AAOS Management of Hip Fractures in Older Adults Evidence-based Clinical Practice Guideline

Case 1 While finding her way to the bathroom during the night, an 88-year-old woman tripped on a throw rug. She noted pain in her right hip and an inability to ambulate. Her husband called 911, and she was transported by ambulance to the emergency department (ED). While in the ED, she was noted to have a shortened and externally rotated right lower extremity. She had a palpable dorsalis pedis pulse, and her lower extremity sensation was intact to light touch. An AP pelvis and lateral right hip radiograph demonstrated a displaced femoral neck fracture (garden IV) (Figure 1). The patient had mild cognitive decline and lived at home with her spouse. She had a history of hypertension and hyperlipidemia. Although she used a cane or walker when she was out of the house, she mostly moved around her home without the assistance of either.Figure 1: AP radiograph showing the left hip of case 1 demonstrating a garden IV displaced femoral neck fracture.All values on the basic metabolic panel were within normal limits, and her hemoglobin (Hb) was 11.3 g/dL. In alignment with the Hip Fracture Clinical Practice Guidelines (CPG) regarding the benefit of interdisciplinary care, a hospitalist who was a member of the orthogeriatrics team saw the patient in the ED and cleared her for surgery (strong strength of evidence, strong strength recommendation: to decrease complication and improve outcomes, interdisciplinary care should be provided to hip fracture patients). In keeping with the Hip Fracture CPG recommendations, the patient was taken to the operating room (OR) the morning after admission (limited strength of evidence, moderate strength recommendation: time to OR between 24 and 48 hours after admission). The patient underwent a hemiarthroplasty through an anterolateral approach (strong strength evidence, strong strength recommendation: arthroplasty for displaced femoral neck fracture/moderate recommendation; moderate strength of evidence, moderate strength recommendation: no preferred hip arthroplasty approach). She underwent spinal anesthesia (strong strength of evidence, strong strength recommendation: either spinal or general anesthesia is appropriate for hip fracture patients). The femoral stem was cemented (strong strength of evidence, strong strength recommendation: use of cemented femoral stem is recommended), and a unipolar femoral head was used (moderate strength of evidence, moderate strength recommendation: unipolar or bipolar hemiarthroplasty may be equally beneficial) (Figure 2). In an effort to decrease bleeding and to decrease the need for transfusion, tranexamic acid (TXA) was administered at the start of the case (strong level of evidence, strong strength recommendation: tranexamic acid should be given to reduce blood loss and need for transfusion).Figure 2: AP radiograph showing the left hip of case 1 status post cemented unipolar hemiarthroplasty.The patient did well postoperatively. Her Hb on postoperative day 1 was 10.0 g/dL. The patient had vitamin D, calcium, and parathyroid hormone levels drawn while in the hospital. An outpatient dual energy X-ray absorptiometry (DEXA) scan was ordered, and she was referred to the Orthopaedics Bone Health Clinic for osteoporosis evaluation and treatment.1 The patient was allowed to weightbear as tolerated and was prescribed enoxaparin for venous thromboembolism (VTE) prophylaxis. Case 2 An 80-year-old woman slipped on ice and fell outside her home. When the woman could not walk and noted significant pain in her right hip, a neighbor found her, and an ambulance was called. She was brought to the ED where an AP pelvis and lateral right hip radiographs were obtained. These demonstrated a comminuted intertrochanteric hip fracture (Figure 3, A and B). She was seen by the hospitalist service and cleared for surgery. While in the ED, as part of a multimodal pain mitigation approach, she underwent an iliofascial block (strong strength of evidence, strong strength recommendation: multimodal analgesia including peripheral block is recommended). With the exception of a Hb of 10.5 g/dL and a glucose of 124 mg/dL, her laboratory values were normal. Although she had notable fracture displacement, her hip was cradled in two pillows, in a position of relative comfort, and no traction was used preoperatively (strong strength of evidence, strong strength recommendation: preoperative traction should not be used for hip fracture patients).Figure 3: AP (A) and lateral (B) radiographs for case 2 demonstrating a comminuted unstable intertrochanteric fracture of the right hip.The patient was taken to the OR later in the afternoon of the day of her admission. Spinal anesthesia was provided. Given the instability of the fracture and its comminuted intertrochanteric nature, she underwent closed reduction and cephalomedullary nail fixation with a long nail (strong strength of evidence, strong strength recommendation: unstable intertrochanteric, subtrochanteric, and reverse obliquity fractures should be treated with cephalomedullary nail fixation; limited strength of evidence, limited strength option options are formed when there is little or no evidence on a topic: short or long cephalomedullary nail may be used) (Figure 4, A–D).Figure 4: AP (A and C) and lateral (B and D) radiographs of the femur demonstrating right hip intertrochanteric fracture for case 2 after undergoing intramedullary nailing with a long cephalomedullary nail.Postoperatively, she was allowed to weightbear as tolerated (limited strength of evidence, limited strength option: immediate, full weight bearing to tolerance after surgery). Postoperatively, she was anemic with a Hb of 7.9 g/dL and symptoms of fatigue and mild hypotension. Therefore, and per Hip Fracture CPG, she underwent transfusion with one unit of packed red blood cells, which brought her Hb up to 9.9 g/dL (moderate strength of evidence, moderate strength recommendation: blood transfusion threshold no higher than 8 g/dL in postoperative, asymptomatic hip fracture patients).2 For VTE prophylaxis, sequential compression devices were used while the patient was in the hospital and Lovenox was administered for 4 weeks postoperatively (moderate strength of evidence, strong strength recommendation: VTE prophylaxis should be used in hip fracture patients). Case 3 A 62-year-old woman with rheumatoid arthritis, treated in the past with prednisone and now on methotrexate, fell and experienced left hip and groin pain. She was unable to walk without pain. She presented to urgent care for evaluation. On examination, the patient reported of new-onset—after the fall—left groin pain. Her discomfort increased with internal and external rotation of that hip. Radiographs of the pelvis and left hip, obtained that day, did not demonstrate a fracture or other abnormality. She was sent home with instruction to use crutches and weightbear as tolerated. She was also advised to return for care and re-evaluation if her discomfort did not abate. Over the ensuing 2 days, her discomfort worsened. She returned to urgent care for re-evaluation. Her examination was unchanged. Although radiographs were not repeated, a left hip MRI scan was obtained. The MRI scan demonstrated a mildly displaced basicervical femoral neck fracture (Figure 5). Given this finding, the patient was admitted to a nearby hospital in anticipation of undergoing open reduction and internal fixation of the fracture.Figure 5: Radiograph showing MRI of the right hip for case 3 demonstrating a slightly displaced basicervical femoral neck fracture after initial negative plain radiographs.The day after admission, under spinal anesthetic, the patient underwent open reduction and internal fixation of her stable femoral neck fracture with a sliding dynamic hip screw3 (moderate strength of evidence, limited strength option: internal fixation, arthroplasty, or nonsurgical care may be considered in stable femoral neck fractures) (Figure 6, A and B). Postoperatively, she was allowed to be weight bearing as tolerated (limited strength of evidence, limited strength option: immediate, full weight bearing to tolerance after surgery). Venous thromboembolism prophylaxis for 1 month was provided, and referral to a Orthopedics Bone Health Clinic for osteoporosis evaluation and treatment was made (strong strength of evidence, strong strength recommendation: VTE prophylaxis should be used in hip fracture patients).Figure 6: Radiographs showing AP (A) and lateral (B) intraoperative fluoroscopic imaging demonstrating the right hip of case 3 immediately after undergoing open reduction and internal fixation with a sliding dynamic hip screw.Case 4 A 71-year-old man who worked as a realtor and lived independently fell while showing clients a home. Secondary to left hip pain, he was unable to get up and an ambulance was called. He was brought to a nearby ED where radiographs were obtained. An AP pelvis and lateral left hip radiograph was obtained. This demonstrated a displaced left femoral neck fracture with mild left hip arthritis (Figure 7). During the history and physical examination obtained in the ED, it was noted that the patient had a history of type 2 diabetes, chronic kidney disease, atrial fibrillation, and hypertension. He was on an oral hypoglycemic for his diabetes and apixaban for his atrial fibrillation. Also obtained in the ED were laboratory test results and an ECG. Laboratory values from a basic metabolic panel were normal with the exception of a creatinine of 1.42 mg/dL and a glucose of 201 mg/dL. Hb was 13.3 g/dL.Figure 7: AP radiograph demonstrating an affected displaced femoral neck fracture and mild osteoarthritis of the right hip of case 4.Despite his comorbidities, the patient was quite independent. He drove, was employed, and could walk, without the use of an assistive device, several blocks. He reported of mild left hip pain before his fall and, in the past year, had been diagnosed with mild left hip osteoarthritis. The patient was seen on the floor by a hospitalist affiliated with the orthogeriatric team and deemed optimized for surgery (strong strength of evidence, strong strength recommendation: to decrease complication and improve outcomes, interdisciplinary care should be provided to hip fracture patients). Given the patient's age, comorbidities, level of function, and underlying osteoarthritis in his left hip, a decision was made, with the patient, to proceed with total hip arthroplasty (THA) for treatment of his displaced left femoral neck fracture (strong strength of evidence, moderate level recommendation: in properly selected patients, there may be a functional benefit to THA over hemiarthroplasty at the risk of increasing complications). While under general endotracheal anesthesia, the patient underwent THA (strong level of evidence, strong strength recommendation: either spinal or general anesthesia is appropriate for hip fracture patients) (Figure 8). The procedure was conducted through a posterior approach (moderate level of evidence, moderate strength recommendation: no preferred hip arthroplasty approach). Note that the femoral implant was noncemented in this patient, which is not aligned with these updated guidelines which strongly supports the use of cemented stems in hip fracture patients. For VTE prophylaxis and for his atrial fibrillation, apixaban was restarted on postoperative day 2.Figure 8: AP radiograph of the right hip of case 4 status post total hip arthroplasty with a notably noncemented femoral implant.