Management of Hip Fractures in the Elderly

- Research gaps

During the preparation of the above guidelines, the GDG have identified several gaps in current research and evidence-based literature. The following list is not exhaustive but could be useful to guide different scientific bodies (universities, research centres and healthcare organisations) in developing their research plans.

1. Epidemiology and National Burden in Egypt

Egypt has emerging data on hip-fracture incidence and geographic variation. However, there is still a lack of a comprehensive national hip-fracture registry that covers public, university, military, insurance, and private hospitals.

Key research gaps include:

·       Determining the true national incidence of fragility hip fractures by governorate, sex, age group, and rural/urban residence.

·       Developing national risk assessment tools to identify patients at risk of fractures early.

·       Identifying seasonal variations, fall locations, mechanisms of injury, and delays in presentation.

·       Assessing mortality rates after hip fractures in Egyptian patients at 30 days, 120 days, and 1 year.

·       Collecting national data on return to mobility, return home, dependency, and caregiver burden.

·       Understanding the cost of hip-fracture care in Egypt, including out-of-pocket expenses.

Possible research questions include:

·       Determining the true annual incidence of low-energy hip fractures among Egyptians aged ≥60 or ≥65 years.

·       Investigating whether outcomes differ between Upper Egypt and Lower Egypt.

·       Assessing the proportion of patients who die within 30 days and 1 year after hip fractures in Egypt.

·       Analysing the direct and indirect costs of hip-fracture care for Egyptian families.

2. Time-to-Surgery and Causes of Surgical Delay

Internationally, timely surgery is considered a crucial quality indicator. The World Health Organization (WHO) has proposed indicators focused on surgery within 48 hours and pharmacological osteoporosis treatment after hip fractures. The National Institute for Health and Care Excellence (NICE) recommends surgery on the day of admission or the day after.

Key research gaps include:

·       Determining the actual time from admission to surgery in Egyptian hospitals.

·       Identifying the medical and system-related causes of delays.

·       Understanding the reasons behind delays due to factors such as theatre availability, implant availability, blood products, ICU beds, finance, consent, and anaesthesia clearance.

·       Exploring the relationship between delays and mortality, complications, length of stay, and cost.

Possible research questions include:

·       Determining the percentage of older Egyptian hip-fracture patients who receive surgery within 48 hours.

·       What are the top five reasons for surgery after 48 hours?

·       Are system delays more common than medical delays?

·       Does a dedicated hip-fracture trauma list improve the time to surgery?

3. Orthogeriatric and multidisciplinary care gaps

Orthogeriatric care is widely recommended, but LMIC studies reveal that specialist orthogeriatric expertise is often unavailable, senior medical input is inconsistent, and care pathways vary significantly between institutions.

Key research gaps:

·       Availability of geriatricians or internists for hip-fracture co-management in Egyptian hospitals.

·       Effect of physician-led perioperative optimization on the time to surgery, delirium, medical complications, and mortality.

·       Feasible Egyptian model: orthogeriatrician, internal medicine physician, anaesthetist-led optimization clinic, or nurse-led pathway.

·       Role of multidisciplinary hip-fracture rounds.

Possible research questions:

·       Does physician/geriatric co-management reduce complications in older Egyptian hip-fracture patients?

·       What is the minimum feasible orthogeriatric model for Egyptian university hospitals?

·       Can a structured multidisciplinary hip-fracture pathway reduce mortality and length of stay?

·       What training do orthopaedic and medical residents need for geriatric trauma care?

·       Can orthogeriatric care integration reduce cost of hip fractures in Egypt.

4. Pain management and regional nerve-block gaps

NICE recommends immediate analgesia, repeated pain assessment, and consideration of nerve blocks when analgesia is inadequate or to limit opioid use.

Key research gaps:

·       Time to first analgesia in Egyptian emergency departments.

·       Use of pain scores in cognitively intact versus impaired patients.

·       Availability and effectiveness of fascia iliaca, femoral nerve, or PENG blocks.

·       Impact of nerve blocks on opioid use, delirium, mobilization, and patient comfort.

Possible research questions:

·       What proportion of hip-fracture patients receive analgesia within 30 minutes?

·       Are regional blocks feasible in Egyptian emergency departments?

·       Does fascia iliaca or PENG block reduce delirium or opioid requirement?

·       Are pain scores reliably documented in older patients with cognitive impairment?

5. Surgical-treatment and implant-selection gaps.

Guidelines recommend procedure selection based on fracture type, pre-fracture function, and medical fitness. NICE recommends arthroplasty for displaced intracapsular fractures, cemented implants for arthroplasty, extramedullary fixation for most trochanteric fractures, and intramedullary fixation for subtrochanteric fractures.

Key research gaps include:

·       Current implant choices in Egypt for displaced intracapsular, trochanteric, and subtrochanteric fractures.

·       Cemented versus uncemented hemiarthroplasty outcomes in Egyptian patients.

·       Use and outcomes of THA versus hemiarthroplasty in active older adults.

·       Implant availability and cost-effectiveness.

·       Reoperation, infection, dislocation, and peri-implant fracture rates.

Possible research questions include:

·       What implants are actually used for hip fractures in Egyptian trauma centers?

·       Is cemented hemiarthroplasty associated with better mobility and fewer reoperations in Egypt?

·       Which Egyptian patients benefit from total hip arthroplasty after displaced femoral neck fracture?

·       What is the reoperation rate after DHS, cephalomedullary nail, and hemiarthroplasty?

6. Anaesthesia and perioperative-risk gaps

NICE recommends offering spinal or general anaesthesia after discussing risks and benefits and considering intraoperative nerve blocks.

Key research gaps include:

·       Spinal versus general anaesthesia outcomes in older Egyptian hip-fracture patients.

·       Anaesthesia-related delay.

·       Bone-cement implantation syndrome incidence and prevention.

·       Perioperative protocols for anticoagulated patients.

·       Availability of high-dependency or ICU beds for frail patients.

Possible research questions include:

·       Does anaesthetic type influence delirium, hypotension, mortality, or mobilization?

·       How often does anticoagulation delay surgery?

·       What is the incidence of complications related to cement during hemiarthroplasty?

·       Can a standard anticoagulation reversal protocol reduce the time to surgery?

7. Mobilization and rehabilitation gaps

NICE recommends physiotherapy assessment and mobilization on the day after surgery unless contraindicated, with daily mobilization thereafter. However, LMIC service-readiness work shows variation in mobilization and weight-bearing protocols.

Key research gaps:

·       Availability of physiotherapy in Egyptian trauma wards, especially on weekends.

·       Time to first mobilization after surgery.

·       Barriers to mobilization, such as pain, fear, family reluctance, staffing, lack of walking aids, and surgeon restrictions.

·       Effect of early mobilization on pneumonia, pressure ulcers, length of stay, and functional recovery.

·       Post-discharge rehabilitation access.

Possible research questions:

·       What percentage of Egyptian hip-fracture patients mobilize by postoperative day 1?

·       What are the main barriers to early mobilization?

·       Does early mobilization reduce length of stay and complications?

·       Is a caregiver-assisted rehabilitation program feasible after discharge?

8. Osteoporosis and secondary-fracture prevention gaps

Egyptian data show a significant osteoporosis treatment gap. In a multicenter study, 82.1% of eligible postmenopausal women and 100% of eligible men were not receiving osteoporosis therapy before their index fragility fracture.

Key research gaps:

·       Proportion of hip-fracture patients discharged on anti-osteoporosis medication.

·       DXA access and whether DXA should delay treatment.

·       Creating alternative osteoporosis screening methods in areas where DXA is not available (e.g.; calcaneal US)

·       Use of vitamin D, calcium, bisphosphonates, denosumab, or anabolic therapy after hip fracture.

·       Medication adherence at 6 and 12 months.

·       Feasibility and effectiveness of Fracture Liaison Service models in Egypt.

Possible research questions:

·       What proportion of Egyptian hip-fracture patients receive osteoporosis treatment after discharge?

·       Does an FLS reduce secondary fractures and improve medication adherence?

·       Is a “treat-first, DXA-later” strategy appropriate for Egyptian hip-fracture patients?

·       What are the barriers to osteoporosis treatment in men after hip fracture?

9. Falls, sarcopenia, and frailty gaps

Egyptian osteoporosis-gap data revealed that falls, sarcopenia, and functional disability were significantly associated with fracture risk, underscoring the need for multifactorial prevention strategies rather than focusing solely on bone density.

Key research gaps include:

·       Prevalence of sarcopenia and frailty among Egyptian hip-fracture patients.

·       Validation of Arabic frailty and sarcopenia tools in acute trauma settings.

·       Relationship between frailty, surgical delay, complications, and mortality.

·       Effectiveness of nutrition, protein supplementation, vitamin D, and strength/balance training.

Possible research questions include:

·       Which frailty score best predicts mortality after hip fracture in Egyptian patients?

·       Is SARC-F a useful screening tool in Egyptian trauma wards?

·       Does nutritional supplementation improve mobilization and recovery?

·       Can falls-risk assessment reduce recurrent falls after hip fracture?

10. Nutrition and pressure-ulcer prevention gaps

The FFN’s minimum dataset includes pressure ulcer development during admission, while its extended dataset includes nutritional assessment because nutrition is a modifiable factor in hip-fracture recovery.

Key research gaps include:

·       Malnutrition prevalence in older Egyptian hip-fracture patients.

·       Use of nutritional screening tools such as MNA or MUST.

·       Relationship between malnutrition and infection, pressure ulcers, delayed mobilization, and mortality.

·       Frequency and severity of pressure ulcers on admission versus hospital-acquired ulcers.

Possible research questions include:

·       What is the prevalence of malnutrition in older Egyptian hip-fracture patients?

·       Does nutrition screening predict complications?

·       Does early protein supplementation reduce pressure ulcers and length of stay?

·       How many pressure ulcers are present on admission due to delayed presentation?

·       What are the causes of delayed presentation in Egyptian population?

11. Patient-reported outcome and quality-of-life

Patient-reported outcome and quality-of-life gaps after geriatric hip fracture remain significant research areas. A systematic review revealed substantial heterogeneity in patient-reported outcome measures, poor reporting of missing data, inconsistent reporting of effect size, and inadequate interpretation of patient-reported outcomes.

Key research gaps include:

The development of Arabic-validated patient-reported outcomes (PROMs) for hip fracture recovery, identifying patient priorities after hip fracture, exploring quality-of-life outcomes beyond mortality, and investigating fear of falling and confidence levels after surgery.

Possible research questions

·       Which Arabic PROM is most suitable for Egyptian hip-fracture patients?

·       What outcomes do Egyptian patients and caregivers consider most important?

·       Does early surgery improve quality of life at 120 days?

·       How does fear of falling affect rehabilitation and return to independence?