The American Academy of Orthopaedic Surgeons (AAOS) has issued updated guidelines for treatment and rehabilitation of elderly patients with hip fractures.
AAOS, the largest not-for-profit education and practice management organization serving orthopedic surgeons and allied health professionals in the world with more than 40, 000 members worldwide, maintains and regularly updates clinical practice guidelines for the treatment and care of various musculoskeletal maladies.
In 2014 AAOS released a Clinical Practice Guideline (CPG) “Management of Hip Fractures in the Elderly, ” which gives a broad overview of care options. Now AAOS has released an Appropriate Use Criteria (AUC) which provides guidance for circumstances when a specific surgical procedure should be applied to hip fractures in the elderly.
The new AUC addressed treatment and rehabilitation of elderly patients with hip fractures in addition to postoperative direction to help prevent fractures from recurring.
Hip Fractures in the Elderly
The economic burden of managing elderly hip fractures is, according to the AAOS, $17-20 billion annually. A typical patient with a hip fracture costs the system about $40, 000 in the first year for direct medical costs and almost $5, 000 in subsequent years.
According to AAOS, between 1986 and 2005 the annual mean number of hip fractures was 957.3 per 100, 000 for women and 414.4 per 100, 000 for men. With aging populations in the U.S., Europe and Japan, the prevalence of hip fractures will continue to rise, if not accelerate.
In the U.S. alone, the number of people older than 65 years of age is expected to increase from 37.1 million to 77.2 million by the year 2040 and the occurrence of hip fractures may well increase to 6.3 million worldwide by 2050 (AAOS information).
“Hip fractures are one of the most feared injuries in older adults because this trauma creates pain and can force a change in lifestyle or limited mobility. We are providing evidence-based assistance for physicians and patients to determine the best course of action for surgery and follow-up care, ” said Robert Quinn, M.D., AUC Section Leader for the AAOS Committee on Evidence-Based Quality and Value.
An analysis of osteoporotic hip fractures published online on September 26, 2011 in the Archives of Internal Medicine pointed at hip fractures as a major cause of increased mortality among elderly patients.
Co-author of the study and senior investigator at the Kaiser Permanente Center for Health Research, Teresa Hillier, M.D., said, “Our study suggests that it is hip fracture, and not just poor health, that puts these women at higher risk of dying.
According to the study’s results, hip fractures occurring in patients between ages of 65 and 69 years created a 5-fold increase in mortality risk within one year of the fracture! Patients 70-79 years old had 10-fold increase in mortality risk within one year of the fracture and patients over than that had a 15-fold increase in mortality risk within one year.
So, these treatment and care guidelines can literally be lifesaving.
Arthroplasty vs. Pinning
When and in which hip fracture patients should a surgeon consider using total hip arthroplasty and when is open reduction and pinning the preferred option?
The AUC guidelines address only patients age 60 or above with fractures caused by low-impact events. The panelists, who were physicians and physical therapists from leading academic medical centers as well as orthopedic and other professional medical societies, reviewed 30 potential patient scenarios to arrive at the panel’s AUC guidelines.
The panel, for example, rated total hip arthroplasty (THR) as “appropriate” for a highly active patient with a non-displaced fracture in the neck of the femur bone. But for the non-ambulatory patient, the panel rated THR as “rarely appropriate.”
The panel also reviewed scenarios where the surgeon reattached bone with a specific type of screw (sliding hip anti-rotation screws) and found that to be “appropriate” for highly active patients with and without arthritis who have a stable fracture of the intertrochanteric crest, located near the top of the femur.
In some cases the AUC review panel did not reach consensus on a single best course of action due to surgeons’ preferences and multiple correct treatments for surgery.
This specific issue was debated at the Current Concepts in Joint Replacement which took place in Las Vegas this past May.
George J. Haidukewych, M.D., Orlando Health Orthopedic Institute, Orlando, Florida, made the point that age is the key determinant when choosing THR or ORIF [open reduction internal fixation] saying: “Whether this patient is under 60 or over 60 should definitely change your management. For patients over age 60 with a displaced femoral neck arthroplasty is clearly the best treatment choice. The failure rate of ORIF in this setting remains over 40% and this is unchanged for the last 70 years.”
“There are prospective level one studies that show clear superiority of total hip over ORIF in the elderly patient and it is even more cost effective than ORIF. Arthroplasty offers a lower reoperation rate, better function, lower cost with the same medical risk.”
“However, in a young patient the best femoral head is your own. You have no activity restrictions. You don’t dislocate, you don’t develop osteolysis, you don’t need cobalt chrome levels and MARS MRIs, you don’t develop infections, and, if God forbid, you need salvage, you’re young and healthy. You could easily tolerate a salvage through total hip arthroplasty.”
“In my opinion, a young, active patient under age 60 should keep his or her own femoral head and ORIF is the best choice. Why? Because you have a high rate of union. You have a documented good survivorship of the femoral head—85% at 10 years.
Dr. Edwin Su Associate Professor of Orthopaedic Surgery, Weill Medical College of Cornell University and surgeon at the Hospital for Special Surgery, New York, New York, who was Dr. Haidukewych’s debating opponent, agreed that age is a key factor in determining whether to choose THR or ORIF saying: “Internal fixation is generally performed for the younger patients or minimally displaced fractures—and I certainly would advocate it for the minimally fracture. It can give them the retention of their own joint, and there are concerns about the longevity of hip arthroplasty in this younger population.”
But, said Dr. Su, THR is a preferred approach for the over-60-year-old patient. “Total hip arthroplasty, I believe, has a lower rate of complications and re-operation. There’s a faster recovery, better pain relief.”
For a transcript and podcast of the CCJR debate titled: Haidukewych v Su: ORIF for Displaced Femoral Neck Fx’s in the <60 Active Patient go to www.ryortho.com.
Hip Fracture Recovery Guidelines and Preoperative Checklist
AAOS also created a “Preoperative Checklist” which it supplied along with the AUC hip fracture guidelines to assist surgeons and allied medical providers in delivering quality care to patients by completing 12 important initiatives.
The checklist included limiting preoperative traction; managing Warfarin, a blood-thinning medication; and discussing the patient’s home environment prior to discharge.
The second AUC, “Appropriate Use Criteria for Postoperative Rehabilitation for Low Energy Hip Fractures in the Elderly, ” included universal recommendations for recovery across elderly patient populations such as:
- Interdisciplinary care to prevent deep vein thrombosis
- Prevention or management of postoperative delirium
- Multi-modal perioperative pain management
- Interdisciplinary management of recovery at rehabilitation and skilled-nursing facilities
- Home care therapy following discharge
- Osteoporosis assessment and management.
Finally, AAOS also supplemented the AUC with a “Perioperative Prevention of Future Fractures Checklist, ” which covered important follow-up measures to reduce patients’ risk for future injuries including a fall prevention program, and supplements and medications to improve bone density.
“It is very important to think ahead to make the right care choices after a fracture is repaired. Not only can this help patients recover, but this also helps prevent fractures from happening again, which is a big problem, ” Dr. Quinn said.
For more information:
Appropriate Use Criteria: http://www.aaos.org/Quality/Appropriate_Use_Criteria_(AUC)/Appropriate_Use_Criteria/?ssopc=1
Clinical Practice Guideline (CPG) “Management of Hip Fractures in the Elderly: http://www.orthoguidelines.org/topic?id=1017
