The document addresses the rising incidence of hip fractures in the elderly, primarily caused by osteoporosis, and outlines the associated complications, which include chronic pain, disability, and increased mortality. It emphasizes the importance of early surgical intervention within 48 hours to improve outcomes and discusses preventative measures such as healthy lifestyle choices, exercise, and osteoporosis screening. The document highlights the significant public health challenge posed by osteoporotic fractures, particularly as global life expectancy increases.

1. HIP FRACTURES IN ELDERLY
- not just a simple matter of fixation
Dr Arun Ravindran
SR/Orthopaedics
SNIMS

2. • Most commonly done Orthopaedic Surgery at
SNIMS – elderly hip fractures

3. • Osteoporosis (Silent killer)
• a major public health problem because of its
association with low-energy trauma or
fragility fractures

4. • Hip fracture has been recognized as the most
serious consequence of osteoporosis
because of its complications, which include…
chronic pain
Disability
diminished quality of life
premature death

5. • Rising life expectancy throughout the globe
• number of elderly individuals is increasing in every
geographical region
• incidence of hip fracture will rise from 1.66 million in
1990 to 6.26 million by 2050

6. • Osteoporotic hip fracture is an established
health problem in the West
• increasingly recognized as a growing problem
in Asia

7. • Most common cause = Osteoporosis
Age
Sex – high incidence in females
C/c medical conditions – thyroid disorders,
intestinal disorders, neurological conditions
Some medications
Nutritional problems
Physical inactivity
Tobacco and alcohol

8. Other common osteoporotic
fractures
• Spine (vertebral compression
fractures)
• Wrist – Colle’s fracture

9. Why this much concern about hip
fractures???
• Making the patient non ambulant
• Complications

10. Quotation – We come to the world under the brim
of Pelvis and go out of the world through the
fracture neck of Femur

11. Complications of Hip Fractures

12. Cognitive and neurological
complications
• 10% cases - mild problems after surgery
(inability to concentrate, write, read a book,
etc) but are able to overcome activities of
daily living

13. • Postoperative delirium –
• 13.5% to 33% of cases
Causes –
 advanced age
 history of cognitive impairment
 history of alcohol abuse
 preoperative medication (special attention to
unrecognized benzodiazepine use)
 type of anesthetic used during surgery
 infection
 urinary retention and fluid or electrolyte disturbance

14. • Regional/Spinal anesthesia reduces the
incidence of delirium, compared to GA early
after surgery
• Supplemental oxygen (3-4 L/min) continually
till day 2 post-surgery, or while patient’s
oxygen saturation is not ≥ 95%

15. Cardiac complications
• 1-year recorded mortality exceeds 20% in
patients with hip fracture
• perioperative myocardial ischemia in aged
patients 35% to 42%
• heart failure and myocardial ischemia - causes
of mortality

16. Vascular complications
• DVT – venography incidence = 27 %
• Thromboprophylaxis reduces incidence by
60%

17. • Mechanical compression
• Pulmonary embolism – 1.5 – 7.5% in first 3
months following hip fracture

18. Pulmonary complications
• exacerbation of chronic lung disease
• Atelectasis
• respiratory failure
• Pneumonia (Hypostatic, aspiration)
• pulmonary thromboembolism and acute
respiratory distress syndrome

19. Gastrointestinal complications
• Dyspepsia
• abdominal distention
• constipation
• Postoperative stress ulcer and secondary
bleeding

20. Urinary tract complications
• Urinary retention, urinary infections and acute
kidney injuries
• intermittent catheterization immediately after
surgery OR catheter removed the morning after
surgery - lower rates of urinary retention
• Urinary catheters should be removed as soon as
possible

21. • UTI - Leading cause of nosocomial infection
• 12% to 61% of all patients with hip fractures
• important risk factor for delirium
• prolong the hospital stay for another 2-5 days
and even a higher mortality rate

22. • Acute Kidney injuries (16-24%)
• Age
• Dehydration
• Nephrotoxic drugs
• CKD etc….
• Maintain hydration
• i/o chart
• Avoid nephrotoxic drugs….

23. Hematologic complications
• blood loss from a hip fracture – about 500 mL
• intraoperative causes - comprise fluid shifting
and significant blood loss during surgery
• Postoperative anemia - repeated phlebotomy
or hemodilutional anemia

24. • Perioperative anemia - adverse events
• related to other medical complications
• increased hospitalization duration, rate of
readmission and death
• Hb ≤ 10 g/dL at admission - increased
mortality at 30 d in patients with hip fractures

25. Endocrine-metabolic
complications
• Diabetes
• Malnutrition – impairs mental, cardiac and
immune functions

26. Presure sores
• Close to 35% of decubitus ulcers occur at the
conclusion of the first week of hospitalization
• Risk factors include age, malnutrition, history
of smoking and systemic illnesses

27. • Special beds
• aggressive skin care
• nursing focused on prevention
• good nutrition….
help prevent the evolution
to ulceration

28. Per and post operative
mortality
• Overall 1 year mortality rate that varies from
14% to 36% among patients aged 65 or above
• Mortality is significantly influenced by
preoperative cognitive state, medical
comorbidities and mobility

29. Risk factors for increased
mortality….
• Dementia
• chronic obstructive pulmonary disease
• chest infection
• heart failure
• Anemia
• abnormal sodium (low or raised)
• elevated urea, creatinine
• malignancy

30. • patients treated non-
operatively have a
higher mortality rate
• Patients operated
within 48 h appear
to have a better
outcome than those
with a delayed
surgical intervention

31. • However, in medically unstable patients, a
delay of surgery does not result in a
statistically significant difference in mortality
compared to patients treated by early surgery

32. Anaesthetic complications of
hip fractures
• Arterial hypotension, defined as a
preoperative drop in mean arterial blood
pressure of more than 30%, or a presurgical
pressure reading of 60-70 mmHg
• Arterial hypotension has been reported in
15%-33% of patients during the first 20 min
after spinal anesthesia induction

33. • cognitive dysfunction during hospitalization –
decreased incidence with spinal anaesthesia
• recent meta-analyses recommend Spinal
anaesthesia as the technique of choice for hip
fracture repair, as long as it is not
contraindicated

34. Bone cement implantation syndrome
• Poorly understood syndrome
• hypoxia, hypotension, cardiac arrhythmias, lung
hypertension, decline in cardiac output
• reduced through…
modern cementing techniques
appropriate anesthesia interventions
adequate patient preparation
avoiding the use of cement altogether

35. • Appropriate analgesic - in most
the best analgesic is surgical
treatment

36. SURGICAL COMPLICATIONS
• INTRACAPSULAR AND EXTRACAPSULAR (IT)
FRACTURES

37. Intracapsular fractures
problems are biological
• Non union
• Avascular necrosis
Extracapsular fractures
problem is mechanical
• malunion

38. • Osteosynthesis – in young age, physiologically
active
• Replacement - in elderly (osteosynthesis
done in impacted fractures)

41. • Leads to repeat surgeries

42. • Dislocations following total hip replacements

43. Acetabular erosions
following
hemiarthroplasty

44. Thigh pain – in
uncemented cases
Femoral fractures

45. • Screw cut out – mainly following incorrect
placement of screws

46. • Femoral shaft fractures

47. • Implant failure

48. • Excessive
screw sliding

49. • Conservative / Operative management ????

50. Most frequently encountered
questions…!!!
Any conservative options??
Will surgery be a success??
Are we giving more pain to the patient by
operating??
What we are gaining by operating a very old
person of low life expecxtancy??

51. If not operating………
Severe pain
Not able to sit up or turn to either side
Bed sore
DVT, pulmonary embolism
Pneumonia……..

52. After fixation of fracture…
• Pain relief
• Bring back to previous
ambulatory status
• Even in a bed ridden patient
– surgery allows better
general care

53. When to operate???
• Within 48 hrs !!!
• Lesser mortality and morbidity for cases
operated within 48 hours

54. Post op period… What we do???
• make patient sit on the first post operative day
• Standing / walker aided ambulation on 2nd day

55. Prevention of Hip fractures in elderly
• Healthy lifestyle choices in early adulthood
build a higher peak bone mass
reduce your risk of osteoporosis in later years
• The same measures may lower your risk of
falls and improve your overall health if you
adopt them at any age

56. • Get enough calcium and vitamin D.
How Much Calcium Do You Need?
Women
Age 50 & younger - 1,000 mg daily
Age 51 & older - 1,200 mg daily
Men
Age 70 & younger - 1,000 mg daily
Age 71 & older - 1,200 mg daily

57. How Much Vitamin D Do You Need?
• Women and Men
• Under age 50 - 400-800 IU daily
• Age 50 and older - 800-1,000 IU daily

58. • Exercise to strengthen bones and improve
balance
• Weight-bearing exercises, such as walking,
help you maintain peak bone density for more
years

59. • Exercise also increases your overall strength,
making you less likely to fall
• Balance training reduce risk of falls, since
balance tends to deteriorate with age

60. • Avoid smoking or excessive drinking
• alcohol - impair balance - likely to fall
• Assess your home for hazards.
Remove throw rugs, keep electrical
cords against the wall, and clear
excess furniture and anything else
that could trip you

61. • Make sure every room and
passageway is well-lit
• Check your eyes. Have an eye
exam every other year, or more
often if you have diabetes or an
eye disease.

62. • Watch your medications.
Feeling weak and dizzy - side
effects of many medications
• Stand up slowly. Getting up too
quickly can cause your blood
pressure to drop and make you
feel wobbly.
• Use a walking stick or walker

63. • Hand rails and grab bars
• Avoid loose clothings

64. • Make it non slip – non slip mats
• Live on one level
• Move carefully

65. Treat Osteoporosis

66. Who all to be screened??? (NOF, US)
• Anyone with a fragility fracture
• All women age 65 and older
• Postmenopausal younger than 65 with risk
factors
• Men over 50 with risk factors

67. • Non pharmacological management
Nutrition – Calcium , protein rich food
Exercise – regular aerobic/moderate weight
bearing exercises
Avoid smoking and alcohol

68. Pharmacologic Treatment
• Calcium & Vit D supplements
• Bisphosphonates
Alendronate 70 mg / month
Risedronate 35 mg/ week
Ibandronate 150 mg / month
Zolendronate - once an year
• Oestrogen – blocks Osteoclastic action
• SERM
• Calcitonin – nasal spray – 200 IU
• Teriparatide – s/c - anabolic effect on trabecular bone
• Fluoride and Strontium – under clinical trial
• Denosumab – s/c every 6 months

69. To conclude….
• Incidence of Elderly Hip fractures is rising
• Major cause is Osteoporosis
• Complication rates are very high compared to
other fractures in the same age group

70. • Most of the cases are treated Surgically
• Surgery to be performed preferably within 48
hrs
• Early mobilisation and ambulation improves
the quality of life and reduce mortality rates

71. • Methods to prevent fall should be taken
• Adopt healthy lifestyles
• Regular exercises according to the age have
important role in maintaining bone density
and muscle power
• Create awareness about Osteoporosis
screening and treatment