What is the optimal management approach for elderly patients with hip fractures, given the high mortality rate?

Optimal Management of Hip Fractures in Elderly Patients

The optimal management of elderly patients with hip fractures requires prompt surgical intervention within 48 hours of injury, combined with orthogeriatric comanagement to reduce mortality and improve functional outcomes. 1

Initial Management and Timing of Surgery

• Elderly patients with hip fractures should receive prompt surgical treatment within 48 hours of admission, as delayed surgical intervention beyond this timeframe is associated with significantly higher mortality 1, 2
• Preoperative care should include adequate pain relief, appropriate fluid management, and thorough medical optimization without unnecessarily delaying surgery 1
• Early surgery (within 24-48 hours) is associated with better functional outcomes, lower rates of perioperative complications, and reduced mortality 3

Surgical Approach Based on Fracture Type

Femoral Neck Fractures

• Stable non-displaced fractures can be treated with percutaneous cannulated fixation 1
• Displaced femoral neck fractures in healthy, active, independent elderly patients without cognitive dysfunction are best treated with total hip replacement arthroplasty allowing immediate full weight-bearing 1
• For frail patients, hemiarthroplasty is preferred due to shorter operative time and lower dislocation risk while maintaining acceptable functional outcomes 1

Trochanteric Fractures

• Stable intertrochanteric fractures should be treated with a sliding hip screw 1
• Unstable intertrochanteric fractures require an antegrade cephalomedullary nail 1
• Subtrochanteric or reverse oblique fractures should be treated with cephalomedullary devices, supported by strong evidence 1

Orthogeriatric Comanagement

• Orthogeriatric comanagement should be provided for all elderly patients with hip fractures to improve functional outcomes, reduce hospital stay, and decrease mortality 1
• This collaborative approach involves orthopedic surgeons working alongside geriatricians to address the complex medical needs of these often multimorbid patients 1
• Regular assessment of cognitive function, nutritional status, renal function, and pressure sore risk is essential during the perioperative period 1

Postoperative Care

• Comprehensive postoperative care should include appropriate pain management, antibiotic prophylaxis, correction of postoperative anemia, and early mobilization 1
• Regular systems examinations, assessment for pressure sores, monitoring of nutritional status and renal function, and regulation of bowel and bladder function are critical components of care 1
• Early mobilization is essential to prevent complications such as pneumonia, deep vein thrombosis, and pressure ulcers 1

Rehabilitation Program

• An appropriate rehabilitation program should consist of early postfracture physical training and muscle strengthening, followed by long-term balance training and multidimensional fall prevention 1
• The rehabilitation program should be tailored to the patient's prefracture functional status and comorbidities 1
• Early mobilization and weight-bearing as tolerated should be encouraged to improve functional outcomes 1

Secondary Fracture Prevention

• Each patient aged 50 years and over with a hip fracture should be systematically evaluated for the risk of subsequent fractures 1
• A Fracture Liaison Service (FLS) is the most effective organizational structure for risk evaluation and treatment initiation for secondary fracture prevention 1
• Pharmacological treatment should use medications demonstrated to reduce the risk of vertebral, non-vertebral, and hip fractures, with regular monitoring for tolerance and adherence 1
• Non-pharmacological interventions include adequate calcium and vitamin D intake, smoking cessation, and limiting alcohol consumption 1

Special Considerations

• For extremely frail patients with advanced comorbidities and limited life expectancy, the decision between operative and non-operative management should be carefully considered, as non-operative management is associated with significantly higher 30-day and 1-year mortality 4
• Patient education about fracture risk factors, follow-up, and duration of therapy is essential for long-term management 1
• The high mortality rate (approximately 30% at 12 months) associated with hip fractures in the elderly reflects the prevalence of comorbidity and the importance of optimal management 5

Common Pitfalls to Avoid

• Delaying surgery beyond 48 hours significantly increases mortality risk and should be avoided unless absolutely necessary for medical stabilization 2, 3
• Underestimating the importance of orthogeriatric comanagement can lead to suboptimal outcomes 1
• Failing to implement a comprehensive rehabilitation program and secondary fracture prevention strategy increases the risk of poor functional recovery and future fractures 1
• Neglecting postoperative care aspects such as nutritional support, cognitive assessment, and early mobilization can lead to increased complications 1