Perioperative Management of Patients With Hip Fracture

The references listed below are used in this DynaMed topic primarily to support background information and for guidance where evidence summaries are not felt to be necessary. Most references are incorporated within the text along with the evidence summaries.

1. American Academy of Orthopaedic Surgeons (AAOS). Management of Hip Fractures in Older Adults: Evidence-Based Clinical Practice Guideline. AAOS 2021 Dec 3 PDF.
2. Lems WF, Dreinhöfer KE, Bischoff-Ferrari H, et al. EULAR/EFORT recommendations for management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures. Ann Rheum Dis. 2017 May;76(5):802-810PDF.
3. National Institute for Health and Clinical Excellence (NICE). Hip fracture: management. NICE 2023 Jan:CG124.
4. Liu J, Ahn J, Elkassabany NM. Optimizing perioperative care for patients with hip fracture. Anesthesiol Clin. 2014 Dec;32(4):823-39.

• British Committee for Standards in Haematology (BCSH) guideline grading system
  • strength of recommendation
    • Grade 1
      • strong recommendations made when there is confidence that benefits do or do not outweigh harm and burden
      • can be applied uniformly to most patients
      • regard as "recommend"
    • Grade 2
      • weak recommendations made where benefits and risks and burdens are closely balanced or magnitude of benefits and risks is less certain
      • require judicious application to individual patients based on patient values and preferences
      • regard as "suggest"
  • quality of evidence
    • A - high
      • further research very unlikely to change confidence in estimate of effect
      • based on randomized trials without important limitations
    • B - moderate
      • further research may well have important impact on confidence in estimate of effect and may change estimate
      • based on randomized trials with important limitations or very strong evidence from observational studies
    • C - low
      • further research likely to have important impact on confidence in estimate of effect and likely to change estimate
      • based on observational studies
    • D - very low
      • any estimate of effect is very uncertain
      • based on any other evidence
  • Reference - BCSH Grading of Recommendations Assessment, Development and Evaluation (GRADE) system
• European League Against Rheumatism/European Federation of National Associations of Orthopaedics and Traumatology (EULAR/EFORT) grading system for recommendations
  • strength of recommendations
    • Grade A - category 1 evidence
    • Grade B - category 2 evidence or extrapolated recommendations from category 1 evidence
    • Grade C - category 3 evidence or extrapolated recommendations from category 1 or 2 evidence
    • Grade D - category 4 evidence or extrapolated recommendations from category 2 or 3 evidence
  • level of evidence
    • Level 1A - meta-analysis of randomized controlled trials
    • Level 1B - ≥ 1 randomized controlled trial
    • Level 2A - ≥ 1 controlled study without randomization
    • Level 2B - ≥ 1 type of quasi-experimental study
    • Level 3 - descriptive studies, such as comparative studies, correlation studies, or case-control studies
    • Level 4 - expert committee reports or opinions and/or clinical experience of respected authorities
  • Reference - EULAR/EFORT recommendation on management of patients older than 50 years with a fragility fracture and prevention of subsequent fractures (Ann Rheum Dis 2017 May;76(5):802PDF)

• American Academy of Orthopaedic Surgeons (AAOS) grading system for recommendations
  • Strong
    • Strong or Moderate strength of evidence
    • evidence from ≥ 2 “High” strength studies with consistent findings to recommend for or against intervention, or rec upgraded from Moderate using evidence to decision framework
  • Moderate
    • Strong, Moderate, or Limited strength of evidence
    • evidence from ≥ 2 “Moderate” strength studies with consistent findings, or evidence from single “High” quality study to recommend for or against intervention, or rec upgraded or downgraded from Limited or Strong using evidence to decision framework
  • Limited
    • Limited or Moderate strength of evidence
    • low strength or conflicting evidence; evidence from ≥ 2 “Low” strength studies with consistent findings OR evidence from single study to recommend for or against intervention, or rec downgraded from Strong or Moderate using evidence to decision framework
  • Consensus
    • no evidence
    • no supporting evidence, or higher quality evidence was downgraded due to major concerns addressed within evidence to decision framework. In absence of reliable evidence, guideline work group is making recommendation based on clinical opinion
  • Option
    • little to no evidence on a topic
    • low-quality evidence or single moderate-quality study (for example, limited strength option), no evidence or only conflicting evidence (for example, consensus option), or statements resulting in limited or consensus strength following EtD Framework ugrading and/or downgrading
  • Reference - AAOS evidence-based guideline on management of hip fractures in older adults (AAOS 2021 Dec 3 PDF)
• American Academy of Orthopaedic Surgeons (AAOS) grading system for recommendations
  • quality and applicability of evidence were used in deriving grades for each recommendation, and both were assessed by evaluating number of flawed domains; for example, interventional study quality was rated as
    • High if 0-1 flawed quality domains
    • Moderate if 2-3 flawed quality domains
    • Low if 4-5 flawed quality domains
    • Very low if > 5 flawed quality domains
  • grades of recommendation
    • Strong - based on ≥ 2 High strength studies with consistent findings for recommending for or against intervention
    • Moderate - based on ≥ 2 Moderate strength studies with consistent findings, or evidence from single High strength study for recommending for or against intervention
    • Limited - based on ≥ 2 Low strength studies with consistent findings, or evidence from a single Moderate strength study for recommending for or against intervention
    • Inconclusive - based on a single Low strength study or conflicting evidence that does not allow recommendation for or against intervention
    • Consensus - based on no supporting evidence; work group makes recommendation based on expert opinion considering known harms and benefits associated with treatment
  • Reference - AAOS guideline on preventing venous thromboembolic disease in patients undergoing elective hip and knee arthroplasty (J Am Acad Orthop Surg 2011 Dec;19(12):768PDF)
• American College of Cardiology/American Heart Association (ACC/AHA) grading system
  • classifications of recommendations
    • Class I - procedure or treatment should be performed or administered
    • Class IIa - reasonable to perform procedure or administer treatment, but additional studies with focused objectives needed
    • Class IIb - procedure or treatment may be considered; additional studies with broad objectives needed, additional registry data would be useful
    • Class III - procedure or treatment is not useful/effective and may be harmful
      • Class III ratings may be subclassified as Class III No Benefit or Class III Harm
  • levels of evidence
    • Level A - data derived from multiple randomized clinical trials or meta-analyses
    • Level B - data derived from single randomized trial or nonrandomized studies
    • Level C - only consensus opinion of experts, case studies, or standard of care
  • Reference - ACC/AHA guideline on cardiovascular assessment and management of patients undergoing noncardiac surgery (Circulation 2014 Dec 9;130(24):e278), commentary can be found in J Neurosurg Anesthesiol 2017 Apr;29(2):189
• European Society of Cardiology/European Society of Anaesthesiology (ESC/ESA) grading system for recommendations
  • classes of recommendations
    • Class I - evidence and/or general agreement that given treatment or procedure is beneficial, useful, and effective
    • Class II - conflicting evidence and/or divergence of opinion about usefulness/efficacy of given treatment or procedure
      • Class IIa - weight of evidence/opinion in favor of usefulness/efficacy
      • Class IIb - usefulness/efficacy less well established by evidence/opinion
    • Class III - evidence or general agreement that given treatment or procedure is not useful/effective, and in some cases may be harmful
  • levels of evidence
    • Level A - data derived from multiple randomized clinical trials or meta-analyses
    • Level B - data derived from single randomized clinical trial or large nonrandomized studies
    • Level C - consensus of opinion of experts and/or small studies, retrospective studies, registries
  • References
    • ESC 2017 guideline focused update on dual antiplatelet therapy in coronary artery disease (Eur Heart J 2018 Jan 14;39(3):213), correction can be found in Eur Heart J 2018 Jun 7;39(22):2089
    • ESC/ESA 2014 guideline on noncardiac surgery: cardiovascular assessment and management (Eur Heart J 2014 Sep 14;35(35):2383)

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  • Strong recommendations may be used when, based on the available evidence, clinicians (without conflicts of interest) consistently have a high degree of confidence that the desirable consequences (health benefits, decreased costs and burdens) outweigh the undesirable consequences (harms, costs, burdens).
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    • Strong recommendations use "should do" phrasing, or phrasing implying an expectation to perform the recommended action for most patients.
    • Conditional recommendations use "consider" or "suggested" phrasing.
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