Postoperative management of hip fractures: interventions associated with improved outcomes

The annual number of hip fractures worldwide is expected to exceed 6 million by 2050. Currently, nearly 50% of hip fracture patients will develop at least one short-term complication including infection, delirium, venous thromboembolism (VTE), pressure ulcers or cardiovascular events. More than half will experience an adverse long-term outcomes including worsened ambulation or functional status, additional fractures and excess mortality. This paper summarizes current evidence for postoperative interventions attempting to improve these outcomes, including pain management, anemia management, delirium prevention strategies, VTE prophylaxis, rehabilitation type, nutritional supplements, anabolic steroids and secondary fracture prevention. Models of care that have been tested in this population including interdisciplinary orthogeriatric services, clinical pathways and hospitalist care are summarized. In general, good quality evidence supports routine use of VTE prophylaxis, and moderate quality evidence supports multifactorial delirium prevention protocols, and a conservative transfusion strategy. Aggressive pain control with higher doses of opiates and/or regional blocks are associated with lower delirium rates. Low-moderate quality evidence supports the use of clinical pathways, and dedicated orthogeriatric consultative services or wards. After hospital discharge, good quality evidence supports the use of bisphosphonates for secondary fracture prevention and mortality reduction. Rehabilitation services are important, but evidence to guide quantity, type or venue is lacking. Additional research is needed to clarify the role of nutritional supplements, anabolic steroids, home care and psychosocial interventions.