INTRODUCTION

Background

Traumatic hip fractures pose a critical orthopedic challenge, disproportionately affecting older adults and significantly compromising mobility and independence. In the United States, approximately 350,000 cases occur annually, and global projections are expected to rise to 6.3 million cases by 2050 [1,2]. The exponential increase in incidence with age underscores the substantial public health implications of this debilitating injury [3]. Management of traumatic hip fractures demands prompt surgical intervention within 24 to 48 hours to reduce mortality and complications [4]. Although orthopedic techniques have advanced, hip fractures continue to cause considerable morbidity, with approximately 20% to 30% of patients experiencing reduced mobility and 1-year mortality rates ranging from 20% to 35% in older adults [5,6]. To address these challenges, clinical practice guidelines (CPGs) serve as action-oriented statements that promote the best possible clinical decisions in a given context, translating complex research evidence into implementable actions that bridge the gap between scientific knowledge and real-world clinical practice.

In addition to guiding clinical decision-making, CPGs support error prevention and safety across healthcare specialties. In many developed nations, medical errors rank as the third leading cause of death, and standardized protocols help prevent systematic errors in decision-making [7]. While each patient requires individualized care, such standardization helps reduce systematic errors in clinical judgment. In the context of hip fractures, research shows that 8.5% of cases involve preventable medical errors, most commonly delays in surgery beyond the recommended 48-hour operative window [8]. This serious outcome underscores the need for consistent adherence to robust clinical protocols. Healthcare facilities that implement strong CPGs experience significantly lower rates of adverse events [9]. The systematic application of evidence-based practice has substantially improved patient safety metrics [10]. Studies demonstrate that proper CPG implementation can yield notable reductions in mortality, with institutions reporting decreases of up to 18% to 22% in in-hospital mortality and reductions in surgical complications of as much as 35% [6,9].

Beyond error reduction, CPGs are particularly valuable in orthopedic trauma, where regional variations influence treatment protocols. Current guidelines emphasize early surgical intervention, individualized rehabilitation, and comprehensive geriatric assessment [10]. Practice patterns differ across continents, reflecting variation in healthcare systems and resource availability; for example, European guidelines often emphasize different considerations than North American or Asian protocols [11]. This diversity in clinical approaches provides an opportunity to develop global best practices that integrate high-quality research evidence. Evaluating the methodological quality of these CPGs is essential to determine their utility in everyday clinical decisions for patients with hip fractures. The AGREE II (Appraisal of Guidelines for Research and Evaluation II) instrument is a widely used, comprehensive tool for appraising CPG quality across domains, including scope and purpose, stakeholder engagement, methodological rigor, clarity of recommendations, applicability, and potential bias from editorial independence [12]. More recently, the AGREE-REX (AGREE-Recommendation Excellence) tool has been introduced to appraise the clinical applicability of CPG recommendations. Used together, AGREE II and AGREE-REX provide crucial insight into a guideline’s methodological quality and clinical relevance.

Objectives

A rigorous critical appraisal of CPGs is essential for translating research into optimal patient care. The quality and clinical relevance of prevalent CPGs for the orthopedic surgical management of hip fractures have not been examined using standardized appraisal tools. Therefore, we conducted a systematic review to evaluate the quality and applicability of CPGs worldwide that address the orthopedic surgical management of traumatic hip fractures. The goal is to ensure that hip fracture management evolves with emerging evidence and technological advancements, ultimately minimizing morbidity, maximizing functional recovery, and decreasing medical errors.

METHODS

The protocol describing this review's methodology and data synthesis plan was registered in the PROSPERO database (No. CRD42024543082)

Search strategy and information sources

The systematic literature search used PubMed, CINAHL, Scopus, Embase, and PEDro databases. Investigators collaborated with a medical librarian to design a keyword-driven strategy (Suppl. 1). The search focused on CPGs that inform surgical intervention decisions for hip fracture populations. The initial search was performed on June 26, 2024, and was followed by a hand search of citation lists and organizational websites.

Eligibility criteria and selection process

Relevant citations were exported into Covidence, a web-based citation management platform for organizing articles from external databases. Two reviewers (KNJ and TKS) initially screened titles and descriptions to identify CPGs addressing the surgical management of traumatic orthopedic hip fractures. Both reviewers then applied the inclusion and exclusion criteria outlined in Table 1 to select articles for full-text review. A hand search was also conducted to identify any additional CPGs that met the inclusion criteria. The reviewers independently read the full-text versions of selected citations and assessed the appropriateness of each article for this review. Agreement on the eligibility of these 13 articles was assessed using unweighted kappa; values >0.70 indicate good agreement, whereas values >0.80 indicate substantial agreement [13]. Any disagreements regarding article eligibility were resolved through discussion.

Data synthesis and evaluation

All included CPGs were appraised for quality and clinical utility using the AGREE II and AGREE-REX tools [12,14]. The AGREE II tool is a 23-item quality assessment covering the domains of scope and purpose, stakeholder involvement, rigor of development, clarity of presentation, applicability, and editorial independence. Each item is scored on a 1–7 scale, with lower values indicating poorer quality and higher values indicating excellent quality. Domain scores were then combined to generate an overall CPG quality score. The AGREE-REX tool analyzes the recommendations within a CPG to determine their quality with respect to clinical application. Its domains include clinical applicability, developers’ and users’ values and preferences, and implementability in practice. Like AGREE II, AGREE-REX uses a 1–7 Likert scale for quality assessment. Based on the AGREE-REX overall score, reviewers provided an overall recommendation for each CPG: recommend its use, recommend its use with modifications, or not recommend it for clinical practice.

A rulebook was created for each tool to assist reviewers in scoring each CPG. Before this review, a pilot appraisal of two unrelated CPGs was completed to standardize procedures and ensure consistent use of the rulebook. The two reviewers then independently scored and appraised the quality of the CPGs included in this review. The reviewers’ appraisal scores were compared using the intraclass correlation coefficient (ICC), which was calculated in IBM SPSS ver. 28 (IBM Corp) [15].

Overall scores of CPG quality were standardized using recommendations from the AGREE Trust. Each AGREE II domain was summarized and scaled using the following equation:

( Obtained Score )−( Minimum Possible Domain Score )( Maximum Possible Domain Score )−( Minimum Possible Domain Score )×100

The minimum possible domain score equals the minimum item score × number of items × number of reviewers, whereas the maximum possible domain score equals the maximum item score × number of items × number of reviewers. The resulting percentage score reflects overall guideline quality, and values ≥70% were deemed high quality for an individual domain. Domain quality profiles were then used to summarize each CPG, and CPGs with more domains meeting the high-quality threshold were considered better-quality guidelines [12,14].

Data extraction

Once all relevant full-text CPGs were identified, guideline characteristics were extracted and summarized. Extracted characteristics included country of reference, the organization creating the guidelines, the professions of guideline developers, evidence levels, grading systems, and target audience. Intervention-related characteristics were also extracted and categorized as surgical, prophylactic, pain relief, and postoperative care interventions.

RESULTS

Study selection

The search yielded 2,574 records related to hip fracture care, of which 439 were duplicates. After screening the remaining articles, we identified 13 that were eligible for full-text review. Disagreements among reviewers occurred only for articles presented as summaries rather than full CPGs. These summary articles were subsequently included in the hand-search component of data collection to locate the missing full-text CPGs. The κ coefficient for agreement between the two reviewers was 0.385, indicating moderate agreement prior to the final inclusion discussion [13]. Fig. 1 illustrates the entire search process, from the initial search to the six CPGs ultimately included in this review.

Characteristics of CPGs

Table 2 summarizes the characteristics of the six included CPGs [16–21]. Approximately 80% of these guidelines were developed by multidisciplinary teams. Fig. 2 depicts the overarching recommendations for surgical intervention, prophylactic measures, pain relief, and postoperative care across all CPGs. Additional details regarding preoperative testing recommendations, anesthesia protocols, and strategies for preventing pressure sores are provided in Suppl. 2 and 3.

There was consensus across all CPGs that surgical intervention should be performed within 24 to 48 hours, underscoring the need to prioritize early surgery in clinical practice. Pain management was another area of agreement, with all CPGs emphasizing the importance of early pain relief for patient comfort. The use of a nerve block during surgery was recommended to optimize pain control during and shortly after the procedure [16–21].

All but two CPGs advised against preoperative traction, citing a lack of robust evidence supporting its effectiveness in clinical practice [16–19]. The recommended type of surgical intervention varied according to fracture type. Most CPGs indicated that clinicians should consider arthroplasty for intracapsular fractures and cephalomedullary devices for subtrochanteric fractures, respectively [16–20]. Imaging recommendations were provided but were supported by low levels of evidence in all guidelines except the 2023 UK National Institute for Health and Care Excellence (NICE) CPG [16–19]. Magnetic resonance imaging may be considered when x-ray imaging is negative, but a hip fracture is still suspected [16]. While some CPGs recommended early mobilization and physical or occupational therapy, others did not include such guidance, omitting an important aspect of postoperative care [16–21].

Quality appraisal

Domain-specific and overall quality consensus scores for the AGREE II and AGREE-REX tools are presented in Tables 3 and 4 [16–21]. Average-measures ICCs indicated good agreement for AGREE II and AGREE-REX (0.87 and 0.89, respectively) [15], and the lower bounds of the 95% confidence intervals exceeded the 0.75 threshold for both values. Similarly, three CPGs scored highly with the AGREE-REX tool, with the AAOS guideline [20] and the ANZHFR guideline [17] demonstrating differing quality ratings across tools. The high-quality CPGs identified with the REX tool scored highly in domains 1 and 3 but only moderately in domain 2, which assesses providers’ and patients’ values and preferences. Considine and Hood [21] and Waddell et al. [18] received low scores on both appraisal tools. Both the SIGN and NICE CPGs demonstrated high-quality scores on AGREE II and AGREE-REX and would be highly recommended for clinical use [16,19]. Based on their appraisal scores, the ANZHFR guideline [17] and the AAOS guideline [20] are recommended with reservations due to limited consideration of clinical application. Considine and Hood [21] and Waddell et al. [18] should not be recommended for clinical practice due to a lack of research rigor.

DISCUSSION

This review synthesized practice recommendations for the orthopedic surgical management of hip fractures reported in CPGs. The overarching theme identified was the efficiency of early care. A consensus recommending surgical management within 24 to 48 hours was evident across all six CPGs. The consistency of this recommendation underscores the importance of prompt surgery to reduce mortality and complication rates in traumatic hip fractures. Furthermore, the review highlighted the value of effective pain management and emphasized prioritizing patient comfort from the initial encounter through postoperative rehabilitation. These results should be interpreted within the context of orthopedic management of traumatic hip fractures rather than the wider, comprehensive care pathway that involves a multidisciplinary team of health professionals, including orthopedic surgeons.

Several recommendations exhibited greater variability in the strength of supporting evidence. Notably, about half of the CPGs offered weak evidence and lacked specific recommendations on diagnostic testing or imaging, which are critical for confirming diagnosis. The absence of clear imaging guidance indicates a significant gap in current clinical protocols. Discharge recommendations were also heterogeneous, with some guidelines advising specific physical therapy mobilization and others offering no recommendation. While most CPGs aim to reduce mortality and morbidity, they are often nonspecific about how postoperative or discharge care influences those outcomes. Silence on discharge recommendations represents a research gap that should be addressed, given the known association between poor functional outcomes and increased mortality after hip fractures [22,23]. Future guidelines might benefit from closer collaboration with physical therapy associations or from referencing established guidance such as the 2021 hip fracture CPG by the American Physical Therapy Association [24].

No prior systematic reviews have combined the AGREE II and AGREE-REX tools to appraise hip fracture CPGs. One similar review evaluated five guidelines, all five of which are included in our appraisal [25]. That review also rated the NICE 2023 CPG as high quality, but it assigned a much lower score to SIGN 2009 CPG. The primary reason cited for the lower SIGN score was insufficient documentation of the rigor of development; in contrast, our study located the supplementary manual, allowing a more in-depth assessment of the SIGN development protocol. Limited access to CPG protocol manuals was a recurrent issue, with more than one CPG requiring direct contact with the publishing authors. This may constrain future appraisals because many of these CPGs have not been updated recently and contact information is increasingly out of date.

The addition of AGREE-REX analysis evaluates the implementability of CPG recommendations in clinical practice [14]. It further influences perceived CPG quality by considering how surgeons and health systems can translate high-quality evidence into immediate practice. This review found that three CPGs scored highly overall but gave limited attention to practitioner and patient values [16,17,19]. Because patient satisfaction directly affects quality-of-care considerations, inadequate attention to patient values may influence health outcomes [26]. Analyses of infrastructure facilitators and barriers were notably limited in AGREE II and AGREE-REX scoring, which affects the consideration of practitioner values. Few appraised CPGs specified whether infrastructural changes were needed or how policies should be updated.

Only three of the six analyzed CPGs demonstrated high methodological rigor and implementability, highlighting the continuing challenges of developing comprehensive and reliable clinical guidance [16,17,19]. Many of these CPGs are several years old, suggesting that some recommendations may be outdated. Another limitation involves overlap in guideline development procedures, as two CPGs (the ANZHFR guideline [17] and Waddell et al. [18]) relied on the rigor of other CPGs, such as NICE 2023 and SIGN 2009 CPGs [16–19]. The NICE guideline was the highest scoring in this review, making it a reasonable source from which to draw development rigor and recommendations [16]; however, the ANZHFR guideline [17] made minimal modifications. As a result, the recommendations were nearly identical and may lack evidence regarding applicability to a different region. Differences in medical infrastructure across countries can limit applicability if modifications are not made.

Limitations

Several limitations should be acknowledged. The primary limitation is the small sample size of only six guidelines. Initially, five CPGs were identified, and the Canadian CPG was discovered after reviewing a similar study. Indexing may also be a limitation in other countries, as many guidelines are released through professional associations rather than in easily accessible or indexed journals. Although we manually searched the webpages of orthopedic surgery associations in different regions, we cannot rule out the possibility that some CPGs published outside peer-reviewed journals were missed. Another limitation is that only English-language publications were included, and CPGs from non–English-speaking countries were excluded. This review also relied on two reviewers to perform the literature search and appraise the CPGs with both AGREE tools. A larger number of reviewers could affect appraisal accuracy, although many systematic reviews employ only two reviewers. Nonetheless, interrater reliability between the two raters was good for determining quality using AGREE II (ICC, 0.87) and AGREE-REX (ICC, 0.89). Although interrater reliability was strong, the appraisal was still conducted by only two reviewers. Future studies may benefit from a larger and more diverse panel to further strengthen the consistency and generalizability of the appraisal process. This review had a clear objective of synthesizing recommendations for the management of hip fractures; however, as noted earlier, hip fracture care requires multidisciplinary action, and future CPGs may benefit from a broader scope. Because this review focused on operative recommendations, the generalizability of its conclusions may be limited.

Conclusions

There is a pressing need for newer, more rigorously developed hip fracture CPGs. Current guidelines increasingly lag behind the contemporary evidence base. Prospective research should prioritize comprehensive CPGs with enhanced methodological quality, more detailed imaging and discharge recommendations, and greater consideration of practitioner and patient-specific factors. Multicenter, international studies could help validate existing recommendations and address the gaps identified in current clinical practice.

ARTICLE INFORMATION

Author contributions

Conceptualization: TKS, KNJ, SPM; Data curation: EWB, MGS; Formal analysis: EWB; Methodology: TKS, KNJ; Visualization: MGS; Writing–original draft: TKS, KNJ, EWB; Writing–review & editing: TKS, KNJ, SPM. All authors read and approved the final manuscript.

Conflicts of interest

The authors have no conflicts of interest to declare.

Funding

The authors received no financial support for this study.

Data availability

Data analyzed in this study are available from the corresponding author upon reasonable request.

Supplementary materials

Fig. 1.

PRISMA (Preferred Reporting Items for Systematic Review and Meta-Analyses) flowchart.

Fig. 2.

Summary of hip fracture management recommendations. DVT, deep vein thrombosis; PT, physical therapy.

REFERENCES

• 1. Kanis JA, Cooper C, Rizzoli R, Reginster JY; Scientific Advisory Board of the European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO) and the Committees of Scientific Advisors and National Societies of the International Osteoporosis Foundation (IOF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 2019;30:3–44.ArticlePubMed
• 2. Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and mortality of hip fractures in the United States. JAMA 2009;302:1573–9.ArticlePubMedPMC
• 3. Johnell O, Kanis JA. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporos Int 2006;17:1726–33.ArticlePubMed
• 4. Pincus D, Ravi B, Wasserstein D, et al. Association between wait time and 30-day mortality in adults with hip fracture. JAMA 2017;318:1994–2003.ArticlePubMedPMC
• 5. Mears SC, Kates SL. A guide to improving the care of patients with fragility fractures, edition 2. Geriatr Orthop Surg Rehabil 2015;6:58–120.ArticlePubMedPMC
• 6. Haentjens P, Magaziner J, Colón-Emeric CS, et al. Meta-analysis: excess mortality after hip fracture among older women and men. Ann Intern Med 2010;152:380–90.ArticlePubMedPMC
• 7. Makary MA, Daniel M. Medical error: the third leading cause of death in the US. BMJ 2016;353:i2139.ArticlePubMed
• 8. Tarrant SM, Hardy BM, Byth PL, Brown TL, Attia J, Balogh ZJ. Preventable mortality in geriatric hip fracture inpatients. Bone Joint J 2014;96-B:1178–84. ArticlePubMedPMC
• 9. Neuman MD, Fleisher LA, Even-Shoshan O, Mi L, Silber JH. Nonoperative care for hip fracture in the elderly: the influence of race, income, and comorbidities. Med Care 2010;48:314–20. ArticlePubMedPMC
• 10. Neuman MD, Silber JH, Magaziner JS, Passarella MA, Mehta S, Werner RM. Survival and functional outcomes after hip fracture among nursing home residents. JAMA Intern Med 2014;174:1273–80.ArticlePubMedPMC
• 11. Lee JK, Mitchell PJ, Ang SB, et al. Survey of awareness and attitudes to the management of fragility fractures among the membership of the Asia Pacific Orthopaedic Association. Arch Osteoporos 2024;19:24. ArticlePubMed
• 12. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010;182:E839–42.ArticlePubMedPMC
• 13. McHugh ML. Interrater reliability: the kappa statistic. Biochem Med (Zagreb) 2012;22:276–82.ArticlePubMedPMC
• 14. Koo TK, Li MY. A guideline of selecting and reporting intraclass correlation coefficients for reliability research. J Chiropr Med 2016;15:155–63.ArticlePubMedPMC
• 15. Brouwers MC, Spithoff K, Kerkvliet K, et al. Development and validation of a tool to assess the quality of clinical practice guideline recommendations. JAMA Netw Open 2020;3:e205535.ArticlePubMedPMC
• 16. UK National Institute for Health and Care Excellence (NICE). Hip fracture: management (CG124) [Internet]. NICE; 2011 [updated 2023 Jan 6; cited 2025 Feb 2]. Available from: https://www.nice.org.uk/guidance/cg124
• 17. Australian and New Zealand Hip Fracture Registry (ANZHFR) Steering Group. Australian and New Zealand guideline for hip fracture care: improving outcomes in hip fracture management of adults. ANZHFR; 2014.
• 18. Waddell J, McMullan J, Lo N, et al. Improving time to surgery: emergency room, preoperative and immediate postoperative clinical practice guidelines for the management of hip fracture patients. Bone and Joint Health Network; 2010.
• 19. Scottish Intercollegiate Guidelines Network (SIGN). Management of hip fracture in older people: a national clinical guideline (SIGN 111). SIGN; 2009.
• 20. American Academy of Orthopaedic Surgeons (AAOS). Management of hip fractures in older adults: evidence-based clinical practice guideline. AAOS; 2021.
• 21. Considine J, Hood K. Emergency department management of hip fractures: development of an evidence‐based clinical guideline by literature review and consensus. Emerg Med (N Y) 2000;12:329–36.Article
• 22. Foss NB, Kristensen MT, Kehlet H. Prediction of postoperative morbidity, mortality and rehabilitation in hip fracture patients: the cumulated ambulation score. Clin Rehabil 2006;20:701–8.ArticlePubMed
• 23. Ganz SB, Peterson MG, Russo PW, Guccione A. Functional recovery after hip fracture in the subacute setting. HSS J 2007;3:50–7.ArticlePubMedPMC
• 24. McDonough CM, Harris-Hayes M, Kristensen MT, et al. Physical therapy management of older adults with hip fracture. J Orthop Sports Phys Ther 2021;51:CPG1–81.ArticlePMC
• 25. Filiatreault S, Hodgins M, Witherspoon R. An umbrella review of clinical practice guidelines for the management of patients with hip fractures and a synthesis of recommendations for the pre-operative period. J Adv Nurs 2018;74:1278–88.ArticlePubMed
• 26. Alibrandi A, Gitto L, Limosani M, Mustica PF. Patient satisfaction and quality of hospital care. Eval Program Plann 2023;97:102251.ArticlePubMed

Figure & Data

References

Citations

Citations to this article as recorded by