From the Guidelines
Operative management significantly reduces mortality in elderly patients with hip fractures, with the most recent evidence suggesting that early surgery, ideally within 24-48 hours of injury, is associated with improved outcomes. The reduction in mortality rates can be attributed to the prevention of complications associated with prolonged immobility, such as pneumonia, pressure ulcers, venous thromboembolism, and urinary tract infections 1. According to the most recent guidelines, surgical timing has been updated to favor surgery within 24 to 48 hours of hospital admission, with the goal of creating a useful guideline for the surgical care of older patients with hip fracture 1.
Key Considerations
- Early surgery, ideally within 24-48 hours of injury, is associated with the best outcomes 1
- The standard operative approach depends on fracture type, with femoral neck fractures typically requiring hemiarthroplasty or total hip arthroplasty, and intertrochanteric fractures managed with dynamic hip screws or intramedullary nails
- Perioperative care should include multimodal pain management, early mobilization within 24 hours post-surgery, thromboprophylaxis, and osteoporosis treatment
- Surgical fixation allows for earlier weight-bearing and rehabilitation, preserving muscle mass and function, and ultimately improving long-term survival and quality of life in this vulnerable population
Evidence-Based Recommendations
The most recent evidence from the American Academy of Orthopaedic Surgeons suggests that operative management is the preferred treatment for elderly patients with hip fractures, with a focus on early surgery and multidisciplinary care 1. While older studies, such as the 2012 guidelines from the Association of Anaesthetists of Great Britain and Ireland, also support early surgical fixation and rehabilitation, the most recent guidelines provide the most up-to-date recommendations for reducing mortality and improving outcomes in this population 1. Therefore, operative management should be prioritized for elderly patients with hip fractures, with a focus on early surgery and comprehensive perioperative care.
From the Research
Operative Management and Mortality Reduction
- Operative management of hip fractures in elderly patients has been shown to reduce mortality rates compared to nonoperative management 2, 3, 4.
- A systematic review of 11 published studies found that nonoperative treatment of hip fractures was associated with higher in-hospital, 30-day, and 1-year mortality rates compared to operative treatment 2.
- Another study found that earlier surgery was associated with a significant reduction in mortality, with a relative risk of 0.81 compared to delayed surgery 3.
- A meta-analysis of 18 studies found that nonoperative management of hip fractures in frail elderly patients was associated with high mortality rates, with pooled mortality rates of 36% at 30 days, 46% at 6 months, and 60% at 1 year 5.
Comparison of Operative and Nonoperative Management
- A retrospective study of 340 patients with hip fractures found that nonoperative management was associated with a higher risk of mortality at 1 and 2 years after fracture, with a four-fold increased risk at 1 year and a three-fold increased risk at 2 years 4.
- Another study found that operative delay was not associated with a worse outcome in patients with comorbidities, but suggested that fracture repair within 48 hours of injury may be beneficial for stable patients 6.
- The evidence suggests that operative management of hip fractures in elderly patients can reduce mortality rates and improve outcomes, although the optimal timing of surgery and the role of nonoperative management in certain patient populations require further study 2, 3, 6, 4.