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Fracture Management

Management of hip fractures in the elderly, focusing on classification-based fixation versus arthroplasty and the impact of physiologic decline on mortality.

Overview

Mortality risk in older adults following a fragility fracture more than doubles within the first year post-fracture [1], with the greatest reduction in survival occurring during this same period [1]. Despite a decline in mortality risk in recent years, older patients with a hip fracture remain at a high risk of surgery-specific and general complications [6]. Hospitals should operate on hip fracture patients within 48 hours after fracture to reduce mortality and intraoperative complications [19]. Early surgery is beneficial for femoral neck fractures regarding mortality and reoperation rates [4], whereas the effect of early surgery on the management of periprosthetic proximal femoral (PPF) fractures appears to be less pronounced [4].

Current hip fracture definitions from healthcare agencies do not align well with those used by practicing orthopaedic surgeons [8]. Prediction models for delayed discharge in elderly patients with hip fracture could support policymakers in developing strategies for optimal management, particularly for individuals at high risk of prolonged length of stay [3]. Total hip arthroplasty (THA) procedures for acetabular fractures in the elderly were associated with lower rates of mortality and further surgery compared with open reduction and internal fixation (ORIF) procedures [20].

Anatomy & Pathophysiology

Osseous Morphology and Risk Factors: Current healthcare agency definitions of hip fracture often fail to align with those used by practicing orthopaedic surgeons [8]. Hip geometry in Arctic populations differs from European data, suggesting a delicate balance in hip geometry [22]. In patients younger than 50 years, hip osteoarthritis, male sex, and age 41 to 50 years were protective factors against periprosthetic fractures [39]. For unstable intertrochanteric fractures, hemiarthroplasty provides faster early mobilization whereas proximal femoral nailing offers superior long-term hip function [47]. Treatment with hemiarthroplasty or angular stable devices in young patients with isolated fracture of the hip was associated with a less favourable hip score outcome [55].

Joint Kinematics and Surgical Outcomes: Hip sphericity improves with hip reconstructive surgery in patients with cerebral palsy [32]. Spinopelvic stiffness is associated with increased age and increased femoral motion, which may lead to impingement and dislocation following total hip arthroplasty [46]. There is no significant benefit for gait kinematics in the early postoperative period (three months) for patients undergoing total hip arthroplasty through a minimally invasive Watson-Jones approach compared with a standard transgluteal approach [45]. Revising the acetabular component to a superior and medial hip center combined with tensor fascia lata reconstruction resulted in improved abductor power and gait for patients with chronic massive abductor tears after failed total hip arthroplasty [49].

Pediatric and Developmental Pathology: Female sex and increasing preoperative slip angle significantly predicted higher risk of total hip arthroplasty following in situ fixation of slipped capital femoral epiphysis [42]. A stable, safe but non-concentric reduction of developmental dysplasia of the hip achieved before the age of two years appears to improve over time with nearly 80% of hips becoming fully concentric by one year [48]. Femoral head reduction associated with coverage and containment procedures is a safe technique that showed improved functional, clinical, and morphological outcomes in Perthes' disease [53].

Acetabular and Post-Traumatic Considerations: Patients with preoperative acetabular morphological risk factors for dislocation might be better candidates for total hip arthroplasty following hemiarthroplasty for femoral neck fractures in the elderly [33]. Step-off displacement ≥ 2 mm and age > 60 years are predictors for conversion to total hip arthroplasty after nonoperative treatment of acetabular fractures [50]. Hip arthroscopy appears effective and safe in the setting of trauma [54].

Implant Mechanics and Long-Term Sequelae: Double-threaded anti-shortening screws are more effective in reducing shortening and improving hip function than single-threaded anti-shortening screws and traditional femoral neck screw fixation [44]. Increasing symptoms and decreased function related to degenerative hip disease may occur fifteen to twenty years after Colonna arthroplasty with concomitant femoral shortening and rotational osteotomy [36]. The risk factors of hip fracture are more personal than environmental [40].

Classification

Other Considerations: Mortality risk in older adults following a fragility fracture more than doubles within the first year post-fracture [1]. Fractures treated with revision for early postoperative femur fracture after uncemented collarless primary total hip carry significant morbidity and potential for further complications [2]. Prediction models for delayed discharge in elderly patients with hip fracture can support policymakers in developing strategies for optimal management, particularly for individuals at high risk of prolonged length of stay [3]. The majority of patient and system factors of mortality post hip fracture were reported by only one or two articles with no proposed mechanisms for their effects on mortality [14]. Current hip fracture definitions used by healthcare agencies do not align well with those used by practicing orthopaedic surgeons [8].

Periprosthetic Femoral Fractures: Type-I intraoperative fractures and all Type-II fractures of the ipsilateral femur in patients with total hip replacement should be stabilized surgically, preferably with a long-stem prosthesis supplemented by internal fixation [5]. Consensus regarding the treatment of periprosthetic femoral fractures around well-fixed stems is lacking [9]. Revision surgery may provide more predictable outcomes for unstable periprosthetic femoral fracture patterns and fractures around polished taper-slip stems [9]. The choice between cemented and cementless femoral fixation for total hip arthroplasty following femoral neck fracture in patients aged 65 and older should consider age, sex, comorbidities, bone quality, and surgical expertise [7].

Acetabular Fractures: Total hip arthroplasty (THA) procedures were associated with lower rates of mortality and further surgery compared with open reduction and internal fixation (ORIF) procedures in the surgical treatment of acetabular fractures in the elderly [20]. In pure transverse acetabular fractures, the intra-articular fracture line distribution is focused on the superior and middle thirds of the joint surface [43]. The text on acetabular fractures represents the sum total of the authors' experience from 1956 to 1971 and is unmatched in size and scope for the management of acetabular fractures [10].

Femoral Neck Fractures: There are minimal differences between implants used for internal fixation of displaced femoral neck fractures based on a critical, evidence-based review of the literature [13].

Pediatric Coxa Vara: Evaluation of coxa vara in childhood should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [12].

Clinical Presentation

Mortality risk in older adults following a fragility fracture more than doubles within the first year post-fracture, representing the period of greatest reduction in survival [1]. Despite a decline in mortality risk in recent years, older patients with hip fractures remain at high risk for surgery-specific and general complications [6]. Hip fractures result in conditions extending beyond orthopaedics to include epidemiology, preventive medicine, internal medicine, endocrinology, critical care, and gerontology [15]. Older patients with hip fractures experience higher mortality and greater deterioration of walking ability compared to younger patients [25].

Epidemiology and Risk Factors: Hip fractures are more common among females across all age groups [25]. Postoperative delirium (POD) and postoperative cognitive decline (POCD) are common in hip fracture patients [29]. The sarcopenia index is a superior prognostic marker to the creatinine–cystatin C ratio for predicting short-term mortality in older adults with hip fracture [30].

Management and Outcomes: Early surgery for hip fracture in older people is associated with better clinical and patient-reported outcomes [17]. While early surgery is beneficial for femoral neck fractures, its effect on the management of periprosthetic proximal femoral (PPF) fractures appears to be less pronounced [4]. Fixation type choice for total hip arthroplasty following femoral neck fracture in patients aged 65 and older should consider age, sex, comorbidities, bone quality, and surgical expertise [7]. There are minimal differences between implants used for internal fixation of displaced femoral neck fractures [13]. Surgeon subspecialty training adds complexity to femoral neck fracture management and influences treatment decisions [18].

Periprosthetic and Revision Fractures: While the majority of fractures treated with revision for early postoperative femur fracture after uncemented collarless primary total hip healed with stable components, the condition carries significant morbidity and potential for further complications [2]. Type-I intraoperative and all Type-II fractures of the ipsilateral femur in patients with total hip replacement should be stabilized surgically, preferably with a long-stem prosthesis supplemented by internal fixation [5]. Consensus regarding treatment of periprosthetic femoral fractures (PFFs) around well-fixed stems is lacking [9]. Revision surgery may provide more predictable outcomes for unstable fracture patterns and fractures around polished taper-slip stems [9].

Pharmacology and Prognosis: Romosozumab did not improve fracture-healing-related clinical and radiographic outcomes in the study population of hip fractures [11]. The majority of patient and system factors of mortality post hip fracture were reported by only one or two articles with no proposed mechanisms for their effects on mortality [14]. Prediction models for delayed discharge in elderly patients with hip fracture can support policymakers in developing strategies for optimal management, particularly for individuals at high risk of prolonged length of stay [3].

Pediatric Considerations: Evaluation of coxa vara in childhood should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [12]. Early recognition and treatment before premature closure of the entire physis and before permanent osseous deformity are essential for a good outcome in premature partial closure of the triradiate cartilage [16].

Investigations

Plain radiography: Early recognition of premature partial closure of the triradiate cartilage is essential to prevent permanent osseous deformity [16]. Evaluation of coxa vara in childhood requires a search for family history, trauma, infection, and associated skeletal abnormalities to classify the condition and select optimal treatment [12]. Current hip fracture definitions from healthcare agencies do not align well with those used by practicing orthopaedic surgeons [8]. Percutaneous screw fixation of acetabular fractures using hip arthroscopy is promising for anatomic reduction of the fracture site and avoiding articular penetration during screw insertion [58].

MRI: No specific MRI findings are detailed in the provided evidence base for this section.

CT: No specific CT findings are detailed in the provided evidence base for this section.

Bone scan: No specific bone scan findings are detailed in the provided evidence base for this section.

Tomosynthesis: No specific tomosynthesis findings are detailed in the provided evidence base for this section.

Aspiration: No specific aspiration findings are detailed in the provided evidence base for this section.

Laboratory: No specific laboratory findings are detailed in the provided evidence base for this section.

Other Considerations: Mortality risk in older adults following a fragility fracture more than doubles within the first year post-fracture [1]. Prediction models for delayed discharge in elderly patients with hip fracture can support policymakers in developing strategies for optimal management, particularly for individuals at high risk of prolonged length of stay [3]. Early postoperative femur fracture after uncemented collarless primary total hip carries significant morbidity and potential for further complications [2]. The effect of early surgery on the management of periprosthetic proximal femoral (PPF) fractures appears to be less pronounced than its beneficial effect in femoral neck fractures [4]. Type-I intraoperative and all Type-II fractures of the ipsilateral femur in patients with total hip replacement should be stabilized surgically, preferably with a long-stem prosthesis supplemented by internal fixation [5]. The choice between cemented and cementless femoral fixation for total hip arthroplasty following femoral neck fracture in patients aged 65 and older should consider age, sex, comorbidities, bone quality, and surgical expertise [7]. Consensus regarding the treatment of periprosthetic femoral fractures (PFFs) around well-fixed stems is lacking [9]. Revision surgery may provide more predictable outcomes for unstable fracture patterns and fractures around polished taper-slip stems [9]. Romosozumab did not improve fracture-healing-related clinical and radiographic outcomes in patients with hip fractures [11]. Surgeon subspecialty adds complexity to femoral neck fracture management, emphasizing the importance of recognizing how surgeon-specific factors influence treatment decisions [18]. Complications in periacetabular osteotomy are increasingly predictable, and patient counseling must extend beyond radiographic correction to include biological considerations and realistic expectations [51]. Percutaneous screw fixation of acetabular fractures using hip arthroscopy offers additional advantages of joint debridement, lavage, and reduced radiation exposure [58]. Early revision of periacetabular osteolysis may help prevent the development of major periprosthetic fractures of the acetabulum [60]. All three surgical methods compared for displaced posterior cruciate ligament tibial insertion avulsion fractures yielded good clinical results and imaging healing [61]. Multiple periprosthetic hip fractures and joint dislocations secondary to general convulsive seizures are extremely rare, and treatment targets should focus on fracture healing and limb function recovery [62]. There are minimal differences between implants used for internal fixation of displaced femoral neck fractures [13]. The text "Fractures of the Acetabulum" represents the sum total of the authors' experience from 1956 to 1971 and is unmatched in size and scope for the management of acetabular fractures [10].

Treatment

Mortality risk in older adults following a fragility fracture more than doubles within the first year post-fracture [1]. Older patients with a hip fracture remain at a high risk of surgery-specific and general complications despite a decline in mortality risk in recent years [6]. Early surgical intervention within 48 hours is beneficial for intra-capsular femoral fractures, increasing survival rates and decreasing postoperative mortality hazard ratios [34], whereas early surgery is not beneficial for extra-capsular femoral fractures regarding survival rates or postoperative mortality hazard ratios [34]. The effect of early surgery on the management of periprosthetic proximal femoral (PPF) fractures appears to be less pronounced compared to its benefit in femoral neck fractures [4].

Operative

Indications: Surgical stabilization is indicated for Type-I intraoperative and all Type-II fractures of the ipsilateral femur in patients with total hip replacement [5]. Revision surgery may provide more predictable outcomes for unstable fracture patterns and fractures around polished taper-slip stems [9]. Consensus regarding treatment of periprosthetic femoral fractures (PFFs) around well-fixed stems is lacking [9]. While the majority of fractures treated with revision for early postoperative femur fracture after uncemented collarless primary total hip arthroplasty healed with stable components, the condition carries significant morbidity and potential for further complications [2].

Surgical Approach / Technique: Type-I intraoperative and all Type-II fractures of the ipsilateral femur in patients with total hip replacement should be stabilized surgically, preferably with a long-stem prosthesis supplemented by internal fixation [5]. Due to medial augmentation and improvement of mechanical stability for the proximal femur, patients might benefit from fracture healing prognosis and function when reconstruction of medial support is performed following failed treatment of femoral trochanteric fractures [26]. Functional return was achieved in all survivors who could walk at the time of injury in the treatment of intertrochanteric and subtrochanteric fractures of the hip by the Ender method, with no non-unions reported [57].

Implant Selection: Cemented hemiarthroplasty offers compelling clinical advantages compared with noncemented hemiarthroplasty for surgical management of displaced femoral neck fractures in the elderly, despite an increase in surgical time [56]. Fixation type choice for total hip arthroplasty following femoral neck fracture in patients aged 65 and older should consider various factors, including age, sex, comorbidities, bone quality, and surgical expertise [7].

Adjuncts: The authors recommend short-term antibiotic prophylaxis for all patients managed with internal fixation for a fracture of the hip [35]. Surgeons may wish to consider streamlining their policy by treating all fractures with a single skin antiseptic, comparing alcohol-based versus aqueous options before surgical fixation of open fractures [41].

Other Considerations: Romosozumab did not improve fracture-healing-related clinical and radiographic outcomes in the study population for the treatment of hip fractures [11]. Administration of parathyroid hormone (PTH) to patients to enhance fracture healing should still be considered experimental [37]. Prediction models for delayed discharge in elderly patients with hip fracture could support policymakers in developing strategies for optimal management, with a particular emphasis on individuals at high risk of prolonged length of stay [3]. There should be caution when using current hip fracture definitions from healthcare agencies because they do not align well with those used by practicing orthopaedic surgeons [8]. The incidence of non-union was 59 per cent and of avascular necrosis 86 per cent in young adults with femoral-neck fractures [52].

Complications

Mortality and Systemic Risk: Mortality risk more than doubled within the first year following a fragility fracture in older adults [1], with the greatest reduction in survival occurring within this initial post-fracture period [1]. The risk of mortality within the first 6 months of observation was significantly and independently associated with low trauma hip fracture [21]. Although the risk of mortality has declined in recent years, older patients with a hip fracture remain at a high risk of surgery-specific and general complications [6]. Geriatric knee fractures pose a similar risk of acute complications, mortality, and readmission compared with patients with hip fractures [27].

Timing of Intervention: Hospitals should operate on patients within 48 hours after fracture to reduce mortality and intraoperative complications [19]. Early surgery has been shown to be beneficial in femoral neck fractures, but its effect on the management of periprosthetic proximal femoral (PPF) fractures appears to be less pronounced [4].

Functional Outcomes and Morbidity: Patients who had a complication after hip fracture observed worse health-related quality of life [28]. While the majority of fractures treated with revision healed with stable components, the condition carries significant morbidity and potential for further complications [2]. Hip fractures result in conditions that extend far beyond orthopaedics concerning epidemiology and preventive medicine, internal medicine and endocrinology, as well as critical care and gerontology [15].

Other Considerations: The majority of patient and system factors of mortality post hip fracture were reported by only one or two articles and with no proposed mechanisms for their effects on mortality [14]. Type-I intraoperative and all Type-II fractures of the ipsilateral femur in patients with total hip replacement should be stabilized surgically, preferably with a long-stem prosthesis supplemented by internal fixation [5].

Recovery

Mortality and Complication Risks: Mortality risk in older adults following a fragility fracture more than doubled within the first year post-fracture [1], with the greatest reduction in survival occurring during this same initial period [1]. The risk of mortality within the first 6 months of observation was significantly and independently associated with low trauma hip fracture [21]. Older patients with a hip fracture remain at a high risk of surgery-specific and general complications despite a decline in mortality risk in recent years [6]. Warfarin therapy at the time of injury is associated with increased time to surgery, a longer hospital stay, and decreased survival after hip fracture [59].

Surgical Management and Healing: Fractures treated with revision for early postoperative femur fracture after uncemented collarless primary total hip carry significant morbidity and potential for further complications, though the majority healed with stable components [2]. The effect of early surgery on the management of periprosthetic proximal femoral (PPF) fractures appears to be less pronounced than its beneficial effect in femoral neck fractures [4]. Type-I intraoperative fractures and all Type-II fractures of the ipsilateral femur in patients with total hip replacement should be stabilized surgically, preferably with a long-stem prosthesis supplemented by internal fixation [5]. Romosozumab did not improve fracture-healing-related clinical or radiographic outcomes in the study population for the treatment of hip fractures [11].

Functional Outcomes and Predictors: Patients who exhibit a smaller decline in functional performance and quality of life three months after hip fracture surgery from pre-fracture status are likely to have improved long-term activities of daily living (ADL) and quality of life (QoL) [24]. The long-term survival of the native hip joint after operatively treated displaced acetabular fractures was good, but injury to the femoral head and acetabular impaction proved to be strong predictors of failure, especially in patients aged > 60 years [31]. The majority of patient and system factors of mortality post hip fracture were reported by only one or two articles with no proposed mechanisms for their effects on mortality [14].

Systemic and Special Considerations: Hip fractures result in conditions that extend far beyond orthopaedics to include epidemiology, preventive medicine, internal medicine, endocrinology, critical care, and gerontology [15]. Early recognition and treatment before premature closure of the entire physis and before permanent osseous deformity are essential for a good outcome in premature partial closure of the triradiate cartilage treated with excision of a physeal osseous bar [16].

Key Evidence

  • [L2] The greatest reduction in survival occurred within the first-year post-fracture, where mortality risk more than doubled. (10.1186/s12891-021-03960-z)
  • [L3] The prediction models could support policymakers in developing strategies for the optimal management of hip fracture patients, with a particular emphasis on individuals at high risk of prolonged length of stay. (10.1186/s12891-023-06166-7)
  • [L3] While early surgery has been shown to be beneficial in femoral neck fractures, its effect on the management of PPF fractures appears to be less pronounced. (10.1016/j.arth.2025.07.009)
  • [L4] Type-I intraoperative and all Type-II fractures should be stabilized surgically, preferably with a long-stem prosthesis supplemented by internal fixation. (10.2106/00004623-198163090-00009)
  • [L2] Although the risk of mortality has declined in recent years, older patients with a hip fracture remain at a high risk of surgery-specific and general complications. (10.1302/0301-620x.107b3.bjj-2024-0858.r1)
  • [L3] Fixation type choice should consider various factors, including age, sex, comorbidities, bone quality, and surgical expertise. (10.1016/j.arth.2024.01.034)
  • [L4] There should be caution when using current hip fracture definitions from healthcare agencies because they do not align well with those used by practicing orthopaedic surgeons. (10.5435/jaaos-d-24-01503)
  • [L5] Consensus regarding treatment of PFFs around well-fixed stems is lacking, but revision surgery may provide more predictable outcomes for unstable fracture patterns and fractures around polished taper-slip stems. (10.1302/2058-5241.5.200003)
  • [L5] The book represents the sum total of the authors' experience from 1956 to 1971 and is unmatched in size and scope, serving as the current state of the art for management of acetabular fractures. (10.2106/00004623-198264090-00031)
  • [L1] Romosozumab did not improve the fracture-healing-related clinical and radiographic outcomes in the study population. (10.2106/jbjs.19.00790)
  • [L5] Evaluation should include a search for family history, trauma, infection, and associated skeletal abnormalities to classify coxa vara and select optimal treatment. (10.5435/00124635-199803000-00003)
  • [L4] Based on a critical, evidence-based review of the current literature, there are minimal differences between implants used for internal fixation of displaced fractures. (10.5435/00124635-200810000-00005)
  • [L5] The majority of patient and system factors of mortality post hip fracture were reported by only one or two articles and with no proposed mechanisms for their effects on mortality. (10.1186/s12891-016-1018-7)
  • [L4] Hip fractures result in conditions that extend far beyond orthopaedics concerning epidemiology and preventive medicine, internal medicine and endocrinology, as well as critical care and gerontology. (10.1186/s13018-021-02292-x)
  • [Case_report] Early recognition and treatment before premature closure of the entire physis and before permanent osseous deformity are essential for a good outcome. (10.2106/00004623-199705000-00019)
  • [L1] Early surgery for hip fracture in older people is associated with better clinical and patient-reported outcomes. (10.1302/0301-620x.108b1.bjj-2025-0035.r1)
  • [L3] This study underscores the complexity added by surgeon subspecialty in femoral neck fracture management and emphasizes the importance of recognizing how surgeon-specific factors influence treatment decisions. (10.5435/jaaos-d-24-00750)
  • [L2] Hospitals should operate on patients within 48 hours after fracture to reduce mortality and intraoperative complications. (10.1302/0301-620x.101b9.bjj-2019-0295.r1)
  • [L4] Despite the wide heterogeneity of fracture types and patient co-morbidities, THA procedures were associated with lower rates of mortality and further surgery when compared with the ORIF procedures. (10.1302/2058-5241.2.160036)
  • [L2] The risk of mortality within the first 6 months of observation was significantly and independently associated with low trauma hip fracture. (10.1186/1471-2474-13-143)
  • [L4] Our findings differed from European data and suggest a delicate balance in hip geometry in Arctic populations. (10.1186/s13018-021-02482-7)
  • [L2] Patients who exhibit a smaller decline in functional performance and quality of life three months after hip fracture surgery from pre-fracture status are likely to have improved long-term ADL and QoL. (10.1186/s13018-023-04278-3)
  • [L3] Hip fractures were more common among females across all age groups with higher mortality and greater deterioration of walking ability noted among older patients. (10.1186/1749-799x-6-5)
  • [L3] Due to the medial augmentation and improvement of the mechanical stability for proximal femur, the patients might benefit from fracture healing prognosis and functional. (10.1186/s12891-022-06004-2)
  • [L3] Geriatric knee fractures pose a similar risk of acute complications, mortality, and readmission compared with patients with hip fractures. (10.5435/jaaos-d-20-00090)
  • [L2] We observed worse health-related QoL in patients who had a complication after hip fracture. (10.1302/0301-620x.107b10.bjj-2024-1448.r1)
  • [L3] POD and POCD are common in hip fracture patients. (10.1302/0301-620x.102b12.bjj-2019-1537.r3)
  • [L3] SI is a reliable and useful marker for predicting short-term mortality in older adults with hip fracture, which can serve as a valuable tool for early diagnosis and intervention in the future. (10.1186/s13018-025-06540-2)
  • [L3] The long-term survival of the native hip joint after acetabular fractures was good, but the presence of injury to the femoral head and acetabular impaction proved to be strong predictors of failure, especially in patients aged > 60 years. (10.1302/0301-620x.99b6.bjj-2016-1013.r1)
  • [L4] Hip sphericity improves with hip reconstructive surgery. (10.1302/0301-620x.103b1.bjj-2020-1339.r1)
  • [L3] Patients with preoperative acetabular morphological risk factors for dislocation might be better candidates for total hip arthroplasty. (10.1016/j.arth.2023.02.042)
  • [L3] Early surgical intervention (within 48 hours) is beneficial for intra-capsular but not extra-capsular femoral fractures, increasing survival rates and decreasing postoperative mortality hazard ratios. (10.1016/j.arth.2013.10.021)
  • [L1] The authors recommend short-term antibiotic prophylaxis for all patients managed with internal fixation for a fracture of the hip. (10.2106/00004623-199301000-00009)
  • [L4] However, increasing symptoms and decreased function related to degenerative hip disease may occur fifteen to twenty years after the procedure. (10.2106/00004623-199701000-00009)
  • [L4] PTH administration to patients to enhance fracture healing should still be considered experimental. (10.1302/0301-620x.98b6.36794)
  • [L3] Hip osteoarthritis, male sex, and age 41 to 50 years were protective factors against periprosthetic fractures. (10.1016/j.arth.2025.08.069)
  • [L3] The risk factors of hip fracture are more personal than environmental. (10.1186/1471-2474-14-207)
  • [L2] Given these findings, surgeons may wish to consider streamlining their policy by treating all fractures with a single skin antiseptic. (10.2106/jbjs.24.01244)
  • [L3] Female sex and increasing preoperative slip angle significantly predicted higher risk of THA. (10.1302/0301-620x.105b12.bjj-2023-0148.r2)
  • [L4] The intra-articular fracture line distribution was focused on the superior and middle thirds of the joint surface. (10.1186/s13018-022-03148-8)
  • [L3] Double-threaded ASS is more effective in reducing shortening and improving hip function than single-threaded ASS and traditional FNS fixation. (10.1186/s13018-025-05822-z)
  • [L2] With regard to gait kinematics in the early postoperative period (three months), the present study showed no significant benefit for patients who underwent a total hip arthroplasty through a minimally invasive Watson-Jones approach in comparison with those who were managed with a standard transgluteal approach. (10.2106/jbjs.h.01086)
  • [L4] Spinopelvic stiffness is associated with increased age and increased femoral motion, which may lead to impingement and dislocation. (10.2106/jbjs.18.00078)
  • [L3] For unstable ITFs, a clinical trade-off exists: HA provides faster early mobilization, whereas PFNA offers superior long-term hip function. (10.1186/s12891-025-09471-5)
  • [L3] A stable, safe but non-concentric reduction achieved before the age of two years appears to improve over time with nearly 80% of hips becoming fully concentric by one year. (10.1302/0301-620x.102b5.bjj-2019-1496.r1)
  • [L4] The study reports that revising the acetabular component to a superior and medial hip center combined with tensor fascia lata reconstruction resulted in satisfactory outcomes for patients with chronic massive abductor tears, with improved abductor power and gait. (10.1016/j.arth.2013.09.056)
  • [L3] Step-off displacement ≥ 2 mm and age > 60 years are predictors for conversion to THA. (10.1302/0301-620x.105b9.bjj-2023-0191.r1)
  • [L4] Complications are increasingly predictable, and patient counseling must extend beyond radiographic correction to include biological considerations and realistic expectations. (10.1016/j.arth.2026.01.056)
  • [L4] The incidence of non-union was 59 per cent and of avascular necrosis 86 per cent in young adults with femoral-neck fractures. (10.2106/00004623-197658050-00020)
  • [L4] FHRO associated with periacetabular procedures is a safe technique that showed improved functional, clinical, and morphological outcomes in Perthes' disease. (10.1302/0301-620x.106b5.bjj-2023-0853.r1)
  • [L4] Hip arthroscopy appears effective and safe in the setting of trauma. (10.1016/j.arthro.2015.12.029)
  • [L3] Treatment with hemiarthroplasty or angular stable devices in this cohort were associated with a less favourable hip score outcome. (10.1302/0301-620x.102b6.bjj-2019-1491.r1)
  • [L1] Despite the increase in surgical time, cemented hemiarthroplasty offers compelling clinical advantages compared with noncemented hemiarthroplasty for surgical management of displaced femoral neck fractures in the elderly. (10.5435/jaaos-d-23-00564)
  • [L4] Functional return was achieved in all survivors who could walk at the time of injury, with no non-unions reported. (10.2106/00004623-197658050-00004)
  • [L4] The authors found the method promising for anatomic reduction of the fracture site and avoiding articular penetration during screw insertion, with additional advantages of joint debridement, lavage, and reduced radiation exposure. (10.1016/j.arthro.2010.04.068)
  • [L3] After controlling for multiple prognostic factors, warfarin therapy at the time of injury is associated with increased time to surgery, length of stay, and decreased survival. (10.1007/s11999-016-5056-0)
  • [L4] Early revision of periacetabular osteolysis may help prevent the development of major fractures. (10.1016/j.arth.2026.03.058)
  • [L3] All three treatments yielded good clinical results and imaging healing. (10.1186/s13018-025-05703-5)
  • [L4] Multiple periprosthetic hip fractures and joint dislocations secondary to seizure are extremely rare, and treatment targets should focus on fracture healing and limb function recovery. (10.1186/s12891-021-04557-2)

References

[1] Mortality in older adults following a fragility fracture: real-world retrospective matched-cohort study in Ontario. BMC Musculoskeletal Disorders. 2021. DOI: 10.1186/s12891-021-03960-z

[2] Early_Postoperative_Femur_Fracture_After_Uncemented_Collarless_Primary_Total_Hip_S0883540315004453. n.d..

[3] Construction and validation of a risk prediction model for delayed discharge in elderly patients with hip fracture. BMC Musculoskeletal Disorders. 2023. DOI: 10.1186/s12891-023-06166-7

[4] The Impact of Surgical Timing on Mortality and Reoperation Rates in Periprosthetic Proximal Femoral Fractures: A Matched Multicenter Cohort Study. The Journal of Arthroplasty. 2026. DOI: 10.1016/j.arth.2025.07.009

[5] Fracture of the ipsilateral femur in patients wih total hip replacement.. The Journal of Bone & Joint Surgery. 1981. DOI: 10.2106/00004623-198163090-00009

[6] The risk of complications after hip fracture. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b3.bjj-2024-0858.r1

[7] Cemented Versus Cementless Femoral Fixation for Total Hip Arthroplasty Following Femoral Neck Fracture in Patients Aged 65 and Older. The Journal of Arthroplasty. 2024. DOI: 10.1016/j.arth.2024.01.034

[8] Defining a Hip Fracture: Surveying Orthopaedic Surgeons to Better Characterize the Injury. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-01503

[9] Postoperative periprosthetic femoral fracture around total hip replacements: current concepts and clinical outcomes. EFORT Open Reviews. 2020. DOI: 10.1302/2058-5241.5.200003

[10] Fractures of the Acetabulum. The Journal of Bone & Joint Surgery. 1982. DOI: 10.2106/00004623-198264090-00031

[11] A Randomized, Placebo-Controlled Study of Romosozumab for the Treatment of Hip Fractures. Journal of Bone and Joint Surgery. 2020. DOI: 10.2106/jbjs.19.00790

[12] Coxa Vara in Childhood: Evaluation and Management. Journal of the American Academy of Orthopaedic Surgeons. 1998. DOI: 10.5435/00124635-199803000-00003

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[14] Patient and system factors of mortality after hip fracture: a scoping review. BMC Musculoskeletal Disorders. 2016. DOI: 10.1186/s12891-016-1018-7

[15] Depicting developing trend and core knowledge of hip fracture research: a bibliometric and visualised analysis. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02292-x

[16] Premature Partial Closure of the Triradiate Cartilage Treated with Excision of a Physeal Osseous Bar. Case Report with a Fourteen-Year Follow-up. The Journal of Bone and Joint Surgery (American Volume)*. 1997. DOI: 10.2106/00004623-199705000-00019

[17] What is the association between time to surgery and patient outcome after hip fracture?. The Bone & Joint Journal. 2026. DOI: 10.1302/0301-620x.108b1.bjj-2025-0035.r1

[18] Treatment of Femoral Neck Fracture Depends on Surgeon Subspecialty Training. Journal of the American Academy of Orthopaedic Surgeons. 2025. DOI: 10.5435/jaaos-d-24-00750

[19] Does time from fracture to surgery affect mortality and intraoperative medical complications for hip fracture patients?. The Bone & Joint Journal. 2019. DOI: 10.1302/0301-620x.101b9.bjj-2019-0295.r1

[20] Surgical treatment of acetabular fractures in the elderly: a systematic review of the results. EFORT Open Reviews. 2017. DOI: 10.1302/2058-5241.2.160036

[21] Mortality after low trauma hip fracture: a prospective cohort study. BMC Musculoskeletal Disorders. 2012. DOI: 10.1186/1471-2474-13-143

[22] Hip geometry in hip fracture patients in Greenland occurring over a 7.7-year period. Journal of Orthopaedic Surgery and Research. 2021. DOI: 10.1186/s13018-021-02482-7

[24] Minimal short-term decline in functional performance and quality of life predicts better long-term outcomes for both in older Taiwanese adults after hip fracture surgery: a prospective study. Journal of Orthopaedic Surgery and Research. 2023. DOI: 10.1186/s13018-023-04278-3

[25] Age Related Incidence and Early Outcomes of Hip Fractures: A Prospective Cohort Study of 1177 patients. Journal of Orthopaedic Surgery and Research. 2011. DOI: 10.1186/1749-799x-6-5

[26] Is the reconstruction of medial support important for revision following failed treatment of femoral trochanteric fractures? a retrospective comparative study. BMC Musculoskeletal Disorders. 2022. DOI: 10.1186/s12891-022-06004-2

[27] A Comparison of Acute Complications and Mortality Between Geriatric Knee and Hip Fractures: A Matched Cohort Study. Journal of the American Academy of Orthopaedic Surgeons. 2020. DOI: 10.5435/jaaos-d-20-00090

[28] The impact of complications on quality of life and mortality after hip fracture. The Bone & Joint Journal. 2025. DOI: 10.1302/0301-620x.107b10.bjj-2024-1448.r1

[29] Factors associated with delirium and cognitive decline following hip fracture surgery. The Bone & Joint Journal. 2020. DOI: 10.1302/0301-620x.102b12.bjj-2019-1537.r3

[30] Sarcopenia index is a superior prognostic marker to creatinine–cystatin C ratio in older adults with hip fracture. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-06540-2

[31] Long-term survival and risk factors for failure of the native hip joint after operatively treated displaced acetabular fractures. The Bone & Joint Journal. 2017. DOI: 10.1302/0301-620x.99b6.bjj-2016-1013.r1

[32] Remodelling of femoral head deformity after hip reconstructive surgery in patients with cerebral palsy. The Bone & Joint Journal. 2021. DOI: 10.1302/0301-620x.103b1.bjj-2020-1339.r1

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[34] Early Operative Intervention Is Associated With Better Patient Survival in Patients With Intracapsular Femur Fractures But Not Extracapsular Fractures. The Journal of Arthroplasty. 2014. DOI: 10.1016/j.arth.2013.10.021

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[40] Hip fracture risk assessment: artificial neural network outperforms conditional logistic regression in an age- and sex-matched case control study. BMC Musculoskeletal Disorders. 2013. DOI: 10.1186/1471-2474-14-207

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[44] Comparative efficacy of different anti-shortening screws in preventing postoperative shortening in displaced femoral neck fractures: a retrospective cohort study. Journal of Orthopaedic Surgery and Research. 2025. DOI: 10.1186/s13018-025-05822-z

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