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• W2011123099 abstract "The AAOS recently published a new clinical practice guideline (CPG) on the management of hip fractures in the elderly.1 This guideline is the most comprehensive CPG the AAOS has released to date and addresses a significant global healthcare concern. It is the result of several years of hard work reviewing over 16,000 abstracts and more than 1700 full-text articles in the process to come up with 25 evidence-based recommendations based on 169 research articles meeting the inclusion criteria and graded as representing best available evidence. This guideline is the product of a multidisciplinary effort led by the AAOS with input from key subspecialty societies including the OTA. It has been endorsed by the OTA, The Hip Society, the American Association of Clinical Endocrinologists (AACE), the US Bone and Joint Initiative, American Geriatrics Society, and the American Academy of Physical Medicine and Rehabilitation (AAPM&R). Unlike many previous CPGs, the majority of the recommendations contained within the scope of this guideline are supported by strong or moderate evidence. The recommendations are designed to be used by orthopaedic surgeons and other physicians to help develop local programs and advocate for improving the standard of care for patients with hip fracture. In addition, these guideline recommendations will provide the foundation for guideline derivative products, such as appropriate use criteria and quality measures that will hopefully serve to further improve care of elderly patients with hip fracture on a national level. Guideline Overview: AAOS CPG Management of Hip Fractures in the Elderly This CPG includes 25 recommendations covering the spectrum of care of the elderly patient with hip fracture. Some of these recommendations can be easily implemented into clinical practice in hopes of simplifying the care of patients with hip fracture, such as finally eliminating the use of skin traction. When hemiarthroplasty is indicated, unipolar and bipolar heads are noted to have equivalent function; therefore, there is little justification to continue to use the more costly bipolar option. There is also strong evidence in support of restricting transfusions in this high-risk patient population. In addition, many of the recommendations support standards of care such as avoiding delays to surgery, minimizing delirium, and preventing future fragility fractures. The recommendations underscore that optimal care of the patient with geriatric hip fracture occurs in the setting of a multidisciplinary team. This includes regional analgesia in the ER with multimodal pain control, anesthesia, postoperative physical therapy, interdisciplinary care, nutritional, calcium and vitamin D supplementation, and osteoporosis evaluation in addition to the surgical recommendations. Several recommendations require more complex clinical decision making than others, taking into account the preferences and risk factors of the patient, experience of the surgeon, and good clinical judgment. These recommendations include the preferential use of cement in arthroplasty to minimize the risk for periprosthetic fracture, the use of the anterolateral approach to reduce dislocation risk, and even the consideration for total hip arthroplasty (THA) for select patients. Ultimately, the use of large patient databases and registry data may help to complement existing comparative evidence to address these challenging clinical questions.2 The recommendation addressing hemiarthroplasty versus THA cites moderate evidence in support of THA in “properly selected patients” with unstable femoral neck fractures. The important part of this recommendation involves not only appropriate patient selection but it is critical that treatment also needs to be predicated on surgeon experience. Although THA may offer improved function and long-term results in select patients, surgeon experience and patient factors need to be considered to outweigh the inherent risks for a more complicated and expensive procedure.2 Moderate strength evidence demonstrated higher dislocation rates with the posterior approach compared with the anterolateral approach when treating displaced femoral neck fractures with hip arthroplasty. The work group noted that both patient- and surgeon-specific factors should be considered when deciding on a surgical approach as some surgeons may not be experienced with the anterolateral approach. As stated in the CPG, “input based on… clinician's surgical experience and skills increases the probability of identifying patients who will benefit from specific treatment options.”1 Recommendations regarding treatment options for intertrochanteric fractures included both moderate strength support for using either cephalomedullary implants or sliding hip screws in the treatment of stable intertrochanteric fractures and moderate strength support for the preferential use of cephalomedullary implants in the treatment of unstable intertrochanteric fractures. There is also a strong recommendation for the use of a cephalomedullary device for the treatment of patients with a subtrochanteric or reverse obliquity fracture. Despite the lack of evidence showing the superiority of any given implant in the treatment of stable intertrochanteric fractures, the use of intramedullary nails by orthopaedic surgeons sitting for the American Board of Orthopaedic Surgery Part II examination increased from 3% in 1999 to 67% in 2006.3 More comparative effectiveness research is needed to support the proposed merits of using cephalomedullary nails in the treatment of stable intertrochanteric femur fractures to justify the increased cost. Proponents of nails cite the advantages of a technique that can be performed percutaneously, biomechanical advantages of the implant, and the utility of the device to treat all intertrochanteric fracture patterns.4 Surgeon experience and familiarity with the technique should also play a role in choice of implant. One clinical question that could not be answered by the published evidence is whether to use a short or long cephalomedullary nail when indicated in the treatment of intertrochanteric hip fractures. At the time of guideline completion, there was insufficient published evidence to formulate a recommendation, and the revised AAOS process prohibits the inclusion of expert opinion in an evidence-based guideline unless the topic could result in catastrophic (loss of life or limb) consequences. Therefore, the work group requested that the OTA address this question by developing a companion consensus statement based on expert opinion to complement the existing clinical guideline. Orthopaedic treatment is continuously evolving, and this is an area where further high-quality research would be very helpful. Moderate evidence supports the recommendation of MRI as the advanced imaging study of choice for diagnosis of presumed hip fracture not apparent on initial radiographs. MRI is the literature standard with regard to accuracy and does not have the time constraints of bone scan, but often CT scan is more accessible. Limited small studies have examined the use of CT scan in the diagnosis of occult hip fractures but because of the lower quality of this existing literature and potential harm with radiation exposure related to the use of CT, this modality was not recommended. Additionally, there is concern that a negative CT is not sufficient to exclude the possibility of fracture. The work group acknowledges with this recombination that the type of secondary imaging used may be limited by considerations of access and availability, and more comparative studies are needed to better delineate the role of advanced imaging. In summary, this CPG provides a frame work of actionable recommendations based on evidence to allow orthopaedic surgeons to become advocates for improving the standard of care with regard to treatment of hip fractures in the elderly. This guideline is not intended to be a “cookbook” meant to discourage innovative care of patients with hip fractures. Rather, it is meant to elevate the current level of care and stimulate additional research where experience and evidence seem to be at odds. As with all evidence-based recommendations, practitioners must also rely on their clinical judgment and experience, as well as their patients' preferences and values when making treatment decisions. Finally, it is important that as clinicians, we close the quality cycle by evaluating the outcomes of these recommendations in patient care to validate the clinical utility of the guideline. To achieve this, the leadership of the AAOS and the OTA are partnering to support an expansion of the hip fracture registry data within the American College of Surgeons National Surgical Quality Improvement Program (NSQIP) database. This expansion of data will be very helpful in validating and updating the recommendations of this guideline and assessing quality of care for patients with hip fracture in the future.5 ACKNOWLEDGMENTS AAOS Management of Hip Fractures in the Elderly Clinical Practice Guideline Work Group: David Jevsevar, MD, MBA; Jayson Murray, MA; and Deborah S. Cummins, PhD." @default.
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• W2011123099 title "From Evidence to Application" @default.
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