Hip fracture surgery

Incidence of perioperative myocardial ischemia in elderly patients is 35-42%.

Within 24 hours is associated with decreased pain, shorter hospital lengths of stay and possible fewer major complications.

Patients undergoing surgery for hip fracture have a higher risk of mortality and medical complications compared with patients undergoing an elective total hip replacement.

The increased risk noted above might be due to advanced age and comorbidities in hip fracture patients compared to total hip replacement patients.

In a large cohort of French patients hip fracture surgery compared to elective total hip replacement had a higher risk of in-hospital mortality after adjusting for patient age, sex and comorbidities (Le Manyache Y et al).

Historically the majority of the femoral neck fractures have been treated with reduction and internal fixation, most current guidelines advocate arthroplasty for displaced fractures of the femoral neck in elderly patients.

In a study of 2016 patients over the age of 50 with a history of or risk factors for cardiovascular disease, and whose hemoglobin was less than 10 g/dL after hip fracture surgery randomized to liberal transfusion or transfusion restricted to symptomatic patients with a hemoglobin of less than 8 g/dL: primary outcome was death or inability to walk across a room on pay 60 of follow-up-there was no reduction in rates of death the inability to walk independently on day 60 or reduction in in-hospital mortality in elderly patients at high cardiovascular risk (FOCUS Investigators).


When complications result in a secondary procedure in an older, frail patient, the results can be devastating.




Treatment of displaced femoral neck fractures, the standard approach is hip arthroplasty with prosthetic joint replacement rather than fracture fixation.




Fracture fixation is associated with high rates of non-unions-5-28%, and avascular necrosis-5-18% because of the tenuous blood supply of the proximal femur.




During hip arthroplasty the femoral stem fixation can be accomplished with cement, or with bony growth into a porous coated implant.


In a Kaiser Permanente evaluation of 6042 patients 3% with uncemented stem surgery had reoperation for loosening or fracture requiring revision surgery compared with 1.3% of 6449 who underwent a cemented procedure.


Most hemiarthroplasties  in the United States are not done with cement, as using cement increases the procedure time, and risks bone cement implantation syndrome.




In patients with hip fracture treated  with hemiarthroplasty  uncemented fixation compared with cemented fixational is associated with a significantly higher risk of aseptic revision (Okie K).




Hip instability and dislocations are the most common reasons for secondary procedures.




The risk of this location is reduced by avoiding prostheses with small heads of less than 32 mm.




The use of dual-mobility acetabular cups lowers the risk of dislocation after total hip arthroplasty for hip fracture.




The use of cemented stems in elderly patients with hip fractures, regardless if a patient receives a total hip oculoplastic or a hemi arthroplasty is currently recommended.

Hip fracture is coming in the elderly, many of whom are on anticoagulation at the time of fracture: there was no association between anticoagulation reversal and 30 day mortality or other clinical outcomes indications on oral anticoagulation like who underwent hip fracture surgery.

Randomized studies show that regional anesthesia compared with general anesthesia does not significantly reduce the incidence severity of postoperative delirium in older adults undergoing hip fracture repair.

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