Did you know that globally, the number of hip
fractures in older adults, well, it's expected
to surge. Up to 4 .5 million by 2050. It's a
staggering figure. It really is. And it's something
of a silent epidemic, isn't it, with just...
devastating consequences. Absolutely. A fracture
like this, it often means a huge drop in quality
of life, loss of mobility, and a frighteningly
high mortality rate. We're talking 24 % within
just one year. And even higher for those in care
homes, sadly. Exactly. The cost, both human and
financial, is just immense. Easily over 40 ,000
pounds a year per patient here in the UK for
the ongoing care. Huge burden. Welcome to the
Deep Dive, our mission to cut through the complexity
and pull out the most vital insights from really
challenging source material. A necessary task.
Today we're tackling something absolutely critical
in healthcare. the best practices for managing
hip fractures in older adults. And we're doing
it by navigating a, well, a very comprehensive
clinical practice guideline. A really important
document. Guiding our dive today is our expert
guest, brilliant at synthesizing this kind of
complex medical information into clear, actionable
understanding. It's great to have you back. Thank
you. It's definitely a topic where clarity rooted
in solid evidence is just desperately needed,
given the scale of the problem. you know, and
its impact. Absolutely. So let's jump straight
in then. Our source material is this clinical
practice guideline specifically for elderly hip
fracture patients. Before we get into the what,
maybe tell us about the how, who put this together,
and what makes it a reliable guide. Right, so
this guideline was developed by a really dedicated
group of physician volunteers. They undertook
a very rigorous systematic review of the vast
body of scientific and clinical literature out
there. And importantly, it was funded independently
by the American Academy of Orthopedic Surgeons,
ALS. So no industry influence here. Ah, that
independence is really key, isn't it? Precisely.
Their scope is specifically adults aged 65 and
older, though they did cast a slightly wider
net, including patients down to 55 if the average
age in the studies they looked at was over 65.
To reflect the typical patient group. Exactly.
It reflects the usual patient population, and
it's focused squarely on the acute management.
So from arrival at hospital through to that initial
discharge. but it doesn't cover prevention or
the crucial phase of post -hospital rehabilitation.
Those are really complex areas in their own right
covered by other guidelines. OK, so focused on
that immediate crisis period, how did they sift
through all that research? I mean, hip fractures
must have been studied extensively. They certainly
have. They conducted really extensive searches
across multiple databases. They started with
a, well, a staggering 8 ,678 abstracts. Wow.
And after multiple filtering rounds, they narrowed
it right down to 212 articles that met their
inclusion criteria for a full text review. Gosh.
It's that kind of thorough process you need to
build a solid foundation. Just cutting down from
over 8 ,000 to around 200 articles sounds like
a massive job in itself. How did they then decide
what the evidence actually meant and, you know,
what strength to give the recommendations? Yeah,
that's the crucial step. They used a formal process
to grade the quality of the evidence itself,
high, moderate, low, or very low. That's based
on study designs, consistency of findings, things
like that. Right. Then, crucially, they determine
the strength of the recommendation. strong, moderate,
limited, or consensus. And this isn't simply
a direct translation of evidence quality. They
use something called an evidence to decision
framework. An evidence to decision framework.
OK. That sounds a bit academic. What does that
mean in practice for clinicians, for patients?
It's actually very practical. It means they didn't
just look at the raw statistics from the studies.
They explicitly considered other factors, too.
Like what? Things like the balance of potential
benefits. versus the harms to the patient, the
magnitude of the effect they saw in the studies,
the feasibility. Can this actually be done in
a real -world hospital? And also, whether patients
would find it acceptable. So wait, they could
potentially give a moderate or even strong recommendation,
even if the evidence quality was technically
low? If say the potential benefit was huge and
the harms were minimal exactly or if it was simply
the universally accepted standard of care already
It allows them to make pragmatic clinically relevant
statements even when perfect high quality evidence
isn't available Which, let's face it, is often
the case in complex surgical and geriatric care.
Sure. And conversely, they might downgrade a
recommendation based on high quality evidence.
If, for example, the potential benefits were
tiny or the harms were significant for a particularly
frail population. It's about balancing all these
factors. Right. And notably, all the recommendations
in this particular guideline achieved 100 % consensus
among the diverse group of experts involved.
100%. Yeah. That's impressive. It is. It lends
significant weight to their conclusions, suggesting
these points are broadly accepted within the
field. Okay, right. Armed with that understanding
of how the guideline was built, let's get into
the findings. Starting with what happens the
moment a patient arrives? Preoperative care.
What did they find, especially regarding some
perhaps traditional practices? Well, one finding
that might surprise quite a few clinicians relates
to preoperative traction. Traction, right. Putting
weights on the leg. Yes. And the guideline issues
a strong recommendation based on high quality
evidence against the routine use of preoperative
traction for hip fractures. Against it. Really,
that feels completely counterintuitive. You sort
of picture traction, helping align the bones,
maybe relieving pain. Well, that's the power
of this kind of rigorous review. Studies consistently
show that applying traction, it just doesn't
offer any clear benefit, not in terms of reducing
pain or improving fracture alignment before surgery,
compared to simply positioning the limb comfortably
with pillows. No benefit at all. None that's
clear from the evidence. And worse, traction
seems to introduce more problems. Like what?
Things like constipation, pressure ulcers developing
from being stuck in bed under traction, and even
potentially increasing the risk of infection
or bleeding complications. So a common practice
that might actually do more harm than good, or
at best, offers no real benefit. That's a very
clear takeaway right there. It is. Okay, what
about the urgency of surgery? Is there a sort
of golden window? The guideline provides a moderate
recommendation here. It's based on low quality
evidence, but it was upgraded using that evidence
to decision framework we talked about. Okay.
And it's for proceeding with surgery within 24
to 48 hours of admission. Right, low quality
evidence, but they still recommend it moderately.
Explain that balance again. Yeah, this is a perfect
illustration of the framework at work. See, randomized
controlled trials are incredibly difficult to
do for surgical timing. Ethically tricky. Exactly.
You can't ethically randomize people to deliberately
delay surgery if you suspect it might be harmful.
But the existing studies, though perhaps lower
quality, consistently showed a trend. Surgery
within that 24 -48 hour window may be associated
with better outcomes overall. Things like reduced
pain, fewer complications, perhaps shorter hospital
stays, and critically, Delaying surgery beyond
this window is generally associated with an increased
risk of mortality and other complications, especially
things like chest infections, pulmonary issues.
OK. So the potential benefit to patients, even
with imperfect evidence, combined with those
known risks of delay, that justified the moderate
recommendation. Right. They do acknowledge, though,
that hitting this target can be challenging.
It depends on the patient's medical stability
and, of course, the hospital's resources and
capacity. That makes perfect sense, balancing
that imperfect evidence with the potential patient
impact. Okay, moving to pain management. These
fractures are, well, they're excruciating. Absolutely.
And here, the evidence is much clearer. There's
a strong recommendation, based on high quality
evidence, for using multimodal analgesia. Multimodal.
Meaning multiple approaches, not just one type
of painkiller. Precisely. specifically including
preoperative nerve blocks nerve blocks before
surgery yes combining different types of pain
relief so for instance using a regional nerve
block near the hip before surgery to numb the
area Alongside PrEP's standard pain medication,
it's proven by high -quality studies to give
superior pain control. And better outcomes. Yes,
and lead to better functional outcomes for patients
afterwards. Right, and managing blood loss during
the surgery itself. Another area with quite clear
direction. There's a strong recommendation backed
by high quality evidence for administering tranhexamic
acid. Tranhexamic acid, okay. This medication
is well established. It's really effective in
reducing blood loss during a procedure and consequently
reducing the need for blood transfusions afterwards.
Makes sense. And relatedly, the guideline includes
a moderate recommendation, this time based on
moderate quality evidence, about blood transfusions
after surgery. What's the guidance there? It
suggests that if a transfusion is needed in a
patient who isn't showing symptoms of anemia,
So they're asymptomatic. The hemoglobin level
threshold used to trigger giving blood should
be no higher than eight grams per deciliter.
So be proactive about reducing bleeding with
medication during surgery. Yes. And then be relatively
conservative about giving blood afterwards if
the patient is otherwise stable and not showing
symptoms. That sums up the evidence -based approach
there. Yes. Now, preventing blood clots, VTE,
venous thromboembolism. That's a major concern
for immobile patients, isn't it? I imagine the
risk is incredibly high after a hip fracture.
It is very high. Hip fracture patients are at
significant risk for potentially fatal blood
clots, like deep vein thrombosis, DVT, or a pulmonary
embolism, PE. Right. So the guideline delivers
a strong recommendation. This one was upgraded
from moderate quality evidence, again, using
that framework, that VTE prophylaxis should be
used. Should be used. Unequivocal. Yes. The potential
benefits of preventing these really serious clots
just far outweigh the relatively low risks associated
with the preventative medication in this particular
population. Does it say which medication or for
how long? Actually, the guideline didn't find
enough evidence to definitively recommend which
specific agent or how long to use it for. But
the core message is unambiguous. Use some form
of VTE prevention. A clear directive then, even
if the specific drug choice is still down to
clinical judgment. Okay, and lastly for pre -op,
the choice of anesthesia, general or spinal.
Right. Based on high -quality evidence, the guideline
makes a strong recommendation here. And that
is? That either spinal or general anesthesia
is appropriate. Oh, so no preference. No. The
studies reviewed showed no significant overall
difference in outcomes favoring one type over
the other. So the choice should really be made
based on the individual patient, their overall
health, the experience of the anesthetist, and
the specific nature of the fracture and the planned
surgery. OK, that covers preparing the patient.
Now for the surgery itself, where the type of
fracture really dictates the approach, doesn't
it? Let's start with femoral neck fractures,
specifically those that are unstable or displaced.
These are the breaks right up near the ball of
the hip joint. Yes, exactly. For these challenging
fractures, the guideline gives a strong recommendation
backed by high quality evidence for arthroplasty.
Arthroplasty, so replacing part or all of the
hip joint. That's right, replacing it. rather
than internal fixation, which is trying to hold
the bone together with screws or plates. Why
is replacing the joint better than fixing the
bone for this specific fracture type in older
people? Well, studies have consistently shown
that for these unstable femoral neck fractures
in this older patient group, arthroplasty leads
to significantly better long -term results. Better
how? Patients tend to have less pain, better
function, fewer complications overall, and crucially,
a much lower chance of needing a second operation
because the initial fixation failed or caused
problems later on. Ah, the re -operation rate.
That's key. It is. The mortality rates were actually
similar between the two methods, but the quality
of life and that need for re -intervention were
strongly in favor of replacement. Okay, so if
arthroplasty is the choice, what type? You hear
about hemiarthroplasty replacing just the ball
versus total hip arthroplasty replacing the ball,
and socket. What about the implant itself? Okay,
so for heme arthroplasty where just the femoral
head the ball is replaced, there's a moderate
recommendation based on moderate quality evidence.
Stating that both unipolar and bipolar implants
are equally beneficial. Studies just didn't show
a significant difference in patient outcomes,
pain, or function between these two slight variations
on replacing the ball component. So either type
of hemi is fine. What about comparing hemi to
a full total hip arthroplasty, THA? Right. Comparing
hemi to THA, replacing both components. There's
a moderate recommendation, but this one was actually
downgraded from high quality evidence. Downgraded?
Why? The guidelines suggest that THA may offer
improved functional benefits over hemiarthroplasty.
But this seems to be primarily in carefully selected
patients, perhaps younger, more active older
adults. OK. But there's a significant caveat.
THA carries a higher risk of certain complications
compared to hemiautroplasty, particularly dislocation.
Ah, dislocation is a major concern with hip replacements.
It is. So you have potentially better function,
but with a higher risk profile. That sounds like
a situation needing a very careful conversation
with the patient and their family. Absolutely.
And as you hinted, it also generally involves
a higher cost for the implant itself and potentially
the procedure fees. Right. The guideline actually
highlighted that more research is needed here,
particularly looking at how surgical timing and
the surgeon's experience with THA, specifically
for fracture cases, might influence these outcomes
and complication rates. More research needed
there. Okay, what about the specific implant
type for the femoral side, the stem that goes
into the thigh bone in arthroplasty? Yes. For
the femoral stem, there's a strong recommendation
based on high quality evidence for using cemented
femoral scums. Cemented stems. Interesting. I
thought uncemented was becoming more common in,
say, elective hip replacements. Why cemented
specifically for fractures in the elderly? That's
an excellent point. And it really highlights
how fracture patterns in older often more osteoporotic
bone, are different from arthritis cases. Different
bone quality. Yes. The evidence strongly supports
cemented stems for the specific patient population
with hip fractures. They're associated with better
short -term patient outcomes, more reliable fixation
in potentially poorer quality bone, and potentially
a lower risk of fractures occurring around the
implant later on, paraprosthetic fractures, compared
to unsemented stems. So better immediate fixation
and maybe fewer late complications. That's what
the evidence suggests. While putting in a cemented
stem can sometimes take slightly longer in surgery
and might involve a little more blood loss during
the procedure, the evidence on improved outcomes
is compelling. And cost. And cemented implants
are generally less expensive as well. That's
a really key detail, the specific demands of
fixing a fracture in potentially weaker bone
driving that recommendation. What about the surgical
approach itself? You know, from the back, the
side, the front, does the evidence favor one?
Here, the guideline has a moderate recommendation
based on moderate quality evidence. It states
that the evidence does not clearly favor one
surgical approach over another. Overall really
no winner definitively. They looked at studies
comparing posterior minimally invasive variations
direct lateral and direct anterior approaches
The findings were well pretty mixed regarding
short -term benefits like initial pain levels
or how quickly patients started walking Okay,
importantly long -term outcomes and overall complication
rates were often similar across the different
approaches studied So it seems like maybe the
surgeon's familiarity and expertise with a particular
approach are probably the most critical factors
here, rather than one approach being inherently
superior based on this evidence. Based on the
current evidence review for this guideline, that
certainly appears to be the case. Okay. Now let's
shift focus slightly to intertrochanteric fractures.
These are lower down the femur compared to the
femoral neck, sort of outside the joint capsule
itself, but still part of the hip region. That's
right. A different fracture pattern. And often
requires a different hardware solution, right?
Exactly. The type of implant usually depends
on whether the fracture pattern is considered
stable or unstable. Let's start with stable ones.
Okay. For stable inner trochanteric fractures,
there's a strong recommendation based on high
-quality evidence. And the recommendation is?
That either a sliding hip screw or a cephalomedulary
device is recommended. Both are good options.
Could you just briefly explain the difference
between those two types of implants again? Certainly.
A sliding hip screw is typically a plate that
runs along the side of the femur, fixed with
screws, and it has a large screw that slides
into the head of the femur. It's an extra medullary
device, meaning it sits outside the bone marrow
cavity. Okay, outside the bone marrow cavity.
Whereas a cephalomedullary device, often called
an intramedullary nail or IM nail, is actually
placed inside the bone marrow canal of the femur.
It's a rod inside the bone, with screws going
up into the femoral head to hold the fracture.
Ah, okay. One outside the bone, one inside. And
for stable fractures, the evidence shows they
both work equally well. That's right. High quality
evidence shows similar clinical outcomes. Things
like walking ability... hospital stay length,
and complication rates like fracture collapse
or implant failure when using either device for
these stable patterns. Okay, but what about the
unstable ones? Yes, for unstable inner trochanteric
fractures, and this includes patterns like subtrochanteric
extension or what's called reverse obliquity,
where the bone fragments are just less stable
and rotational forces are a bigger issue. Right,
more complex breaks. Exactly. For those, the
picture changes. Here, there's a strong recommendation,
also based on high -quality evidence, that patients
should be treated with a cephalomedullary device,
the intramedullary nail. So, for unstable breaks,
the nail inside the bone is strongly preferred
over the plate on the outside. Why the clear
preference here? The evidence is quite strong
for these unstable patterns. Intramedullary nails
provide better biomechanical stability. They're
better at resisting the forces that want to displace
these unstable fragments. Mechanically stronger
for that situation. Yes. Compared to sliding
hip screws, studies looking specifically at unstable
fractures show a significant treatment benefit
with cephalomedular devices. This can include
potentially improved walking ability and sometimes
fewer blood transfusions needed, perhaps due
to reduced surgical trauma, compared to fitting
a plate. It's just a more reliable construct
for these more complex fracture patterns. That's
a crucial distinction based on fracture stability.
Now, what about the length of that intramedullary
nail? Sometimes you hear about short versus long
nails. Does the guideline address that? Yes,
it does. This is addressed as a limited option
based on moderate quality evidence. A limited
option, meaning? Meaning both short and long
suflamedullary nails are considered acceptable
treatment options for pertrochanteric fractures,
which includes many of these intertrochanteric
patterns. there isn't strong evidence favoring
one over the other definitively. So what did
the evidence actually show when comparing them?
Well, studies comparing short and long nails
for these patterns suggest that short nails might
have some minor advantages, things like potentially
less operating time, maybe less blood loss, or
reduced x -ray exposure during surgery. Some
potential procedural benefits. Yes, but importantly,
there wasn't a consistent, significant difference
found in overall adverse events or those really
important patient outcomes like walking recovery
or final function. So similar outcomes overall?
Pretty much. Interestingly, though, some lower
quality evidence hinted at a potentially higher
risk of paraprosthetic fracture. That's a fracture
around the implant itself with the short nails.
Ah, okay. So short nails might be slightly easier
or quicker to put in, but the long -term functional
outcome might be similar. And there's maybe a
slight question mark, a potential signal. of
a higher risk of another fracture around the
nail later on. Exactly. And because of that uncertainty
and the moderate quality of the evidence, the
guideline notes this as an area really needing
more high quality research to provide a more
definitive answer. Hence, it remains a limited
option rather than a stronger recommendation.
OK, understood. We've navigated the surgical
maze there. Let's look at what happens after
the oper... the journey towards recovery. What
stands out as the most impactful post -operative
recommendation? Probably the most strongly supported
post -operative recommendation, and this is based
on high quality evidence, is the use of interdisciplinary
care programs. The guideline makes a strong recommendation
that these programs should be used. Interdisciplinary
care programs, what does that actually look like
in practice? What is that for a hip fracture
patient? Well, it really means moving away from
just the surgical team managing the patient in
isolation. It involves a properly coordinated
approach. bringing together orthopedic surgeons,
geriatricians, doctors, specializing in elderly
care. Crucial for this group. Absolutely. Plus
nurses, physical therapists, occupational therapists,
social workers, and potentially others like pain
specialists or nutritionists. It's a whole team.
Working together. Working together, yes. To manage
not just the fracture recovery itself, but also
the patient's overall medical health, their cognitive
function, nutritional status, psychological well
-being, and their social support needs for discharge.
So, really treating the whole patient, not just
the broken bone, does the evidence truly show
this makes a big difference? Unequivocally, yes.
The evidence is really strong on this. These
coordinated programs are proven to significantly
decrease complications during the hospital stay
and improve overall outcomes. Studies show reduced
in -hospital mortality, fewer medical complications
like pneumonia or cardiac events, and while the
evidence on longer term things like functional
recovery, mobility, and return to their previous
living situation showed positive trends, some
studies specifically reported significant improvements
in patients' cognitive status and a reduction
in symptoms of depression. That's powerful, suggesting
it helps with both physical and mental recovery,
which is just so vital in this older population.
The guideline mentioned feasibility. Are these
programs easy to implement everywhere? Well,
the guideline notes that feasibility has been
shown, meaning it is possible to set these up
in hospitals. However, it also points out that
more robust data is probably needed on the specific
cost effectiveness of these programs compared
to more traditional care models. Right. The cost
argument. Always a challenge in scaling up what
we know works. Okay, one more key post -op question.
Getting patients moving. Weight bearing. Should
they be up and walking immediately or should
it be restricted? Ah, yes. This is listed as
a limited option and it's based on very low quality
evidence that was actually downgraded. Very low
quality and downgraded, okay. Yes. The guideline
states that immediate weight bearing as tolerated
by the patient may be considered. May be considered?
That doesn't sound like a ringing endorsement
based on very low quality evidence. It isn't,
no. It really highlights the lack of strong evidence
to definitively say immediate weight bearing
is superior or even safe for all patients or
all fracture types and fixation methods. So what's
the thinking? Well, there's potential for benefits.
Maybe faster functional recovery, reduced length
of stay, possibly lower overall costs, and the
feasibility is supported by the fact that most
patients do eventually bear weight as tolerated
anyway. But there's still significant variation
in practice. The guideline noted that roughly
25 % of providers still apply some form of weight
bearing restriction after surgery. A quarter
is still restricted. Yes, which indicates a lack
of universal agreement. or, perhaps more accurately,
insufficient evidence to change that practice
definitively for everyone. It really remains
an area where clinical judgment based on the
specific fracture, the fixation achieved, and
the individual patient factors is absolutely
crucial. That makes sense. So looking back at
this whole guideline, it really feels like a
critical map through a very complex landscape.
It truly is. I mean, taking thousands of research
papers and distilling them down into practical
evidence graded recommendations requires immense
effort and a really rigorous methodology like
the one used here, including that evidence to
decision framework. Yeah. It provides clear directions
in many crucial areas, even if it also honestly
highlights where the evidence is still thin.
And frankly, more research is needed. It helps
clinicians make the best possible choices for
their patients based on the current knowledge
base. So if we were to pull out the absolute
essential takeaways from this deep dive, the
things you really need to know about best practices
for elderly hip fractures. Okay. Well, several
points are really critical and well supported
by evidence. First, forget routine preoperative
traction. The evidence is strongly against it.
Right. And second, aiming for surgery within
that 24 -48 hour window, it may improve outcomes,
even if the evidence quality itself is lower.
Okay. Third, preventing blood clots with VTE
prophylaxis is essential. That's a strong recommendation.
Let's do. Fourth, effective pain management using
multiple methods, definitely including nerve
blocks, is key. As is using tranexamic acid to
reduce surgical blood loss, both of those are
strong recommendations. Got it. Fifth, for specific
fracture types, those unstable femoral neck fractures
should ideally be treated with arthroplasty.
using a cemented femoral stem. Arthroplasty with
cement. And unstable intertrochanteric fractures
are best managed with a cephalomidulary device,
that intramidulary nail. Nail for unstable intertrox.
And finally, postoperatively, implementing those
interdisciplinary care programs is a strongly
recommended, evidence -backed way to improve
overall patient outcomes. Those are incredibly
valuable insights, really boiling down years
of research into practical steps. Thank you so
much for expertly guiding us through this vital
area of care. It was a pleasure, you know, getting
these evidence -based practices into wider, consistent
use across the board. That's really the next
big challenge, isn't it? It certainly is. If
you found this deep dive valuable, please do
consider rating and sharing the show. And finally,
a thought to leave you with. While comprehensive
guidelines like this provide strong guidance
on how to optimally treat hip fractures based
on evidence, how do healthcare systems truly
ensure these best practices are consistently
implemented across all hospitals, all care settings?
Especially when faced with those practical challenges,
the resource issues, and the varying provider
preferences that the guidelines themselves sometimes
touch upon. It leaves you wondering, doesn't
it, about that gap between knowing what to do
and consistently doing it everywhere for everyone.