AAOS Recommends Specific Treatment, Rehabilitation for Elderly Hip Fracture Patients

The American Academy of Orthopaedic Surgeons (AAOS) Board of Directors recently approved Appropriate Use Criteria (AUC) for treatment and rehabilitation of elderly patients with hip fractures, in addition to postoperative direction to help prevent fractures from recurring.

A common fracture in older adults, hip fractures often occur due to falls or slips because bones are fragile.

“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.

Pinning bones back together using surgical screws versus reconstructing the hip joint through total hip replacement (THR) surgery has long been debated. The AUC criteria rely on peer-reviewed studies and practices to recommend different procedures depending on a patient’s individual indications such as activity levels, bone and joint health, location(s) of the fracture, and whether the break is stable or displaced. The AUC addresses patients age 60 and above with fractures caused by low-impact events.

The AUC panel included physicians and physical therapists from leading academic medical centers, in addition to orthopedic and other professional medical societies, who reviewed 30 potential patient scenarios to create the “Appropriate Use Criteria for the Treatment of Hip Fractures in the Elderly.” Each treatment in each patient scenario is rated “appropriate,” “may be appropriate,” and “rarely appropriate.”

For example, THR is rated “appropriate” for a highly active patient with a non-displaced fracture in the neck of the femur bone. However, the same procedure is “rarely appropriate” for a non-ambulatory patient.

Another example rates reattaching bone with a specific type of screw (sliding hip anti-rotation screws) as “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.

Quinn added that 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.

Accompanying the AUC, the AAOS created a “Preoperative Checklist” to assist surgeons and allied medical providers in delivering quality care to patients by completing 12 important initiatives. They include 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,” provides universal recommendations for recovery across elderly patient populations including:

• 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; and
• Osteoporosis assessment and management.

Supplementing the AUC, a “Perioperative Prevention of Future Fractures Checklist,” emphasizes important follow-up measures to reduce patients’ risk for future injuries. Participation in a fall prevention program, and supplements and medications to improve bone density are among the recommendations.

“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,” Quinn said.

AAOS created the AUCs following the 2014 release of the Clinical Practice Guideline (CPG) “Management of Hip Fractures in the Elderly,” which gives a broad overview of care options. In contrast, the AUC provides guidance for circumstances when a specific surgical procedure should be applied.