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September 09, 2014

American Academy of Orthopaedic Surgeons releases new guidelines on hip fractures in older adults, ACL injuries, and infant dysplasia of the hip

ROSEMONT, Ill. - The American Academy of Orthopaedic Surgeons (AAOS) today released three new clinical practice guidelines (CPG) featuring evidence-based recommendations for diagnosing and treating  hip fractures in patients age 65 and older, anterior cruciate ligament (ACL) injuries, and dysplasia of the hip in infants up to 6 months of age. These recommendations are meant to be used as an educational tool to augment the clinical judgment of healthcare providers and patient preferences and values when making clinical decisions regarding these conditions.
 
“Management of Hip Fractures in the Elderly”
The CPG addresses “a global health care challenge, as the occurrence of hip fractures is increasing related to the aging of the population and current prevalence of osteoporosis,” a progressive disease causing bone loss and hip fractures, said Karl Roberts, MD, vice chair of the AAOS Clinical Practice Guideline on the Management of Hip Fractures in the Elderly work group.
 
Many of the recommendations in the new CPG have the ultimate goal of reducing “delirium” in hip fracture patients, according to W. Timothy Brox, MD, chair of the AAOS Clinical Practice Guideline on the Management of Hip Fractures in the Elderly work group. Delirium, also known as acute confusion, is common among hip fracture patients. Multiple studies have found that patients with postoperative delirium are less likely to return to their pre-injury level of function, are more frequently placed in nursing homes, and have an increased rate of mortality.
 
“The more you can reduce the incidence of delirium, the faster and more effectively the patient will recover,” said Dr. Brox.
 
Most notably, the CPG includes a “strong” recommendation for preoperative regional analgesia to reduce pain in hip fracture patients, a practice that is not standard of care in all hospital settings. The hip fracture CPG also recommends:  
 
  • Hip fracture surgery within 48 hours of hospital admission.
  • Intensive physical therapy following hospital discharge to improve functional outcomes.
  • An osteoporosis evaluation, as well as Vitamin D and calcium supplements, for patients following a hip fracture.
 
This CPG has been endorsed by the United States Bone and Joint Initiative (USBJI), the Orthopaedic Trauma Association (OTA), the American Association of Clinical Endocrinologists (AACE) and the Hip Society.
 
Read the full guideline.
 
“Management of Anterior Cruciate Ligament Injuries”
Anterior cruciate ligament (ACL) tears are among the most common injuries occurring in athletes participating in high-demand sports like soccer, football and basketball.
 
In patients who are appropriate candidates for surgery, the new CPG recommends, with “moderate” supporting evidence, that reconstructive surgery occur within five months of an ACL injury to protect the knee joint. 


“In an active patient, if you wait too long to surgically repair the ACL, there is a risk for additional injury to the knee,” said Kevin Shea, MD, chair of the AAOS Clinical Practice Guideline on the Management of ACL Injuries work group. “Therefore, surgery within five months of injury may have some advantages.  Nonsurgical treatment also is appropriate for some patients, including those with less active lifestyles who do not place significant demands on the knee."
 
The CPG also states that there is moderate evidence supporting surgical reconstruction in active, young adult (age 18-35) patients with an ACL tear. The CPG supports the use of autograft (the patient’s own tissue), “or appropriately processed allograft (donor) tissue,” for repairing a sprained or torn ACL.  However, younger or highly-active patients may not do as well with allograft tissue as recent research has found a higher failure rate among patients under age 25 who have undergone allograft surgery.
 
In addition, the CPG:
 
  • Supports the standard practice of obtaining a relevant history and performing a musculoskeletal exam of the lower extremities in diagnosing an ACL injury. Magnetic resonance imaging (MRI) can confirm an injury to the ACL or other structures.
  • Supports the use of either patellar tendon or hamstring tendons for autograft surgery, with moderate strength evidence.
  • States that good outcomes may be obtained with either a single bundle (one large graft) or double bundle (two smaller grafts) surgical technique.
 
This CPG has been endorsed by the National Academy of Sports Medicine (NASM), American Orthopaedic Society for Sports Medicine (AOSSM) and the National Athletic Trainers Association (NATA).
 
Read the full guideline.
 
“Detection and Nonoperative Management of Pediatric Developmental Dysplasia of the Hip in Infants Up to 6 Months of Age”
 
Although screening for developmental dysplasia of the hip (DDH) most often includes an ultrasound before age 6 months, the new CPG recommends selective ultrasound screening if an infant has the following DDH risk factors: breech presentation at birth, a family history of DDH or signs/history of hip instability. Developmental dysplasia of the hip can be detected by listening and feeling for “clunks” as the hip is placed in different positions.
 
Developmental dysplasia typically presents at birth, although the condition may develop later during a child’s first year of life. In DDH, the ball is loose in the hip socket, making it unstable and prone to dislocation. While DDH rectifies itself in some patients, corrective treatment may be necessary to prevent long-term pain and early-onset osteoarthritis. In infants, a soft harness can keep the hip socket in place. Surgery may be necessary in older children or in younger children when the harness is unsuccessful in stabilizing the hip.
 
“There is only limited evidence to show that ultrasound is useful in diagnosing DDH in children younger than 6 months of age,” said Kishore Mulpuri, MD, chair of the AAOS Clinical Practice Guideline Detection and Nonoperative Management of Pediatric DDH in Infants Up to 6 Months of Age work group.  However, if the child has a risk factor, or presents with DDH symptoms, the hip “needs to be evaluated further with an imaging exam.”
 
The CPG does not recommend routine ultrasound screening in infants less than age 6 weeks, even for those children with risk factors for DDH.
 
“There is a widely held public perception that screening and early detection of DDH is a good thing, and the CPG does not refute this,” said Kit Song, MD, vice chair of the AAO Clinical Practice Guideline Detection and Nonoperative Management of Pediatric DDH in Infants Up to 6 Months of Age work group. However, “more research is needed to better define who needs treatment and what that treatment should be.”


This CPG has been endorsed by the Pediatric Orthopaedic Society of North America (POSNA), the
Society of Diagnostic Medical Sonography, and the Society for Pediatric Radiology.
 
Read the guideline.
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