Hip fracture surgery
Hip fracture is common, especially in older adults after a fall. It almost always needs surgery, and the goal is to relieve pain and restore walking as soon as possible: regaining mobility early is what most protects overall health.
Why operate early
With few exceptions, a hip fracture is operated on early: NICE recommends operating on the day of admission or the day after, and the AAOS makes a moderate-strength recommendation to operate within the first 24 to 48 hours, although the evidence behind it is of low quality. Keeping the person in bed is usually more dangerous than the surgery itself: it promotes thrombosis, pneumonia, pressure sores and muscle loss. So the goal is to stabilize the hip and get the person back on their feet as soon as possible.
Before surgery the general condition —anemia, hydration, anticoagulant medication— is quickly optimized, ideally together with geriatrics or internal medicine, without delaying the operation more than necessary.
The type of fracture determines the treatment
The hip can fracture in two main areas: the femoral neck (just below the head) or the trochanteric region (a little lower). Where and how the bone breaks, together with the person's age and activity, determines whether it is better to fix the fracture or replace the joint.
Fix or replace
The fracture is stabilized while preserving the patient's own bone. For stable trochanteric fractures the standard is a sliding hip screw; for reverse oblique, subtrochanteric fractures or those extending into the shaft, an intramedullary nail is used. Femoral neck fractures that are non-displaced, or that occur in younger patients, are fixed with screws, aiming to preserve the femoral head.
In displaced neck fractures in older adults, the displacement compromises the blood supply to the femoral head, with a high risk that the fracture will not unite or that the head will become necrotic; that is why it is preferred to replace it with a prosthesis. The choice between a partial prosthesis (hemiarthroplasty) and a total one follows the person's previous functional capacity: a total hip replacement is considered for people who before the fracture walked outdoors on their own with no more than a cane, who are in a condition to tolerate the surgery, and who are expected to remain independent in their activities of daily living beyond two years; for everyone else, a hemiarthroplasty better serves the goal of walking again soon. Previous wear of the joint also weighs on the decision. In this indication the femoral stem is fixed with cement, which reduces the risk of fracture around the implant and of persistent pain in osteoporotic bone; the acetabular cup may or may not be cemented, depending on the quality of the bone.
Recovery
Rehabilitation starts the same day or the day after, standing and walking with assistance; in most cases weight-bearing is allowed from the start. Physiotherapy and good pain control are key to regaining walking and independence.
Recovering from a hip fracture also means caring for the whole person: nutrition, fall prevention and osteoporosis treatment are part of the plan to prevent a second fracture.
Risks and considerations
- Venous thrombosis and medical complications, related to the patient's frailty.
- Infection of the wound or of the prosthesis.
- Dislocation of the prosthesis, in replacements.
- Failure of the fixation or nonunion, which may require another operation.
- A hip fracture is a serious event: it can leave a stepwise loss of function and of independence, and it affects long-term general health, with a risk of death that is meaningful in the first year, especially in frail people or those with other illnesses. Regaining walking early and treating osteoporosis is what most prevents this.
Shared decision-making
With a hip fracture, with few exceptions, the conversation is not whether to operate —keeping the person in bed is usually more dangerous than the surgery— but which operation and with what goals: we review the type of fracture, how you were doing beforehand and your other medical conditions in order to choose between fixing the fracture and replacing the joint, and we agree on the goals of treatment with you and your family. Surgery does not guarantee an outcome; it aims to relieve pain and return your ability to walk as soon as possible.
This information is educational and does not replace a medical evaluation. Every case requires an individualized assessment and treatment, and no surgery guarantees an outcome.
Questions about your case?
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