WEBVTT 00:00:00.000 --> 00:00:02.299 Did you know that globally, the number of hip 00:00:02.299 --> 00:00:05.320 fractures in older adults, well, it's expected 00:00:05.320 --> 00:00:09.919 to surge. Up to 4 .5 million by 2050. It's a 00:00:09.919 --> 00:00:12.039 staggering figure. It really is. And it's something 00:00:12.039 --> 00:00:14.380 of a silent epidemic, isn't it, with just... 00:00:14.220 --> 00:00:16.820 devastating consequences. Absolutely. A fracture 00:00:16.820 --> 00:00:19.920 like this, it often means a huge drop in quality 00:00:19.920 --> 00:00:23.339 of life, loss of mobility, and a frighteningly 00:00:23.339 --> 00:00:26.179 high mortality rate. We're talking 24 % within 00:00:26.179 --> 00:00:28.920 just one year. And even higher for those in care 00:00:28.920 --> 00:00:32.539 homes, sadly. Exactly. The cost, both human and 00:00:32.539 --> 00:00:35.640 financial, is just immense. Easily over 40 ,000 00:00:35.640 --> 00:00:37.799 pounds a year per patient here in the UK for 00:00:37.799 --> 00:00:40.539 the ongoing care. Huge burden. Welcome to the 00:00:40.539 --> 00:00:43.920 Deep Dive, our mission to cut through the complexity 00:00:43.920 --> 00:00:46.060 and pull out the most vital insights from really 00:00:46.060 --> 00:00:48.259 challenging source material. A necessary task. 00:00:48.439 --> 00:00:50.259 Today we're tackling something absolutely critical 00:00:50.259 --> 00:00:52.939 in healthcare. the best practices for managing 00:00:52.939 --> 00:00:55.240 hip fractures in older adults. And we're doing 00:00:55.240 --> 00:00:58.219 it by navigating a, well, a very comprehensive 00:00:58.219 --> 00:01:00.399 clinical practice guideline. A really important 00:01:00.399 --> 00:01:03.140 document. Guiding our dive today is our expert 00:01:03.140 --> 00:01:06.599 guest, brilliant at synthesizing this kind of 00:01:06.599 --> 00:01:10.140 complex medical information into clear, actionable 00:01:10.140 --> 00:01:12.420 understanding. It's great to have you back. Thank 00:01:12.420 --> 00:01:16.560 you. It's definitely a topic where clarity rooted 00:01:16.560 --> 00:01:19.120 in solid evidence is just desperately needed, 00:01:19.379 --> 00:01:21.290 given the scale of the problem. you know, and 00:01:21.290 --> 00:01:23.650 its impact. Absolutely. So let's jump straight 00:01:23.650 --> 00:01:26.250 in then. Our source material is this clinical 00:01:26.250 --> 00:01:29.269 practice guideline specifically for elderly hip 00:01:29.269 --> 00:01:31.909 fracture patients. Before we get into the what, 00:01:32.069 --> 00:01:34.650 maybe tell us about the how, who put this together, 00:01:34.670 --> 00:01:37.370 and what makes it a reliable guide. Right, so 00:01:37.370 --> 00:01:40.010 this guideline was developed by a really dedicated 00:01:40.010 --> 00:01:42.870 group of physician volunteers. They undertook 00:01:42.870 --> 00:01:46.829 a very rigorous systematic review of the vast 00:01:46.829 --> 00:01:48.969 body of scientific and clinical literature out 00:01:48.969 --> 00:01:51.769 there. And importantly, it was funded independently 00:01:51.769 --> 00:01:53.750 by the American Academy of Orthopedic Surgeons, 00:01:53.840 --> 00:01:57.579 ALS. So no industry influence here. Ah, that 00:01:57.579 --> 00:02:00.480 independence is really key, isn't it? Precisely. 00:02:00.780 --> 00:02:03.939 Their scope is specifically adults aged 65 and 00:02:03.939 --> 00:02:06.180 older, though they did cast a slightly wider 00:02:06.180 --> 00:02:09.599 net, including patients down to 55 if the average 00:02:09.599 --> 00:02:12.139 age in the studies they looked at was over 65. 00:02:12.219 --> 00:02:14.740 To reflect the typical patient group. Exactly. 00:02:14.800 --> 00:02:17.139 It reflects the usual patient population, and 00:02:17.139 --> 00:02:18.860 it's focused squarely on the acute management. 00:02:18.900 --> 00:02:22.020 So from arrival at hospital through to that initial 00:02:22.020 --> 00:02:25.110 discharge. but it doesn't cover prevention or 00:02:25.110 --> 00:02:28.169 the crucial phase of post -hospital rehabilitation. 00:02:28.669 --> 00:02:30.770 Those are really complex areas in their own right 00:02:30.770 --> 00:02:33.400 covered by other guidelines. OK, so focused on 00:02:33.400 --> 00:02:36.639 that immediate crisis period, how did they sift 00:02:36.639 --> 00:02:38.780 through all that research? I mean, hip fractures 00:02:38.780 --> 00:02:41.060 must have been studied extensively. They certainly 00:02:41.060 --> 00:02:43.699 have. They conducted really extensive searches 00:02:43.699 --> 00:02:46.000 across multiple databases. They started with 00:02:46.000 --> 00:02:50.000 a, well, a staggering 8 ,678 abstracts. Wow. 00:02:50.240 --> 00:02:52.080 And after multiple filtering rounds, they narrowed 00:02:52.080 --> 00:02:54.780 it right down to 212 articles that met their 00:02:54.780 --> 00:02:57.319 inclusion criteria for a full text review. Gosh. 00:02:57.419 --> 00:02:59.360 It's that kind of thorough process you need to 00:02:59.360 --> 00:03:01.629 build a solid foundation. Just cutting down from 00:03:01.629 --> 00:03:04.349 over 8 ,000 to around 200 articles sounds like 00:03:04.349 --> 00:03:07.849 a massive job in itself. How did they then decide 00:03:07.849 --> 00:03:10.750 what the evidence actually meant and, you know, 00:03:10.870 --> 00:03:13.090 what strength to give the recommendations? Yeah, 00:03:13.110 --> 00:03:15.849 that's the crucial step. They used a formal process 00:03:15.849 --> 00:03:18.050 to grade the quality of the evidence itself, 00:03:18.770 --> 00:03:21.750 high, moderate, low, or very low. That's based 00:03:21.750 --> 00:03:24.330 on study designs, consistency of findings, things 00:03:24.330 --> 00:03:27.389 like that. Right. Then, crucially, they determine 00:03:27.389 --> 00:03:30.180 the strength of the recommendation. strong, moderate, 00:03:30.520 --> 00:03:33.400 limited, or consensus. And this isn't simply 00:03:33.400 --> 00:03:35.879 a direct translation of evidence quality. They 00:03:35.879 --> 00:03:38.539 use something called an evidence to decision 00:03:38.539 --> 00:03:40.860 framework. An evidence to decision framework. 00:03:40.919 --> 00:03:43.060 OK. That sounds a bit academic. What does that 00:03:43.060 --> 00:03:45.580 mean in practice for clinicians, for patients? 00:03:45.659 --> 00:03:47.780 It's actually very practical. It means they didn't 00:03:47.780 --> 00:03:49.979 just look at the raw statistics from the studies. 00:03:50.539 --> 00:03:52.360 They explicitly considered other factors, too. 00:03:52.419 --> 00:03:54.479 Like what? Things like the balance of potential 00:03:54.479 --> 00:03:57.500 benefits. versus the harms to the patient, the 00:03:57.500 --> 00:03:59.259 magnitude of the effect they saw in the studies, 00:03:59.719 --> 00:04:02.860 the feasibility. Can this actually be done in 00:04:02.860 --> 00:04:06.560 a real -world hospital? And also, whether patients 00:04:06.560 --> 00:04:08.639 would find it acceptable. So wait, they could 00:04:08.639 --> 00:04:12.639 potentially give a moderate or even strong recommendation, 00:04:12.780 --> 00:04:15.020 even if the evidence quality was technically 00:04:15.020 --> 00:04:18.939 low? If say the potential benefit was huge and 00:04:18.939 --> 00:04:21.579 the harms were minimal exactly or if it was simply 00:04:21.579 --> 00:04:24.000 the universally accepted standard of care already 00:04:24.000 --> 00:04:27.680 It allows them to make pragmatic clinically relevant 00:04:27.680 --> 00:04:31.100 statements even when perfect high quality evidence 00:04:31.100 --> 00:04:34.129 isn't available Which, let's face it, is often 00:04:34.129 --> 00:04:36.509 the case in complex surgical and geriatric care. 00:04:36.709 --> 00:04:38.769 Sure. And conversely, they might downgrade a 00:04:38.769 --> 00:04:40.689 recommendation based on high quality evidence. 00:04:41.129 --> 00:04:42.889 If, for example, the potential benefits were 00:04:42.889 --> 00:04:45.629 tiny or the harms were significant for a particularly 00:04:45.629 --> 00:04:48.069 frail population. It's about balancing all these 00:04:48.069 --> 00:04:50.870 factors. Right. And notably, all the recommendations 00:04:50.870 --> 00:04:54.410 in this particular guideline achieved 100 % consensus 00:04:54.410 --> 00:04:56.670 among the diverse group of experts involved. 00:04:57.129 --> 00:05:00.610 100%. Yeah. That's impressive. It is. It lends 00:05:00.610 --> 00:05:02.930 significant weight to their conclusions, suggesting 00:05:02.930 --> 00:05:05.589 these points are broadly accepted within the 00:05:05.589 --> 00:05:08.509 field. Okay, right. Armed with that understanding 00:05:08.509 --> 00:05:10.829 of how the guideline was built, let's get into 00:05:10.829 --> 00:05:13.910 the findings. Starting with what happens the 00:05:13.910 --> 00:05:16.449 moment a patient arrives? Preoperative care. 00:05:17.209 --> 00:05:19.870 What did they find, especially regarding some 00:05:19.870 --> 00:05:22.680 perhaps traditional practices? Well, one finding 00:05:22.680 --> 00:05:25.399 that might surprise quite a few clinicians relates 00:05:25.399 --> 00:05:27.819 to preoperative traction. Traction, right. Putting 00:05:27.819 --> 00:05:30.899 weights on the leg. Yes. And the guideline issues 00:05:30.899 --> 00:05:33.839 a strong recommendation based on high quality 00:05:33.839 --> 00:05:36.720 evidence against the routine use of preoperative 00:05:36.720 --> 00:05:39.540 traction for hip fractures. Against it. Really, 00:05:39.540 --> 00:05:41.779 that feels completely counterintuitive. You sort 00:05:41.779 --> 00:05:44.180 of picture traction, helping align the bones, 00:05:44.319 --> 00:05:46.720 maybe relieving pain. Well, that's the power 00:05:46.720 --> 00:05:49.920 of this kind of rigorous review. Studies consistently 00:05:49.920 --> 00:05:52.240 show that applying traction, it just doesn't 00:05:52.240 --> 00:05:55.079 offer any clear benefit, not in terms of reducing 00:05:55.079 --> 00:05:57.860 pain or improving fracture alignment before surgery, 00:05:58.259 --> 00:06:00.500 compared to simply positioning the limb comfortably 00:06:00.500 --> 00:06:03.100 with pillows. No benefit at all. None that's 00:06:03.100 --> 00:06:06.220 clear from the evidence. And worse, traction 00:06:06.220 --> 00:06:08.839 seems to introduce more problems. Like what? 00:06:09.050 --> 00:06:12.269 Things like constipation, pressure ulcers developing 00:06:12.269 --> 00:06:15.089 from being stuck in bed under traction, and even 00:06:15.089 --> 00:06:17.250 potentially increasing the risk of infection 00:06:17.250 --> 00:06:20.350 or bleeding complications. So a common practice 00:06:20.350 --> 00:06:22.829 that might actually do more harm than good, or 00:06:22.829 --> 00:06:25.629 at best, offers no real benefit. That's a very 00:06:25.629 --> 00:06:28.009 clear takeaway right there. It is. Okay, what 00:06:28.009 --> 00:06:30.069 about the urgency of surgery? Is there a sort 00:06:30.069 --> 00:06:33.319 of golden window? The guideline provides a moderate 00:06:33.319 --> 00:06:35.680 recommendation here. It's based on low quality 00:06:35.680 --> 00:06:38.600 evidence, but it was upgraded using that evidence 00:06:38.600 --> 00:06:40.500 to decision framework we talked about. Okay. 00:06:40.980 --> 00:06:43.199 And it's for proceeding with surgery within 24 00:06:43.199 --> 00:06:45.680 to 48 hours of admission. Right, low quality 00:06:45.680 --> 00:06:47.699 evidence, but they still recommend it moderately. 00:06:47.899 --> 00:06:50.180 Explain that balance again. Yeah, this is a perfect 00:06:50.180 --> 00:06:53.259 illustration of the framework at work. See, randomized 00:06:53.259 --> 00:06:55.720 controlled trials are incredibly difficult to 00:06:55.720 --> 00:06:58.480 do for surgical timing. Ethically tricky. Exactly. 00:06:58.680 --> 00:07:01.399 You can't ethically randomize people to deliberately 00:07:01.399 --> 00:07:03.899 delay surgery if you suspect it might be harmful. 00:07:04.819 --> 00:07:07.560 But the existing studies, though perhaps lower 00:07:07.560 --> 00:07:10.879 quality, consistently showed a trend. Surgery 00:07:10.879 --> 00:07:14.579 within that 24 -48 hour window may be associated 00:07:14.579 --> 00:07:17.560 with better outcomes overall. Things like reduced 00:07:17.560 --> 00:07:21.360 pain, fewer complications, perhaps shorter hospital 00:07:21.360 --> 00:07:24.540 stays, and critically, Delaying surgery beyond 00:07:24.540 --> 00:07:27.100 this window is generally associated with an increased 00:07:27.100 --> 00:07:29.699 risk of mortality and other complications, especially 00:07:29.699 --> 00:07:31.959 things like chest infections, pulmonary issues. 00:07:32.439 --> 00:07:35.339 OK. So the potential benefit to patients, even 00:07:35.339 --> 00:07:37.240 with imperfect evidence, combined with those 00:07:37.240 --> 00:07:40.079 known risks of delay, that justified the moderate 00:07:40.079 --> 00:07:42.519 recommendation. Right. They do acknowledge, though, 00:07:42.639 --> 00:07:44.360 that hitting this target can be challenging. 00:07:44.699 --> 00:07:46.480 It depends on the patient's medical stability 00:07:46.480 --> 00:07:48.579 and, of course, the hospital's resources and 00:07:48.579 --> 00:07:50.939 capacity. That makes perfect sense, balancing 00:07:50.939 --> 00:07:53.019 that imperfect evidence with the potential patient 00:07:53.019 --> 00:07:56.660 impact. Okay, moving to pain management. These 00:07:56.660 --> 00:07:59.879 fractures are, well, they're excruciating. Absolutely. 00:08:00.240 --> 00:08:03.100 And here, the evidence is much clearer. There's 00:08:03.100 --> 00:08:05.480 a strong recommendation, based on high quality 00:08:05.480 --> 00:08:09.680 evidence, for using multimodal analgesia. Multimodal. 00:08:09.819 --> 00:08:12.360 Meaning multiple approaches, not just one type 00:08:12.360 --> 00:08:15.939 of painkiller. Precisely. specifically including 00:08:15.939 --> 00:08:18.480 preoperative nerve blocks nerve blocks before 00:08:18.480 --> 00:08:21.300 surgery yes combining different types of pain 00:08:21.300 --> 00:08:24.899 relief so for instance using a regional nerve 00:08:24.899 --> 00:08:27.339 block near the hip before surgery to numb the 00:08:27.339 --> 00:08:30.569 area Alongside PrEP's standard pain medication, 00:08:31.110 --> 00:08:33.110 it's proven by high -quality studies to give 00:08:33.110 --> 00:08:35.809 superior pain control. And better outcomes. Yes, 00:08:35.850 --> 00:08:37.929 and lead to better functional outcomes for patients 00:08:37.929 --> 00:08:40.789 afterwards. Right, and managing blood loss during 00:08:40.789 --> 00:08:43.490 the surgery itself. Another area with quite clear 00:08:43.490 --> 00:08:45.980 direction. There's a strong recommendation backed 00:08:45.980 --> 00:08:48.820 by high quality evidence for administering tranhexamic 00:08:48.820 --> 00:08:51.059 acid. Tranhexamic acid, okay. This medication 00:08:51.059 --> 00:08:53.220 is well established. It's really effective in 00:08:53.220 --> 00:08:55.940 reducing blood loss during a procedure and consequently 00:08:55.940 --> 00:08:58.220 reducing the need for blood transfusions afterwards. 00:08:58.320 --> 00:09:01.100 Makes sense. And relatedly, the guideline includes 00:09:01.100 --> 00:09:03.700 a moderate recommendation, this time based on 00:09:03.700 --> 00:09:06.580 moderate quality evidence, about blood transfusions 00:09:06.580 --> 00:09:09.320 after surgery. What's the guidance there? It 00:09:09.320 --> 00:09:11.240 suggests that if a transfusion is needed in a 00:09:11.240 --> 00:09:13.580 patient who isn't showing symptoms of anemia, 00:09:13.710 --> 00:09:16.789 So they're asymptomatic. The hemoglobin level 00:09:16.789 --> 00:09:19.470 threshold used to trigger giving blood should 00:09:19.470 --> 00:09:21.690 be no higher than eight grams per deciliter. 00:09:21.870 --> 00:09:24.929 So be proactive about reducing bleeding with 00:09:24.929 --> 00:09:28.870 medication during surgery. Yes. And then be relatively 00:09:28.870 --> 00:09:31.129 conservative about giving blood afterwards if 00:09:31.129 --> 00:09:33.049 the patient is otherwise stable and not showing 00:09:33.049 --> 00:09:35.549 symptoms. That sums up the evidence -based approach 00:09:35.549 --> 00:09:38.490 there. Yes. Now, preventing blood clots, VTE, 00:09:38.909 --> 00:09:41.299 venous thromboembolism. That's a major concern 00:09:41.299 --> 00:09:43.200 for immobile patients, isn't it? I imagine the 00:09:43.200 --> 00:09:45.399 risk is incredibly high after a hip fracture. 00:09:45.600 --> 00:09:48.340 It is very high. Hip fracture patients are at 00:09:48.340 --> 00:09:50.460 significant risk for potentially fatal blood 00:09:50.460 --> 00:09:54.080 clots, like deep vein thrombosis, DVT, or a pulmonary 00:09:54.080 --> 00:09:56.559 embolism, PE. Right. So the guideline delivers 00:09:56.559 --> 00:09:58.720 a strong recommendation. This one was upgraded 00:09:58.720 --> 00:10:00.980 from moderate quality evidence, again, using 00:10:00.980 --> 00:10:03.759 that framework, that VTE prophylaxis should be 00:10:03.759 --> 00:10:07.580 used. Should be used. Unequivocal. Yes. The potential 00:10:07.580 --> 00:10:10.139 benefits of preventing these really serious clots 00:10:10.139 --> 00:10:14.399 just far outweigh the relatively low risks associated 00:10:14.399 --> 00:10:16.620 with the preventative medication in this particular 00:10:16.620 --> 00:10:18.980 population. Does it say which medication or for 00:10:18.980 --> 00:10:22.120 how long? Actually, the guideline didn't find 00:10:22.120 --> 00:10:24.379 enough evidence to definitively recommend which 00:10:24.379 --> 00:10:27.019 specific agent or how long to use it for. But 00:10:27.019 --> 00:10:30.200 the core message is unambiguous. Use some form 00:10:30.200 --> 00:10:32.669 of VTE prevention. A clear directive then, even 00:10:32.669 --> 00:10:34.909 if the specific drug choice is still down to 00:10:34.909 --> 00:10:38.429 clinical judgment. Okay, and lastly for pre -op, 00:10:38.690 --> 00:10:42.129 the choice of anesthesia, general or spinal. 00:10:42.450 --> 00:10:45.149 Right. Based on high -quality evidence, the guideline 00:10:45.149 --> 00:10:47.210 makes a strong recommendation here. And that 00:10:47.210 --> 00:10:49.570 is? That either spinal or general anesthesia 00:10:49.570 --> 00:10:53.029 is appropriate. Oh, so no preference. No. The 00:10:53.029 --> 00:10:54.750 studies reviewed showed no significant overall 00:10:54.750 --> 00:10:56.850 difference in outcomes favoring one type over 00:10:56.850 --> 00:10:58.860 the other. So the choice should really be made 00:10:58.860 --> 00:11:00.879 based on the individual patient, their overall 00:11:00.879 --> 00:11:03.639 health, the experience of the anesthetist, and 00:11:03.639 --> 00:11:05.779 the specific nature of the fracture and the planned 00:11:05.779 --> 00:11:08.620 surgery. OK, that covers preparing the patient. 00:11:08.899 --> 00:11:11.460 Now for the surgery itself, where the type of 00:11:11.460 --> 00:11:13.320 fracture really dictates the approach, doesn't 00:11:13.320 --> 00:11:15.559 it? Let's start with femoral neck fractures, 00:11:15.940 --> 00:11:18.240 specifically those that are unstable or displaced. 00:11:18.639 --> 00:11:20.500 These are the breaks right up near the ball of 00:11:20.500 --> 00:11:24.379 the hip joint. Yes, exactly. For these challenging 00:11:24.379 --> 00:11:27.440 fractures, the guideline gives a strong recommendation 00:11:27.440 --> 00:11:31.000 backed by high quality evidence for arthroplasty. 00:11:31.240 --> 00:11:34.019 Arthroplasty, so replacing part or all of the 00:11:34.019 --> 00:11:36.669 hip joint. That's right, replacing it. rather 00:11:36.669 --> 00:11:39.009 than internal fixation, which is trying to hold 00:11:39.009 --> 00:11:41.889 the bone together with screws or plates. Why 00:11:41.889 --> 00:11:44.370 is replacing the joint better than fixing the 00:11:44.370 --> 00:11:47.190 bone for this specific fracture type in older 00:11:47.190 --> 00:11:49.570 people? Well, studies have consistently shown 00:11:49.570 --> 00:11:51.690 that for these unstable femoral neck fractures 00:11:51.690 --> 00:11:54.110 in this older patient group, arthroplasty leads 00:11:54.110 --> 00:11:56.409 to significantly better long -term results. Better 00:11:56.409 --> 00:11:58.929 how? Patients tend to have less pain, better 00:11:58.929 --> 00:12:02.330 function, fewer complications overall, and crucially, 00:12:02.549 --> 00:12:04.850 a much lower chance of needing a second operation 00:12:04.850 --> 00:12:07.389 because the initial fixation failed or caused 00:12:07.389 --> 00:12:10.409 problems later on. Ah, the re -operation rate. 00:12:10.490 --> 00:12:13.429 That's key. It is. The mortality rates were actually 00:12:13.429 --> 00:12:15.950 similar between the two methods, but the quality 00:12:15.950 --> 00:12:18.669 of life and that need for re -intervention were 00:12:18.669 --> 00:12:21.769 strongly in favor of replacement. Okay, so if 00:12:21.769 --> 00:12:24.190 arthroplasty is the choice, what type? You hear 00:12:24.190 --> 00:12:26.509 about hemiarthroplasty replacing just the ball 00:12:26.509 --> 00:12:29.820 versus total hip arthroplasty replacing the ball, 00:12:30.080 --> 00:12:33.000 and socket. What about the implant itself? Okay, 00:12:33.019 --> 00:12:35.360 so for heme arthroplasty where just the femoral 00:12:35.360 --> 00:12:37.840 head the ball is replaced, there's a moderate 00:12:37.840 --> 00:12:40.259 recommendation based on moderate quality evidence. 00:12:41.000 --> 00:12:43.659 Stating that both unipolar and bipolar implants 00:12:43.659 --> 00:12:46.399 are equally beneficial. Studies just didn't show 00:12:46.399 --> 00:12:48.580 a significant difference in patient outcomes, 00:12:48.799 --> 00:12:51.700 pain, or function between these two slight variations 00:12:51.700 --> 00:12:54.399 on replacing the ball component. So either type 00:12:54.399 --> 00:12:57.049 of hemi is fine. What about comparing hemi to 00:12:57.049 --> 00:13:00.970 a full total hip arthroplasty, THA? Right. Comparing 00:13:00.970 --> 00:13:03.830 hemi to THA, replacing both components. There's 00:13:03.830 --> 00:13:06.230 a moderate recommendation, but this one was actually 00:13:06.230 --> 00:13:08.669 downgraded from high quality evidence. Downgraded? 00:13:08.669 --> 00:13:11.769 Why? The guidelines suggest that THA may offer 00:13:11.769 --> 00:13:14.330 improved functional benefits over hemiarthroplasty. 00:13:14.970 --> 00:13:17.649 But this seems to be primarily in carefully selected 00:13:17.649 --> 00:13:20.769 patients, perhaps younger, more active older 00:13:20.769 --> 00:13:23.009 adults. OK. But there's a significant caveat. 00:13:23.910 --> 00:13:26.929 THA carries a higher risk of certain complications 00:13:26.929 --> 00:13:30.769 compared to hemiautroplasty, particularly dislocation. 00:13:31.429 --> 00:13:34.309 Ah, dislocation is a major concern with hip replacements. 00:13:34.549 --> 00:13:37.950 It is. So you have potentially better function, 00:13:38.129 --> 00:13:40.929 but with a higher risk profile. That sounds like 00:13:40.929 --> 00:13:43.289 a situation needing a very careful conversation 00:13:43.289 --> 00:13:45.370 with the patient and their family. Absolutely. 00:13:45.750 --> 00:13:47.990 And as you hinted, it also generally involves 00:13:47.990 --> 00:13:50.950 a higher cost for the implant itself and potentially 00:13:50.950 --> 00:13:53.460 the procedure fees. Right. The guideline actually 00:13:53.460 --> 00:13:55.399 highlighted that more research is needed here, 00:13:55.700 --> 00:13:57.779 particularly looking at how surgical timing and 00:13:57.779 --> 00:13:59.799 the surgeon's experience with THA, specifically 00:13:59.799 --> 00:14:02.580 for fracture cases, might influence these outcomes 00:14:02.580 --> 00:14:04.799 and complication rates. More research needed 00:14:04.799 --> 00:14:07.620 there. Okay, what about the specific implant 00:14:07.620 --> 00:14:09.720 type for the femoral side, the stem that goes 00:14:09.720 --> 00:14:12.399 into the thigh bone in arthroplasty? Yes. For 00:14:12.399 --> 00:14:14.899 the femoral stem, there's a strong recommendation 00:14:14.899 --> 00:14:18.159 based on high quality evidence for using cemented 00:14:18.159 --> 00:14:20.879 femoral scums. Cemented stems. Interesting. I 00:14:20.879 --> 00:14:23.379 thought uncemented was becoming more common in, 00:14:23.379 --> 00:14:26.659 say, elective hip replacements. Why cemented 00:14:26.659 --> 00:14:29.820 specifically for fractures in the elderly? That's 00:14:29.820 --> 00:14:31.399 an excellent point. And it really highlights 00:14:31.399 --> 00:14:35.419 how fracture patterns in older often more osteoporotic 00:14:35.419 --> 00:14:38.000 bone, are different from arthritis cases. Different 00:14:38.000 --> 00:14:41.039 bone quality. Yes. The evidence strongly supports 00:14:41.039 --> 00:14:43.539 cemented stems for the specific patient population 00:14:43.539 --> 00:14:46.659 with hip fractures. They're associated with better 00:14:46.659 --> 00:14:49.840 short -term patient outcomes, more reliable fixation 00:14:49.840 --> 00:14:53.100 in potentially poorer quality bone, and potentially 00:14:53.100 --> 00:14:55.019 a lower risk of fractures occurring around the 00:14:55.019 --> 00:14:57.799 implant later on, paraprosthetic fractures, compared 00:14:57.799 --> 00:15:00.940 to unsemented stems. So better immediate fixation 00:15:00.940 --> 00:15:04.179 and maybe fewer late complications. That's what 00:15:04.179 --> 00:15:06.679 the evidence suggests. While putting in a cemented 00:15:06.679 --> 00:15:09.019 stem can sometimes take slightly longer in surgery 00:15:09.019 --> 00:15:11.019 and might involve a little more blood loss during 00:15:11.019 --> 00:15:13.940 the procedure, the evidence on improved outcomes 00:15:13.940 --> 00:15:17.059 is compelling. And cost. And cemented implants 00:15:17.059 --> 00:15:19.250 are generally less expensive as well. That's 00:15:19.250 --> 00:15:22.470 a really key detail, the specific demands of 00:15:22.470 --> 00:15:25.370 fixing a fracture in potentially weaker bone 00:15:25.370 --> 00:15:28.870 driving that recommendation. What about the surgical 00:15:28.870 --> 00:15:31.350 approach itself? You know, from the back, the 00:15:31.350 --> 00:15:33.929 side, the front, does the evidence favor one? 00:15:34.710 --> 00:15:37.210 Here, the guideline has a moderate recommendation 00:15:37.210 --> 00:15:40.269 based on moderate quality evidence. It states 00:15:40.269 --> 00:15:42.549 that the evidence does not clearly favor one 00:15:42.549 --> 00:15:45.179 surgical approach over another. Overall really 00:15:45.179 --> 00:15:48.600 no winner definitively. They looked at studies 00:15:48.600 --> 00:15:51.720 comparing posterior minimally invasive variations 00:15:51.720 --> 00:15:54.600 direct lateral and direct anterior approaches 00:15:54.600 --> 00:15:57.519 The findings were well pretty mixed regarding 00:15:57.519 --> 00:15:59.659 short -term benefits like initial pain levels 00:15:59.659 --> 00:16:01.840 or how quickly patients started walking Okay, 00:16:02.139 --> 00:16:04.940 importantly long -term outcomes and overall complication 00:16:04.940 --> 00:16:07.100 rates were often similar across the different 00:16:07.100 --> 00:16:10.049 approaches studied So it seems like maybe the 00:16:10.049 --> 00:16:12.450 surgeon's familiarity and expertise with a particular 00:16:12.450 --> 00:16:14.509 approach are probably the most critical factors 00:16:14.509 --> 00:16:16.990 here, rather than one approach being inherently 00:16:16.990 --> 00:16:19.629 superior based on this evidence. Based on the 00:16:19.629 --> 00:16:21.590 current evidence review for this guideline, that 00:16:21.590 --> 00:16:24.429 certainly appears to be the case. Okay. Now let's 00:16:24.429 --> 00:16:28.070 shift focus slightly to intertrochanteric fractures. 00:16:28.710 --> 00:16:31.350 These are lower down the femur compared to the 00:16:31.350 --> 00:16:34.029 femoral neck, sort of outside the joint capsule 00:16:34.029 --> 00:16:36.690 itself, but still part of the hip region. That's 00:16:36.690 --> 00:16:38.710 right. A different fracture pattern. And often 00:16:38.710 --> 00:16:40.549 requires a different hardware solution, right? 00:16:40.830 --> 00:16:43.389 Exactly. The type of implant usually depends 00:16:43.389 --> 00:16:45.230 on whether the fracture pattern is considered 00:16:45.230 --> 00:16:48.529 stable or unstable. Let's start with stable ones. 00:16:48.629 --> 00:16:51.590 Okay. For stable inner trochanteric fractures, 00:16:51.889 --> 00:16:54.850 there's a strong recommendation based on high 00:16:54.850 --> 00:16:57.250 -quality evidence. And the recommendation is? 00:16:57.370 --> 00:17:01.809 That either a sliding hip screw or a cephalomedulary 00:17:01.809 --> 00:17:04.369 device is recommended. Both are good options. 00:17:04.569 --> 00:17:06.410 Could you just briefly explain the difference 00:17:06.410 --> 00:17:09.049 between those two types of implants again? Certainly. 00:17:09.589 --> 00:17:11.509 A sliding hip screw is typically a plate that 00:17:11.509 --> 00:17:13.490 runs along the side of the femur, fixed with 00:17:13.490 --> 00:17:16.269 screws, and it has a large screw that slides 00:17:16.269 --> 00:17:18.809 into the head of the femur. It's an extra medullary 00:17:18.809 --> 00:17:20.930 device, meaning it sits outside the bone marrow 00:17:20.930 --> 00:17:22.289 cavity. Okay, outside the bone marrow cavity. 00:17:22.450 --> 00:17:24.890 Whereas a cephalomedullary device, often called 00:17:24.890 --> 00:17:27.930 an intramedullary nail or IM nail, is actually 00:17:27.930 --> 00:17:30.430 placed inside the bone marrow canal of the femur. 00:17:30.619 --> 00:17:33.519 It's a rod inside the bone, with screws going 00:17:33.519 --> 00:17:35.740 up into the femoral head to hold the fracture. 00:17:35.960 --> 00:17:38.819 Ah, okay. One outside the bone, one inside. And 00:17:38.819 --> 00:17:40.759 for stable fractures, the evidence shows they 00:17:40.759 --> 00:17:43.339 both work equally well. That's right. High quality 00:17:43.339 --> 00:17:45.920 evidence shows similar clinical outcomes. Things 00:17:45.920 --> 00:17:48.650 like walking ability... hospital stay length, 00:17:49.130 --> 00:17:51.069 and complication rates like fracture collapse 00:17:51.069 --> 00:17:53.970 or implant failure when using either device for 00:17:53.970 --> 00:17:56.190 these stable patterns. Okay, but what about the 00:17:56.190 --> 00:17:59.250 unstable ones? Yes, for unstable inner trochanteric 00:17:59.250 --> 00:18:01.930 fractures, and this includes patterns like subtrochanteric 00:18:01.930 --> 00:18:04.349 extension or what's called reverse obliquity, 00:18:04.490 --> 00:18:06.390 where the bone fragments are just less stable 00:18:06.390 --> 00:18:08.910 and rotational forces are a bigger issue. Right, 00:18:09.049 --> 00:18:12.130 more complex breaks. Exactly. For those, the 00:18:12.130 --> 00:18:14.930 picture changes. Here, there's a strong recommendation, 00:18:15.029 --> 00:18:17.529 also based on high -quality evidence, that patients 00:18:17.529 --> 00:18:19.630 should be treated with a cephalomedullary device, 00:18:20.210 --> 00:18:23.309 the intramedullary nail. So, for unstable breaks, 00:18:23.690 --> 00:18:26.289 the nail inside the bone is strongly preferred 00:18:26.289 --> 00:18:29.089 over the plate on the outside. Why the clear 00:18:29.089 --> 00:18:31.750 preference here? The evidence is quite strong 00:18:31.750 --> 00:18:34.630 for these unstable patterns. Intramedullary nails 00:18:34.630 --> 00:18:37.569 provide better biomechanical stability. They're 00:18:37.569 --> 00:18:40.009 better at resisting the forces that want to displace 00:18:40.009 --> 00:18:42.250 these unstable fragments. Mechanically stronger 00:18:42.250 --> 00:18:44.809 for that situation. Yes. Compared to sliding 00:18:44.809 --> 00:18:47.529 hip screws, studies looking specifically at unstable 00:18:47.529 --> 00:18:50.190 fractures show a significant treatment benefit 00:18:50.190 --> 00:18:53.170 with cephalomedular devices. This can include 00:18:53.170 --> 00:18:55.849 potentially improved walking ability and sometimes 00:18:55.849 --> 00:18:58.390 fewer blood transfusions needed, perhaps due 00:18:58.390 --> 00:19:00.750 to reduced surgical trauma, compared to fitting 00:19:00.750 --> 00:19:03.470 a plate. It's just a more reliable construct 00:19:03.470 --> 00:19:06.480 for these more complex fracture patterns. That's 00:19:06.480 --> 00:19:08.539 a crucial distinction based on fracture stability. 00:19:08.799 --> 00:19:10.640 Now, what about the length of that intramedullary 00:19:10.640 --> 00:19:12.920 nail? Sometimes you hear about short versus long 00:19:12.920 --> 00:19:15.279 nails. Does the guideline address that? Yes, 00:19:15.279 --> 00:19:17.660 it does. This is addressed as a limited option 00:19:17.660 --> 00:19:19.960 based on moderate quality evidence. A limited 00:19:19.960 --> 00:19:23.039 option, meaning? Meaning both short and long 00:19:23.039 --> 00:19:26.220 suflamedullary nails are considered acceptable 00:19:26.220 --> 00:19:28.940 treatment options for pertrochanteric fractures, 00:19:29.359 --> 00:19:31.539 which includes many of these intertrochanteric 00:19:31.539 --> 00:19:34.299 patterns. there isn't strong evidence favoring 00:19:34.299 --> 00:19:36.319 one over the other definitively. So what did 00:19:36.319 --> 00:19:38.339 the evidence actually show when comparing them? 00:19:38.509 --> 00:19:40.470 Well, studies comparing short and long nails 00:19:40.470 --> 00:19:42.869 for these patterns suggest that short nails might 00:19:42.869 --> 00:19:45.430 have some minor advantages, things like potentially 00:19:45.430 --> 00:19:48.509 less operating time, maybe less blood loss, or 00:19:48.509 --> 00:19:50.829 reduced x -ray exposure during surgery. Some 00:19:50.829 --> 00:19:53.930 potential procedural benefits. Yes, but importantly, 00:19:54.329 --> 00:19:57.130 there wasn't a consistent, significant difference 00:19:57.130 --> 00:20:00.470 found in overall adverse events or those really 00:20:00.470 --> 00:20:02.730 important patient outcomes like walking recovery 00:20:02.730 --> 00:20:05.430 or final function. So similar outcomes overall? 00:20:05.829 --> 00:20:09.059 Pretty much. Interestingly, though, some lower 00:20:09.059 --> 00:20:11.559 quality evidence hinted at a potentially higher 00:20:11.559 --> 00:20:14.079 risk of paraprosthetic fracture. That's a fracture 00:20:14.079 --> 00:20:16.000 around the implant itself with the short nails. 00:20:16.460 --> 00:20:20.059 Ah, okay. So short nails might be slightly easier 00:20:20.059 --> 00:20:22.880 or quicker to put in, but the long -term functional 00:20:22.880 --> 00:20:25.200 outcome might be similar. And there's maybe a 00:20:25.200 --> 00:20:27.539 slight question mark, a potential signal. of 00:20:27.539 --> 00:20:29.480 a higher risk of another fracture around the 00:20:29.480 --> 00:20:32.799 nail later on. Exactly. And because of that uncertainty 00:20:32.799 --> 00:20:35.240 and the moderate quality of the evidence, the 00:20:35.240 --> 00:20:37.680 guideline notes this as an area really needing 00:20:37.680 --> 00:20:41.299 more high quality research to provide a more 00:20:41.299 --> 00:20:43.980 definitive answer. Hence, it remains a limited 00:20:43.980 --> 00:20:46.400 option rather than a stronger recommendation. 00:20:46.980 --> 00:20:49.640 OK, understood. We've navigated the surgical 00:20:49.640 --> 00:20:52.240 maze there. Let's look at what happens after 00:20:52.240 --> 00:20:55.400 the oper... the journey towards recovery. What 00:20:55.400 --> 00:20:57.720 stands out as the most impactful post -operative 00:20:57.720 --> 00:21:00.680 recommendation? Probably the most strongly supported 00:21:00.680 --> 00:21:02.599 post -operative recommendation, and this is based 00:21:02.599 --> 00:21:05.619 on high quality evidence, is the use of interdisciplinary 00:21:05.619 --> 00:21:08.640 care programs. The guideline makes a strong recommendation 00:21:08.640 --> 00:21:11.160 that these programs should be used. Interdisciplinary 00:21:11.160 --> 00:21:12.940 care programs, what does that actually look like 00:21:12.940 --> 00:21:14.900 in practice? What is that for a hip fracture 00:21:14.900 --> 00:21:17.279 patient? Well, it really means moving away from 00:21:17.279 --> 00:21:19.319 just the surgical team managing the patient in 00:21:19.319 --> 00:21:21.539 isolation. It involves a properly coordinated 00:21:21.539 --> 00:21:24.160 approach. bringing together orthopedic surgeons, 00:21:24.460 --> 00:21:27.579 geriatricians, doctors, specializing in elderly 00:21:27.579 --> 00:21:30.619 care. Crucial for this group. Absolutely. Plus 00:21:30.619 --> 00:21:33.299 nurses, physical therapists, occupational therapists, 00:21:33.579 --> 00:21:35.700 social workers, and potentially others like pain 00:21:35.700 --> 00:21:38.220 specialists or nutritionists. It's a whole team. 00:21:38.259 --> 00:21:41.480 Working together. Working together, yes. To manage 00:21:41.480 --> 00:21:44.920 not just the fracture recovery itself, but also 00:21:44.920 --> 00:21:47.839 the patient's overall medical health, their cognitive 00:21:47.839 --> 00:21:50.720 function, nutritional status, psychological well 00:21:50.720 --> 00:21:53.460 -being, and their social support needs for discharge. 00:21:53.660 --> 00:21:56.880 So, really treating the whole patient, not just 00:21:56.880 --> 00:21:59.700 the broken bone, does the evidence truly show 00:21:59.700 --> 00:22:02.259 this makes a big difference? Unequivocally, yes. 00:22:02.759 --> 00:22:05.180 The evidence is really strong on this. These 00:22:05.180 --> 00:22:07.500 coordinated programs are proven to significantly 00:22:07.500 --> 00:22:09.819 decrease complications during the hospital stay 00:22:09.819 --> 00:22:13.119 and improve overall outcomes. Studies show reduced 00:22:13.119 --> 00:22:16.220 in -hospital mortality, fewer medical complications 00:22:16.220 --> 00:22:19.099 like pneumonia or cardiac events, and while the 00:22:19.099 --> 00:22:21.680 evidence on longer term things like functional 00:22:21.680 --> 00:22:24.460 recovery, mobility, and return to their previous 00:22:24.460 --> 00:22:27.460 living situation showed positive trends, some 00:22:27.460 --> 00:22:30.220 studies specifically reported significant improvements 00:22:30.220 --> 00:22:32.980 in patients' cognitive status and a reduction 00:22:32.980 --> 00:22:35.920 in symptoms of depression. That's powerful, suggesting 00:22:35.920 --> 00:22:38.339 it helps with both physical and mental recovery, 00:22:38.420 --> 00:22:41.160 which is just so vital in this older population. 00:22:41.799 --> 00:22:43.559 The guideline mentioned feasibility. Are these 00:22:43.559 --> 00:22:46.099 programs easy to implement everywhere? Well, 00:22:46.160 --> 00:22:48.079 the guideline notes that feasibility has been 00:22:48.079 --> 00:22:50.819 shown, meaning it is possible to set these up 00:22:50.819 --> 00:22:53.319 in hospitals. However, it also points out that 00:22:53.319 --> 00:22:56.200 more robust data is probably needed on the specific 00:22:56.200 --> 00:22:58.519 cost effectiveness of these programs compared 00:22:58.519 --> 00:23:00.680 to more traditional care models. Right. The cost 00:23:00.680 --> 00:23:02.839 argument. Always a challenge in scaling up what 00:23:02.839 --> 00:23:05.740 we know works. Okay, one more key post -op question. 00:23:06.720 --> 00:23:10.180 Getting patients moving. Weight bearing. Should 00:23:10.180 --> 00:23:12.200 they be up and walking immediately or should 00:23:12.200 --> 00:23:15.119 it be restricted? Ah, yes. This is listed as 00:23:15.119 --> 00:23:17.500 a limited option and it's based on very low quality 00:23:17.500 --> 00:23:19.960 evidence that was actually downgraded. Very low 00:23:19.960 --> 00:23:22.880 quality and downgraded, okay. Yes. The guideline 00:23:22.880 --> 00:23:25.339 states that immediate weight bearing as tolerated 00:23:25.339 --> 00:23:28.519 by the patient may be considered. May be considered? 00:23:28.809 --> 00:23:31.170 That doesn't sound like a ringing endorsement 00:23:31.170 --> 00:23:34.150 based on very low quality evidence. It isn't, 00:23:34.250 --> 00:23:36.849 no. It really highlights the lack of strong evidence 00:23:36.849 --> 00:23:38.930 to definitively say immediate weight bearing 00:23:38.930 --> 00:23:43.190 is superior or even safe for all patients or 00:23:43.190 --> 00:23:45.910 all fracture types and fixation methods. So what's 00:23:45.910 --> 00:23:48.849 the thinking? Well, there's potential for benefits. 00:23:49.069 --> 00:23:51.680 Maybe faster functional recovery, reduced length 00:23:51.680 --> 00:23:55.000 of stay, possibly lower overall costs, and the 00:23:55.000 --> 00:23:56.660 feasibility is supported by the fact that most 00:23:56.660 --> 00:23:59.019 patients do eventually bear weight as tolerated 00:23:59.019 --> 00:24:02.160 anyway. But there's still significant variation 00:24:02.160 --> 00:24:04.519 in practice. The guideline noted that roughly 00:24:04.519 --> 00:24:07.799 25 % of providers still apply some form of weight 00:24:07.799 --> 00:24:09.619 bearing restriction after surgery. A quarter 00:24:09.619 --> 00:24:12.819 is still restricted. Yes, which indicates a lack 00:24:12.819 --> 00:24:16.019 of universal agreement. or, perhaps more accurately, 00:24:16.839 --> 00:24:19.380 insufficient evidence to change that practice 00:24:19.380 --> 00:24:22.160 definitively for everyone. It really remains 00:24:22.160 --> 00:24:24.619 an area where clinical judgment based on the 00:24:24.619 --> 00:24:27.400 specific fracture, the fixation achieved, and 00:24:27.400 --> 00:24:29.640 the individual patient factors is absolutely 00:24:29.640 --> 00:24:32.140 crucial. That makes sense. So looking back at 00:24:32.140 --> 00:24:33.880 this whole guideline, it really feels like a 00:24:33.880 --> 00:24:36.119 critical map through a very complex landscape. 00:24:36.349 --> 00:24:39.069 It truly is. I mean, taking thousands of research 00:24:39.069 --> 00:24:41.210 papers and distilling them down into practical 00:24:41.210 --> 00:24:44.190 evidence graded recommendations requires immense 00:24:44.190 --> 00:24:46.910 effort and a really rigorous methodology like 00:24:46.910 --> 00:24:49.490 the one used here, including that evidence to 00:24:49.490 --> 00:24:52.069 decision framework. Yeah. It provides clear directions 00:24:52.069 --> 00:24:54.970 in many crucial areas, even if it also honestly 00:24:54.970 --> 00:24:56.809 highlights where the evidence is still thin. 00:24:57.170 --> 00:24:59.670 And frankly, more research is needed. It helps 00:24:59.670 --> 00:25:01.509 clinicians make the best possible choices for 00:25:01.509 --> 00:25:03.029 their patients based on the current knowledge 00:25:03.029 --> 00:25:06.009 base. So if we were to pull out the absolute 00:25:06.009 --> 00:25:08.529 essential takeaways from this deep dive, the 00:25:08.529 --> 00:25:10.630 things you really need to know about best practices 00:25:10.630 --> 00:25:13.029 for elderly hip fractures. Okay. Well, several 00:25:13.029 --> 00:25:14.769 points are really critical and well supported 00:25:14.769 --> 00:25:17.890 by evidence. First, forget routine preoperative 00:25:17.890 --> 00:25:20.109 traction. The evidence is strongly against it. 00:25:20.309 --> 00:25:22.329 Right. And second, aiming for surgery within 00:25:22.329 --> 00:25:25.990 that 24 -48 hour window, it may improve outcomes, 00:25:26.049 --> 00:25:28.029 even if the evidence quality itself is lower. 00:25:28.210 --> 00:25:31.049 Okay. Third, preventing blood clots with VTE 00:25:31.049 --> 00:25:34.170 prophylaxis is essential. That's a strong recommendation. 00:25:34.410 --> 00:25:37.829 Let's do. Fourth, effective pain management using 00:25:37.829 --> 00:25:39.769 multiple methods, definitely including nerve 00:25:39.769 --> 00:25:43.390 blocks, is key. As is using tranexamic acid to 00:25:43.390 --> 00:25:46.009 reduce surgical blood loss, both of those are 00:25:46.009 --> 00:25:49.190 strong recommendations. Got it. Fifth, for specific 00:25:49.190 --> 00:25:52.750 fracture types, those unstable femoral neck fractures 00:25:52.750 --> 00:25:54.730 should ideally be treated with arthroplasty. 00:25:54.839 --> 00:25:57.740 using a cemented femoral stem. Arthroplasty with 00:25:57.740 --> 00:26:00.559 cement. And unstable intertrochanteric fractures 00:26:00.559 --> 00:26:02.980 are best managed with a cephalomidulary device, 00:26:03.400 --> 00:26:06.279 that intramidulary nail. Nail for unstable intertrox. 00:26:06.539 --> 00:26:09.339 And finally, postoperatively, implementing those 00:26:09.339 --> 00:26:11.799 interdisciplinary care programs is a strongly 00:26:11.799 --> 00:26:14.619 recommended, evidence -backed way to improve 00:26:14.619 --> 00:26:17.059 overall patient outcomes. Those are incredibly 00:26:17.059 --> 00:26:19.519 valuable insights, really boiling down years 00:26:19.519 --> 00:26:22.559 of research into practical steps. Thank you so 00:26:22.559 --> 00:26:24.740 much for expertly guiding us through this vital 00:26:24.740 --> 00:26:26.859 area of care. It was a pleasure, you know, getting 00:26:26.859 --> 00:26:30.660 these evidence -based practices into wider, consistent 00:26:30.660 --> 00:26:32.839 use across the board. That's really the next 00:26:32.839 --> 00:26:35.059 big challenge, isn't it? It certainly is. If 00:26:35.059 --> 00:26:37.559 you found this deep dive valuable, please do 00:26:37.559 --> 00:26:40.420 consider rating and sharing the show. And finally, 00:26:40.680 --> 00:26:43.339 a thought to leave you with. While comprehensive 00:26:43.339 --> 00:26:45.559 guidelines like this provide strong guidance 00:26:45.559 --> 00:26:47.759 on how to optimally treat hip fractures based 00:26:47.759 --> 00:26:50.480 on evidence, how do healthcare systems truly 00:26:50.480 --> 00:26:52.980 ensure these best practices are consistently 00:26:52.980 --> 00:26:56.880 implemented across all hospitals, all care settings? 00:26:57.259 --> 00:26:59.599 Especially when faced with those practical challenges, 00:26:59.799 --> 00:27:02.039 the resource issues, and the varying provider 00:27:02.039 --> 00:27:04.059 preferences that the guidelines themselves sometimes 00:27:04.059 --> 00:27:06.019 touch upon. It leaves you wondering, doesn't 00:27:06.019 --> 00:27:08.319 it, about that gap between knowing what to do 00:27:08.319 --> 00:27:11.400 and consistently doing it everywhere for everyone.