Management of Hip Fractures in the Elderly

Planning the theatre team

Recommendation

·       Schedule hip fracture surgery on a planned trauma list

·       Consultants or senior staff must supervise trainees and junior members of the anaesthesia, surgical, and theatre teams when they carry out hip fracture procedures (Good practice statement)

Remarks

Hip fracture patients should be prepared for the next operative list after admission, with a senior orthopaedic surgeon and an anaesthetist attending the surgery. The presence of a dedicated team for the management of geriatric hip trauma patients is recommended.

Summary of evidence

Planning the theatre team for the management of geriatric hip trauma patients is recommended⁷. A comprehensive geriatric fracture program has been described^38,39 as an alternative approach to managing fragility fractures. An organized geriatric hip fracture program provides numerous benefits to patients with hip fractures, care providers, and health systems. Protocol-driven perioperative approaches should be employed, focusing on pre, intraoperative, and postoperative optimization of the patient to facilitate early repair of the fracture that may then translate into better outcomes and hence alleviate the individual patient's burden as well as the socioeconomic load for society. These benefits include shorter time to surgery, earlier postoperative mobilization, shorter hospital stay, reduced in-hospital mortality, and reduced postoperative complications.

Rationale for the recommendation

People with a hip fracture can experience pain and anxiety while waiting for an operation. Delays in surgery are associated with negative outcomes for mortality and return to mobility. This approach aims to reduce unnecessary delays, which are associated with negative outcomes and prolonged hospital stays for the patient. It also helps to avoid repeated fasting and potential cancellations often associated with emergency lists. A planned trauma list includes specific healthcare professionals with the expertise required for hip surgery. Senior staff supervision can help to reduce the risk of complications during the surgery. Senior supervision is a crucial factor for patients, who rate the presence of specialists as the most important factor in their preference for a planned operation, as it can reduce the risk of complications during surgery. 

Stable Femoral Neck Fractures

Recommendation

In patients with stable femoral neck fractures (impacted/non-displaced, Garden’s I and II, Annex 6: Garden Classification of Femoral Neck Fracture), internal fixation or arthroplasty may be considered, after assessment of the patient and imaging of the hip joint. (Conditional recommendation, Low quality evidence)

Remarks

The decision of management of undisplaced apparently stable femoral neck fractures is multifaceted and depends on several factors (Annex 6: Garden Classification of Femoral Neck Fracture). The bone quality and the sagittal tilt seen in the lateral view or CT scan affect the decision-making of internal fixation vs arthroplasty. The pre-injury functional state of the patient also affects the decision.

Summary of evidence

The decision-making of internal fixation in undisplaced femoral neck fracture is conditioned on the true stability of the fracture, Garden classifications I and II without posterior or anterior tilt ^{40, 41} and the relatively good bone quality for the anchor of the internal fixation tools. There is no reported superior long-term outcome of arthroplasty compared to internal fixation ^{42, 2, 7}.

Rationale for the recommendation

Internal fixation may be the preferred treatment for physiologically fit elderly patients with Garden I and II, with posterior tilt <20°, good bone quality, independent ambulation, and reasonable life expectancy. Primary arthroplasty should be considered when the probability of fixation failure is high. It is indicated when posterior tilt >20° (Okike K et al. 2019, Papadelis E et al. 2023), associated severe osteoporosis, frailty, and poor compliance of the patient, and pre-existing hip osteoarthritis. Age >80 years with multiple risk factors is also an indication. Arthroplasty did not show superior long-term outcomes compared to internal fixation of non-displaced femoral neck fractures. 

Unstable femoral neck fractures – arthroplasty vs fixation

Recommendation:

For displaced (Garden III/IV) fractures neck femur in ambulatory or functionally independent elderly patient, HA or THA is strongly recommended over internal fixation. (Strong Recommendation, High quality evidence:).

Remarks

Fixation is associated with high failure rates (25–40%), frequent reoperations, and inferior functional outcomes. Compared with the internal fixation group, patients that underwent hemiarthroplasty had a lower reoperation rate and an equivalent overall mortality rate ^7,37,43-45

Contraindications to arthroplasty:

1.     Patient was non ambulatory pre fracture (bedbound or wheelchair- dependent)

2.     Life expectancy is less than 12 months (metastatic cancer, end stage organ failure)

3.     High surgical risk (ASA IV, not optimized despite best efforts)

 Conclusions

In ambulatory patient with unstable fractures femoral neck, Arthroplasty is recommended over fixation   

Summary of evidence

Arthroplasty is preferred when:

1.     Patient is active and can benefit from better functional outcomes

2.     Minimizing reoperation risk is a priority

3.     Patient needs faster return to walking with less pain

Internal Fixation may be considered when:

1.     Patient has low activity levels or advanced dementia

2.     Patient has limited life expectancy

3.     High surgical risk Favors shorter procedure time

Important Notes:

1.     Mortality rate is similar in both groups (~25% at 1 year)

2.     Decision should focus on expected quality of life rather than survival alone

3.     Shared decision-making with patient/family is essential after explaining risks and benefits

Rationale for the recommendation

1. Reoperation Rate ⁴⁶

·       Internal Fixation: Very high (26–32%)

·       Arthroplasty: Low (6–9%)

·       Relative Risk: 0.29 (Favors arthroplasty)

o   This means the risk of reoperation is 3.4 times higher with internal fixation

2. Non-union/Avascular Necrosis (AVN)

·       Internal Fixation: Common problem (20–40%)

·       Arthroplasty: Very rare (<2%)

·       Not applicable for relative risk calculation (too rare with arthroplasty)

3. 1-Year Mortality Rate

·       Identical in both groups (~25%)

·       No statistically significant difference

4. 1-Year Functional Outcomes

·       Internal Fixation: Worse mobility, more pain

·       Arthroplasty: Better walking ability, less pain

·       Standardized mean difference: +0.4 (Favors arthroplasty)

Unipolar/bipolar hemiarthroplasty

Recommendation

Use a femoral stem design other than Austin Moore or Thompson stems for arthroplasties. Unipolar (Austin Moore or Thompson) prosthesis should be used in strictly limited conditions, e. g. Unavailable bipolar prosthesis. (Good practice statement, Moderate quality evidence:)

Remarks

Where the unipolar head has a single articulation between the prosthesis and the acetabulum, the bipolar head offers a second articulation between an inner smaller head and the polyethylene liner of the larger outer head. In theory this reduces stress on the acetabular surface and thereby acetabular erosion. Acetabular erosion is believed to cause pain and impaired hip function.

Summary of evidence

RCTs comparing unipolar and bipolar, showed better Health-related quality of life and hip function for bipolar. The average four years follow-up showed less acetabular erosion by using bipolar^47-53.

Rationale for the recommendation

In spite that both replace the femoral head for hip fractures, but bipolar's dual articulation aims for better preservation of the natural socket (acetabulum), and for a better range of motion

UNSTABLE FEMORAL NECK FRACTURES - Total Arthroplasty vs Hemi Arthroplasty

Recommendation

Recommendation 1: For fit, active elderly patients (≥60 years) with displaced femoral neck fractures, Total Hip Arthroplasty (THA) is suggested rather than Hemiarthroplasty (HA) to improve function and reduce revision risk. (Conditional recommendation, Moderate quality evidence)

Recommendation 2: For frail, medically complex, or cognitively impaired patients with limited mobility, Hemiarthroplasty (HA) may be preferred due to shorter operative time and reduced perioperative risk. (Conditional recommendation, Moderate quality evidence)

Recommendation 3: Decisions should incorporate individual patient comorbidities, cognition, pre-fracture mobility, surgical risk, and patient preference. (Strong recommendation, Moderate quality evidence)

Remarks

The pathways below integrate evidence quality with clinical risk stratification to provide decision support.

Pathway A: Fit, Active Elderly (>60, Independent, Low Comorbidity)

Goal: Maximize postoperative function and quality of life.

Recommendation:

·       Total Hip Arthroplasty (THA) preferred.

Rationale:

• Functional benefit: Moderate evidence supports better function and quality of life with THA⁴⁴.
• Revision and survivorship: Comparable or lower mid-term revision with THA⁵⁴.
• Dislocation risk: Slightly elevated but clinically acceptable in active patients⁵⁵.

Considerations:

• Use THA construct tailored to reduce dislocation risk (dual-mobility etc.)
• Ensure surgical team experience.

Pathway B: Medically Complex, High Surgical Risk (≥60, Multiple Comorbidities, Frailty)

Goal: Minimize perioperative risk and complications.

Recommendation:

·       Hemiarthroplasty (HA) preferred.

Rationale:

• Operative time and physiologic stress: HA has shorter operation and less surgical complexity⁵⁶.
• Functional demands lower: Functional advantage of THA may be less relevant⁴⁴.
• Dislocation risk lower: HA has lower hip dislocation rates⁵⁵.

Pathway C: Intermediate Risk (Moderate Comorbidity, Ambulatory but Dependent)

Goal: Balance function and surgical risk.

Recommendation:

·       Consider HA if frailty is significant; THA if moderate comorbidity but preserved cognition and activity.

Rationale:

• If cognitive impairment or limited mobility, HA likely sufficient⁵⁷.
• If moderate risks with good activity, THA may yield functional benefits.

Summary of evidence

The evidence suggests that THA provides slightly better functional outcomes and quality of life than HA, with comparable revision rates and mortality. HA, however, may be preferable in patients with higher surgical risk due to shorter operative time and lower dislocation risk.

A. Functional Outcomes and Quality of Life

 

B. Revision and Reoperation

 

C. Complications and Risks

Outcome	Evidence Source	Effect	Certainty (GRADE)	Comments
Dislocation	Observational analyses	Slightly higher with THA	Moderate	Large cohort data show increased dislocation risk with THA (absolute difference small)55.
Operative time	Meta-analyses	Longer with THA	Moderate	Consistent finding: THA takes longer than HA56.
Mortality	Meta-analyses	No clear difference	Low	Mortality differences not consistently significant60.
Periprosthetic fracture / infection	Meta-analyses	Similar	Low-Moderate	Complication trends similar across groups56.

 

4. Summary of Evidence

 

Figure 1: Forest plot summarizing comparative outcomes for THA versus HA across revision rate, functional outcome, dislocation, and mortality

 

Rationale for the recommendation

Fit, Active Elderly Patients Population:
Patients ≥60 years, cognitively intact, ambulatory, independent, with low surgical risk (ASA I–II).

Recommendation: Perform total hip arthroplasty (THA) rather than hemiarthroplasty to optimize function and quality of life.

Rationale:

• THA provides better functional outcomes and HRQoL.
• Revision rates are comparable or lower long-term.
• Slightly higher dislocation risk can be mitigated by surgical technique (e.g., dual-mobility cup).

Implementation notes:

• Use cemented femoral stems for stability.
• Consider posterior-lateral or anterolateral approaches with soft-tissue repair.
• Employ early mobilization and physiotherapy.

Frail or Medically Complex Patients Population:

Patients ≥75 years, frail, with multiple comorbidities (ASA III–IV), limited ambulation, or cognitive impairment.

Recommendation: Perform hemiarthroplasty (HA) rather than total hip arthroplasty to minimize operative risk.

Rationale:

• Shorter operative time and less blood loss.
• Lower dislocation rate.
• Functional benefit of THA less relevant due to low activity levels.

Implementation notes:

• Use cemented bipolar or unipolar head per institutional preference.
• Prioritize rapid surgery (<48 hours after fracture) and early mobilization.

Intermediate Risk / Mixed Profile Population:
Patients with moderate comorbidities (ASA II–III), ambulatory with aids, or mildly dependent.

Recommendation: Individualize the choice based on cognitive status, pre-fracture activity, and surgical expertise.

Rationale:

• THA if ambulatory and cognitively intact.
• HA if dependent, low activity, or poor bone quality.
• Engage in shared decision-making with patient and family.

 

Implementation Considerations

• Institutional expertise: THA requires advanced surgical capability; if not available, HA remains appropriate.
• Cemented fixation: Recommended for both THA and HA in elderly patients.
• Dual mobility cups: Recommended when performing THA in high-dislocation-risk patients.
• Timing: Surgery ideally within 48 hours of fracture to reduce mortality and complications.
• Rehabilitation: Early mobilization and comprehensive geriatric input improve outcomes.

Use of cement in arthroplasty

Recommendation

Cemented stem implants are preferred in patients undergoing surgery with arthroplasty.  (Conditional recommendation, High quality evidence)

Remarks

The use of cement in arthroplasty has the potential to secure the implant in an osteoporotic patient and reduce the need for revision secondary to loosening of the prosthesis.

Summary of evidence

Evidence based studies and RCTs showed that cemented fixation in THA after hip fractures is associated with lower revision rates, but similar mortality compared to cementless fixation^62-68

Rationale for the recommendation

Some concerns exist around the use of cement and the possibility of bone cement implantation syndrome. Bone cement implantation syndrome is a poorly understood phenomenon which is characterised by one or more of the following: hypoxia, hypotension, cardiac arrhythmias, increased pulmonary vascular resistance and cardiac arrest. It can occur at a number of stages during an arthroplasty including during femoral reaming, insertion of cement or the prosthesis and at the time of reduction of the joint. Its exact aetiology and pathophysiology remain poorly understood as does an accurate figure of the true incidence of the syndrome.

Surgical Approach

Recommendation

In patients undergoing treatment of femoral neck fractures with hip arthroplasty, evidence does not show a favoured surgical approach. Select approach based on surgeon’s experience and preference (Good practice statement)

Remarks

The data in newer studies show no difference in the dislocation rates between the different surgical approaches, including the posterior approach. This contrasts with the earlier data in older publications which showed higher dislocation rate with the posterior approach in comparison to the lateral approach.

Summary of evidence

One high quality study⁶⁹, seven moderate quality studies^70-76 and two low quality studies^77,78 were included in the evidence for this recommendation.

The high-quality study⁷⁵ compared hemiarthroplasty with the anterolateral approach to hemiarthroplasty with the direct lateral approach and reported that while there were elevated levels of serum creatine kinase (CK) observed in the anterolateral approach group, no correlation between CK levels and the Timed Up and Go test or the Trendelenburg sign at 3 months were found.

There were also 8 citations about surgical approach in the surgical treatment of femoral neck fractures with moderate evidence strength. Jianbo (2019)⁷⁰ reported on a prospective, randomized study of 100 patients. They specifically compared the clinical outcomes and complications of using either the conventional posterior approach, or with using a minimally invasive surgery (MIS) and muscle preserving approach (the Suprapath approach). There was less blood loss, and low transfusion rate in the MIS group. There was less pain, and better function within the first week in the minimally invasive group, but no differences between the groups at the 3-month interval. Repantis (2015)⁷³ reported on the comparative results of a prospective, randomized study in 80 patients using either a MIS approach or in using the posterior approach. It was a single-surgeon series. There was less pain in the MIS group in the short term. There was no difference in any of the other outcomes or complications up to 4 years of follow up. In another comparative study, Saxer (2018)⁷⁴ reported on the results of 190 patients using either a MIS or using the lateral approach. There was less pain, and faster ambulation in the first 3 weeks in the MIS group. There was no difference in any of the other outcomes, or in the complications between the groups. Verzellotti (2019)⁷⁶ reported on the comparative results of using the direct anterior (DA) which is muscle preserving, or in using the posterior approach in 100 patients. There was less pain in the DA group in the first month after surgery. There was no difference in the other outcomes or complications between the groups. The operative time was longer in the DA group. Parker (2015)⁷² reported the comparative results of a multi-centre, prospective, randomized study in 216 patients using either the posterior or the lateral approach. There was no difference in any of the outcome measures analyzed between the groups. In a prospective, randomized study in 150 patients, Ugland (2018)⁶⁹ reported higher risk of post-surgery Trendelenburg gait when the arthroplasty was done using the lateral approach in contrast to using the anterolateral approach (more abductor muscle preserving). Two low strength articles^77,78 (Biber 2012, Skoldenberg 2010) compared the posterior approach to the direct lateral approach for performing arthroplasty in the patients with femoral neck fractures. While neither of the included studies specifically addressed any functional outcomes, they both demonstrated statistically significant differences in dislocation rates, favouring the direct lateral approach.

Rationale for the recommendation

The existing evidence does not support superiority of one surgical approach. Future well designed RCTs should include a comparison of the anterior approach with the posterior and the lateral approach. Any future studies related to surgical approach should also include pain and functional data associated with the approaches. This may have important implications for patient selection and recovery needs such as assistive devices or therapy needs.

Sliding hip screw versus cephalomedullary intramedullary nail for stable intertrochanteric fracture

Recommendation:

In patients with stable intertrochanteric fractures, use of either a sliding hip screw or a cephalomedullary device is recommended. Use a dynamic hip screw (DHS) in preference to an intramedullary nail in patients with stable intertrochanteric fractures (Strong recommendation, High quality evidence)

Remarks

Stable trochanteric fractures are simple two-part intertrochanteric fractures with posteromedial cortical continuity and lateral wall integrity. This fracture pattern is considered stable as it will resist medial compressive loads once reduced.

Summary of evidence

Sliding hip screw versus intramedullary nail for trochanteric fracture

Parker et al. (2012)⁷⁹ compared the sliding hip screw with the Targon PF intramedullary nail in the treatment of 600 cases of trochanteric hip fracture among 598 patients (mean age=82 years, 80% women). Patients were randomised to treatment with a sliding hip screw or intramedullary nail, and all operations were either performed or supervised by a single orthopaedic surgeon. Patients were reviewed 6 weeks after discharge, and followed up at 3, 6, and 12 months after injury by a research nurse blinded to treatment.

There were no significant differences between groups for total hospital stay (p=0.3), wound healing complications (p=1), other fracture-related complications (p values ranging from 0.12 to 1), loss of hip flexion (p=0.31), or shortening (p=1) at 6 weeks. There were also no significant differences between groups at 1 year for mortality (indicated by Kaplan-Meier curve) or pain (p=0.26). There was, however, a significantly greater recovery of mobility at 1 year with intramedullary nail versus sliding hip screw (difference in mobility score of approximately 0.5 on a scale from 0 to 9, p=0.01).

Cai et al. (2016) ⁸⁰ in a prospective, randomised blinded study included patients aged over 65 years with stable intertrochanteric fractures (Evans grades I and II). The patients were allocated to one of two groups treated via extramedullary or intramedullary fixation. Extramedullary (compared with intramedullary) fixation of stable intertrochanteric fractures significantly reduces perioperative blood loss but affords similar functional outcomes and times to union. In view of the morbidity and complications associated with acute anaemia and transfusions, extramedullary fixation may be the optimal choice for treatment of stable fractures, being associated with reduced blood loss.

Lewis et al. (2022)⁸¹ included randomised controlled trials (RCTs) and quasi-RCTs comparing cephalomedullary nails with extramedullary implants for treating fragility extracapsular hip fractures in older adults. They concluded that Extramedullary devices, most commonly the sliding hip screw, yield very similar functional outcomes to cephalomedullary devices in

the management of extracapsular fragility hip fractures. There is a reduced risk of infection and non-union with cephalomedullary nails; however, there is an increased risk of implant-related fracture that is not attenuated with newer designs. 

Sliding hip screw versus proximal femoral locking compression plate for stable intertrochanteric fracture

Zhong B et al. (2014) ⁸²  compared proximal femoral locking compression plate (PFLCP) and DHS fixation in intertrochanteric fractures. They concluded that PFLCP can offer better functional outcomes and fewer complications for subtrochanteric femoral fractures. DHS fixation is preferable for stable intertrochanteric fractures. For unstable intertrochanteric fractures, the value of PFLCP fixation needs to be confirmed by further clinical studies.

Rationale for the recommendation

Stable trochanteric fractures have posteromedial continuity and have lateral wall integrity that enables these fractures to resist compressive medial loads, and if they are well reduced and varus reduction is avoided, both intramedullary and extramedullary implants will maintain the fracture reduction and resist failure. This will allow early weight bearing of patients, whether they are operated upon by intramedullary or extramedullary implant. The cost of cephalomedullary devices is generally more than sliding hip screw fixation in most institutions. Cephalomedullary nail fixation reduces the length of hospital stay and fewer complications (Xu 2018), which can decrease the overall costs with cephalomedullary devices.

Cephalomedullary device – unstable intertrochanteric fractures

Recommendation:

In patients with unstable intertrochanteric fractures, the use of cephalomedullary device is recommended. (Strong recommendation, High quality evidence)

Remarks

Unstable trochanteric fractures are fractures with comminution, posteromedial fragment, deficient lateral wall, reversed oblique, and subtrochanteric extension. This fracture pattern is considered unstable as it will drift into varus and/or medialization with exposure to compressive loads.

Summary of evidence

In a systematic review and meta-analysis conducted by Zeelenberg ML et al. (2024)⁸³, current literature shows that several functional outcomes, complications, and surgical outcomes were statistically in favor of intramedullary fixation when compared with extramedullary fixation of AO/OTA 31-A2 fractures. However, as several of the differences found appear not to be clinically relevant and for many outcomes data remains sparse or heterogeneous, complete superiority of IM fixation for AO type 31-A2 fractures remains to be confirmed.

Kassem et al. (2022)⁸⁴, in another systematic review and meta-analysis to compare DHS with trochanter stabilizing plate (TSP) and short proximal femoral nails (PFNs) in unstable trochanteric fractures in terms of the functional and radiological outcomes. They concluded that the use of PFN in unstable trochanteric fractures was associated with a shorter time until union and a faster return to the pre-fracture level of activity than the DHS+TSP. However, postoperative hip function, walking independence, as well as complication and one-year mortality rates were comparable. Based on these findings, they suggested that PFN is the first-choice implant for the unstable (AO/OTA 31-A2) intertrochanteric fractures.

Lewis et al. (2022), in a systematic review, included older adults with both stable and unstable extracapsular fractures. Their findings indicate that there may be no difference between cephalomedullary nails versus dynamic fixed-angle plates

Proximal femoral locking compression plate versus intramedullary nailing for unstable intertrochanteric fracture

Zhong B et al. (2014)⁸² concluded that in unstable intertrochanteric fractures, the value of PFLCP fixation needs to be confirmed by further clinical studies. Fixation with an intramedullary nail is still the best option for patients with unstable intertrochanteric fractures; however, controlled studies are needed.

Zhang S et al. (2025)⁸⁵ conducted a systematic review and meta-analysis of randomized controlled trials with the aim of summarizing the latest evidence for the effectiveness and safety of a variety of implants for fixation of intertrochanteric fractures. They concluded that InterTAN nail (ITN) clearly reduces the incidence of non-mechanical major post-surgery complications and non-specific mechanical complications; however, it is associated with an increased risk of intraoperative complications. No differences were observed between SHS and other implants regarding Harris hip score, reoperation rate, and overall mechanical complications. Most comparisons evaluating the efficacy of these implants are supported by moderate confidence of evidence. Further large-scale, longitudinal, randomized controlled trials are necessary to provide more robust and consistent evidence.

Rationale for the recommendation

Unstable intertrochanteric fractures are fractures that may have comminution, posteromedial fragment, deficient lateral wall, reversed oblique, or subtrochanteric extension. This fracture pattern is considered unstable as it will drift into varus and/or medialization with exposure to compressive loads. Fixation with an intramedullary nail is still the best option for patients with unstable intertrochanteric fractures, as it is biomechanically superior to an extramedullary implant.

Cephalomedullary device – subtrochanteric/reverse obliquity fractures

Recommendation:

In patients with subtrochanteric or reverse obliquity fractures a cephalomedullary device is recommended. (Strong recommendation, High quality evidence)

Remarks

Reverse obliquity fractures are a subset of intertrochanteric/peritrochanteric fractures that are an unstable pattern. Though subtrochanteric fractures are more of a proximal femur fracture, they can be a component of an intertrochanteric fracture as well.

Summary of evidence

Xie et al. (2019) ⁸⁶ in a meta-analysis suggested that intramedullary fixation for subtrochanteric fracture might be superior to extramedullary fixation in terms of shorter operation time, less intraoperative blood loss, shorter length of incision, length of stay, and better functional outcomes. Meanwhile, intramedullary fixation had a lower rate of fixation failure and reoperation. Therefore, intramedullary fixation is recommended as the treatment of subtrochanteric fractures. Larger multi-centre and high-quality RCTs are required for further research. 

The results of a meta-analysis conducted by Wang J et al. (2020)⁸⁷ revealed that intramedullary fixation can confer shorter union time, lower non-union, and reoperation rates compared with extramedullary fixation. They considered intramedullary nailing as the first selection for the treatment of patients with subtrochanteric fractures.

Plating may be considered in select cases, such as periprosthetic fractures, proximal deformities, or salvage situations.⁸⁸

Rationale for the recommendation

Intramedullary nailing is the implant of choice in subtrochanteric fractures and reverse obliquity fractures. It is biomechanically superior to a surface implant.

Blood transfusion

Recommendation

A blood transfusion threshold of no higher than 8g/dl is suggested in asymptomatic postoperative hip fracture patients. (Conditional recommendation, Moderate quality evidence)

Remarks

Moderate-strength evidence suggests that restrictive transfusion practices reduce utilization of transfusions and may decrease infections without increasing adverse outcomes in major orthopaedic surgery. ^89-93

Initial Assessment

1.     Hemodynamic status (stable/unstable)

2.     Haemoglobin (Hb) level

3.     Symptoms of anaemia (tachycardia, hypotension, dyspnoea, chest pain, dizziness)

4.     Cardiovascular comorbidities

Decision Nodes

·       Hb < 8 g/dL → transfuse

·       Hb 8–10 g/dL → transfuse if symptomatic or high cardiac risk

·       Hb >10 g/dL → no transfusion, monitor

Transfusion Strategy

·       Restrictive strategy preferred

·       Number of units per transfusion (usually 1 unit at a time, reassess Hb)

·       Monitor for transfusion reactions

Reassessment

·       Post-transfusion Hb

·       Re-evaluate symptoms

·       Repeat transfusion only if Hb < 8 g/dL or persistent symptoms

Pre-op Optimization

·       Ensure hemodynamic stability

·       Correct coagulopathy if present

·       Proceed to surgery once stable

Optional Branches

·       Non-operative/palliative care for patients with limited life expectancy or refusal of transfusion

·       Consider erythropoietin or iron supplementation if appropriate

Refusal of blood transfusion

When an elderly hip-fracture patient needs transfusion but refuses ^93-96

1. Confirm capacity & informed refusal

·       Assess and document decision-making capacity.

·       Clearly explain:

·       Why blood may be needed

·       Risks of refusing transfusion (anaemia, cardiac events, death)

·       Available alternatives

·       Obtain written informed refusal (ideally with a witness).

·       If the patient lacks capacity → follow advance directives or legally authorized surrogate.

If the patient has capacity, their refusal must be respected, even if life-threatening.

2. Clarify what is acceptable

Many patients who refuse “blood” may accept:

·       Cell salvage (closed circuit)

·       Acute normovolaemic haemodilution

·       Albumin

·       Coagulation factors (e.g., fibrinogen, PCC)

·       Erythropoietin

·       Iron therapy

Do not assume refusal of all blood products — ask and document precisely.

3. Optimize pre-operative haemoglobin

If surgery can be delayed safely (24–48 h max in hip fractures):

·       IV iron (e.g., ferric carboxymaltose)

·       Erythropoietin (EPO)

·       Folic acid + vitamin B12

·       Minimize blood sampling

4. Choose the least blood-loss strategy

Surgical

·       Prefer hemiarthroplasty over THA when appropriate

·       Cemented stems (shorter operative time)

·       Meticulous haemostasis

·       Minimize operative time

Anaesthetic

·       Regional anaesthesia (spinal) if feasible

·       Controlled hypotension (careful in elderly)

·       Tranexamic acid (TXA) — IV ± topical

5. Intra- and post-operative blood conservation

·       TXA significantly reduces blood loss in hip fracture surgery

·       Cell salvage if acceptable

·       Maintain normothermia

·       Restrictive transfusion thresholds (already transfusion-free)

6. Post-operative management

·       Tolerate lower Hb if patient is asymptomatic

·       Oxygen therapy

·       Treat anaemia aggressively with iron/EPO

·       Early mobilization to reduce complications

7. Ethical & legal principles

·       Autonomy overrides beneficence in a competent adult

·       Forced transfusion = assault

·       Thorough documentation protects both patient and physician

·       Involve:

·       Ethics committee (if available)

·       Hospital legal team (high-risk cases)

Summary of evidence

A restrictive red blood cell transfusion strategy is supported by high-quality evidence in elderly patients with hip fractures. Randomized controlled trials, including the FOCUS trial⁹², demonstrated that transfusing asymptomatic patients only when hemoglobin falls below 8g/dL does not increase mortality, cardiovascular complications, functional recovery impairment, length of hospital stay, or loss of independent ambulation compared with a liberal transfusion strategy.

International guidelines, including those from the AABB⁹³, NICE⁹¹, and AAOS², therefore recommend a restrictive transfusion threshold for most elderly hip fracture patients, while emphasizing that symptomatic anemia, ongoing bleeding, hemodynamic instability, or evidence of tissue hypoxia may justify transfusion at higher hemoglobin levels.

For patients who decline blood transfusion, patient blood management measures such as intravenous iron, erythropoietin, tranexamic acid, meticulous surgical hemostasis, minimization of phlebotomy, optimization of oxygen delivery, and early mobilization are recommended to reduce transfusion requirements.

The evidence supporting a restrictive transfusion threshold in elderly hip fracture patients^{2,7,91-93,97,98} is considered high quality, with strong consistency across randomized trials and major international guidelines.

Rationale for the recommendation

A restrictive transfusion strategy is recommended for most elderly patients with hip fractures. Current high-quality evidence demonstrates that using a haemoglobin threshold of 8 g/dL (unless the patient is symptomatic or has ongoing bleeding) is safe and effective. Compared with a liberal transfusion strategy, it does not increase:

·       30- or 60-day mortality

·       Cardiovascular complications

·       Functional recovery

·       Independent walking ability

·       Length of hospital stay

·       Discharge destination

Restrictive transfusion also reduces unnecessary exposure to blood products and transfusion-related complications while conserving healthcare resources (Annex 7: Blood transfusion in elderly hip fracture patients (flowchart)).

Tranexamic acid

Recommendation

Tranexamic acid should be administered to reduce blood loss and blood transfusion in patients with hip fractures. (Strong recommendation, High quality evidence)

Remarks

Tranexamic acid was not associated with higher incidence of mortality or symptomatic thromboembolic events.

1. Assess Patient Eligibility

·       Confirm hip fracture requiring surgery (intracapsular or extracapsular)

·       Age > 65 years

·       Check for contraindications:

o   Active thromboembolic disease (DVT, PE)

o   History of stroke or myocardial infarction within 6 months

o   Active intravascular clotting disorder

o   Known hypersensitivity to TXA

o   Severe renal impairment

2. Decide on Route and Dose

·       IV TXA is preferred

·       Typical regimen:

o   Bolus: 1 g IV preoperatively (within 30 min before incision)

o   Optional second dose: 1 g IV postoperatively or infusion over 8 hours in high-risk bleeding patients

·       Adjust dose for renal impairment

3. Timing of Administration

·       Preoperative: ideally at induction of anaesthesia

·       Some protocols allow additional intraoperative/topical dose if significant bleeding risk

4. Monitor Patient

·       Watch for thromboembolic complications

·       Monitor haemoglobin postoperatively

·       Assess need for transfusion

5. Postoperative Considerations

·       Early mobilization

·       Thromboprophylaxis as per institutional protocol (e.g., LMWH or DOAC)

·       Reassess bleeding risk and renal function

6. Contraindicated Patients

·       Avoid TXA if active clotting risk or severe renal impairment

·       Consider alternative blood conservation strategies

Summary of evidence

High-quality evidence demonstrates that tranexamic acid (TXA) significantly reduces perioperative blood loss and the need for allogeneic blood transfusion in elderly patients undergoing hip fracture surgery without increasing the risk of venous thromboembolism (VTE), myocardial infarction, stroke, or all-cause mortality^99-101.

Multiple randomized controlled trials¹⁰² and meta-analyses^99-101 have consistently shown reductions in total blood loss (approximately 200–400 mL) and transfusion rates (relative reduction of approximately 30–50%) compared with placebo or standard care. These benefits are observed across different surgical procedures, including hemiarthroplasty, total hip arthroplasty for fracture, and internal fixation.

Current evidence indicates that both intravenous and topical TXA are effective. Intravenous administration is supported by the largest body of evidence, while topical TXA provides a reasonable alternative when systemic administration is contraindicated. No clear superiority of one route over the other has been demonstrated.

Large observational studies and systematic reviews have found no significant increase in symptomatic deep vein thrombosis, pulmonary embolism, myocardial infarction, stroke, or mortality when TXA is used in appropriately selected patients receiving standard thromboprophylaxis.

Based on the consistency of evidence, major international organizations, including the American Academy of Orthopedic Surgeons (AAOS)² and the National Institute for Health and Care Excellence (NICE)⁷, recommend considering routine TXA administration in hip fracture surgery unless contraindications exist.

Strength of Evidence

 

Guideline Statement

 High-certainty evidence supports the use of tranexamic acid in elderly patients undergoing hip fracture surgery. TXA consistently reduces perioperative blood loss and transfusion requirements without increasing thromboembolic or cardiovascular complications when used with standard venous thromboembolism prophylaxis. Therefore, routine perioperative administration of TXA should be considered in the absence of contraindications (Annex 8: Tranexamic acid (TXA) in elderly hip fracture patients).

Rationale for the recommendation

Patients with hip fractures may benefit from TXA to reduce blood loss and subsequent transfusion. Use of tranexamic acid in hip fracture patients may result in lower blood loss and transfusion rates compared to placebo in several high-quality studies. Studies were unable to detect any difference in adverse events with use of tranexamic acid such as infection, wound complication, DVT, CVA, PE or MI^7,37,102-107

Interdisciplinary care programs

Recommendation

On admission, offer patients a formal, acute orthogeriatric or orthopaedic ward-based fracture program that includes the following steps:

·       Comprehensive orthogeriatric assessment to evaluate both current and baseline level of functioning  

·       Rapid optimization to make patient fit for surgery

·       Identify individual goals for multidisciplinary rehabilitation to recover mobility and independence, and to achieve return to pre-fracture residence when possible

·       Offer longitudinal, coordinated, orthogeriatric and multidisciplinary review

·       Provide liaison or integration with related services, particularly mental health (delirium prevention), falls prevention, bone health, primary care and social services

·       Clinical and service governance responsibility for all stages of the pathway of care and rehabilitation, including those provided in the community.

(Conditional recommendation, High quality evidence)

Remarks

Hip Fracture Program (HFP):

It is a comprehensive interdisciplinary evidence-based model of immediate and longitudinal interdisciplinary assessment, management and discharge planning⁷. Instead of the traditional model of orthopaedic care followed by routine transfer for rehabilitation elsewhere (e.g. orthopaedic or general rehabilitation units), interdisciplinary model provides many benefits including expediting and organizing both assessment and care in the acute hospital, promoting prompt discharge (wherever possible) to the patient’s normal home setting. It is more cost-effective compared to traditional model as established following the latest NICE CG124 (Clinical Guideline 124) evidence review^7,108.

Prompt, effective analgesia, anaesthesia and surgery, coordinated with structured, medical and multidisciplinary management from presentation to hospital discharge, are therefore needed and have been shown to deliver improved outcomes cost-effectively⁷.

The medical and multidisciplinary ‘ortho-geriatrician’ role was developed by physicians in clinical gerontology but is applicable to the care of hip fractures in adults of all ages¹⁰⁹.

Summary of evidence

A RCT (Randomized Clinical Trial)¹¹⁰ of 199 patients analysed admittance to a geriatric rehabilitation ward (comprising a geriatric team applying comprehensive geriatric assessment) versus regular orthopaedic care immediately postoperative to hip fracture surgery. Patients randomized to geriatric ward had less postoperative delirium (being shorter in those who developed it), fewer pressure ulcers, less malnutrition, fewer urinary tract infections, fewer falls, fewer new fractures during hospitalization, shorter hospital length of stay, and a 3-fold odds ratio of walking independently 1 year after. They also found that the best effect was seen in patients with dementia.

Another RCT¹¹¹ of 459 patients with hip fracture compared orthogeriatric co-management versus care by a geriatric consultant team versus standard orthopaedic care. Compared with standard care and geriatric consultant team care, orthogeriatric care showed significantly better outcomes in terms of time-to-surgery and in-hospital medical complications. Versus standard care, orthogeriatric care was also associated with significant reductions in hospital length of stay and in-hospital mortality.

Rationale for the recommendation

Ortho-geriatric team involvement in care provision for hip fracture patients from admission to discharge reduces complications, improves both in-hospital and long-term outcomes and reduces cost of care.

Postoperative Rehabilitation
1.  Timing of Mobilization

Recommendation

In patients undergoing surgical stabilization of hip fractures, early mobilization, including functional movement within 24–48 hours postoperatively is recommended, provided the patient is medically and mobilization is consistent with the surgeon’s postoperative instructions (Strong recommendation, High quality evidence)

Remarks

Mobilization should begin with bed mobility and progress to sitting, standing, and assisted ambulation as tolerated. Progression should be individualized according to pain levels, hemodynamic stability, cardiopulmonary status, and overall medical condition. Delays in mobilization may be necessary in cases of medical instability but should be minimized whenever possible.

Summary of evidence

Multiple randomized controlled trials¹¹² and systematic reviews^113,114 have consistently demonstrated that early mobilization following hip fracture surgery is associated with reduced postoperative complications, including pneumonia, thromboembolic events, delirium, and pressure injuries. Early mobilization has also been shown to improve functional recovery, reduce length of hospital stay, and enhance the likelihood of returning to pre-fracture mobility levels. Across studies, mobilization initiated within the first 24–48 hours is superior to delayed mobilization strategies.

Rationale for the recommendation

Early mobilization mitigates the adverse physiological effects of prolonged bed rest, supports cardiovascular and pulmonary function, and promotes neuromuscular activation necessary for recovery of mobility, independence, and overall functional outcomes. 

2. Weight-Bearing

Recommendation

Following hip fracture surgery, weight-bearing should be initiated as early as clinically feasible, with full weight-bearing as tolerated recommended after stable fixation, unless contraindicated by surgical or patient-specific factors (Conditional recommendation, Low quality evidence)

Remarks

In cases of uncertain fixation stability, complex fracture patterns, or compromised bone quality, temporary partial or restricted weight-bearing may be considered. Decisions should be guided by operative findings, implant stability, surgeon recommendations, patient cognitive status, and safety within the rehabilitation environment.

Summary of evidence

Available evidence, primarily from observational studies¹¹⁵ and cohort analyses^2,116-118, suggests that early weight-bearing after stable fixation does not increase the risk of implant failure, non-union, or reoperation. Several studies report improved functional outcomes and earlier return to ambulation with early weight-bearing strategies¹¹⁹. However, high-quality randomized controlled trials specifically comparing weight-bearing protocols after hip fracture surgery remain limited.

Rationale for the recommendation

Early weight-bearing facilitates functional recovery, improves patient confidence during ambulation, and reduces complications related to immobility, while allowing clinicians to individualize care based on surgical stability and patient safety considerations.

3. Rehabilitation Pathway

Recommendation

Rehabilitation after hip fracture surgery should follow a structured, phased pathway, spanning the acute inpatient phase, home or inpatient rehabilitation services, and outpatient rehabilitation, aligned with the patient’s recovery stage and care setting (Conditional recommendation, Low Quality evidence)

Remarks

The rehabilitation pathway should prioritize early mobility and functional independence during hospitalization, followed by progressive strengthening, balance training, and gait restoration after discharge. Coordination among healthcare providers across settings is essential to ensure continuity of care.

Summary of evidence

Studies evaluating multidisciplinary and continuity-based rehabilitation models^120,121 demonstrate improvements in mobility, functional outcomes, and discharge disposition. However, variability in rehabilitation protocols, intensity, and care settings limits the ability to identify a single optimal pathway. Evidence supports the concept of structured progression rather than any specific standardized protocol.

Rationale for the recommendation

A structured rehabilitation pathway ensures continuity of care, promotes timely progression of functional goals, optimizes resource utilization, and addresses the evolving physical and functional needs of patients recovering from hip fractures.

4. Fall Prevention

Recommendation

Fall prevention strategies should begin with identification and management of underlying fall risk factors, including muscle weakness, balance deficits, cognitive impairment, medication-related side effects, orthostatic hypotension, visual impairment, and environmental hazards. These strategies should be systematically integrated into all phases of postoperative rehabilitation following hip fracture surgery (Conditional recommendation, High quality evidence)

Remarks

Fall prevention interventions should include fall risk assessment, balance and strength training, home based exercise program, medication review, environmental hazard modification, vision assessment, and appropriate prescription and training in assistive device use.

Summary of evidence

Strong evidence from randomized controlled trials and meta-analyses^122-124 demonstrates that multifactorial fall prevention programs significantly reduce fall risk in older adults. Although many studies include broader geriatric populations, evidence supports similar benefits in individuals recovering from hip fracture, who are at particularly high risk for recurrent falls and secondary fractures.

Rationale for the recommendation

Patients recovering from hip fractures are vulnerable to recurrent falls due to residual weakness, balance impairment, and fear of falling. Addressing modifiable risk factors is essential to ensure long-term safety, preserve functional gains, and prevent secondary injuries.

5. Outcome Assessment

Recommendation

Standardized functional and mobility outcome measures, such as the Timed Up and Go Test (TUG test), should be used regularly to guide rehabilitation progression and monitor recovery after hip fracture surgery. (Conditional recommendation, Low quality evidence)

Remarks

Outcome measures should be feasible, clinically meaningful, and sensitive to change in older adults. Assessments may include measures of mobility, balance, gait performance, activities of daily living, and pain.

Summary of evidence

Although outcome measures such as gait speed, Timed Up and Go, and functional mobility scales are widely used in clinical practice and research, evidence supporting the superiority of any single tool in guiding rehabilitation outcomes remains limited. Current evidence^125,126 supports consistent and repeated use of standardized measures rather than reliance on subjective assessment alone.

Rationale for the recommendation

Regular outcome assessment facilitates individualized goal setting, enhances communication among care providers, and allows early identification of delayed recovery, complications, or need for modification of the rehabilitation plan.

6. Discharge Planning After Hip Fracture Surgery

Recommendation

Discharge planning should begin early during hospitalization and be individualized based on medical stability, functional recovery, cognitive status, family support, and access to rehabilitation services. In the Egyptian healthcare setting, most patients require a short inpatient stay followed by home-based or facility-based rehabilitation. Early discharge within 24–48 hours may be considered for selected, medically stable patients with adequate family support and rehabilitation access. Same-day or next-day discharge should be limited to exceptional cases. (Conditional recommendation, Low quality evidence)

Remarks

Discharge planning should address discharge destination, functional readiness (safe transfers and assisted ambulation), caregiver education, provision of walking aids, and coordination of outpatient or home-based rehabilitation. Family caregivers play a central role in post-discharge care in Egypt and should be included early in planning and education.

Summary of evidence

Hip fracture specific randomized evidence for same-day discharge is limited. Observational studies indicate that structured, early discharge planning improves care transitions and functional outcomes without increasing readmissions when rehabilitation continuity is ensured. Evidence from elective arthroplasty populations shows that same-day or 1-day discharge can be safe in selected patients, supporting a readiness-based rather than time-based discharge approach, though direct extrapolation to hip fracture patients should be cautious^127,128.

Rationale for the recommendation

Early and coordinated discharge planning reduces risks associated with prolonged hospitalization, including delirium and deconditioning, and supports safe transition to rehabilitation. Discharge timing should prioritize patient safety, caregiver preparedness, and continuity of rehabilitation rather than length of stay alone.

 

7.    Assistive Devices (Walker and Cane)

Recommendation

Following hip fracture surgery, appropriate assistive devices should be prescribed and regularly reassessed to support safe ambulation. A walker is recommended in the early postoperative phase, with progression to a cane held in the contralateral hand to the operated limb as balance, strength, and weight-bearing tolerance improve. (Good practice statement, Low quality evidence)

Remarks

Assistive device selection should be individualized based on balance capacity, lower-limb strength, pain, cognitive status, and environmental demands. Proper fitting, patient education, and supervised training are essential. Transition from a walker to a cane should be guided by functional performance rather than time since surgery alone.

Summary of evidence

Systematic reviews and biomechanical studies demonstrate that walkers provide greater stability during early postoperative ambulation, while cane use improves gait efficiency during later recovery. Biomechanical evidence consistently shows that using a cane in the contralateral hand reduces hip joint reaction forces and hip abductor demand on the operated side. Clinical practice guidelines support this progression strategy, although randomized controlled trials specific to hip fracture populations remain limited^126,129.

Rationale for the recommendation

Assistive devices enhance safety and confidence during ambulation after hip fracture surgery. Using a cane in the contralateral hand optimizes biomechanical unloading of the operated hip, improves gait symmetry, and reduces fall risk while promoting progressive independenc

Patient and carer information

Recommendation

It is crucial to offer the patients (or when appropriate, their carers) information about their medical diagnosis and its implications and treatment options and management plan either verbally or in printed form (Good practice statement).

Remarks

Family, friends and carers can provide support to patients to prepare for the first few weeks after discharge. From simple tasks like measuring the heights of patient’s bed, toilet and chair to providing physical and emotional support, the role of carers is important for the patients.

Decision making process must be based on information, involving family and carers can be crucial in cases where the patient is incapacitated due to delirium and can help as proxy in making informed medical decisions.

Summary of evidence

The care burden following hip fracture may decrease over time; however, it often lasts for over 12 months. Caregivers tend to experience the greatest stress for the first 2 months post-fracture, with the stress being associated with increased care demands and care cost^130-133. Educating them beforehand sets realistic expectation to carers.

Rationale for the recommendation

Providing clear information to patients and carers supports shared decision-making, treatment adherence, realistic expectations, and active participation in rehabilitation, ultimately contributing to safer and more patient-centred care. Details should include their exact diagnosis, choices available for analgesia and other medications, surgical procedures, choices of anaesthesia, possible complications, postoperative care and rehabilitation plans, short and long term expected outcomes and which healthcare professionals are involved⁷.