Appropriate Use Criteria: Postoperative Rehabilitation of Low Energy Hip Fractures in the Elderly

The American Academy of Orthopaedic Surgeons (AAOS) approved the Appropriate Use Criteria (AUC) document Postoperative Rehabilitation of Low Energy Hip Fractures in the Elderly in an effort to assist the clinician in caring for these injuries. Here, we present a clinical scenario and a postoperative rehabilitation treatment option to demonstrate how these AUC can be incorporated into clinical decision making. History A 62-year-old man presented to the emergency department after experiencing a fall. He was living at home and tripped and fell, sustaining an injury to the right hip. He has a history of coronary artery disease, myocardial infarction with prior stenting, hypertension and hyperlipidemia, and stroke with residual dysarthria. He also had a fracture of the left hip that was treated in 2010. His presurgical functional status was ambulatory at home. Patient Assessment and Treatment The patient was transferred from another hospital for care, and on admission to the emergency department, he was found to have a displaced femoral neck fracture of the right hip (Figure 1). Metabolic bone workup demonstrated a serum calcium level of 8.3 mg/dL, a 25-hydroxy vitamin D level of 18.4 ng/mL, and an intact parathyroid hormone level of 113.2 pg/mL. Vitamin D supplementation was started preoperatively.Figure 1: A, Preoperative AP radiograph of the pelvis demonstrating a displaced right femoral neck fracture and a prior left femoral shaft fracture treated with intramedullary nailing. B, Preoperative AP radiograph of the right hip demonstrating the displaced femoral neck fracture.The patient was seen and assessed by the internal medicine team for preoperative risk assessment. He was felt to be a satisfactory surgical candidate. On the day after admission, the patient underwent total hip arthroplasty using an anterior approach. Rehabilitation After surgery, the patient underwent occupational and physical therapy. On postoperative day 5, the patient was discharged home and began outpatient rehabilitation, including occupational and physical therapy. At 3 months postoperatively, he noted no pain, walked using a cane, and was taking calcium and vitamin D supplements. Radiography showed satisfactory implant position (Figure 2). He did not experience any perioperative adverse events.Figure 2: Postoperative AP radiographs of the pelvis (A) and the right hip (B) demonstrating a satisfactory result after right total hip arthroplasty. C, Postoperative lateral radiograph of the right hip demonstrating satisfactory implant position.Discussion This case best reflects Scenario 31 of the American Academy of Orthopaedic Surgeons AUC for the Postoperative Rehabilitation of Low Energy Hip Fractures in the Elderly1 (Table 1). In this case, hip fracture fixation was achieved with a total hip arthroplasty using an anterior approach. This patient was high functioning before the injury; discharge to home with instructions to continue outpatient physical and occupational therapy was the appropriate rehabilitation choice. Assessment for and management of osteoporosis were performed, and initial treatment with calcium and vitamin D supplementation was begun to correct the significant vitamin D deficiency diagnosed preoperatively.