1.1 Epidemiology

Most fractures of the hip in the elderly are caused by falls from standing height. In 2000, there were an estimated 424,000 hip fractures worldwide in men and 1,098,000 in women. Based on changing demographics and the increase in life expectancy, by 2025 hip fractures in men are expected to rise by 89%, resulting in 800,000 hip fractures per year in men, while the number of hip fractures in women will rise by 69% and reach 1.8 million [1]. In addition, 5% of patients with hip fracture have a simultaneous fragility fracture (most commonly at the wrist) and there is an 8% chance of sustaining a fracture of the contralateral hip in the next 8 years [2].

Hip fracture in the elderly is associated with nearly 30% mortality within the first year. There is also a considerable decrease in mobility and a third of the patients have a long-term decrease in daily activities that reduces their independence [3].

1.2 Special characteristics

This group of patients has been carefully studied, resulting in a more effective, multidisciplinary team approach to their care. This team comprises medical, geriatric, anesthetic, physiotherapy, nursing and orthopedic colleagues, all working together to provide expeditious care for this special group of patients.

2.1 Case history and physical examination

A full geriatric medical, anesthetic and orthopedic assessment of the patient is essential and surgery should be performed, without delay, once the patient is considered medically fit for surgery.

The patient usually presents with a history of a simple fall followed by pain and inability to bear weight. Prodromal hip pain occurs in patients with pathological and stress fractures as well as those with preexisting hip arthritis. A full medical history to identify comorbidities and other potential causes of recurrent falls is essential. Key prognostic factors including mobility, residential status, and cognitive state must be recorded in all elderly patients.

Clinical examination will usually identify a short and externally rotated leg with severe pain on hip rotation. A full medical examination is essential and the orthopedic surgeon must also assess for associated fragility fractures in the upper limbs, evaluate the neurovascular status of the leg to look for peripheral vascular disease, and check for the presence of preexisting decubitus ulcers. More details on the patient workup can be found in the chapter on fragility fractures and orthogeriatric care (see chapter 4.8).

In younger patients, a hip fracture usually occurs following high-energy trauma, thus these patients require a full evaluation for multiple system trauma.

2.2 Imaging

A standard AP pelvis x-ray plus a cross-table lateral x-ray of the ipsilateral proximal femur are required. Special attention should be paid to the lateral cortex of the proximal femur to look for undisplaced fracture lines or a coronal split fracture to anticipate intraoperative problems. This might change an alleged simple fracture into a complex one. If intramedullary (IM) osteosynthesis is considered, imaging of the femoral shaft should be included for measurement of the width of the medullary cavity and assessment of diaphyseal morphology. With excessive anterior bowing of the femur it may be impossible to insert a nail because the tip of the IM nail might perforate the anterior cortex of the femoral shaft or cause a fracture.

An occult hip fracture is relatively common in elderly patients who present with hip pain and inability to bear weight sometimes without a history of injury. There is no deformity of the leg but there may be tenderness over the hip and pain on loading or rotation. If plain x-rays show no fracture, magnetic resonance imaging (MRI) is the investigation of choice as it has a higher diagnostic accuracy than computed tomography (CT) for detecting occult fractures of the hip [3, 4].

4.1 AO/OTA Fracture and Dislocation Classification

According to the AO/OTA Fracture and Dislocation Classification fractures of the proximal femur are divided into three types ( Fig 6.6.1-2 ).

The AO/OTA Fracture and Dislocation Classification subdivides trochanteric fractures into three groups: 31A1 fractures are simple 2-part pertrochanteric fractures with good bony support at the medial cortex and are considered to be stable fractures after anatomical reduction; 31A2 fractures are multifragmentary pertrochanteric fractures with an incompetent lateral wall and are considered unstable; 31A3 fractures are intertrochanteric fractures with a horizontal line at the level of the lesser trochanter (reverse oblique). If the center of the fracture is distal to the inferior extent of the lesser trochanter, the fracture is classified as a proximal one-third diaphyseal fracture (32A).

4.2 Other key classifications

Other commonly used classifications include the Evans classification of intertrochanteric fractures, the Garden classification of intracapsular fractures, and the Pipkin classification of femoral head fractures [7, 8].

6.1 Timing of surgery

In general, nearly all patients will undergo operative treatment.

Nonoperative treatment, consisting of long-lasting immobilization, mostly with some kind of external splint and reduction device (traction or spica), is cumbersome for the patient, labor-intensive for nursing, expensive, and accompanied by bad outcomes. After assessment by the geriatric team, it is estimated that 5–8% of elderly patients with a proximal femoral fracture may not be candidates for operative treatment because of terminal illness. This group of patients should be treated with palliative care only.

In young patients with displaced intracapsular proximal femoral fractures, internal fixation must be carried out without delay to preserve the femoral head. Anatomical reduction is essential and this usually requires an open surgical approach and stable internal fixation.

A dislocated hip, broken or not, must be reduced urgently and kept in the reduced position. This is best achieved with the patient under general anesthesia with muscle relaxation. After reduction, joint stability should be examined and another standard AP view of the pelvis should be taken. The width and congruity of the joint space are compared with the opposite side. On the injured side, interposed fragments, a torn and inverted labrum, or a folded ligamentum teres may cause the joint space to appear wider. A CT scan of the hip will permit assessment of loose bone fragments within the joint, impaction and fractures of the femoral head.

For most elderly patients with a hip fracture, the sooner that they can be treated, the better, as medical conditions will be exacerbated with the compromised patient confined to bed and requiring analgesia (see chapter 4.8).

6.2 Implant considerations

The cornerstone of all operative treatment options is the anatomical reduction of the fracture and correct placement of the implant used.

For trochanteric fractures (31A1 and 31A2) IM fixation may be associated with shorter operation time, less blood loss, and earlier weight bearing but the method has not yet proven to be superior to extramedullary fixation with a sliding hip screw for extracapsular fractures [9] and the reoperation rate is significantly higher with IM fixation.

In contrast, reverse oblique fractures (31A3) have better outcomes with IM nail fixation but the use of a sliding hip screw with a trochanteric stabilization plate may be effective ( Fig 6.6.1-3 ).

Sliding hip screw systems (eg, the dynamic hip screw [DHS]) are the implant of choice for stable fractures (31A1) [10]. They allow secondary impaction of the fracture along the axis of the barrel of the sliding hip screw ( Fig 6.6.1-4 ), if it has been placed correctly in the center of the femoral head [11]. Positioning in the superior quadrant may lead to failure by cutout, particularly in osteoporotic bone. To avoid this, central placement of the guide wire is essential and has to be checked carefully with the use of x-rays in two planes ( Video 6.6.1-1 ) to achieve a tip-apex distance of less than 25 mm.

Intramedullary systems like the proximal femoral nail antirotation and trochanteric femoral nail (TFN) have some biomechanical characteristics that may have advantages in unstable trochanteric fractures (31A2, 31A3) ( Fig 6.6.1-5 ) although these advantages have not yet been proven in prospective clinical studies [10]. Distal locking should be static ( Video 6.6.1-2 ).

Unstable intertrochanteric fracture includes [12]:

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  Posteromedial comminution (may collapse into varus with rotational instability)

  
  
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  Intertrochanteric with subtrochanteric extension

  
  
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  Lateral wall blow-out (no buttress for the proximal neck fragment)

  
  
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  Reverse oblique fracture (the femoral shaft displaces medially)

  
  
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  Reverse oblique variant (the major obliquity is oriented from proximal-anterior to distal-posterior)

Ongoing large randomized controlled trials comparing different implants with clinical outcome criteria will provide important data to support decision making in the treatment of femoral neck fractures.

A treatment algorithm should address the age, the level of activity, bone density, additional diseases (comorbidities), estimated life expectancy, and the compliance of the patient [13]. For the treatment of displaced intracapsular fractures, metaanalyses indicate that internal fixation may lead to lower infection rates, less blood loss, shorter operative time, and less postoperative mortality, whereas replacement arthroplasty significantly reduces the reoperation rate [14]. Accordingly, there seems to be an agreement that patients older than 80 years, or patients with accompanied ipsilateral arthrosis, rheumatoid arthritis, or a fracture in pathological bone should be treated with replacement arthroplasty, either hemiarthroplasty or total hip replacement. Patients of any age with severe chronic illness or a limited life expectancy should also be managed with a prosthesis [3]. There is no evidence for improved outcome or cost-effectiveness of bipolar implants [15]. Internal fixation is the treatment of choice for patients with high functional demands and good bone stock. Patients who are younger than 65 years, have a low American Society of Anesthesiologists score, are healthy and mobile should have urgent anatomical open reduction and internal fixation [16] but surgeons must be aware that some women develop osteoporosis at an earlier age.