Abstract
OBJECTIVES: To determine evidence-based best practices for elderly hip fracture patients from the time of hospital admission to 6 months postfracture.
DATA SOURCES: MEDLINE, Cochrane Library, CINAHL, Embase, PEDro, Ageline, NARIC, and CIRRIE databases were searched for potentially eligible articles published between 1985 and 2004.
REVIEW METHODS: Two independent reviewers determined studies appropriate for inclusion using standardized selection criteria, extracted data, evaluated internal validity, and then rated studies according to levels of evidence. Only Level 1 or 2 evidence was included in our summary of clinical recommendations.
RESULTS: Spinal anesthesia, pressure-relieving mattresses, perioperative antibiotics, and deep vein thromboses prophylaxes had consistent evidence of benefit. Routine preoperative traction was not associated with any benefits and should be abandoned. Types of surgical management, postoperative wound drainage, and even “multidisciplinary” care, lacked sufficient evidence to determine either benefit or harm. There was little evidence to either determine best subacute rehabilitation practices or to direct ongoing medical issues (e.g., nutrition). Studies conducted during the subacute recovery period were heterogeneous in terms of treatment settings, interventions, and outcomes studied and had no clear evidence for best treatment practices.
CONCLUSIONS: The evidence for perioperative practices is relatively robust and evidence-based perioperative treatment guidelines can be easily established. Conversely, more evidence is required to better guide the care of elderly patients with hip fracture during the subacute recovery period and convalescence.
Similar content being viewed by others
References
Wilkins K. Health care consequences of falls for seniors. Health Reports. 1999;10:47–5.
Brainsky A, Glick H, Lydick E, et al. The economic cost of hip fractures in community-dwelling older adults: a prospective study. J Am Geriatr Soc. 1997;45:281–7.
Cooper C, Campion G, Melton LJ. Hip-fractures in the elderly—a worldwide projection. Osteoporosis Int. 1992;2:285–9.
Gullberg B, Johnell O, Kanis JA. World-wide projections for hip fracture. Osteoporosis Int. 1997;7:407–13.
Maggi S, Kelsey JL, Litvak J, Heyse SP. Incidence of hip fractures in the elderly: a cross-national analysis. Osteoporosis Int. 1991;1:232–41.
Donald IP, Bulpitt CJ. The prognosis of falls in elderly people living at home. Age Ageing. 1999;28:121–5.
Haentjens P, Autier P, Barette M, Boonen S. The economic cost of hip fractures among elderly women: a one-year, prospective, observational cohort study with matched-pair analysis. J Bone Jt Surg [Am]. 2001;83:493–500.
Wiktorowicz ME, Goeree R, Papaioannou A, Adachi JD, Papadimitropoulos E. Economic implications of hip fracture: health service use, institutional care and cost in Canada. Osteoporosis Int. 2001;12:271–8.
Landis JR, Koch GG. The measurement of observer agreement for categorical data. Biometrics. 1977;33:159–74.
Hayward Ree, ed. User Guides Interactive. Chicago, Ill: JAMA Publishing Group; 2002.
Wright JG, Swiontkowski MF, Heckman JD. Introducing levels of evidence to the journal. J Bone Jt Surg [Am]. 2003;85:1–2.
Parker MJ. Pre-operative traction for fractures of the proximal femur. Cochrane Database Syst Rev. 2003; Issue 3.
Rosen JE, Chen FS, Hiebert R, Koval KJ. Efficacy of preoperative skin traction in hip fracture patients: a prospective, randomized study. J Orthop Trauma. 2001;15:81–5.
Allman RM, Goode PS, Burst N, Bartolucci AA, Thomas DR. Pressure ulcers, hospital complications, and disease severity: impact on hospital costs and length of stay. Adv Wound Care. 1999;12:22–30.
Baumgarten M, Margolis D, Berlin JA, et al. Risk factors for pressure ulcers among elderly hip fracture patients. Wound Repair Regen. 2003;11:96–103.
Hofman A, Geelkerken RH, Wille J, Hamming J, Hermans J, Breslau P. Pressure sores and pressure-decreasing mattresses—controlled clinical-trial. Lancet. 1994;343:568–71.
Nuffield Institute of Health, University of Leeds, NHS Centre for Review and Dissemination. How effective are pressure-relieving interventions for the prevention and treatment of pressure sores? Effective Health Care Bull. 1995;2:1–15.
Bredahl C, Nyholm B, Hindsholm KB, Mortensen JS, Olesen AS. Mortality after hip fracture: results of operation within 12 h of admission. Injury. 1992;23:83–6.
Dolk T. Operation in hip fracture patients—analysis of the time factor. Injury. 1990;21:369–72.
Grimes JP, Gregory PM, Noveck H, Butler MS, Carson JL. The effects of time-to-surgery on mortality and morbidity in patients following hip fracture. Am J Med. 2002;112:702–9.
Hamlet WP, Lieberman JR, Freedman EL, Dorey FJ, Fletcher A, Johnson EE. Influence of health status and the timing of surgery on mortality in hip fracture patients. Am Orthop. 1997;26:621–7.
Hoenig H, Rubenstein LV, Sloane R, Horner R, Kahn K. What is the role of timing in the surgical and rehabilitative care of community-dwelling older persons with acute hip fracture? Arch Int Med. 1997;157:513–20.
Orosz GM, Magaziner J, Hannan EL, et al. Association of timing of surgery for hip fracture and patient outcomes. JAMA. 2004;291:1738–43.
Parker MJ, Pryor GA. The timing of surgery for proximal femoral fractures. J Bone Jt Surg [Br]. 1992;74:203–5.
Rogers FB, Shackford SR, Keller MS. Early fixation reduces morbidity and mortality in elderly patients with hip fractures from low-impact falls. J Trauma Inj Infect Crit Care. 1995;39:261–5.
Todd CJ, Freeman CJ, Camilleri-Ferrante C, et al. Differences in mortality after fracture of hip: the east Anglian audit. BMJ. 1995;310:904–8.
Zuckerman JD, Skovron ML, Koval KJ, Aharonoff G, Frankel VH. Postoperative complications and mortality associated with operative delay in older patients who have a fracture of the hip. J Bone Jt Surg [Am]. 1995;77:1551–6.
Audige L, Hanson B, Swiontkowski MF. Implant-related complications in the treatment of unstable intertrochanteric fractures: meta-analysis of dynamic screw-plate versus dynamic screw-intramedullary nail devices. Int Orthop. 2003;27:197–203.
Bhandari M, Devereaux PJ, Swiontkowski MF, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck: a meta-analysis. J Bone Jt Surg [Am]. 2003;85:1673–81.
Masson M. Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev. 2002; Issue 4.
Parker MJ, Handoll HHG, Bhargara A. Conservative versus operative treatment for hip fractures. Cochrane Database Syst Rev. 2000; Issue 4.
Parker MJ, Handoll HHG, Bhonsle S, Gillespie WJ. Condylocephalic nails versus extramedullary implants for extracapsular hip fractures. Cochrane Database Syst Rev. 1998; Issue 4.
Parker MJ. Gamma and other cephalocondylic intramedullary nails versus extramedullary implants for extracapsular hip fractures. Cochrane Database Syst Rev. 2004; Issue 1.
Parker MJ, Handoll HHG, Chinoy MA. Extramedullary fixation implants and external fixators for extracapsular hip fractures. Cochrane Database Syst Rev. 2002; Issue 4.
Parker MJ, Blundell C. Choice of implants for internal fixation of femoral neck fractures—meta analysis of 25 randomised trials including 4925 patients. Acta Orthop Scand. 2002;69:138–43.
Parker MJ. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev. 2004; Issue 2.
Parker MJ. Internal fixation implants for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev. 2001; Issue 4.
Parker MJ. Replacement arthroplasty versus internal fixation for extracapsular hip fractures. Cochrane Database Syst Rev. 1997; Issue 2.
Tidermark J, Ponzer S, Svensson O, Soderqvist A, Tornkvist H. Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly. A randomised, controlled trial. J Bone Jt Surg [Br]. 2003;85:380–8.
Rodgers A, Walker N, Schug S, McKee A, Kehler H, van Zundert A. Reduction of postoperative mortality and morbidity with epidural or spinal anaesthesia: results from overview of randomised trials. BMJ. 2000;321:1493–7.
Parker MJ, Handoll HH, Griffiths R. Anaesthesia for hip fracture surgery in adults. Cochrane Database Syst Rev. 2004; Issue 4.
Anderson FA Jr., Wheeler HB, Goldberg RJ, et al. A population-based perspective of the hospital incidence and case-fatality rates of deep vein thrombosis and pulmonary embolism. The Worcester DVT Study. Arch Int Med. 1991;151:933–8.
Eriksson BI, Lassen MR, PENT asaccharide in HIP-FRActure Surgery Plus Investigators. Duration of prophylaxi against venous thromboembolism with fondaparinux after hip fracture surgery: a multicenter, randomized, placebo-controlled, double-blind study. Arch Intern Med. 2003;163:1337–42.
Handoll HH, Farrar MJ, McBirnie J, et al. Heparin, low molecular weight heparin and physical methods for preventing deep vein thrombosis and pulmonary embolism following surgery for hip fractures. Cochrane Database Syst Rev. 2002; Issue 4.
Geerts WH, Pineo GF, Heit JA, et al. Prevention of venous thromboembolism. The 7th ACCP conference on antithrombotic and thrombolytic therapy. Chest. 2004;126:338–400S.
Gillespie WJ, Walenkamp G. Antibiotic prophylaxis for surgery for proximal femoral and other closed long bone fractures. Cochrane Database Syst Rev. 2001; Issue 1.
Parker MJ. Closed suction surgical wound drainage after orthopaedic surgery. Cochrane Database Syst Rev. 2001; Issue 4.
Johansson I, Athlin E, Frykholm L, Bolinder H, Larsson G. Intermittent versus indwelling catheters for older patients with hip fractures. J Clin Nurs. 2002;11:651–6.
Southwell-Keely JP, Russo RR, March L, Cumming R, Cameron I, Brnabic AJ. Antibiotic prophylaxis in hip fracture surgery: a metaanalysis. Clin Orthop. 2004;419:179–84.
Skelly JM, Guyatt GH, Kalbfleisch R, Singer J, Winter L. Management of urinary retention after surgical repair of hip fracture. Can Med Assoc J. 1992;146:1185–9.
Morrison RS, Magaziner J, McLaughlin MA, et al. The impact of post-operative pain on outcomes following hip fracture. Pain. 2003;103:303–11.
Scheini H, Virtanen T, Kentala E, et al. Epidural infusion of bupivacaine and fentanyl reduces perioperative myocardial ischaemia in elderly patients with hip fracture—a randomized controlled trial. Acta Anaesthesiol Scand. 2000;44:1061–70.
Matot I, Oppenheim-Eden A, Ratrot R, et al. Preoperative cardiac events in elderly patients with hip fracture randomized to epidural or conventional analgesia. Anesthesiology. 2003;98:156–63.
Beers MH. Explicit criteria for determining potentially inappropriate medication use by the elderly. An update. Arch Intern Med. 1997;157:1531–6.
Herrmann FR, Safran C, Levkoff SE, Minaker KL. Serum albumin level on admission as a predictor of death, length of stay, and readmission. Arch Int Med. 1992;152:125–30.
Patterson BM, Cornell CN, Carbone B, Levine B, Chapman D. Protein depletion and metabolic stress in elderly patients who have a fracture of the hip. J Bone Jt Surg [Am]. 1992;74:251–60.
Avenell A, Handoll HHG. Nutritional supplementation for hip fracture aftercare in the elderly. Cochrane Database Syst Rev. 2004; Issue 1.
Tkatch L, Rapin C-H, Rizzoli R, et al. Benefits of oral protein supplementation in elderly patients with fracture of the proximal femur. J Am Coll Nutr. 1992;11:519–25.
Tidermark J, Ponzer S, Carlsson P, et al. Effects of protein-rich supplementation and nandrolone in lean elderly women with femoral neck fractures. Clin Nutr. 2004;23:587–96.
Cameron I, Handoll H, Finnegan T, Madhok R, Langhorne P. Co-ordinated multidisciplinary approaches for inpatient rehabilitation of older patients with proximal femoral fractures. Cochrane Database Syst Rev. 2001; Issue 3.
Cameron ID, Lyle DM, Quine S. Accelerated rehabilitation after proximal femoral fracture: a randomized controlled trial. Disabil Rehabil. 1993;15:29–34.
Galvard H, Samuelsson SM. Orthopedic or geriatric rehabilitation of hip fracture patients: a prospective, randomized, clinically controlled study in Malmo, Sweden. Aging. 1995;7:11–6.
Hagsten B, Svensson O, Gardulf A. Early individualized postoperative occupational therapy training in 100 patients improves ADL after hip fracture: a randomized trial. Acta Orthop Scand. 2004;75:177–83.
Huusko TM, Karppi P, Avikainen V, Kautiainen H, Sulkava R. Intensive geriatric rehabilitation of hip fracture patients: a randomized, controlled trial. Acta Orthop Scand. 2002;73:425–31.
March LM, Cameron ID, Cumming RG, et al. Mortality and morbidity after hip fracture: can evidence based clinical pathways make a difference? J Rheumatol. 2000;27:2227–31.
Naglie G, Tansey C, Kirkland JL, et al. Interdisciplinary inpatient care for elderly people with hip fracture: a randomized control trial. Can Med Assoc J. 2002;167:25–32.
Roberts HC, Pickering RM, Onslow E, et al. The effectiveness of implementing a care pathway for femoral neck fracture in older people: a prospective controlled before and after study. Age Ageing. 2004;33:178–84.
Swanson CE, Day GA, Yelland CE, et al. The management of elderly patients with femoral fractures. A randomised controlled trial of early intervention versus standard care. Med J Austral. 1998;169:515–8.
Choong PF, Langford AK, Dowsey MM, Santamaria NM. Clinical pathway for fractured neck of femur: a prospective, controlled study. Med J Austral. 2000;172:423–6.
Huusko TM, Karppi P, Avikainen V, Kautiainen H, Sulkava R. Randomised, clinically controlled trial of intensive geriatric rehabilitation in patients with hip fracture: subgroup analysis of patients with dementia. BMJ. 2000;321(34 ref):1107–11.
Binder EF, Brown M, Sinacore DR, Steger-May K, Yarasheski KE, Schechtman KB. Effects of extended outpatient rehabilitation after hip fracture: a randomized controlled trial. JAMA. 2004;292:837–46.
Koval KJ, Aharonoff GB, Su ET, Zuckerman JD. Effect of acute inpatient rehabilitation on outcome after fracture of the femoral neck or intertrochanteric fracture. J Bone Jt Surg [Am]. 1998;80:357–64.
Kramer AM, Steiner JF, Schlenker RE, et al. Outcomes and costs after hip fracture and stroke: a comparison of rehabilitation settings. JAMA. 1997;277:396–404.
Kuisma R. A randomized, controlled comparison of home versus institutional rehabilitation of patients with hip fracture. Clin Rehabil. 2002;16:553–61.
Levi SJ. Posthospital setting, resource utilization, and self-care outcome in older women with hip fracture. Arch Phys Med Rehabil. 1997;78:973–9.
Sherrington C, Lord SR, Herbert RD. A randomised trial of weight-bearing versus non-weight-bearing exercise for improving physical ability in inpatients after hip fracture. Austral J Physiother. 2003; 49:15–22.
Tinetti ME, Baker DI, Gottschalk M, et al. Home-based multicomponent rehabilitation program for older persons after hip fracture: a randomized trial. Arch Phys Med Rehabil. 1999;80:916–22.
Rolland Y, Pillard F, Lauwers-Cances V, Busquere F, Vellas B, Lafont C. Rehabilitation outcome of elderly patients with hip fracture and cognitive impairment. Disabil Rehabil. 2004;26:425–31.
Prevention and Management of Hip Fracture in Older People. www.sign.ac.uk/guidelines/fulltext/56/index.html. 2002. Scottish Intercollegiate Guidelines Network.
March LM, Chamberlain AC, Cameron ID, et al. How best to fix a broken hip. Fractured Neck of Femur Health Outcomes Project Team. Med J Austral. 1999;170:489–94.
Morrison RS, Chassin MR, Siu AL. The medical consultant’s role in caring for patients with hip fracture. Ann Int Med. 1998;128:1010–20.
Author information
Authors and Affiliations
Corresponding author
Additional information
The authors have no conflicts of interest to report.
Dr. Majumdar is a Population Health Investigator of AHFMR and a New Investigator of the Canadian Institutes of Health Research.
Grant Support: This project was sponsored and funded by the Alberta Heritage Foundation for Medical Research and Alberta Health and Wellness.
Rights and permissions
About this article
Cite this article
Beaupre, L.A., Jones, C.A., Saunders, L.D. et al. Best practices for elderly hip fracture patients. J GEN INTERN MED 20, 1019–1025 (2005). https://doi.org/10.1111/j.1525-1497.2005.00219.x
Received:
Revised:
Accepted:
Issue Date:
DOI: https://doi.org/10.1111/j.1525-1497.2005.00219.x