Best practices in the management of proximal femoral fractures in elderly patients on the ward: a narrative review

Abstract

• Proximal femoral fractures are common in the elderly population and are associated with significant morbidity, mortality, and major functional consequences.

• Their management represents an ongoing challenge. Care for this frail population must be coordinated, standardized, and multidisciplinary.

• These fractures represent a significant public health concern, prompting numerous studies to explore organizational strategies and risk factors aimed at minimizing related complications.

• This article reviews current recommendations for the management of proximal femoral fractures in the elderly, including definitions of geriatric and frail patients, service organizations, and clinical pathways.

• It also provides an overview of the latest recommendations for the management of medical problems and anticoagulation in elderly patients with proximal femur fractures.

Introduction

Proximal femoral fractures (PFFs) are common in the elderly and are associated with significant morbidity and mortality (1). In Europe, approximately 600,000 patients above 60 years old suffer from a PFF every year (2). Although the incidence of fractures is falling in many countries, this is not enough to offset the increase in the aging population. As a result, the number of proximal femur fractures is set to double over the next 20–30 years (3). This has a major impact on healthcare and economic resources. The financial burden associated with these fractures, due to heavy reliance on hospital facilities and extended hospitalizations, is expected to parallel that of strokes and exceed the costs of various common cancers (4). By age 80, the risk of developing a PFF is approximately 20% for women and 10% for men (5) and the 1-year mortality rate can be as high as 30% (6). As this is a major public health issue, many healthcare providers have attempted to identify organizational strategies and risk factors that can help reduce complications associated with these fractures (4, 7). Optimal PFF management in the elderly involves multidisciplinary protocol-driven care and appropriate surgical indications to provide these patients with the best chances of favorable outcomes (8).

This article provides an up-to-date synthesis that incorporates not only the latest recommendations from various professional societies but also the most recent findings from the literature. Particular emphasis is placed on the importance of interdisciplinary co-management between medical and surgical teams, the early initiation of rehabilitation protocols, the use of regional analgesic blocks for optimal pain control, and the specific considerations required for the management of patients receiving anticoagulant therapy.

Definition of the geriatric patient

There is no clear consensus on the definition of a geriatric patient. The World Health Organization (WHO) qualifies patients over 65 years of age as geriatric. It then divides this population into subgroups: the ‘young-elderly’ between 65 and 74 years, the ‘old-elderly’ from 75 to 94 years, and ‘oldest-elderly’ from 95 years and above (9).

Caterino et al. observed a notable rise in the 12-month mortality rate in patients above 70 years and suggested this cutoff for defining the geriatric patient (10). However, when the associated increased rate of medical and surgical postoperative complications is considered, a common threshold of 75 years is usually accepted for geriatric patients in developed countries (11).

Definition of the frail patient

Geriatric patients admitted to the emergency department are often categorized as frail. Frailty is defined as a state of increased vulnerability that can have deleterious consequences for health (12). Patients may be categorized as non-frail, pre-frail, or frail. Frail patients face elevated risks of falls, disability, hospital readmissions, and death. Similarly, frailty reflects the patient’s overall health status prior to surgery and influences the likelihood of developing perioperative complications (13). There is no single definition of the frail patient in the literature. A number of tools have been developed to better define and assess the complications that can arise in elderly patients. These include the comprehensive geriatric assessment (CGA), the frailty index (FI), and the clinical frailty scale (CFS) (14, 15). The latter evaluates the patient’s autonomy, illness, and dementia, providing a comprehensive assessment of their health status, which defines a progression of mortality with an increasing score (16).

Service organization

Geriatric patients are often burdened with several comorbidities, which induce a fragile state of health that may be negatively affected by an acute event such as a PFF. The literature reports a postoperative complication rate ranging from 20 to 50% in these patients (17).

The complex and multifaceted management of geriatric patients has led healthcare staff to develop a collaboration between orthopedic surgeons, geriatricians, and specialists in bone diseases. The first description of such a multidisciplinary approach was published in 1967 by Irvine & Devas who set out the first principles for the management of the orthogeriatric patient (18). These principles have since been applied in many hospitals worldwide. The Rochester model has served as a reference for many modern orthogeriatric services in the form of an interdisciplinary protocol-driven care pathway (19). This approach is well established to enhance the quality and cost-effectiveness of patient care while also reducing complications, readmissions, and mortality rates (17, 20, 21). Friedman et al. synthesized five principles as a requirement for any orthogeriatric service (Table 1) (22).

Table 1.

Summary of Friedman’s principles.

Friedman’s principles of the orthogeriatric fracture center
1. Most patients benefit from surgical stabilization of their fracture
2. The sooner the patients have surgery, the less time they have to develop iatrogenic illness
3. Co-management with frequent communication avoids iatrogenesis
4. Standardized protocols decrease unwarranted variability
5. Discharge planning begins at admission

There are four main multidisciplinary care models described in the literature (Table 2). Each of these report superior outcomes compared to a purely orthopedic stewardship. It can be generally stated that the greater the collaboration, the better the outcomes (23).

Table 2.

Model of an orthogeriatric service (29, 30, 31).

Type	Service	Responsible staff	Consultant
Type 1	Orthopedic	Orthopedist	Geriatrician, on demand
Type 2	Orthopedic	Orthopedist	Geriatrician, daily visit
Type 3	Geriatric	Geriatrician	Orthopedist, on demand
Type 4	Orthogeriatric	Orthopedist and geriatrician	Integrated multidisciplinary care

Currently, the integration of orthopedic and geriatric care has become the gold standard in the management of patients over 75 years. Many hospitals have transitioned to integrated orthogeriatric care models. While some studies have demonstrated reductions in 30-day mortality, length of hospital stay (24), and improvements in time to surgery (25), other studies have shown that geriatric intervention has a positive synergistic effect on patient management, leading to improved survival outcomes (26). A recent meta-analysis reported a reduction in length of hospital stay, hospital mortality, one-year mortality, and incidence of delirium. However, no significant decrease was observed in readmission rates or time to surgery (27).

Ultimately, in addition to improving the quality of care for these patients, the co-management model does not increase overall healthcare costs, demonstrating its clinical and economic efficiency (28).

At present, no model of geriatric and orthopedic co-management shows superiority over the other. All agree that any chosen model needs to be adapted to the organizational, economic, and staff resources available at any given institution (29, 30, 31, 32). However, recent studies have demonstrated that early implementation of a geriatrician-led multiprofessional rehabilitation program provides additional benefits compared to standard orthogeriatric care (33).

Standardized patient care

There is growing interest in the development of evidence-based standardized pathways, also referred to as fast-track or rapid recovery pathways. These pathways allow smoother transitions between each stage of patient care and better coordination among stakeholders. They also reduce the likelihood of undesirable variability in patient care. A standardized approach requires considering each patient’s unique comorbidities and focuses on stress reduction, optimal pain management, nutrition assessment, and promoting early mobilization, all of which have been reported to improve outcomes (34).

A study from 2023 identified 11 factors that may improve quality of care and reduce hospital costs. These factors include (but are not limited to) prompt admission to a hip fracture ward, assessment by an orthogeriatrician, prompt postoperative mobilization, 7-day physiotherapy provision, effective delirium avoidance, and hospital clinical governance supported by a fracture liaison service (FLS) (4).

Although such pathways are mostly applied to elective joint replacement surgery, the literature supports a positive effect on postoperative complications (35), shorter hospital stays (36), and cost-efficiency for hip fracture patients (37).

Key points

Time to surgery

Proximal femoral fractures require surgical fixation or joint replacement. Non-operative treatment increases the risk of mortality when compared with surgical treatment. Most guidelines recommend surgical management within 24–48 h after admission (33, 34, 35). This reduces the risk of mortality and major postoperative complications. The optimal timing, however, is currently debated. In 2010, a meta-analysis of 16 studies including nearly 13,000 patients demonstrated a significantly reduced mortality rate by reducing the surgical delay from 72 to 48 h (35). In 2020, the HIP ATTACK investigators compared outcomes between accelerated surgery within 6 h versus a standard surgery within 24 h after admission. They showed a significant reduction in delirium and pain scores but failed to identify a reduction in mortality with prompter surgery (38). In 2022, a study concluded that surgery within 48 h of the patient’s admission reduced 30-day mortality and hospitalization time (37). Finally, Fenwick et al. showed no significant difference in mortality rate between the two groups treated within 24 h and 24–48 h, while comparing all patients treated within 48 h and after 48 h revealed a significant difference in mortality (39).

It is generally agreed upon that the shorter the wait the better. Although ‘ultra-early surgery’ does not seem to provide any benefit on mortality, it does allow faster postoperative mobilization and pain reduction (40).

Preoperative considerations

Geriatric patients often present with several comorbidities, including heart failure, myocardial infarction, diabetes, and renal failure, which complicate their overall management. In addition, many also experience acute medical issues, such as infections, dehydration, cachexia, and hypoglycemia, thus increasing their vulnerability. Furthermore, the chronic use of medications, such as benzodiazepines, antidepressants, and antipsychotics, which are common in this population, can contribute to an increased risk of falls and PFF occurrences. These conditions place them at risk of developing pre- and postoperative adverse events (41, 42). Surgical management within 48 h is often challenging, and delays may arise from the necessity to stabilize their status before surgery.

McLaughlin et al. described a number of major conditions that are correlated with postoperative mortality, including the state of shock, ventricular arrhythmia, pulmonary sepsis, acute infarction, respiratory failure with hypercapnia, electrolyte disorder or major blood sugar disorder, and acute renal failure or anemia with Hb < 80 g/L (43).

The 2020 anesthesia guidelines for the treatment of PFF have adopted specific criteria and described preoperative complications that may be ‘reasonable’ causes for delaying surgery (Hb < 80 g/L, uncontrolled diabetes, uncontrolled heart failure, pulmonary infection with sepsis, plasma sodium concentration <120 or >150 mmol/L, plasma potassium concentration <2.8 or >6.0 mmol/L, uncontrolled or acute onset left ventricular failure, correctable cardiac arrhythmia with a ventricular rate > 120 bpm, and reversible coagulopathy) (44).

Holt et al. reported that delaying surgery in order to stabilize these reversible criteria preoperatively did not result in excess mortality but failed to improve survival (45, 46). Therefore, the potential benefits of postponing surgery need to be weighed against patient discomfort and decubitus-related complications.

Pneumonia occurs most frequently, and its preoperative incidence is estimated to be from 0.3 to 3.2% (47, 48). Preoperative pneumonia is associated with increased postoperative mortality among patients undergoing orthopedic, thoracic, and vascular surgery (49). There are currently limited predictive scores to assess the risk of occurrence and severity of postoperative complications. In a study by Shen et al., a score >3 on the CURB-65 index, which assesses the severity of pneumonia, was an indicator of higher postoperative mortality at 1 year among patients with preoperative pneumonia and PFF (50, 51). Preoperative pneumonia should be treated as promptly as possible. In the literature, there is limited evidence for or against delaying surgery. Some studies report that delayed surgery in order to optimize and initiate treatment for pneumonia was not associated with an increase in overall complications (26). However, there is a general agreement that surgery should not be delayed unless absolutely necessary (i.e., sepsis).

Type of anesthesia

General and spinal anesthesia have been used for several decades and are well-recognized modalities in the management of orthopedic patients. With age, patients develop a progressive loss of functional organ reserves. The pharmacokinetics and pharmacodynamics of drugs also change. This has an impact on anesthesia and pain management (52). Anesthesia is therefore a major challenge in the management of orthogeriatric patients (53). Numerous studies have evaluated the benefits of locoregional versus general anesthesia with the former usually being associated with a reduction in mortality (54), delirium (55), and major complications (56). Age itself should not be considered a contraindication to general anesthesia.

Not all studies concur on this topic, however. A 2021 randomized superiority trial including 16,000 patients compared these two modalities for hip surgery in geriatric patients. It demonstrated that spinal anesthesia was not superior to general anesthesia in terms of survival and gait recovery at 60 days. It also demonstrated that postoperative delirium was similar with both anesthesia modalities (57). Likewise, two recent (2023 and 2024) meta-analyses found that the type of anesthesia did not affect 30-day mortality or postoperative complications, such as pneumonia or delirium (55, 56). It did, however, report a reduced risk of in-hospital mortality with regional anesthesia (58).

Preoperative medications

The prevalence of antithrombotic therapy, which includes both anticoagulant and antiplatelet agents, among patients with proximal femur fractures ranges from approximately 20 to 40% and 25 to 35%, respectively, highlighting the necessity of considering their impact on surgical timing (59). Antiaggregants such as aspirin or clopidogrel (Plavix®) are not typically considered a contraindication for surgery within 24–48 h of admission and will not necessarily need to be discontinued (60). However, the management of old- or new-generation anticoagulants, such as Coumadin (Sintrom®) or direct oral anticoagulants (DOACs) (Apixaban®, Rivaroxaban®, and Dabigatran®), is different. In the case of Coumadin, protocols vary but many suggest vitamin K supplementation in order to normalize the INR (international normalized ratio) before surgery. Performing surgery in anticoagulated patients may increase the risk of intra- and postoperative bleeding despite adequate surgical technique (61, 62, 63). The recommendations on INR values suggest a value < 1.5 to safely perform surgery (59, 64). There are a few commercially available antidotes for DOACs, such as idarucizumab (Praxbind®, Boehringer Ingelheim, Germany) for Dabigatran® and andexanet alfa (Andexxa®, Portola Pharmaceuticals, USA) for Apixaban® and Rivaroxaban® (65). Alternatively, prothrombin complex concentrate (PCC) and activated PCC may be used (66). However, these antidotes are not always available and the classical recommendation for patients with DOACs is to postpone the intervention for 48 h (67). A 2023 study including 3,429 patients demonstrated a reduction in 30-day mortality in patients with DOACs, operated within 48 h at the cost of an increased risk of transfusion (68).

Faranoni et al. suggested an algorithm for patients taking Dabigatran®, Apixaban®, or Rivaroxaban® to be admitted for surgery and recommended that these medicines be stopped 24–48 h before a low risk and high risk of bleeding surgery, respectively. When plasmatic dosage is performed, 30 ng/mL or less is considered safe to proceed with surgery (63). In patients at high risk of thromboembolic events, low-molecular-weight heparin (LMWH) may be initiated at anticoagulant discontinuation; however, recommendations whether to initiate LMWH before surgery must be based on patient-specific thromboembolic risk factors and warrants cardiologic evaluation (69).

Recent studies recommend operating on patients taking DOACs and not delaying surgery (66, 67, 68). Pankratz et al. demonstrated that patients on DOACs do not experience increased mortality. Although there may be a higher risk of transfusion and hematoma, proper pre- and postoperative preparation (blood coagulation optimization, hemodilution control, use of tranexamic acid, reduced surgical time, etc.) may justify proceeding with surgery under DOACs, considering the advantages over delayed surgery (70). Furthermore, a recent study reported that surgical management within 24 h in patients on anticoagulants does not increase postoperative bleeding or the need for transfusion (71). Moreover, apart from pre-existing heart failure, Neumann et al.’s study did not demonstrate any comorbidity that could justify delaying surgery under anticoagulation. Indeed, patients on anticoagulants had a poor prognosis because of their comorbidity, not because of the anticoagulation itself (72). Finally, patients have a shorter hospital stay (73). These recent publications represent an important finding, particularly in light of the increasing number of patients treated with direct oral anticoagulants.

Anemia

The prevalence of anemia in elderly patients with PFF is high, reaching almost 50% on admission (74). This is a risk factor for 30-day mortality, longer length of stay, and poorer functional outcome after hip fracture surgery (75, 76). Fracture bleeding and iron deficiency on admission are causes of anemia that may require treatment to improve perioperative and postoperative status. In geriatric patients with isolated hip fractures, a hemoglobin level ≤ 70 g/L is associated with an increased risk of adverse outcomes. This association appears to be more pronounced in individuals over the age of 79 (77). Although the use of a restrictive transfusion strategy remains debated, evidence suggests that it may reduce the incidence of transfusion-related complications, especially among older adults (78). While the optimal transfusion threshold remains controversial, multiple authoritative guidelines, such as those issued by the American Academy of Orthopaedic Surgeons and the American Association of Blood Banks, support a restrictive transfusion strategy with a hemoglobin threshold of 80 g/L in hemodynamically stable, asymptomatic patients (79, 80). Studies analyzing the outcomes of perioperative transfusions above this threshold did not prove to be beneficial in terms of postoperative mortality (81).

With the aim of minimizing blood loss, the use of tranexamic acid represents a useful tool in the management of patients with femoral neck fractures requiring hemi- or total hip arthroplasty. It reduces the risk of intraoperative bleeding and transfusion without increasing the risk of thromboembolic complications (82). In addition, its topical use on hemiarthroplasty or total hip arthroplasty appears to be more effective in reducing blood loss and transfusion than IV administration alone or in combination (83). Its use is all the more important as it reduces the risk of postoperative transfusions and the 30-day readmission rate in patients on DOACs (71). On the other hand, red blood cell recycling devices are not cost-efficient and their use should not be proposed in the treatment of PFF (84).

The prevalence of iron deficiency reaches 50% in both symptomatic and non-symptomatic anemia patients (85). Numerous studies have described the use of iron to reduce the number of blood transfusions and protocols for administration before or after surgery, but there seems to be no clearly defined protocol. Studies showed a decrease in the number of transfusions among patients receiving postoperative iron for anemia without complications or major adverse effects (85, 86, 87, 88, 89). In 2025, a study reported a reduction in both short- and long-term mortality, as well as a decrease in transfusion requirements (90). However, no definitive threshold for iron deficiency has been established, and only the presence of associated anemia indicates the need for additional iron supplementation.

Investigations

In dealing with patient evaluation before surgery, a legitimate question pertains to which investigations are useful and will ultimately influence patient management, especially if these might interfere with prompt surgical management. One common example is the inclusion of cardiac ultrasound in the anesthesiologic workup. Sawhney et al. demonstrated that performing echocardiography did not result in any cardiological intervention in their series and significantly prolonged time to surgery (91). Furthermore, it did not alter the perioperative mortality rate (92, 93) or prolong hospital stay, but it was associated with increased mortality risk and lengthened stay in the intensive care unit (94).

Analgesia

Pain management in PFF is challenging due to difficulties in pain assessment, comorbidities, altered pharmacokinetics, and undesirable effects (95). Effective pain management is associated with significantly improved outcomes, while poor pain control predisposes patients to delirium, which itself dramatically increases mortality and morbidity at 1 year (96).

First-level analgesics alone, such as paracetamol or non-steroidal anti-inflammatory drugs (NSAIDs), are often insufficient to provide proper analgesia. Besides, 40% of patients with PFF have at least moderate chronic renal failure, limiting prolonged NSAID use (97). Opioids are associated with an increased risk of confusion and delirium. Nevertheless, adequate opioid titration is considered to be the most effective method and should be administered before each patient manipulation (98).

Other approaches used to reduce opioid consumption include preoperative nerve blocks (e.g., femoral nerve, lateral cutaneous nerve of the thigh, iliac fascia, and psoas blocks) and have shown to be effective (97). The iliac fascia block can be performed in the emergency department by the emergency team or orthopedic surgeons and integrated into the initial management of patients (99). Pain is relieved approximately 30 min after block placement, allowing basic mobilization and thus reducing the risk of pulmonary infection (100) and postoperative delirium (101). However, nerve blocks do not reduce the risk of mortality or acute coronary syndrome (100). Recent studies evaluating the Pericapsular Nerve Group (PENG) block in elderly patients undergoing hip surgery consistently demonstrate its efficacy in enhancing analgesia and facilitating early recovery. Its use has been shown to reduce postoperative opioid consumption following general anesthesia (102) while also facilitating patient positioning prior to the administration of regional anesthesia. Moreover, this technique appears to be more effective than the fascia iliac block (103). In addition, the use of ropivacaine at a concentration of 0.25% allows for effective analgesia while minimizing the risk of systemic toxicity (104).

Overall, pain management must be tailored to patient comorbidities and pain levels in a multimodal fashion. Pain management will be made easier by limiting delays to surgery and minimizing unnecessary patient mobilization prior to fracture fixation. Moreover, it is important to keep in mind that fracture fixation or joint replacement itself is an effective way to reduce pain and contribute to patient comfort.

Vitamin D

The prevalence of vitamin D deficiency is high (34–80%) among patients with PFF (105, 106). Vitamin D deficiency is associated with an increased risk of falls, impaired bone strength, and risk of hip fracture (107). A vitamin D level < 30 nmol/L is associated with poorer functional mobility and higher perioperative and 1-year mortality rates (108). Patients presenting with an osteoporotic fracture may benefit from vitamin D supplementation in case of deficiency (109). Each 25 nmol/L increase in serum vitamin D level is associated with a 20% reduction in the risk of proximal femur fractures (110). The European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO) recommends a minimum serum vitamin D level of 50 nmol/L to ensure optimal bone healing (111) and an additional 800 IU/day supplementation (112).

Postoperative rehabilitation

Postoperative rehabilitation is essential in the management of patients with PFF. Early mobilization and full weight-bearing in geriatric patients can reduce pain and shorten the length of hospital stay (113). Delayed initiation of postoperative physiotherapy is associated with increased in-hospital mortality (114). As a corollary, prolonged bed rest increases the risk of complications, including, but not limited to, delirium, pulmonary infection, decubitus ulcers, deep vein thrombosis (DVT), urinary tract infections, sepsis, myocardial infarction, stroke, and wound infection (115). As an example, pneumonia may be prevented by early mobilization due to improved thoracic ampliation and recruitment of respiratory muscles (116).

Given the importance of avoiding prolonged recumbency, many guidelines recommend mobilization on the first day after surgery and at least once a day thereafter (41, 42, 79, 117). Immediate postoperative mobilization usually begins with in-chair sitting positions (118) with passive and active range of motion (ROM), active side-to-side turning, and exercises in bed (cycling) (119).

The treatment of PFF should allow elderly people to walk immediately with their full weight on the affected limb. Inability to do so is a poor prognostic factor (117, 120). Restrictions in weight-bearing in older PFF patients are not only detrimental to their mobility but are also ineffective (113, 121, 122). In order to promote rehabilitation, postoperative partial weight-bearing for these patients should be abandoned.

Fracture liaison service

The concept of a FLS was introduced in 1990 (123). The aim of a FLS is to assess and provide care and offer a continuum in the treatment of patients with fragility fractures. Following PFF, the risk of presenting another osteoporotic fracture is twice as likely (124). The implementation of an in-hospital FLS model has been associated with nearly a 50% reduction in subsequent hip fractures, along with a decrease in mortality (125). In 2024, a meta-analysis further confirmed the effectiveness of FLS in reducing secondary fractures reinforcing its relevance and utility in the geriatric population (126).

Conclusion

The management of geriatric patients with PFF is challenging, and a multidisciplinary orthogeriatric approach of varying complexity has become the gold standard. The effectiveness of this approach is compounded by protocol-driven clinical pathways. Prompt and coordinated surgical management is essential to reduce adverse outcomes. Evidence-based protocols are effective in providing safe and reliable patient care. Current recommendations offer best-practice guidelines to teams dealing with PFF in geriatric patients.

ICMJE Statement of Interest

The authors declare that there is no conflict of interest that could be perceived as prejudicing the impartiality of the work reported.

Funding Statement

This work did not receive any specific grant from any funding agency in the public, commercial, or not-for-profit sector.

Author contribution statement

OV was the major contributor and critically revised the manuscript. WB, AG, PLDG, BC, and DH critically revised the manuscript.