Should surgical intervention be performed for hip fractures?

Surgical Management of Hip Fractures

Hip fractures almost always require surgical intervention due to their devastating effects on patients and the significant improvement in outcomes with operative treatment. 1

Types of Hip Fractures and Appropriate Surgical Interventions

Femoral Neck Fractures

• Stable/non-displaced femoral neck fractures: Can be treated with cannulated fixation in a percutaneous manner 1
• Displaced femoral neck fractures:
  • In healthy, active, independent older individuals without cognitive dysfunction: Total hip arthroplasty (THA) is recommended 1
  • In frail patients: Hemiarthroplasty is preferred due to shorter operative time and lower dislocation risk 1
  • THA may offer improved function over hemiarthroplasty but comes with increased risk of complications 1

Trochanteric Fractures

• Stable intertrochanteric fractures: Sliding hip screw is favored 1
• Unstable intertrochanteric fractures: Antegrade cephalomedullary nail is recommended 1
• Subtrochanteric or reverse oblique fractures: Strong evidence supports using cephalomedullary devices 1

Timing of Surgery

• Surgery should be performed within 24-48 hours of hospital admission 1
• Recent evidence suggests improved outcomes with surgery within 24 hours at high-volume centers with dedicated hip fracture programs 1
• Delay in surgical treatment beyond 48 hours is associated with significantly higher mortality 2
• The Association of Anaesthetists of Great Britain and Ireland explicitly states that "surgery is the best analgesic for hip fractures" 1

Important Surgical Considerations

• Cemented femoral stems should be used in arthroplasty for hip fractures (Strong recommendation) 1

  • Evidence shows reduced risk of periprosthetic fracture compared to non-cemented stems 1
  • Note that cemented stems may increase surgical time and blood loss 1

• Surgical approach (anterior, lateral, or posterior) does not significantly affect outcomes in hip fracture arthroplasty 1

Perioperative Management

• Multimodal analgesia incorporating preoperative nerve blocks is strongly recommended 1
• Tranexamic acid should be administered to reduce blood loss and blood transfusion requirements 1
• Interdisciplinary care programs should be used to decrease complications and improve outcomes 1
• Appropriate prophylaxis should include:
  • Antibiotics (particularly against Staphylococcus aureus) before surgery 3
  • Thromboembolic prophylaxis, preferably with low-molecular-weight heparin 3

Postoperative Care

• Early mobilization is a key part of management 1, 4
• Almost all patients should be allowed to mobilize without restrictions on weight bearing or hip movements 5
• Rehabilitation is critical to long-term recovery 3
• An appropriate rehabilitation program should include:
  • Early post-fracture introduction of physical training and muscle strengthening 1
  • Long-term continuation of balance training and multidimensional fall prevention 1

Common Complications to Monitor

• Medical complications affect approximately 20% of patients with hip fracture 6
• Key complications include:
  • Cognitive and neurological alterations
  • Cardiopulmonary issues
  • Venous thromboembolism
  • Urinary tract complications
  • Perioperative anemia
  • Pressure sores 6

Secondary Prevention

• Patients should receive osteoporosis evaluation and treatment 3
• Unless contraindicated, bisphosphonate therapy should be used to reduce risk of subsequent fractures 3
• Fall prevention assessment and education should be provided 3