Hip fractures

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1st line –

internal fixation

Surgery within 24-48 hours of admission may be associated with better outcomes.[17] The American Academy of Orthopaedic Surgeons 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]

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 re-operations.[74] One randomized controlled trial in patients with undisplaced or displaced low-energy fracture of the hip determined that reoperation rates at 24 months were similar for the two surgical fixation methods.[75]

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prophylactic antibiotics

Treatment recommended for ALL patients in selected patient group

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] Antibiotics significantly reduce the risk of postoperative superficial and deep wound infection.[72][73]

Either a first- or second-generation cephalosporin is usually given.[72][73] In patients with major extremity trauma undergoing surgery, the American Academy of Orthopaedic Surgeons 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]

Consideration should also be given to identify those at possible risk of infection with MRSA, such as MRSA carriers. Such individuals should receive appropriate prophylaxis, which will depend on the resistance profile. Specialist advice from a microbiologist is advisable.

Primary options

cefazolin: 1-2 g intravenously prior to surgery

clindamycin: 900 mg intravenously prior to surgery

Secondary options

piperacillin/tazobactam: 3.375 to 4.5 g intravenously prior to surgery

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Plus –

venous thromboembolism prophylaxis

Treatment recommended for ALL patients in selected patient group

Strongly recommended in all patients.[17]

Guidelines from the American Academy of Orthopaedic Surgeons 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]

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tranexamic acid and/or blood transfusion

Treatment recommended for ALL patients in selected patient group

The American Academy of Orthopaedic Surgeons (AAOS) strongly recommends tranexamic acid to reduce blood loss and blood transfusion in patients with hip fractures.[17] 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]

Primary options

tranexamic acid: consult specialist for guidance on dose

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Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Assess patients for volume depletion and administer intravenous fluids according to local protocols.[113]

Multimodal analgesia incorporating preoperative nerve block is recommended by the American Academy of Orthopaedic Surgeons (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]

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] There is some suggestion that extended rehabilitation may be beneficial.[129]

Coordinated multidisciplinary rehabilitation programs may result in an increased percentage of patients returning home and remaining there following a hip fracture.[114][123][124]

Clinical care pathways may be associated with a shorter length of hospital stay.[114]

Implementation of comprehensive geriatric assessment programs may be of benefit in the perioperative period.[127]

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]

displaced: <65 years of age

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1st line –

internal fixation

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]

Back

Plus –

prophylactic antibiotics

Treatment recommended for ALL patients in selected patient group

Primary options

cefazolin: 1-2 g intravenously prior to surgery

clindamycin: 900 mg intravenously prior to surgery

Secondary options

piperacillin/tazobactam: 3.375 to 4.5 g intravenously prior to surgery

Back

Plus –

venous thromboembolism prophylaxis

Treatment recommended for ALL patients in selected patient group

Recommended for all patients.

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]

Back

Plus –

tranexamic acid and/or blood transfusion

Treatment recommended for ALL patients in selected patient group

The American Academy of Orthopaedic Surgeons (AAOS) strongly recommends tranexamic acid to reduce blood loss and blood transfusion in patients with hip fractures.[17] Consider a blood transfusion threshold of no higher than 8 g/dL, taking into account the overall clinical context and individual patient factors.[17][115][116]

Primary options

tranexamic acid: consult specialist for guidance on dose

1st line – arthroplasty

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Assess patients for volume depletion and administer intravenous fluids according to local protocols.[113]

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 orthopedic providers, alongside nursing, dietary, and rehabilitation providers such as occupational and physical therapists.[17] There is some suggestion that extended rehabilitation may be beneficial.[129]

Coordinated multidisciplinary rehabilitation programs may result in an increased percentage of patients returning home and remaining there following a hip fracture.[114][123][124]

Clinical care pathways may be associated with a shorter length of hospital stay.[114]

displaced: >65 years or equal to 65 years of age

Back

1st line –

arthroplasty

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]

The AAOS strongly recommends arthroplasty over fixation in patients with unstable (displaced) femoral neck fractures. 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]

Most surgeons favor hemiarthroplasty for patients over 80 years of age.[21][91] The AAOS guideline also states that unipolar or bipolar hemiarthroplasty in patients 65 years and older can be equally beneficial.[17]

Back

Plus –

prophylactic antibiotics

Treatment recommended for ALL patients in selected patient group

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]

Primary options

cefazolin: 1-2 g intravenously prior to surgery

clindamycin: 900 mg intravenously prior to surgery

Secondary options

piperacillin/tazobactam: 3.375 to 4.5 g intravenously prior to surgery

Back

Plus –

venous thromboembolism prophylaxis

Treatment recommended for ALL patients in selected patient group

Strongly recommended in all patients.[17]

Guidelines from the American Academy of Orthopaedic Surgeons 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] 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]

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Assess patients for volume depletion and administer intravenous fluids according to local protocols.[113]

Coordinated multidisciplinary rehabilitation programs may result in an increased percentage of patients returning home and remaining there following a hip fracture.[114][123][124]

Clinical care pathways may be associated with a shorter length of hospital stay.[114]

Implementation of comprehensive geriatric assessment programs may be of benefit in the perioperative period.[127]

extracapsular (intertrochanteric) fracture

undisplaced

Back

Plus –

prophylactic antibiotics

Treatment recommended for ALL patients in selected patient group

Primary options

cefazolin: 1-2 g intravenously prior to surgery

clindamycin: 900 mg intravenously prior to surgery

Secondary options

piperacillin/tazobactam: 3.375 to 4.5 g intravenously prior to surgery

Back

Plus –

venous thromboembolism prophylaxis

Treatment recommended for ALL patients in selected patient group

Strongly recommended in all patients.[17]

Back

Plus –

tranexamic acid and/or blood transfusion

Treatment recommended for ALL patients in selected patient group

Primary options

tranexamic acid: consult specialist for guidance on dose

Back

Plus –

supportive care

Treatment recommended for ALL patients in selected patient group

Assess patients for volume depletion and administer intravenous fluids according to local protocols.[113]

Multimodal analgesia incorporating preoperative nerve block is recommended by the American Academy of Orthopaedic Surgeons (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., positioning, splinting, 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]

Coordinated multidisciplinary rehabilitation programs may result in an increased percentage of patients returning home and remaining there following a hip fracture.[114][123][124]

Clinical care pathways may be associated with a shorter length of hospital stay.[114]

Implementation of comprehensive geriatric assessment programs may be of benefit in the perioperative period.[127]

displaced (stable or unstable)

Back

1st line –

internal fixation

Operative management includes internal fixation with either a dynamic hip screw or a cephalomedullary (intramedullary) nail in patients with stable intertrochanteric fractures.[17]

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 toward 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]

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]

Back

Plus –

prophylactic antibiotics

Treatment recommended for ALL patients in selected patient group

Primary options

cefazolin: 1-2 g intravenously prior to surgery

clindamycin: 900 mg intravenously prior to surgery

Secondary options

piperacillin/tazobactam: 3.375 to 4.5 g intravenously prior to surgery

Back

Plus –

venous thromboembolism prophylaxis

Treatment recommended for ALL patients in selected patient group

Strongly recommended in all patients.[17]

Back

Plus –

tranexamic acid and/or blood transfusion

Treatment recommended for ALL patients in selected patient group

Primary options

tranexamic acid: consult specialist for guidance on dose