This clinical practice guideline was developed by the AAOS Physician Volunteer Task Force based on a systematic review of available scientific and clinical research. This clinical practice guideline is not a fixed treatment protocol and some patients may need to be adjusted as appropriate. Patient conditions in the clinic may not be identical to those in clinical trials. Clinicians should make independent judgments about the treatment of patients based on their individual circumstances.
General Provisions
This clinical practice guideline is based on a systematic review of currently published information on the management of hip fractures in patients over 65 years of age. In addition to the recommended clinical practice, the guideline also addresses the limitations of the literature and the region itself, which are subject to further study in the future.
This guideline is intended for all practicing physicians and surgeons involved in the management of hip fractures in the elderly, and some of the information in the guideline may also be useful for developers of relevant practice guidelines and decision makers.
Target Audience
This guideline is intended for orthopaedic surgeons and internists who treat hip fractures in the elderly. References to orthopaedic surgeons are to physicians who have completed their medical training and are qualified for orthopaedic residency, some of whom may have completed subspecialty training. Insurers, government agencies, and health policy makers will also find the latest clinical evidence in this guideline. The guidelines are also appropriate for primary care physicians in adult medicine, geriatricians, hospitals specializing in adult medicine, physical therapists, occupational medicine physicians, nursing staff, physician assistants, emergency physicians, and other health care professionals who treat this patient population.
The determination of treatment modalities for hip fractures should be based on a full discussion between the patient and his or her representative and the physician regarding all feasible treatment options. The final decision should be made only after the patient and/or his representative have been informed of the available treatment options and have discussed them with the physician. The physician can then combine his or her experience in conservative treatment and surgery to help the patient choose the most appropriate treatment option.
Advanced imaging
MRI should be performed in suspected cases of hip fracture if the initial X-ray does not show any abnormalities.
Recommended intensity: moderate
Preoperative regional analgesia
Regional analgesia can improve preoperative pain in patients with hip fractures
Recommended intensity: strong
Preoperative traction
Preoperative traction is not supported routinely in cases of hip fracture
Recommended intensity: moderate
Timing of surgery
Surgery within 48 hours of admission for hip fractures is associated with better outcomes
Recommended intensity: moderate
Aspirin and clopidogrel
No delay in surgery for hip fractures in patients taking aspirin and/or clopidogrel
Recommended intensity: limited
Anesthesia
Similar results with general or spinal anesthesia in patients undergoing hip fracture surgery
Recommended intensity: strong
Stable femoral neck fracture
Stable (non-displaced) femoral neck fractures should be surgically fixed internally
Recommended intensity: moderate
Displaced femoral neck fractures
Unstable (displaced) femoral neck fractures should be replaced with an artificial joint
Recommended intensity: strong
Unipolar or bipolar
Unipolar and bipolar femoral head replacements are similar in the treatment of unstable (displaced) femoral neck fractures
Recommended strength: moderate
Semipolar or total hip
Total hip replacement is preferable in appropriate patients with unstable (displaced) femoral neck fractures
Recommended strength: medium
Cemented femoral stem
Cemented femoral stems are preferred in patients with femoral neck fractures for arthroplasty
Recommended strength: medium
Surgical Approach
The posterior approach for hip replacement in displaced femoral neck fractures has a higher rate of dislocation
Recommended strength: medium
Stable intertrochanteric fracture
Stable intertrochanteric fractures can be treated with hip slide screws or proximal intramedullary nails
Recommended strength: medium
Subrotor fracture or reverse oblique row fracture
Proximal intramedullary nailing for subrotor fractures or anteversion fractures
Recommended strength: strong
Unstable inter-rotor fracture
Proximal intramedullary nailing for unstable intertrochanteric fractures
Recommended strength: moderate
Prevention of venous thrombosis
Prevention of venous thromboembolism is required in patients with hip fractures
Recommended intensity: moderate
Threshold for blood transfusion
The critical value of blood transfusion for asymptomatic anemia after hip fracture is less than 8 g/dl
Recommended intensity: strong
Physical functional therapy
Supervised physical function therapy throughout the recovery process, including at home, improves function and prevents falls
Recommended intensity: moderate
Intensive Physical Therapy
Intensive home physical therapy improves functional outcomes
Recommended Intensity: Intense
Nutrition
The addition of nutrition to patients with possible nutritional deficiencies may improve functional outcomes and reduce mortality, so patients should be evaluated for nutritional status.
Recommended intensity: moderate
Multidisciplinary treatment
Multidisciplinary collaboration can lead to better functional outcomes in mild to moderate dementia with hip fracture
Recommended intensity: strong
Postoperative multimodal analgesia
Postoperative multimodal analgesia for hip fracture should be performed
Recommended intensity: strong
Calcium and vitamin D
Vitamin D and calcium supplementation after hip fracture surgery
Recommended intensity: moderate
Monitoring
Preoperative monitoring of serum albumin and creatinine levels to assess the risk of hip fracture
Recommended intensity: limited
Evaluation and treatment of osteoporosis
Evaluation and treatment of osteoporosis should be performed after hip fracture
Recommended intensity: Moderate