From the Guidelines
Operative management for an 88-year-old female with a hip fracture and low cardiac risk should ideally occur within 24-48 hours of hospital admission. This recommendation is based on the most recent evidence from the American Academy of Orthopaedic Surgeons, which suggests that early surgery is associated with improved outcomes, including reduced morbidity and mortality 1. Early surgery is recommended to reduce complications associated with prolonged immobilization, including pressure ulcers, venous thromboembolism, pneumonia, and urinary tract infections.
The patient should receive appropriate preoperative medical optimization, including:
- Pain management with scheduled acetaminophen (1000 mg every 6 hours) and judicious opioid use as needed, while avoiding NSAIDs due to bleeding risk
- Venous thromboembolism prophylaxis should be initiated promptly with low molecular weight heparin (enoxaparin 40 mg subcutaneously daily) or fondaparinux (2.5 mg subcutaneously daily)
- Adequate hydration, electrolyte correction, and management of chronic conditions should be addressed before surgery Despite advanced age, early operative intervention improves functional outcomes and reduces mortality compared to delayed surgery or non-operative management 1. The specific surgical approach (internal fixation versus arthroplasty) will depend on fracture type, bone quality, and the patient's functional status, but the timing principle remains consistent regardless of the chosen technique.
From the Research
Operative Management for Hip Fractures in Elderly Patients
- The decision for operative management in an 88-year-old female with a hip fracture and a low risk of heart disease should be based on the type of fracture, the patient's overall health, and mobility status 2, 3, 4.
- For patients over 80 years old, the mortality rate is high, and the type of surgery, male gender, older age, blood transfusion requirements, and high Charlson comorbidity index (CCI) score are associated with mortality 4.
- Hemiarthroplasty (HA) is usually performed in elderly individuals who are institutionalized and have limited physical activity, while total hip arthroplasty (THA) is associated with better functional outcomes and a lower risk of revision surgery in self-sufficient, physically active patients 2.
- Internal fixation is often used for undisplaced intracapsular fractures, with benefits including shorter operation time, reduced orthopedic ward stay, and lower incidence of peri-operative complications 3.
- The choice of surgical fixation, such as sliding hip screw versus cancellous screws, does not significantly affect the risk of reoperation, but may influence the risk of avascular necrosis 5.
Considerations for Operative Management
- Preoperative optimization and postoperative care are critical for elderly patients with hip fractures 4.
- The patient's walking ability, level of self-sufficiency, nutritional status, and haematocrit should be evaluated before surgery 2.
- Factors amenable to treatment should be corrected by working jointly with geriatricians to develop a preoperative management strategy 2.
- The type of implant used, such as unipolar or bipolar hemiarthroplasty, or conventional or dual-mobility total hip arthroplasty, may affect the outcome of surgery 2.