AAOS CPG Hip Fractures in the Elderly

1. AAOS CPGHip Fractures in the Elderly Eric S. Moghadamian M.D. Associate Professor, Orthopaedic Surgery and Sports Medicine Southeast Fracture Symposium 01/31/2019

2. Disclosures • Zimmer-Biomet

4. What it is…. • based on a systematic review of literature • patients over the age of 65. • intended to serve as an information resource • decision makers • developers of practice guidelines and recommendations.

5. What it is not….. • Is not intended to be a fixed protocol. • Is not intended to stand alone.

6. What it is not….. • Is not intended to be a fixed protocol. • Is not intended to stand alone. • patients may not necessarily be the same as those in clinical trials • treatment based on a clinician’s independent medical judgment and clinical circumstances • Treatments rely on mutual communication between patient and healthcare provider

7. Who…. • Orthopaedicsurgeons • Physicians (PCP, geriatricians, hospitalists, ER) managing elderly patients with hip fractures • PA, ARNP, PT/OT

8. Who…. • Insurance payers • Governmental bodies • Health-policy decision-makers • “may find this guideline useful as an evolving standard of evidence”

10. 72 y.o. female presents to the emergency department after a fall from standing with complaints of right hip and groin pain. Initial radiographs are negative for a hip fracture but your clinical index of suspicion remains high. The appropriate next step in management of the patient would be:

11. 72 y.o. female presents to the emergency department after a fall from standing with complaints of right hip and groin pain. Initial radiographs are negative for a hip fracture but your clinical index of suspicion remains high. The appropriate next step in management of the patient would be: • CT scan • MRI • Bone scan • Weight bearing radiographs • 50% partial weight bearing with repeat radiographs in one week

12. MRI is the advanced imaging of choice • Able to demonstrate causes of hip pain other than fracture as well • Limited hip MRIs • lower cost and shorter duration than standard MRI

13. Performing regional anesthesia in elderly patients with hip fractures:

14. Performing regional anesthesia in elderly patients with hip fractures: • Should be done upon admission • Should be performed in the OR prior to surgery • Should only be performed by anesthesiologists trained in regional anesthetic pain techniques • Results in increased postoperative delirium • Leads to increased surgical complications

15. Early regional anesthesia is recommended • Improves pre operative pain control • Reduces post op delirium • Any provider with adequate training • Fascia iliaca block • Femoral block • Epidural • Emergency room administered continuous epidural anesthesia • reduction of MI events preoperatively in high risk patients

16. Preoperative traction in elderly patients with hip fractures:

17. Preoperative traction in elderly patients with hip fractures: • Reduces pain • Should only be applied via skin traction • Reduces operative time • All of the above • None of the above

18. Preoperative traction for elderly patients is not supported • No traction vs. skeletal traction. vs. skin traction • No difference in pain alleviation or analgesia administered • Complained of worsened initial pain with skeletal traction

19. In order to achieve optimal outcomes in elderly patients with hip fractures, hip fracture surgery should be performed:

20. In order to achieve optimal outcomes in elderly patients with hip fractures, hip fracture surgery should be performed: • Within 24 hours • Within 48 hours • Within 4 days of admission • Whenever I get an opening in my elective schedule later this week (“Can’t cancel an elective THA, it’s bad for business”

21. Hip fracture surgery within 48 hours of admission is associated with better outcomes • Improved outcomes • mortality • pain • complications • LOS • In general, patients should go to the operating room as soon as possible when they have been medically optimized

22. A 69 y.o male presents with an isolated displaced femoral neck fracture. Your surgical plan is for total hip arthroplasty. The patient has a hx of cardiac stenting and is on clopidogrel. You should delay surgery :

23. A 69 y.o male presents with an isolated displaced femoral neck fracture. Your surgical plan is for total hip arthroplasty. The patient has a hx of cardiac stenting and is on clopidogrel. You should delay surgery : • 48 hours • 5 days • 1 week • No indication to delay (“All bleeding stops eventually!”)

24. Antiplatelet therapy ( ASA /Clopidgrel) • No disadvantage to not delaying • Possible advantage to those where surgery is not delayed • Recommendation aimed at preventing unhelpful delays in surgery • Does not refer to Eliquis/Direct Factor 10A inhibitors

25. True or False Surgical treatment of hip fractures should be performed under spinal anesthesia whenever possible. False

26. General versus spinal anesthesia • No major difference and outcomes are similar • When in doubt, let your anesthesia provider dictate choice of anesthesia

27. True or False Nondisplaced stable and valgus impacted femoral neck fractures should be treated nonoperatively whenever possible.

28. True or False Nondisplaced stable and valgus impacted femoral neck fractures should be treated nonoperatively whenever possible. False

29. Nondisplaced /Valgus impacted • Recommend operative fixation for patients with stable (non-displaced) femoral neck fractures • Low risk, earlier mobilization and fewer complications • Goal is to prevent displacement

30. Displaced femoral neck fractures in the elderly should ideally be treated with:

31. Displaced femoral neck fractures in the elderly should ideally be treated with: • ORIF with compression hip screw and side plate • ORIF three cannulated screws • CR/PP • Arthroplasty via and lateral or Modified Hardinge approach • Arthroplasty via a posterior approach

32. Recommend arthroplasty as TOC for patients with displaced femoral neck fractures • Higher dislocation rate with posterior approach in the treatment of displaced femoral neck fractures

33. Recommend arthroplasty as TOC for patients with displaced femoral neck fractures • Higher dislocation rate with posterior approach in the treatment of displaced femoral neck fractures Functional outcomes and physician familiarity not addressed

34. An active 65 year old male with no medical comorbidities and normal mentation presents with hip pain after a fall from standing height. The optimal treatment for this patient is:

35. An active 65 year old male with no medical comorbidities and normal mentation presents with hip pain after a fall from standing height. The optimal treatment for this patient is: • Bipolar hemiarthroplasty with a cemented stem • Unipolar hemiarthroplasty with a cemented stem • THA with a press fit stem • THA with a cemented stem

36. Benefit to total hip arthroplasty in properly selected patients with unstable (displaced) femoral neck fractures • Lower pain score • Lower revision rates for wear • Preferentialuse of cemented femoral stems in patients undergoing arthroplasty for femoral neck fractures. • Randomized controlled trials have largely failed to demonstrate differences with the exception of fracture risk which appears to be higher in press fit stems • In general, both approaches yielded acceptable functional results with low complication rates.

37. An active 71 year old male with no medical comorbidities and normal mentation presents with hip pain after a fall from standing height. His radiographs reveal a stable intertrochanteric hip fracture. The optimal treatment for this patient is:

38. An active 71 year old male with no medical comorbidities and normal mentation presents with hip pain after a fall from standing height. His radiographs reveal a stable intertrochanteric hip fracture. The optimal treatment for this patient is: • A compression hip screw and side plate • A cephalomedullary device • All of the above • None of the above

39. Stable IT hip fracture • Perhaps less blood loss and OR time with compression hip screw but • Minimal difference in regards to functional outcomes, hospital stay, collapse, mortality

40. An active 71 year old male with no medical comorbidities and normal mentation presents with the following radiographs The optimal treatment for this patient is:

41. An active 71 year old male with no medical comorbidities and normal mentation presents with the following radiographs The optimal treatment for this patient is: • Compression hip screw and side plate • Proximal femoral locking plate • Short cepahmolmedullary device • Long cephalomedullary device

42. Recommendations: • Cephalomedullary device for unstable IT fractures • Cephalomedullary device for subtrochanteric and reverse obliquity fractures • OTA Companion Statement • recommends that long cephalomedullarynails be used for subtrochantericand reverse obliquity fractures.

43. An 71 year old male with a hx of CAD underwent fixation of a right IT hip fracture with a cephalomeduallry device. His would is clean and without drainage and he has minimal swelling of the thigh. He has no orthostasis and is otherwise asymptomatic. On POD#1 his H/H is 8.5/25. Appropriate management of his anemia includes:

44. An 71 year old male with a hx of CAD underwent fixation of a right IT hip fracture with a cephalomeduallry device. His would is clean and without drainage and he has minimal swelling of the thigh. He has no orthostasis and is otherwise asymptomatic. On POD#1his H/H is 8.5/25. Appropriate management of his anemia includes: • Stopping all VTE prophylaxis • Transfusing 1 u PRBC • Transfusing 2 u PRBC • Clinical observation and repeat H/H if indicated

45. Transfusion threshold - 8g/dl • Cardiac patients • No transfusions as long as >8g/dl and asymptomatic • Symptoms or signs appropriate for transfusion • cardiac pain • congestive heart failure • unexplained tachycardia • hypotension unresponsive to fluid replacement.

46. Additional Reccomendations: • Interdisciplinary care team for hip fracture patients with dementia • Postoperative multimodal anesthesia • Intensive home PT

47. Additional Reccomendations: • VTE prophylaxis • Nutritional supplementation • Osteoporosis evaluation and treatment • Postoperative calcium and Vitamin D supplementation • 800-2000 IU/day Vitamin D • Calcium Carbonate 1200mg/day

48. Summary • Recommendations • Should do, not must do • Valuable resource • Educate providers • Improve hip fracture care for elderly patients • “Primum non nocere” • Always do what’s in the best interest of your specific patient