations aim to prevent or decrease delirium.
According to CPG vice chair Karl Roberts, MD, hip fractures present “a global health care challenge, as the occurrence of hip fractures is increasing related to the aging of the population and current prevalence of osteoporosis.” In the elderly, hip fractures often follow low-energy trauma and are linked to osteoporosis, low bone mass, and other medical conditions that may increase the likelihood of falls. In 1996, the estimated number of hip fractures in the United States was 340,000, mostly among women older than 65 years. Annual worldwide incidence was approximately 1.7 million.
The recommendations are intended as an educational and decision-making tool to enhance clinical judgment while considering patient preferences and values. Other organizations endorsing this CPG are the US Bone and Joint Initiative, the Orthopaedic Trauma Association, the American Association of Clinical Endocrinologists, and the Hip Society.
Specific CPG recommendations include the following:
- preoperative regional analgesia to reduce pain in patients with hip fracture;
- hip fracture surgery within 48 hours of hospital admission;
- intensive physical therapy after hospital discharge to improve functional outcomes;
- osteoporosis workup after hip fracture, with vitamin D and calcium supplementation as needed;
- use of a cephalomedullary device for subtrochanteric or reverse obliquity fracture;
- blood transfusion threshold no higher than 8 g/dL in asymptomatic postoperative hip fracture patients;
- use of an interdisciplinary care program in patients with mild to moderate dementia to improve functional outcomes; and
- multimodal pain management after hip fracture surgery.
All CPG authors or contributors filed a disclosure statement and provided full disclosure of potential conflicts of interest before voting on the CPG recommendations. This CPG was funded exclusively by the American Academy of Orthopaedic Surgeons.
Evidence-Based Clinical Practice Guideline. American Academy of Orthopaedic Surgeons. Published online September 5, 2014. Full text