Recommendations

Key Recommendations

Treatment is most commonly surgical and depends on the location of the fracture and whether it is displaced. Operative management results in a reduced length of hospital stay and improved rehabilitation compared with conservative methods (bed rest and traction), which are no longer recommended.[59]

Multiple guidelines recommend early surgery following medical assessment.[60][61][62] Surgery within 24-48 hours of admission may be associated with better outcomes.[17] The American Academy of Orthopaedic Surgeons (AAOS) recommends that patients with open fractures are brought to the operating room for debridement and irrigation as soon as reasonable, and ideally within 24 hours post injury.[57][58]

  • Meta-analyses report reduced mortality and reduced complications following early surgery.[63][64] In one large retrospective cohort study, hip fracture surgery within 24 hours was associated with significantly reduced risk of 30-day mortality compared with surgery after 24 hours (5.8% vs. 6.5%, respectively).[65]

  • Accelerated surgery (median time from hip fracture diagnosis to surgery of 6 hours) did not significantly reduce risk of mortality or a composite of major complications compared with standard care (surgery within 24 hours) in one large randomized controlled trial (RCT).[66]

Venous thromboembolism prophylaxis

Guidelines from the AAOS strongly recommend venous thromboembolism (VTE) prophylaxis in all patients ages 65 years or older. There are significant established risk factors for VTE in these patients, including age, presence of hip fracture, major surgery, delays to surgery, and the potential serious consequences of failure to provide prophylaxis.[17] This recommendation was based on data from six moderate-quality studies and four low-quality studies that showed the risk of deep vein thrombosis (DVT) was significantly less with VTE prophylaxis than with control. Most general complications were not significantly different between treatment groups and there was some evidence that mortality was less with prophylaxis when compared with control groups.[17] Other guidelines agree that some form of prophylaxis is necessary regardless of the patient's age; however, there is no consensus on choice of agent or duration.[67][68][69] Total hip arthroplasty and open reduction and internal fixation of hip fractures, and surgery due to major trauma, are among the orthopedic procedures with the highest DVT risk.[70] With contemporary surgical protocols the prevalence of VTE after total hip arthroplasty has been reported to be up to 22%, using venography as a diagnostic method, even with pharmacologic prophylaxis.[71]

See Venous thromboembolism (VTE) prophylaxis.

Preoperative antibiotic therapy

Early delivery of antibiotics is suggested to lower the risk of deep infection in the setting of open fracture in major extremity trauma.[57][58] Results from meta-analyses suggest that prophylactic antibiotics significantly reduce the risk of postoperative superficial and deep wound infection (relative risk reduction of 45% to 60%, depending on analysis).[72][73] The use of multiple antibiotics or antibiotic use for more than 24 hours had no further effect on postoperative infection.

Most trials used a regimen either 1 hour prior to induction or at induction, and most antibiotics delivered were intravenous and either a first- or second-generation cephalosporin.[72][73] In patients with major extremity trauma undergoing surgery, the AAOS strongly recommends that antibiotic prophylaxis with systemic cefazolin or clindamycin be administered, except for type III (and possibly type II) open fractures, for which additional gram-negative coverage (e.g., piperacillin/tazobactam) is preferred.[57][58] However, local sensitivities and protocols should be followed for antibiotic selection.

In patients with major extremity trauma undergoing surgery, local antibiotic prophylactic strategies such as vancomycin powder, tobramycin-impregnated beads, or gentamicin-covered nails may be beneficial, when available.[57][58]

One systematic review and meta-analysis suggests that both single-dose and multi-dose antibiotic prophylaxis reduce the risk of deep surgical site infection, with similar effect size.[73]

Intracapsular (femoral neck) fracture: undisplaced

Treatment in most instances is internal fixation with a dynamic hip screw, or multiple cannulated screws, when the wound is determined to be clean.[57][58][60] One Cochrane review comparing screws and fixed angle plates found there may be little or no difference in functional status, quality of life, 1-year mortality, or unplanned reoperations.[74] One RCT in patients with undisplaced (66%) or displaced (34%) low-energy femoral neck fracture determined that reoperation rates at 24 months were similar for the two surgical fixation methods.[75] Secondary analysis of this RCT, and results from a retrospective cohort study, reported an association between preoperative posterior tilt ≥20° and increased risk of subsequent arthroplasty in patients with undisplaced or minimally displaced femoral neck fractures (Garden I-II). Arthroplasty may, therefore, be a superior initial treatment option to internal fixation for patients with posterior tilt ≥20°.[76][77]

Intracapsular (femoral neck) fracture: displaced

Surgical approach to repair of displaced femoral neck fracture may be influenced by several factors, including patient age.

For patients ages younger than 65 years, most surgeons favor urgent (<12-24 hours from injury) open reduction and internal fixation due in part to a potential increased risk of avascular necrosis to the femoral head.[78][79] However, evidence is conflicting regarding rates of avascular necrosis and timing of surgery.[80][81]

For patients 65 years and older with unstable (displaced) femoral neck fractures, the AAOS strongly recommends arthroplasty over fixation.

  • Randomized trials comparing arthroplasty (hemi- and/or total hip arthroplasty) with internal fixation have consistently reported better outcomes (reoperation rate, pain scores, functional status, and/or complication rate) for arthroplasty.[17][82][83][84]

  • Evidence from meta-analyses suggests that mortality at 1 year did not differ; arthroplasty was associated with greater operative time, and significantly increased the risk of infection and blood loss.[85][86]

  • In appropriately selected patients aged 65 years and older with unstable (displaced) femoral neck fractures, there may be a functional benefit to total hip arthroplasty over hemiarthroplasty at the risk of increasing complications.[17] Several studies demonstrate a small functional outcome benefit and fewer reoperations in patients who received total hip arthroplasty. However, the effect size in these studies is small and mortality rates were largely unaffected within the first 4 years after treatment.[17][87][88][89][90] The AAOS also notes that patient exclusion criteria in some of these studies reflect the general bias among surgeons toward performing total hip arthroplasty in patients who are higher functioning and more likely to be independent community ambulators.[17] The AAOS, therefore, recommends that cautious decision-making around total hip arthroplasty versus hemiarthroplasty for lower functioning patients may be justified considering the bias and risk for complications.[17]

Despite the apparent benefits of total hip arthroplasty (reflected in some US and UK guideline recommendations for total hip arthroplasty in ambulatory patients with displaced femoral neck fractures), many surgeons prefer hemiarthroplasty for older patients with displaced femoral neck fracture.[17][62][91][92][93] Ambulatory status and decreased risk of dislocation (instability) have been cited as factors for choosing hemiarthroplasty.[17][93]

Surgeon volume is associated with reduced risk for dislocation and revision in patients undergoing primary total hip arthroplasty.[94]

Most surgeons favor hemiarthroplasty for patients over 80 years of age.[21][91]

The AAOS guideline states that unipolar or bipolar hemiarthroplasty in patients 65 years and older can be equally beneficial.[17]

Patient preference

  • In a decision board study, when patients were asked which procedure they would prefer if they had a displaced neck of femur fracture, 93% of participants chose a total hip replacement over a hemiarthroplasty as their treatment of choice. Important factors in their decision were the perception of a greater walking distance, less residual pain, and risk of reoperation.[95]

Cemented versus uncemented hemiarthroplasty

  • Guidelines recommend the use of cemented femoral stems in patients undergoing arthroplasty for femoral neck fracture based upon studies that demonstrated improved outcomes (decreased pain and increased mobility) when cemented stems were compared with first-generation uncemented stems (e.g., Austin-Moore prosthesis).[17][96] Subsequent trials, systematic reviews, and meta-analyses confirmed these findings, or reported no difference between cemented and uncemented femoral stems.[97][98][99][100]

  • One 2017 systematic review and meta-analysis of contemporary stems for displaced fracture of the femoral neck found that cemented femoral stems were associated with fewer implant-related complications than uncemented stems, but mortality did not differ between the two fixation methods.[101]

  • A small, single-center RCT of patients with femoral neck fracture (n=141) treated with arthroplasty suggested that cemented stems provide improved functional outcome scores compared with modern uncemented femoral stems.[97] A larger, multicenter RCT to compare cemented hemiarthroplasty with contemporary modern hydroxyapatite-coated uncemented hemiarthroplasty is ongoing.[102]

  • One Cochrane review identified moderate-certainty evidence of a benefit with cemented hemiarthroplasty consistent with clinically small-to-large differences in health-related quality of life and reduction in the risk of mortality at 12 months, but little or no difference in performance of activities of daily living and independent mobility. The risks of most adverse events were similar. However, cemented hemiarthroplasties led to fewer periprosthetic fractures intraoperatively and postoperatively, but had a higher risk of pulmonary embolus.[103][Figure caption and citation for the preceding image starts]: Anteroposterior pelvic radiograph showing a left intracapsular fracture fixed with a sliding hip screw constructFrom the collection of Bradley A. Petrisor, MSc, MD, FRCSC and Mohit Bhandari, MD, MSc, FRCSC [Citation ends].Anteroposterior pelvic radiograph showing a left intracapsular fracture fixed with a sliding hip screw construct

Extracapsular (intertrochanteric) fracture

Undisplaced

  • Treatment is internal fixation with a dynamic hip screw or cephalomedullary nail when the wound is determined to be clean.[57]

Displaced (stable or unstable)

  • Operative management includes internal fixation with either a dynamic hip screw or a cephalomedullary (intramedullary) nail in patients with stable intertrochanteric fractures when the wound is determined to be clean.[17][57][Figure caption and citation for the preceding image starts]: Intramedullary nail (cephalomedullary) for the treatment of an unstable intertrochanteric fractureFrom the collection of Bradley A. Petrisor, MSc, MD, FRCSC and Mohit Bhandari, MD, MSc, FRCSC [Citation ends].Intramedullary nail (cephalomedullary) for the treatment of an unstable intertrochanteric fracture

Choice of device

  • Overall, trends in management have led to cephalomedullary nails being selected more commonly (68%) than sliding hip screws (19%) for the management of both stable and unstable intertrochanteric hip fractures, with ease of surgical technique being the most commonly cited reason.[104]

    • One RCT suggested a trend towards improved early mobility (<12 months) in patients treated with cephalomedullary nails.[105] Larger cohort studies indicate that there may be a higher rate of 30-day mortality, and bleeding, respiratory, and clotting complications in those treated with a cephalomedullary device.[106] This, in combination with a lack of long-term differences, indicates that cephalomedullary implants are likely being overutilized in lieu of sliding hip screws, with perceived ease of surgical technique and nonclinically significant shorter surgical times being the major drivers of implant selection.

  • Guidelines from the AAOS strongly recommend use of either a sliding hip screw or a cephalomedullary device in patients with stable intertrochanteric fractures.[17] Fixation with either an extramedullary or intramedullary implant show similar clinical outcomes.[107][108]

    • Results from early trials suggested that intramedullary nails were associated with increased risk of intra- or postoperative femoral fracture in patients with stable or unstable extracapsular proximal femoral fracture (compared with dynamic hip screws).[109] This was largely due to a mismatch between intramedullary nail geometry and femoral anatomy, with the implant having a lower radius of curvature than that of the femoral bow. Subsequent-generation intramedullary nails have addressed this by adjusting nail designs for improved femoral fit, and are less likely to be associated with periprosthetic fractures.[96]

    • Multiple studies including prospective cohorts and RCTs continue to show equivalent outcomes between the two fixation options with respect to mortality, rates of failure, need for reoperation, length of stay, complications, and mobility at 1 year.[105][109][110][111] One prospective randomized trial found no difference in functional outcome, hospital stay, fracture collapse, or mortality between a cephalomedullary nail and an extramedullary sliding hip screw and plate device that offers two points of fixation into the femoral head.[108]

  • The AAOS strongly recommends that patients with unstable intertrochanteric fractures should be treated with a cephalomedullary device.[17]

  • In patients with subtrochanteric or reverse obliquity fractures, the AAOS recommends a cephalomedullary device.[17] This recommendation is on the basis of apparent treatment benefit with lower general complication rate and wound infection rates, improved mobility, and decreased limb shortening.[17][112]

Supportive care

Assess patients for volume depletion and administer intravenous fluids according to local protocols.[113] Postoperative supportive care includes optimizing pain control, nutrition, physical therapy, and multidisciplinary rehabilitation programs for postoperative mobility.[114]

The AAOS suggests a blood transfusion threshold of no higher than 8 g/dL in asymptomatic postoperative hip fracture patients ages 65 years and older to decrease the likelihood of transfusion-associated complications and cost; other guidelines recommend the same transfusion threshold (<8 g/dL) regardless of patient age.[17][115][116] Overall clinical context and individual patient factors should be considered.[116] The AAOS strongly recommends tranexamic acid to reduce blood loss and blood transfusion in patients with hip fractures.[17]

Postoperative pain management

  • Multimodal analgesia incorporating preoperative nerve block is recommended by the AAOS to treat pain after hip fracture.[17]

  • Analgesia can be delivered with nerve blocks (i.e., fascia iliaca compartment block), patient-controlled analgesia, or prescription of routine opioids or epidural analgesia.[117] Requirements may be related in part to the particular surgery that was done (e.g., dynamic hip screw, cephalomedullary device, hemiarthroplasty, etc).[118]

  • High-quality evidence indicates that pre- or postoperative peripheral nerve blocks for hip fractures reduce pain on movement within 30 minutes after block placement. Moderate-quality evidence shows reduced risk for pneumonia and decreased time to first mobilization with peripheral nerve block (single-shot blocks).[119]

  • Opioid alternatives, both pharmacologic (e.g., nonsteroidal anti-inflammatory drugs [NSAIDs], acetaminophen) and nonpharmacologic (e.g., transcutaneous electrical stimulation, ice, cognitive therapies) should be considered alongside opioid-sparing protocols when possible given the risks of opioid analgesics (adverse events, misuse, opioid use disorder, and diversion for nonmedical use).[120][121][122]​​

Physical therapy and rehabilitation

  • Patients are generally prescribed physical therapy and rehabilitation; weight-bearing and range-of-motion activities are usually at the discretion of the treating surgeon. Based on limited evidence, the AAOS suggests consideration of immediate, full weight-bearing to tolerance.[17] Interdisciplinary care programs should be used in the care of patients with hip fractures to decrease complications and improve outcomes.[17] This may include geriatric and orthopedic providers, alongside nursing, dietary, and rehabilitation providers such as occupational and physical therapists.[17] Coordinated multidisciplinary rehabilitation programs may result in an increased percentage of patients returning home and remaining there following a hip fracture.[114][123][124] Specifically, patients monitored by a geriatrician postoperatively and given frequent physical therapy and occupational therapy in an acute care or rehabilitation setting may experience improved recovery of ambulatory and functional ability.[125][126] Use of clinical care pathways may be associated with a shorter length of hospital stay.[114]

  • Implementation of comprehensive geriatric assessment (CGA) programs may be of benefit in the perioperative period. CGAs are a coordinated, multidisciplinary assessment of the medical, psychosocial, and functional capabilities and limitations of older patients, and have been shown to improve outcomes (mortality, length of stay, re-admission, cost, discharge to an increased level of care) in people with hip fracture.[127]

  • There is limited evidence that home rehabilitation post-discharge improves long-term outcomes.[128] There is some suggestion that extended rehabilitation may be beneficial.[129]

Dietary supplementation

  • There is low-quality evidence that oral multinutrient supplements (nonprotein energy, protein, vitamins, and minerals) started before or soon after surgery may prevent complications within the first 12 months after hip fracture, with no clear effect on mortality.[130] [ Cochrane Clinical Answers logo ]

  • Some studies have assessed the use of anabolic steroids, separately or in combination with nutritional supplements, after surgical treatment of patients with geriatric hip fracture; however, there is insufficient evidence to determine their effect.[131]

Wound coverage

  • Wound coverage within 7 days from injury date is recommended by the AAOS.[57][58] After closed fracture fixation, negative-pressure wound therapy may mitigate the risk of revision surgery or surgical-site infections for higher-energy injuries with internal degloving (i.e., Morel-Lavallée lesions), or in patients with elevated body mass index; however, after open fracture fixation, negative-pressure wound therapy does not appear to offer an advantage when compared with sealed dressings as it does not decrease wound complications or amputations.[57][58] Silver-coated dressings are not recommended as they do not improve outcomes or decrease pin-site infections.[57][58]

Preoperative traction

Preoperative traction, including both skin and skeletal traction, should not be routinely used.[17] Preoperative traction provides no benefit with regard to pain, ease of obtaining a reduction, or the quality of the reduction at the time of surgery.[17][60][132]

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