Post-surgery interventions for hip fracture: a systematic review of randomized controlled trials

Abstract

Background Interventions provided after hip fracture surgery have been shown to reduce mortality and improve functional outcomes. While some systematic studies have evaluated the efficacy of post-surgery interventions, there lacks a systematically rigorous examination of all the post-surgery interventions which allows healthcare providers to easily identify post-operative interventions most pertinent to patient’s recovery. Objectives We aim to provide an overview of the available evidence on post-surgery interventions provided in the acute, subacute and community settings to improve outcomes for patients with hip fractures. Methods We performed a systematic literature review guided by the Preferred Reporting Items for Systematic review and Meta-Analysis (PRISMA). We included articles that were (1) randomized controlled trials (RCTs), (2) involved post-surgery interventions that were conducted in the acute, subacute or community settings and (3) conducted among older patients above 65 years old with any type of non-pathological hip fracture that was surgically treated, and who were able to walk without assistance prior to the fracture. We excluded (1) non–English language articles, (2) abstract-only publications, (3) articles with only surgical interventions, (4) articles with interventions that commenced pre-surgery or immediately upon completion of surgery or blood transfusion, (5) animal studies. Due to the large number of RCTs identified, we only included “good quality” RCTs with Jadad score ≥ 3 for data extraction and synthesis. Results Our literature search has identified 109 good quality RCTs on post-surgery interventions for patients with fragility hip fractures. Among the 109 RCTs, 63% of the identified RCTs (n = 69) were related to rehabilitation or medication/nutrition supplementation, with the remaining RCTs focusing on osteoporosis management, optimization of clinical management, prevention of venous thromboembolism, fall prevention, multidisciplinary approaches, discharge support, management of post-operative anemia as well as group learning and motivational interviewing. For the interventions conducted in inpatient and outpatient settings investigating medication/nutrition supplementation, all reported improvement in outcomes (ranging from reduced postoperative complications, reduced length of hospital stay, improved functional recovery, reduced mortality rate, improved bone mineral density and reduced falls), except for a study investigating anabolic steroids. RCTs involving post-discharge osteoporosis care management generally reported improved osteoporosis management except for a RCT investigating multidisciplinary post-fracture clinic led by geriatrician with physiotherapist and occupational therapist. The trials investigating group learning and motivational interviewing also reported positive outcome respectively. The other interventions yielded mixed results. The interventions in this review had minor or no side effects reported. Conclusions The identified RCTs regarding post-surgery interventions were heterogeneous in terms of type of interventions, settings and outcome measures. Combining interventions across inpatient and outpatient settings may be able to achieve better outcomes such as improved physical function recovery and improved nutritional status recovery. For example, nutritional supplementation could be made available for patients who have undergone hip fracture surgery in the inpatient settings, followed by post-discharge outpatient osteoporosis care management. The findings from this review can aid in clinical practice by allowing formulation of thematic program with combination of interventions as part of bundled care to improve outcome for patients who have undergone hip fracture surgery.

Nutrition, Vitamin D, and Calcium in Elderly Patients before and after a Hip Fracture and Their Impact on the Musculoskeletal System: A Narrative Review

“…A systematic review of RCTs evaluated post-surgery interventions for patients with hip fractures, including nutritional supplementation, among various other strategies such as rehabilitation, osteoporosis management, and fall prevention. This review highlighted the diversity of interventions tested and underscored the need for well-rounded postoperative care to improve outcomes in fragile hip fracture patients [ 103 ]. The included RCTs considered just calcium and vitamin D supplementation, while interventions to increase nutritional calcium intake by means of dairy products or other calcium sources were not mentioned [ 103 ].…”

“…This review highlighted the diversity of interventions tested and underscored the need for well-rounded postoperative care to improve outcomes in fragile hip fracture patients [ 103 ]. The included RCTs considered just calcium and vitamin D supplementation, while interventions to increase nutritional calcium intake by means of dairy products or other calcium sources were not mentioned [ 103 ]. Calcium supplements (i.e., calcium carbonate or citrate) along with vitamin D compounds are often easily prescribed, but they are often not tolerated and not taken in the long term.…”

Characteristics and Effects of Home-Based Digital Health Interventions on Functional Outcomes in Older Patients With Hip Fractures After Surgery: Systematic Review and Meta-Analysis

“…Previous research found that combining postsurgical interventions for patients with fragility hip fractures across inpatient and outpatient settings may be able to improve physical function recovery and discovered that 63% of the studies were related to rehabilitation or medication or nutrition supplementation [ 13 ].…”

A commentary on ‘Comparison of risk of complication between neuraxial anaesthesia and general anaesthesia for hip fracture surgery: a systematic review and meta-analysis’

“…Hip fracture is an acute surgical condition, and ~98% of patients warrant an operation requiring anesthesia 1 . As the geriatric group is often associated with frailty and multiple comorbidities, patients undergoing hip fracture surgery are at a significantly higher risk of perioperative mortality and morbidity, including postoperative delirium, respiratory complications, myocardial ischemia, and cerebrovascular accidents.…”