Management of proximal femur fractures in the elderly: current concepts and treatment options

Abstract

As one of the leading causes of elderly patients’ hospitalisation, proximal femur fractures (PFFs) will present an increasing socioeconomic problem in the near future. This is a result of the demographic change that is expressed by the increasing proportion of elderly people in society. Peri-operative management must be handled attentively to avoid complications and decrease mortality rates. To deal with the exceptional needs of the elderly, the development of orthogeriatric centres to support orthogeriatric co-management is mandatory. Adequate pain medication, balanced fluid management, delirium prevention and the operative treatment choice based on comorbidities, individual demands and biological rather than chronological age, all deserve particular attention to improve patients’ outcomes. The operative management of intertrochanteric and subtrochanteric fractures favours intramedullary nailing. For femoral neck fractures, the Garden classification is used to differentiate between non-displaced and displaced fractures. Osteosynthesis is suitable for biologically young patients with non-dislocated fractures, whereas total hip arthroplasty and hemiarthroplasty are the main options for biologically old patients and displaced fractures. In bedridden patients, osteosynthesis might be an option to establish transferability from bed to chair and the restroom. Postoperatively, the patients benefit from early mobilisation and early geriatric care. During the COVID-19 pandemic, prolonged time until surgery and thus an increased rate of complications took a toll on frail patients with PFFs. This review aims to offer surgical guidelines for the treatment of PFFs in the elderly with a focus on pitfalls and challenges particularly relevant to frail patients.

Comparing Perioperative Outcome Measures of the Dynamic Hip Screw and the Femoral Neck System

“…There is still an ongoing debate among orthopaedic specialists about whether patients may be eligible for reconstruction instead of an arthroplasty procedure. Various individual factors need to be considered, including the specific type of fracture and individual patient characteristics such as biological age, comorbidities, and previous mobility [ 4 ]. Furthermore, the typical complications of each of these approaches also need to be taken into account [ 21 , 22 ].…”

“…When discussing these data, one must consider that the latter two studies excluded typical patients: Hu et al solely included patients under 60 years old and Zhou et al excluded severely ill patients and patients with pre-existing severe cognitive dysfunction [ 15 , 18 ]. Hence, these studies may not reflect the typical, rising elderly patient cohort [ 4 ]. Partly, our results are in line with those of the aforementioned authors.…”

“…Several authors have worked on standardised treatment concept that take into account the fracture location, fracture classification, and patients’ individual risk factors [ 4 , 5 ]. However, these concepts remain highly heterogeneous, especially regarding the indication for osteosynthetic reconstruction or replacement with a hemi- or total hip arthroplasty.…”

Patient-specific risk factors for adverse outcomes following geriatric proximal femur fractures

“…For the specific fracture region, several suitable surgical treatment options are described and include arthroplasty and external or internal fixation (such as intramedullary nailing or sliding hip screws). The optimal surgical strategy has been reviewed extensively elsewhere and is determined based on international guidelines [ 1 , 2 ]. In addition to the fracture patterns, this strategy also has to consider the patients’ comorbidities, prognosis and potential risk factors.…”

Tips and tricks to avoid implant failure in proximal femur fractures treated with cephalomedullary nails: a review of the literature

“…The majority of proximal femur fractures occur in patients above age 75 [1] . These fractures are one of the leading causes for hospital admission in elderly patients and the top reason for their admission to an orthopedic ward.…”