University of Massachusetts Medical School Faculty Publications

UMMS Affiliation

Department of Orthopedics and Physical Rehabilitation

Publication Date


Document Type



Health Services Administration | Orthopedics | Surgery | Surgical Procedures, Operative


Background: Osteoporotic hip fractures typically occur in frail elderly patients with multiple comorbidities, and repair of the fracture within 48 h is recommended. Pre-operative evaluation sometimes involves transthoracic echocardiography (TTE) to screen for heart disease that would alter peri-operative management, yet TTE can delay surgery and is resource intensive. Evidence suggests that the use of clinical practice guidelines (CPGs) can improve care. It is unclear which guidelines are most useful in hip fracture patients.

Questions/Purposes: We sought to evaluate the performance of the five commonly used CPGs in determining which patients with acute fragility hip fracture require TTE and to identify common features among high-performing CPGs that could be incorporated into care pathways.

Patients and Methods: We performed a retrospective study of medical records taken from an institutional database of osteoporotic hip fracture patients to identify those who underwent pre-operative TTE. History and physical examination findings were recorded; listed indications for TTE were compared against those given in five commonly used CPGs: those from the American College of Cardiology/American Heart Association (ACC/AHA), the British Society of Echocardiography (BSE), the European Society of Cardiology and the European Society of Anaesthesiology(ESC/ESA), the Association of Anaesthetists of Great Britain and Ireland (AAGBI), and the Scottish Intercollegiate Guidelines Network (SIGN). We then calculated the performance (sensitivity and specificity) of the CPGs in identifying patients with TTE results that had the potential to change peri-operative management.

Results: We identified 100 patients who underwent pre-operative TTE. Among those, the patients met criteria for TTE 32 to 66% of the time, depending on the CPG used. In 14% of those receiving TTE, the test revealed new information with the potential to change management. The sensitivity of the CPGs ranged from 71% (ESC/ESA and AAGBI) to 100% (ACC/AHA and SIGN). The CPGs' specificity ranged from 37% (BSE) to 74% (ESC/ESA). The more sensitive guidelines focused on a change in clinical status in patients with known disease or clinical concern regarding new-onset disease.

Conclusions: In patients requiring fixation of osteoporotic hip fractures, TTE can be useful for identifying pathologies that could directly change peri-operative management. Our data suggest that established CPGs can be safely used to identify which patients should undergo pre-operative TTE with low risk of missed pathology.


clinical practice guidelines, echocardiogram, peri-operative management, pre-operative clearance

Rights and Permissions

Copyright © The Author(s) 2020. Open Access. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit

DOI of Published Version



Swart E, Adair C, Seymour RB, Karunakar MA. Clinical Practice Guidelines on Ordering Echocardiography Before Hip Fracture Repair Perform Differently from One Another. HSS J. 2020 Dec;16(Suppl 2):378-382. doi: 10.1007/s11420-020-09762-8. Epub 2020 Jun 8. PMID: 33376460; PMCID: PMC7749896. Link to article on publisher's site

Related Resources

Link to Article in PubMed

Journal/Book/Conference Title

HSS journal : the musculoskeletal journal of Hospital for Special Surgery

PubMed ID


Creative Commons License

Creative Commons Attribution 4.0 License
This work is licensed under a Creative Commons Attribution 4.0 License.