Bradley R. Wasserman, MD

ABSTRACT: Hip fractures in older patients are projected to increase in frequency as the US population continues to age. A thorough history and physical examination is essential. The initial workup should include radiographic imaging. Operative stabilization is the treatment of choice for most femoral neck or intertrochanteric hip fractures. The goals should be to achieve a stable reduction to allow for early patient mobilization, restore the patient's preinjury level of function, and minimize the risk of medical complications. Postoperative complications are associated with mortality and diminished return of function. All patients with hip fractures should receive perioperative deep venous thrombosis chemoprophylaxis, unless it is contraindicated. A multidisciplinary approach to postoperative rehabilitation can shorten the inpatient stay and decrease the mortality rate. (

Hip fractures in older patients are associated with significant morbidity and mortality. They occur most frequently in these patients and are projected to increase in frequency as the US population continues to age.

A thorough history and physical examination is essential to ensure that medical management of comorbidities before surgical intervention is optimized and to evaluate other potential injuries associated with the inciting event. The patient's functional and social status should be assessed to help predict and plan the clinical outcome. Each patient's functional goals are critical factors in surgical decision making; these goals should be considered by the patient, his or her family, the primary care physician, and the surgeon. In determining the ideal setting for reaching rehabilitation goals, coordination between a social worker, case manager, physiatrist, and the patient and his family is invaluable.

In older patients, we perform operative fixation with screws in nondisplaced fractures and either hemiarthroplasty or total hip arthroplasty in displaced fractures; in younger patients, we attempt closed or open reduction and operative fixation in almost all fractures. We avoid use of a hemiarthroplasty or total hip arthroplasty in younger patients because they probably will outlast the life span of the implant and subsequently require revision surgery (or surgeries). The younger and more active the patient, the more likely (and earlier) he will wear out his prosthesis and require a revision,which will result in less bone stock with each subsequent surgery. Therefore, we attempt operative fixation after reduction in almost all younger patients.

In this article, we describe the epidemiology of hip fractures in older patients, the medical evaluation, and the surgical options and risk factors. We also discuss the postoperative complications and rehabilitation. 

About 250,000 hip fractures occur in the United States each year at an annual cost of about $9 billion.

 Based on conservative assumptions, the population of US persons 65 years and older is projected to grow to 78 million in the year 2050 from 35 million in 2000

; accordingly, the incidence of hip fractures is expected to double by 2050.

Trochanteric hip fractures represent almost half of proximal femur fractures; the female-to-male ratio ranges from 2:1 to 8:1.

 The average patient age at which trochanteric hip fractures occur is 82.1 years; for femoral neck fractures, the average age is 77.9 years.

 Women have 80% of trochanteric hip fractures; the incidence doubles for each decade after age 50 years.

The mortality rates of femoral neck and intertrochanteric fractures are comparable, ranging from 14% to 50% within the first year after injury. The highest mortality occurs within the first 4 to 6 months after fracture. Mortality rates are higher in men and patients older than 75 years than in women and younger persons.

 showed a 1-year mortality rate of only 12.7% for older patients with a hip fracture who were community dwelling and cognitively intact.

The patient's initial workup should include radiographic imaging of any painful or ecchymotic areas of the body. A complete blood cell count,coagulation profile, and electrolyte panel should be obtained because many older patients live alone and may experience long delays before treatment, resulting in dehydration and poor nutrition. A Foley catheter should be used to monitor urinary output adequately and help hemodynamic monitoring.

Osteoporosis often results in "insufficiency" fractures-fractures that occur in compromised or weakened bone after a physiologic load. Hip fractures tend to occur after a traumatic episode.Although osteoporosis may be a confounding factor, trauma usually is the cause.

In some older patients, cardiopulmonary disease is a major factor that may affect the ability to tolerate surgery and rehabilitation; obtaining an internal medicine consultation on admission for preoperative medical optimization is desirable. In addition, chemoprophylaxis and/or mechanical prophylaxis against deep venous thrombosis (DVT) should be instituted as early as possible because patients may be immobile for up to 2 days. If low-molecular-weight heparin is administered, it should be discontinued 12 to 24 hours before surgery.

Operative stabilization is the treatment of choice for a patient with nearly any femoral neck or intertrochanteric hip fracture. Nonoperative management of hip fractures in older patients is associated with extremely high mortality rates and limited functional recovery; therefore, such an approach should be reserved for those "too sick" to undergo repair.

With all hip fracture surgery, the goals are to achieve a stable reduction to allow for early patient mobilization, restore the patient's preinjury level of function, and minimize the risk of medical complications. Toward these ends, early treatment with surgical stabilization is recommended.

When operative treatment is indicated, proceeding with surgery as soon as the patient's condition has been medically optimized and cleared for surgery is best. Zuckerman and associates

 prospectively studied 367 patients who had a hip fracture to determine the effect of an operative delay on postoperative complications and on the 1-year mortality rate.When the patients' age, sex, and number of medical comorbidities were controlled, an operative delay beyond 3 days doubled the mortality rate by the end of the first postoperative year.

Choice of anesthetic technique has not been proved to have an impact on the mortality rate in older patients with hip fractures. Bigler and colleagues

 compared the effect of general anesthetic with that of spinal anesthetic on mental function and morbidity up to 3 months postoperatively in 40 older patients (mean age, 78.9 years) undergoing acute hip fracture surgery. The authors noted no persistent mental impairment in either group, and there was no difference in mortality or complication rate. However, there was a shorter time to ambulation in those who received spinal anesthetic.

In a case series of 631 community-dwelling older patients who sustained a femoral neck or intertrochanteric hip fracture, patients were evaluated prospectively to determine the effect, if any, of anesthetic technique on ambulatory ability and percent functional recovery at 3, 6, and 12 months after hip fracture.

 The authors noted a significant increase in recovery of ambulatory ability and percent functional recovery at 6 months in patients who had received general anesthetic. After controlling for potential confounding variables,however, they observed no differences between groups at any of the time intervals. 

Surgeons must understand the implant options available and try to achieve accurate alignment and proper implant positioning. Surgical options for femoral neck fractures include internal fixation with cannulated screws and replacement-either a hemiarthroplasty (replacing the femoral head and neck) or a total hip arthroplasty, which includes the femoral head, neck, and acetabulum.The decision to repair or replace is based on a variety of factors, including the fracture pattern, the patient's functional status, medical comorbidities and, if present, preoperative hip symptoms.

For nondisplaced or minimally displaced femoral neck fractures, the use of 3 cannulated screws-via an open or closed approach (Figures 1 and 2)-has proved to be the gold standard. The treatment of choice for displaced femoral neck fractures in older patients is a hemiarthroplasty (Figures 3 and 4) or total hip arthroplasty; a variety of implants are available, depending on the surgeon's preference.When implant options for arthroplasty are being considered, the choice of manufacturer is less important than the choice of implant type (eg, hemiarthroplasty vs total hip arthroplasty).

Anteroposterior (A) and lateral (B) radiographs of an 83-year-old woman obtained after a mechanical trip and fall demonstrate a valgus-impacted left femoral neck fracture. 

Percutaneous pinning of the left femoral neck fracture is seen in anteroposterior pelvis (A) and lateral (B) radiographs obtained 6 weeks post closed reduction. 

Anteroposterior (A), traction and internal rotation (B), and lateral (C) radiographs of an 83-year-old woman obtained after a mechanical trip and fall demonstrate a displaced right femoral neck fracture. 

Anteroposterior pelvis (A) and right hip (B) radiographs post right hip hemiarthroplasty are shown here. 

Articles

ABSTRACT: Hip fractures in older patients are projected to increase infrequency as the US population continues to age.

Author | Bradley R. Wasserman, MD

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Managing Hip Fractures in Older Patients: Perioperative Decision Making