Hip Fracture Management in Older Adults in Resource-Constrained Settings: Determinants, Care Pathways, and Outcomes-A Systematic Review and Meta-Analysis
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Abdirahman Ibrahim Ismail1, Otim Aaron Thomas1, Vivian Onyinye Ojiakor2
1Department of Orthopedic Surgery Kampala International University Teaching Hospital Ishaka Bushenyi Ishaka Uganda.
Background And Aims:
Hip fractures in older adults cause substantial mortality and functional decline, particularly where access to timely surgery is limited. This review synthesized the determinants, management pathways, and outcomes of hip fractures in resource-constrained settings and evaluated the association between non-operative management (NOM) and mortality.
Methods:
PubMed, Scopus, and Web of Science were searched from January 1, 2015, to January 25, 2026. Eligible studies included older adults with hip fractures managed in resource-constrained settings and reported management determinants, care pathways, or clinical outcomes. Study selection and reporting followed PRISMA 2020 and MOOSE recommendations. Mortality comparing NOM with operative management was pooled using a random-effects model. Risk of bias and certainty of evidence were assessed using design-appropriate tools and a GRADE-informed approach.
Results:
Fourteen studies were included. NOM prevalence ranged from approximately 10% to more than 30%. Selection of NOM and delayed surgery reflected patient factors, including advanced age, frailty, comorbidity, impaired premorbid mobility, and cognitive impairment, alongside system constraints such as out-of-pocket costs, limited theater capacity, workforce and implant shortages, and delayed referral. Three LMIC/UMIC cohort studies contributed to the mortality meta-analysis. NOM was associated with higher mortality than operative management (RR 2.76, 95% CI 1.14-6.70), with substantial heterogeneity (I2 = 84.3%). Certainty of the evidence was very low because of the observational designs, heterogeneity, and confounding by indication.
Conclusion:
NOM and delayed hip fracture care reflect both clinical vulnerability and health-system constraints. Although NOM was associated with higher mortality, the limited observational evidence, substantial heterogeneity, and confounding by indication preclude causal interpretation. Strengthening financing, referral pathways, surgical capacity, implant availability, and perioperative care may improve equitable access to timely treatment.
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