Clinical outcomes and treatment of hip fractures

The worldwide prevalence of hip fracture is increasing as the mean age of the population increases. Despite advances in anesthesia, nursing care, and surgical techniques, however, the outcome of treatment is often poor, and hip fractures remain a significant source of morbidity and mortality for the elderly population. For these patients, operative treatment is considered to be optimal and most cost-effective for displaced intracapsular fractures and all extracapsular fractures. Undisplaced intracapsular fractures can be treated with bed rest and 6-8 weeks' delay of weight bearing in the "younger" elderly (< or = 70 years). The timing of surgery remains controversial, and evidence that a delay in operating leads to increased morbidity is inconclusive. In general, early surgery is indicated in premorbidly fit patients, whereas surgery should be delayed if correctable comorbidities are present. Methods of intracapsular fracture repair very geographically and according to surgeon preference. Prospective, randomized, case-controlled studies are needed to compare repair methods, including internal fixation versus hemiarthroplasty for intracapsular fractures and use of uncemented versus cemented hemiarthroplasty protheses. Extracapsular fractures are usually repaired using a dynamic hip screw or other variant of sliding nail fixation. The mortality rate after hip fracture appears to vary in association with poorly controlled systemic disease (particularly if multiple comorbidities are present); cognitive disorders; operative intervention before stabilization if > or = 3 comorbidities are present; and, in the absence of prophylaxis, deep vein thrombosis; the associations between mortality and male sex, advanced age, and anesthetic type are less clear. The factors associated with the recovery of walking ability include young age, male sex, absence of dementia, absence of postoperative confusional state, and use of a walking aid before the fracture. Many determinants of outcome are independent of the level of care given and are dependent on prefracture status. To maximize rehabilitation potential, a multidisciplinary approach using skilled medical, nursing, and paramedical care appears to be optimal. Prospective case-controlled studies are required to demonstrate the long-term effectiveness of specialist rehabilitation units. In today's cost-cutting environment, caution must be taken to prevent short-term cost-saving measures from compromising long-term outcome for elderly hip fracture patients.