Introduction

In response to the American Society for Bone and Mineral Research (ASBMR) [1], international call to action to address the low rate of diagnosis and treatment of osteoporosis post hip fracture a Canadian multi-disciplinary group has developed recommendations addressing post hip fracture care. The goal is to meet the Canadian quality indicators [2] and provide the best evidence-based strategies for care following a low trauma hip fracture from an orthopedic, geriatric medicine, and rehabilitation perspective. These recommendations are expected to reduce recurrent fractures and improve mobility and healthcare outcomes as well as healthcare costs.

This Canadian position paper outlining post hip fracture orthogeriatric care addresses the challenges and best practice strategies in Canada. It supports the global efforts of the International Osteoporosis Foundation (IOF) [3] in its goal to ensure effective pharmacologic intervention following fragility fracture with the launch of the IOF Capture the Fracture [4] initiative. The new Capture the Fracture Partnership in fact aims to reduce the incidence of hip and vertebral fractures due to osteoporosis by 25% by 2025 [4]. It also supports the initiatives of the Fragility Fracture Network (FFN) [5], which has emphasized the value of multi-disciplinary care with an orthogeriatric perspective focusing on early rehabilitation following a fragility fracture. The FFN also emphasizes the value of reliable secondary prevention, reducing falls risk and addressing bone health following a fragility fracture (FFN—four pillars).

This manuscript was developed by a team of multidisciplinary experts in post-fracture care. The patient perspective has also been captured and the document was reviewed and approved by the Bone Research and Education Center patient support program.

Key messages to enhance post-operative care are also provided.

Methodology

A comprehensive narrative review of the literature was conducted to identify and synthesize key articles on post hip fracture orthogeriatric care for each of the individual sections. Multiple search terms for each section were included (for example, emergency department, post hip fracture, and orthogeriatric care). Hand searching of reference lists of relevant articles was also conducted. We included articles with the following criteria (1) adults aged 50 years and older; (2) described care delivered to patients undergoing surgery for hip fracture including preoperative assessment, anesthesia management, surgery, pain management, post-operative management, osteoporosis management, nutrition, and rehabilitation; (3) randomized control trials (RCT), observational studies, systematic reviews, and guideline publications; and (4) English language articles. No limitations were placed on publication date to provide a comprehensive summary of current knowledge. Findings are summarized for each section below. This report is also guided by key quality indicators for hip fracture care provided by Health Quality Ontario (HQO) and Alberta Health Services (AHS) [2, 6].

Results

Emergency department management

The early recognition and initiation of treatment of patients with hip fractures in the emergency room optimizes care. A number of “Fast-Track” pathways have been developed that allow patients with suspected hip fractures to receive adequate analgesia, early optimization and rapid diagnosis, and ensure timely care [7]. Early diagnosis and transfer to an appropriate inpatient bed is required, as it may reduce the risk of pressure ulcers from prolonged periods of immobilization in emergency room stretchers. Pre-operative traction in this setting is of no increased benefit [8].

Multi-disciplinary care in the preoperative setting allows for rapid medical optimization and has the potential to reduce delays to surgery, incidence of delirium, and in-patient mortality [9, 10]. An orthogeriatric care model with co-management by orthopedic surgeons and clinicians with expertise in the care of geriatric patients has gained traction in recent years [11,12,13]. Co-management models have been shown to reduce the time to surgery and mortality rates in hip fracture patients [9]. Standardized pre-operative order sets should be initiated upon diagnosis in the emergency department. Standardized order sets and care pathways expedite care, reduce medical errors, and improve preoperative pain management [14]. Key pre-operative assessments should include a pre-fracture functional status, evaluation of fluid balance, cognitive and delirium screening, preoperative bloodwork, electrocardiography, and evaluation of home medications [15].

Surgery within 48 h

The evidence supporting timely surgery for patients with hip fractures has grown in recent years. Following a hip fracture, patients often experience significant pain, blood loss, and a period of immobilization. This inciting event leads to a hyper-coagulable, catabolic stress state that increases the risk of serious perioperative complications [16,17,18]. It is thought that timely surgical care shortens the exposure to this harmful state, reducing the risk of perioperative morbidity and mortality. Population-based cohort data from Ontario demonstrates that surgery within 24 h from presentation to hospital significantly reduces the overall mortality rate and risk of complications [19]. A recent RCT demonstrated that early surgery reduced mortality in high risk patients with elevated preoperative troponin levels [20]. If surgery is delayed for more than 12 h from the time of hospital admission, it is recommended that thromboprophylaxis be started pre-operatively with low molecular weight heparin (LMWH) [20, 21].

Early surgery in this population requires coordination among several medical and surgical specialists and allied health staff and administrators. Standardized protocols, order sets, and dedicated hip fracture care pathways are imperative to ensure that patients who have sustained a hip fracture receive surgery within 48 h of arriving to the hospital and as soon as possible [10]. Although a recent RCT found that “accelerated surgery” for hip fracture, i.e., within 12 h of arrival at hospital, did not significantly result in a reduction in death or a composite of major complications compared with “standard care” [20], it has been established that early surgery within 24–48 h has proven benefits [10, 19] and this approach has been widely adopted. Surgery should not be delayed if possible for patients on anticoagulation as the risks of delayed surgery outweigh the risks of intraoperative bleeding [22, 23]. Recent meta-analyses have identified that hip fracture patients who present on oral anti-coagulants have significantly delayed time-to-surgery and this is related to higher mortality rates [24, 25]. Hip fracture care pathways are being studied and there is increasing support for safe and early coordinated medical and surgical care for patients with hip fractures presenting on pre-injury anti-coagulation [26].

Multi-modal analgesia/nerve blocks

In addition to around the clock simple analgesia such as acetaminophen, regional nerve blocks can be a safe adjunctive method to improve pain management in patients with hip fractures. They have been shown to decrease opioid use and reduce the rate and length of delirium while also decreasing the length of stay in the hospital [27,28,29]. When done early, they can also assist with decreasing the time to mobility while also increasing functional walking distance [27]. This can be done and supplemented with other modes of analgesia as well to provide optimal pain relief for the patient.

The most common blocks are the femoral nerve block and the fascia iliaca compartment block (FICB). Both have been shown to be effective in providing analgesia to patients and can be done as a single-shot injection within the first few hours of presentation once the fracture is confirmed. These can be done under ultrasound guidance to help visualize the anatomy and target the specific region or using the landmark technique. These should be performed by a trained medical professional but can be done by providers of any specialty who have undergone sufficient training.

Typically, a long-acting anesthetic, such as ropivacaine or bupivacaine, is chosen. Pain relief can be felt up to 12 h or more, with the ability to repeat the block until surgery is performed. Patients should be monitored for 30–60 min after the block for signs of local systemic anesthetic toxicity (LAST). Absolute contraindications include patient refusal or allergy to local anesthetic agents. Patients on anticoagulation can receive regional nerve blocks for hip fractures with complications being rare but will need to be considered on an individual basis with risks such as hematoma or minor bleeding around the puncture site [30].

Surgery for stable intertrochanteric fractures

Inter-trochanteric hip fractures are extracapsular and have minimal risk of nonunion or subsequent osteonecrosis of the femoral head. Given this, they are treated with fixation with either a sliding hip screw (Fig. 1a) or with an intramedullary nail (Fig. 1b). The stability of inter-trochanteric fractures is generally determined by the fracture morphology and involvement of the post-eromedial calcar. Stable fracture patterns generally resist further fracture displacement following an adequate reduction and generally include two-part intertrochanteric fractures [31]. For stable intertrochanteric fractures, the clinical and radiographic outcomes are similar between sliding hip screws and intramedullary nails [32, 33]. Sliding hip screws are significantly less expensive than intramedullary nails and are more cost-effective for stable inter-trochanteric hip fractures [34]. In the era of value-based healthcare, sliding hip screws should be utilized preferentially when indicated in this patient population.

Fig. 1
figure 1

(a) Sliding hip screw for intertrochanteric fracture. (b) Intra-medullary nail for inter-trochanteric fracture

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Surgery for subtrochanteric or unstable intertrochanteric fractures

Sub-trochanteric and unstable inter-trochanteric hip fractures are a challenging entity that commonly present to orthopedic surgeons. Unstable intertrochanteric hip fractures include those with post-eromedial comminution, a reverse obliquity fracture pattern, sub-trochanteric extension, and lateral wall comminution [31, 35] (Fig. 2). These unstable fracture patterns are associated with fixation failure and a cephalomedullary nail provides a more favorable biomechanical construct compared to a sliding hip screw in this setting. Patients with a sub-trochanteric or reverse obliquity inter-trochanteric fracture should be treated surgically with intramedullary nails to reduce complication rates [2]. Patients who are low demand with unstable inter-trochanteric fractures can be treated surgically with intra-medullary nails or sliding hip screws as the use of intramedullary nail fixation may be less beneficial in this setting and may not lead to improved functional outcomes [2, 36]. Patients with unstable fracture patterns who are high demand and are able to ambulate without walking aids should be treated surgically with intra-medullary nails [37]. Fracture reduction and implant position are critical variables that play a large role in outcome for all methods of treatment [38]. Long intra-medullary nails are recommended over short nails by some authors, but most comparative studies show no advantage of one technique over the other [39, 40].

Fig. 2
figure 2

Unstable inter-trochanteric fracture of the right hip

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Surgery for displaced intracapsular fractures

Displaced intra-capsular hip fractures (femoral neck fractures) (Fig. 3) are at a high risk of avascular necrosis (AVN) and nonunion due to disruption of the blood supply to the femoral neck and head. Surgical options for displaced femoral neck fractures include fixation with either a sliding hip screw or cannulated screws or hip arthroplasty (Fig. 4a). In the elderly patient population, arthroplasty has demonstrated superior results compared to fixation. Arthroplasty results in lower reoperation rates and improved functional outcomes and higher patient satisfaction and quality of life when compared to fixation [41]. In young patients (< 60) who are high functioning and active, clinicians may choose to perform fixation in attempts to save the native joint after discussing the risks and benefits with the patient [42]. Given the risk of AVN, some experts advocate for expedited surgery early after diagnosis. However, there is growing evidence to suggest that the risk of AVN and poor outcomes is directly correlated with the initial fracture displacement and reduction, and surgical timing may not impact outcomes in this population [43].

Fig. 3
figure 3

Femoral neck (intra-capsular) fracture of the left hip

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Fig. 4
figure 4

(a) Sliding hip screw for intra-capsular fracture (femoral neck fracture). (b) Bipolar hemiarthroplasty of the left hip (cemented femoral stem). (c) Cemented left hip replacement (arthroplasty)

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In patients undergoing arthroplasty for a displaced intra-capsular hip fracture, both hemiarthroplasty and total hip arthroplasty are surgical options [44] (Fig. 4b and c). Hemiarthroplasty involves replacing the femoral head and neck with a prosthesis and total hip arthroplasty involves replacing both the femoral head and acetabular articular surface with prosthetic components. A recent large, international, RCT comparing hemiarthroplasty to total hip arthroplasty demonstrated similar outcomes between the two groups [44]. Total hip arthroplasty should be considered in patients with pre-existing arthritic hip pain or younger, active patients with a longer life expectancy. In considering the use of hemiarthroplasty, modern unipolar and bipolar implants may both be advantageous. When undergoing arthroplasty for a displaced intra-capsular hip fracture, cemented components for the femur should be used to reduce the risk of re-operation and periprosthetic fractures.

Weight-bearing as tolerated

Early post-operative mobilization in hip fracture patients reduces serious post-operative complications including pneumonia, thromboembolism, urinary tract infections, and pressure ulcers. Prolonged immobilization and lack of early weight-bearing have been shown to increase mortality in this patient population [45, 46]. Older patients with hip fractures, particularly those with underlying dementia and delirium, may not be able to comply with weight-bearing restrictions in the postoperative period [47]. Weight-bearing restrictions have been shown to reduce overall mobility without actually reducing the load placed on the affected extremity [48]. Immediate post-operative weight-bearing after hip fracture surgery has not been shown to increase the rate of revision surgery [47, 49, 50]. Given the negative consequences and ineffectiveness of weight-bearing restrictions in hip fracture patients, they should be avoided, and the vast majority of patients should be allowed to mobilize and weight bear as tolerated. Weight-bearing restrictions may be warranted in younger patients who undergo fixation of intra-capsular hip fractures in attempts to salvage the native joint. In these rare situations in which restricted weight-bearing is warranted, a clear plan for progression of mobility and weight bearing should be in place prior to hospital discharge.

Screening for and managing delirium

Delirium, characterized by an acute onset and fluctuation in cognition, consciousness, disorganized thinking, and attention, is a common and serious complication in older patients after hip fracture surgery [51, 52]. The incidence of delirium among hip fracture patients is 20–50% [53]. Post-operative delirium is often associated with falls, impaired functional and cognitive recovery, prolonged hospital stays, discharge to long-term care, and mortality compared to hip fracture patients without delirium, and it may also increase the risk of dementia [54,55,56]. See Tables 1 and 2 for risk factors and causes of delirium. Evaluating risk factors for delirium prior to hip fracture surgery can assist clinicians in identifying patients at risk and facilitating optimal use of preventative measures.

Table 1 Risk factors for delirium in hip fracture patients
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Table 2 DIMES mnemonic for major causes of delirium [57]
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Hip fracture patients should be screened for delirium at admission and throughout the hospital stay as an important step in delirium management is early detection and prevention [58]. Routine laboratory tests, review of patient’s medical history and current illness, and the implementation of a screening test on admission can assist in evaluating a patient for delirium. The Confusion Assessment Method (CAM) is a quick, accurate, and commonly used tool for screening for delirium [59, 60]. It can be incorporated into routine assessments of patients and has been shown to have high sensitivity and specificity (sensitivity of 94% (95% confidence interval (CI), 91–97%) and specificity of 89% (95% CI, 85–94%)) [59, 61]. Diagnosis of delirium may also be completed according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V) criteria, International Classification of Diseases (ICD-10), and the Delirium Rating Scale [51, 62, 63]. As delirium is often associated with pre-existing cognitive impairment, baseline cognitive assessment can be performed, using assessment tools such as the Standardized Mini-Mental State Examination (MMSE) [64], Montreal Cognitive Assessment (MoCA) [65], Mini-Cog [66], Short Portable Mental Status Questionnaire (SPMSQ) [67], and upon hospital admission [68]. Due to the high prevalence of post-operative delirium, hospitalized adult patients should be assessed at least daily for delirium [69].

Management strategies for delirium should be focused on prevention and symptom management. Once delirium has developed, there is limited evidence that pharmacologic therapy is beneficial [70]. A non-pharmacological multicomponent approach is highly effective to reduce the number and duration of delirium episodes [71]. Programs such as the Hospital Elder Life Program (HELP) is a multicomponent approach that uses delirium prevention strategies (such as maintaining orientation, reducing sensory deficits, ensuring adequate nutrition, and hydration) to reduce functional decline, placement in long-term care facilities, and improve overall quality of hospital care [72, 73]. In-patient geriatric consultation as part of a multidisciplinary team has also been shown to decrease episodes of delirium by 40% in patients with hip fracture [74]. A comprehensive geriatric assessment focusing on evaluation of medications, alcohol intake, detailed patient history, early identification and treatment of complications, and mobilization has been shown to decrease the occurrence of delirium [75]. Physical exercise and rehabilitation can improve cognitive function among older adults and decrease the risk of delirium [76,77,78]. Prevention strategies should be prioritized in at-risk patients as such approaches can reduce the development of delirium but have no impact on duration of delirium once it develops.

Once delirium is diagnosed, it is important to identify and treat underlying causes, provide supportive care, and prevent complications. It should be noted that there no specific drugs that are approved the management of delirium. Drug treatments can lead to increased harm to patients, including increased morbidity (including falls and fractures) and mortality.

Pharmacological therapy should only be initiated if non-pharmacological strategies are not adequate to control symptoms and the patient is at risk of harm to themselves or others.

See Table 3 for pharmacologic therapy that may be initiated as indicated [2, 6, 58].

Table 3 Treatment for complications of hyperactive delirium
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Frailty is a clinical condition associated with increased vulnerability, which results from aging-related decline across psychological, physical, and social functioning [79]. Frail older adults undergoing hip fracture surgery are at increased risk of developing postoperative delirium, longer length of hospital stay, poor functional status, inability to recover pre-fracture mobility, and are more likely to be discharged to a long-term care facility [80]. Examples of frailty assessment methods include the Cardiovascular Health Study (CHS) frailty phenotype method (Fried’s phenotype method) [79] and the Frailty Index (FI) [81]. The Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) is a reliable tool to predict mortality or institutional care needs after hip fracture (available here: https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.htmll) [82]. Evaluating frailty is essential in patients undergoing hip fracture surgery to prevent adverse outcomes and improve the overall health status of older adults at discharge.

In summary, delirium is a preventable clinical syndrome that is associated with multiple complications including dementia, functional impairment, prolonged length of stay, long-term care admission, and death [83, 84]. Implementation of a multi-component non-pharmacological prevention program is effective in preventing delirium and improving outcomes for older adults.

Post-operative management

Hip fractures are associated with a high risk of post-operative complications including heart failure, chest infections, pressure injuries, and delirium [85,86,87]. Factors associated with increased risk of post-operative complications include three or more co-morbidities, frailty, underlying respiratory disease, and malignancy [85, 88]. Cohesive, inter-disciplinary, orthogeriatric management has been recommended to optimize care [2, 89, 90].

A systematic approach to post-operative management is required to optimize recovery. Areas of focus should include the following:

  1. 1.

    Nutritional assessment (see Sect. "Nutrition" for more detail)

    Nutritional assessment is essential. Malnutrition can be screened for using validated tools including the mini-nutritional assessment-short form (MNA-SF) [91] and malnutrition universal screening tool (MUST) [92]. Accurate assessment of muscle mass and body weight is advised. Protein and high-energy supplements should be provided if required.

  2. 2.

    Pressure injury prevention and care

    Pressure injuries are common yet preventable [93]. They are associated with delayed rehabilitation, poorer prognosis, and increased risk of death [94]. Risk factors include poor nutritional status, low body weight, incontinence, diabetes, neuropathy, poor skin condition, and prolonged immobility. Pressure injury risk assessment should be undertaken using a validated tool such as the Braden Scale [95]. Skin care precautions should be taken, such as proper turning, repositioning, and use of pressure relieving equipment.

  3. 3.

    Catheter care

    Urinary catheters should be removed by post-operative day 1. If post-operative catheterization is necessary beyond day 1, consider intermittent catheterization. Urinary retention is not uncommon with the addition of iron, calcium, decreased mobility, and constipation—consider post-void residuals if patient is not voiding, has delirium, and/or constipation.

  4. 4.

    Fluid balance assessment

    Changes in fluid balance are common post-operatively. The goal of perioperative fluid management is to optimize cardiac output without precipitating cardiac failure. Dehydration can lead to hypotension, acute kidney injury, and delirium whereas fluid overload can lead to cardiac failure. Post-operative strategies to optimize fluid status include avoiding prolonged periods of fasting, assisting with oral fluid intake, monitoring fluid intake and output and the patient’s vital signs [87]. If dehydration cannot be rectified through oral rehydration, consider careful iv fluid administration with regular monitoring.

  5. 5.

    Venous thromboprophylaxis

    In patients undergoing hip fracture surgery, the American College of Chest Physicians (CHEST) recommends the use of thromboprophylaxis for a minimum of 10 days post-operatively [21]. The National Institute for Health and Care Excellence (NICE) recommends the use of LMWH or fondaparinux for 28 to 35 days, while Thrombosis Canada similarly supports enoxaparin, dalteparin, tinzaparin, or fondaparinux for 14 to 35 days post-operatively [96, 97]. Other subspecialty societies, including the Orthopedic Trauma Association (OTA) and the European Society of Anesthesiology also support aspirin use post-operatively for up to 35 days following hip fracture surgery [98, 99]. Recent meta-analyses demonstrate equivalence for the use of Direct Oral Anti-Coagulants (DOACs), compared with other pharmacologic thromboprophylaxis [100, 101]. Therefore, pharmacologic thromboprophylaxis using LMWH, aspirin (ASA), or DOACs are recommended for up to 35 days following hip fracture surgery (Table 4) [100,101,102].

Table 4 Summary of current thromboprophylaxis guidelines following hip fracture surgery
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  1. 6.

    Fall risk assessment including medication review

A multi-factorial falls risk assessment should be performed including the following domains [103].

  1. a.

    Focused fall history

  2. b.

    Detailed medication review including identification of fall risk inducing drugs (FRIDs) [104]

  3. c.

    Physical examination including gait, balance, mobility, neurological and cognitive function, muscle strength, cardiovascular status, visual acuity, and examination of feet and footwear

  4. d.

    Functional assessment

  5. e.

    Environmental assessment

Rehabilitation

Morbidity post-fracture is due to decreased mobility, impaired balance, and fear of falling [105], resulting in an increased risk of falls. These causes prevent approximately 40% of older people from returning to pre-fracture daily activity [106].

Cognitive impairment (dementia or delirium) does not preclude rehabilitation [78, 107]. Delay in initiation of rehabilitation increases risk for hospital mortality (OR 2.2, 95% CI 1.06–4.42, p value 0.034) [108]. Appropriate adaptation of the program to meet individual patient’s needs is advised [109]. See Alberta Health Services regarding post-discharge instructions (available here: http://www.rehabcarealliance.ca/uploads/File/Initiatives_and_Toolkits/QBP/UPDATED_November_2017-_Hip_Fracture_QBP_Rehabilitative_Best_Practices_Framework.pdf) [110]. It is important that rehabilitation happens not only acutely, but post-acutely (recovery hospital) and in the community after discharge. It can take up to 9 months for balance deficits and approximately 1 year for gait and walking speed to recover.

Mechanical load induced by exercise produces stress upon bones and enhances bone formation. Progressive resistance exercise, weight-bearing impact training, and functional balance training constitute most exercise programs. Resistance exercise and impact training promote the greatest bone formation. These recommendations have been developed in a pre-fragility fracture population [111] but are now being applied to post-fracture populations [112]. The general principles are correct technique, gradual loading increments, and avoiding activities that might increase risk for falls [113].

Rehabilitation should include balance training to reduce risk of future falls and fractures. A recent meta-analysis revealed that the balance training group had improved overall physical functioning, gait, lower limb strength, performance tasks, and activity of daily living compared with the control group [114]. More high-quality and large-scale RCTs are needed to identify the optimal regimen of balance training after hip fracture.

Individualized exercise approaches, considering patient preferences and integrating factors associated with patient adherence within the context of physiotherapy (such as counseling sessions, workbooks and goal setting, motivational interviewing, and cognitive behavioral therapy) will improve outcomes [109]. Recently published Clinical Practice Guidelines [115] in post-operative hip fracture patients included a multi-disciplinary approach, progressive resistance exercises, and balance training. Early ambulation, weight-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested [115]. However, in a Cochrane analysis [116] although number needed to treat was 25 patients (95% CI 15 to 100) to avoid one “poor outcome” (defined as mortality and decline in residential status at one year), results were generally borderline. In a hospital in-patient setting, there is moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of “poor outcome” (death or deterioration in residential status). However, there is low-certainty evidence that multi-disciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low-certainty evidence that multi-disciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. The borderline measurable effect of rehabilitation has prompted combination strategies-with nutrition (see section on nutrition) and/ or medications.

Encouraging data comparing in-hospital geriatric care and rehabilitation, to early discharge with a home-based rehabilitation program, has shown that in older people with hip fracture, early discharge followed by geriatric interdisciplinary home rehabilitation resulted in a comparable recovery of independence in activities of daily living (ADL) at 3 and 12 months [117]. A retrospective study also showed similar outcomes between home and in-patient rehabilitation, even though the inpatient group was more medically complex [118]. In addition, outpatient rehabilitation has been shown to be cost saving in one 10-week outreach rehabilitation intervention for nursing home residents who sustained a hip fracture, through reduced post-fracture hospital re-admissions [119]. In-patient clinical care pathways (CCPs) that extended to the outpatient setting showed greater improvements in Health-Related Quality of Life (HRQoL) and physical function compared to CCPs that were only inpatient or outpatient [120]. A feasibility trial also demonstrated that outreach participants achieved better locomotion by 3 months post-fracture compared with participants receiving usual post-fracture care; benefits were sustained to 12 months post-fracture. In adjusted analyses, outreach participants also showed sustained benefits in physical function and HRQoL [121]. See the Fresh Start program for hip fracture recovery guide (available here: https://vch.eduhealth.ca/PDFs/FB/FB.863.F73.pdf) [122].

Inequity to access post hip fracture rehabilitation is an issue in most countries. Consistent decision criteria for access to hip fracture rehabilitation will assist in guiding a standard approach to providing rehabilitation, particularly for patients with cognitive impairment [107, 113].

Recommendations: early mobilization post-operatively including strength, balance, and ADL exercises, home or hospital based are both feasible options; ideally, continuation of the program in the community; ensure equity with clinical practice guidelines; combine rehabilitation with nutritional support.

Osteoporosis management and fracture prevention

Osteoporosis is associated with an increased fracture risk. The estimated mortality rate within the first year following a hip fracture is approximately 37% and 28% in men and women, respectively [123]. Given the high risk of fracture among older adults, it is important to initiate pharmacologic therapy for osteoporosis to prevent fractures both in acute and long-term or outpatient care. Following a hip fracture, patients should undergo a comprehensive assessment by a clinician with osteoporosis expertise and be offered appropriate pharmacologic intervention. Currently, osteoporosis treatment rate following a major osteoporotic fracture is unacceptably low [124, 125]. Pharmacotherapy can reduce the risk of subsequent clinical fractures, as well as improve survival [126]. BMD can be used to monitor treatment efficacy.

Hip and vertebral fractures confer a very high fracture risk and require pharmacologic therapy, preferably with an anabolic agent in order to improve the quality and microstructure of the skeleton [127, 128]. After an initial fracture (spine, hip, pelvis, femur, or clavicle), women have an increased risk of fracture with as high as a 25% risk of second fracture within 2 years, and the risk increases with age [129]. Among women with a prior clinical fracture, 17.9% fractured again within 2-years following the initial fracture and 4.8% sustained a hip fracture [129]. This concept of imminent fracture risk, with an acute rise in fracture risk within the first two years following an index fragility fracture, supports the initiation of targeted therapeutic intervention as soon as possible after a fragility fracture [130]. Appropriate pharmacologic therapy for osteoporosis should be offered for patients, regardless of patient age.

Risk factors for osteoporosis include postmenopausal bone loss as well as age related declines in bone density [131]. Many other diseases and drugs may contribute to further bone loss [132,133,134,135]. A detailed evaluation with exclusion of secondary causes of bone loss prior to confirming a diagnosis of postmenopausal osteoporosis is essential (see Table 5).

Table 5 Summary of the secondary causes of bone loss and relevant investigations [132,133,134,135]
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We recommend completing the following laboratory tests listed in Table 4 on admission to hospital in order to expedite initiation of appropriate pharmacologic intervention for the underlying osteoporosis.

General internal medicine (GIM) specialists are also closely involved in the care of hospitalized patients post hip fracture. Often, these patients are referred to internal medicine for pre-operative assessment and GIM is concurrently involved in the management of their medical concerns post-operatively. Unfortunately, osteoporosis care is often overlooked during these critical assessments. We strongly recommend internists address skeletal health and ensure exclusion of secondary causes of osteoporosis during the pre-operative assessment of hip fracture patients. It is essential to provide appropriate post-op follow-up with implementation of drug therapy for the underlying osteoporosis prior to discharge.

Renal osteodystrophy chronic kidney disease (CKD) stage 4 (eGFR < 30 ml/min) and 5 (eGFR < 15 ml/min) are associated with changes in serum calcium, phosphorus, parathyroid hormone (PTH), 1,25 dihydroxyvitamin D, and fibroblast growth factor-23 (FGF-23) resulting in abnormal bone structure and function [136]. Hip fracture risk increases dramatically with declines in eGFR. A careful evaluation of the biochemical profile is necessary prior to implementation of drug therapy. In the presence of CKD, osteoporosis may also be complicated by the presence of impaired bone mineralization or osteomalacia. Bone turnover may be elevated or suppressed, and this will impact the choice of drug therapy. It is necessary to normalize vitamin D levels as well as both serum calcium corrected for albumin as well as serum phosphate. PTH should be evaluated and is expected to be elevated with declines in eGFR below 60mls/min [136]. In patients with CKD stage 3a–5 not on dialysis, the optimal PTH level is not known. The Kidney Disease Improving Global Outcomes (KDIGO) guidelines suggest that patients with levels of intact PTH progressively rising or persistently above the upper normal limit for the assay be evaluated for modifiable factors, including hyperphosphatemia, hypocalcemia, high-phosphate intake, and vitamin D deficiency. The current KDIGO guidelines [136] suggest in stage 5 CKD that the PTH level be maintained in the 2–9 × the upper level of normal. Pharmacologic intervention with an anabolic agent may be appropriate off label in the presence of low turnover and an anti-resorptive agent may be suitable if remodeling is elevated. Bisphosphonates are contraindicated if the eGFR < 30-35mls/min.

Fracture risk assessment with and without BMD

High fracture risk is confirmed in the presence of a hip or vertebral fracture, OR > 1 fragility fracture, OR steroid use (prednisone ≥ 7.5 mg or equivalent for ≥ 3 months in the previous year) and concomitant history of a prior fragility fracture. All fragility fractures (low trauma) of the hip have a high fracture risk and require consideration of pharmacologic intervention regardless of the calculated fracture risk. Fracture risk can be calculated by the Fracture Risk Assessment Tool (FRAX) or Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tool [137,138,139,140]. FRAX has been developed and validated in 11 different cohorts including the Canadian population and has been calibrated to fracture and mortality rates in Canada. FRAX can be used with or without BMD to predict the 10-year risk of hip and major osteoporotic fracture (MOF) [141,142,143]. FRAX with BMD (area under the curve (AUC) = 0.72) had a higher discriminative ability for osteoporotic fracture than FRAX without BMD (AUC = 0.69) [144].

Self-reported falls in the previous year are an additional risk factor, independent of FRAX, with a hazard ratio (HR) of 1.64 in women aged 70–90 [145].

Non-pharmacologic interventions and treatment of osteoporosis

  • Nutrition: see section on nutrition page 27

  • Calcium and vitamin D

    1. o

      Adults aged 50 years and older should ensure an adequate calcium intake of 1200 mg elemental calcium daily [146], ideally from dietary sources as there have been concerns regarding the association of calcium supplements and increased risk of cardiovascular disease and nephrolithiasis [147, 148]. Estimation of dietary calcium intake can be performed using the Osteoporosis Canada calcium calculator, https://osteoporosis.ca/calcium-calculator [149]. If supplements are necessary, calcium carbonate or calcium citrate can be prescribed

    2. p

      Vitamin D adequacy is essential for optimal intestinal calcium absorption and may also improve balance and muscle strength and decrease the risk of falls [150, 151]. A meta-analysis conducted in postmenopausal women showed a significant reduction in hip and non-vertebral fracture risk with vitamin D supplements at doses of 700–800 IU or more daily [151]. Vitamin D supplementation should be offered, targeting a serum 25 hydroxyvitamin D (25(OH)D) level of 75–125 nmol/L. It is important to ensure that the 25(OH) vitamin D levels are normal before initiating anti resorptive treatment. Vitamin D levels below 25 nmol/L may be associated with osteomalacia and may require replacement for several months prior to initiating additional pharmacologic intervention [152]

  • Physical activity

    1. o

      A daily weight bearing exercise program should be emphasized, as regular physical activity has been shown to improve femoral neck (FN) and lumbar spine (LS) BMD in postmenopausal women [153]

  • Lifestyle changes

    1. o

      Smoking cessation is advised as cigarette use has been reported to increase osteoporosis fracture risk [154]

    2. p

      Alcohol intake should be limited to no more than 2 units daily, as higher intake has been associated with an increased fracture risk [155]

  • Fall prevention programs for the elderly

    Multiple risk factors for falls have been identified in elderly patients, including cognitive impairment, use of sedative medications, disabilities affecting the lower extremities, poor vision, and abnormalities of balance and gait [156]. Interventions targeting those risk factors may decrease the risk of falls and meta-analysis have proven fall prevention programs to be effective both in community dwelling elderly as well as nursing home residents [157]

Pharmacologic interventions

Osteoporosis treatment options include [128, 158,159,160]:

  • Bisphosphonates, oral (alendronate, risedronate), or intravenous (zoledronate)

  • Denosumab

  • Romosozumab

  • Teriparatide/abaloparatide

  • Selective estrogen receptor modulators (SERMS) (raloxifene or bazedoxifene)

  • Menopausal hormonal therapy (MHT)

Treatment options

Anabolic therapy

 An anabolic agent is the preferred option following a hip fracture due to greater impact on fracture risk reduction in comparison to bisphosphonate therapy, see Table 6 and Fig. 5. This was demonstrated in the vertebral fracture treatment comparisons in osteoporotic women (VERO) study comparing the efficacy of teriparatide 20 µg sc daily versus risedronate 35 mg weekly in this head-to-head trial on the occurrence of new radiographic vertebral fractures [161]. Teriparatide decreased new vertebral fractures by 56%, relative risk (RR) 0.44, CI 0.29–0.68, p < 0.01, and clinical fractures (vertebral and non-vertebral) by 52% (hazard ratio (HR) 0.48, CI 0.32–0.74, p < 0.01) in comparison to risedronate [161]. The Active-Controlled Fracture Study in Postmenopausal Women with Osteoporosis at High Risk (ARCH) study compared romosozumab to alendronate in a head to head trial [162]. The romosozumab treated group had a 48% lower risk of new vertebral fractures and a 27% lower risk of clinical fractures when compared to alendronate [162].

  • Romosozumab: is a humanized monoclonal antibody to sclerostin. It increases bone formation and reduces bone resorption and is indicated in the presence of a very high fracture risk. The treatment dose is 210 mg subcutaneously (given as 2 injections of 105 mg each) monthly for up to 12 months. Romosozumab has been shown to reduce the risk of vertebral, hip, and non-vertebral fractures [162, 163]. In the fracture study in postmenopausal women with osteoporosis (FRAME), study romosozumab was compared to placebo and was effective in reducing vertebral and clinical fracture risk [164]. It was well tolerated with no increase in the risk of major adverse cardiovascular events. In the ARCH trial, romosozumab was compared to alendronate [162]. Major adverse cardiovascular adverse events were seen more frequently in the romosozumab group (2.0%) than in the alendronate group (1.1%) [162, 163]. Therefore, romosozumab is contraindicated in the presence of a prior myocardial infarct or stroke and clinicians should carefully consider the risks/benefits ratio in patients with multiple cardiovascular risk factors

  • Teriparatide: is a recombinant human parathyroid hormone (rPTH) 1–34 and is an anabolic agent indicated in the presence of a very high fracture risk. It increases bone formation as well as bone resorption. The treatment dose is 20 mcg subcutaneously daily for up to 24 months. Teriparatide has been shown to reduce the risk of both vertebral and non-vertebral fragility fractures in post-menopausal women at high fracture risk [161]. In the Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE) trial, the incidence of hypercalcemia was 6.4% in teriparatide treated patients [165]. It is important to ensure that the serum calcium corrected for albumin and PTH levels are normal prior to initiating therapy. Teriparatide is contraindicated in individuals with a prior history of malignancy or radiation therapy, as well as in patients with eGFR < 15 ml/min

  • Abaloparatide: is a modified PTH-related peptide. It is an anabolic agent indicated in the presence of a very high fracture risk. It increases bone formation as well as bone resorption. The treatment dose is 80 mcg subcutaneously once daily for up to 24 months. It has been shown to reduce both vertebral and non-vertebral fragility fractures [165]. In the ACTIVE study, the incidence of hypercalcemia was 3.4% in abaloparatide treated patients and hypercalcemia and hyperparathyroidism need to be excluded prior to treatment initiation. It is also contraindicated in the presence of prior malignancy or radiation therapy [165]

  • Anti-resorptive therapy

    If it is not possible to proceed with an anabolic after a hip fracture, then, denosumab or other anti-resorptive therapies such as IV zoledronate or an oral bisphosphonate such as alendronate or risedronate may be offered. Due to the high risk of fracture recurrence, it is advised that treatment be initiated prior to discharge from hospital if at all possible.

  • Denosumab: is an anti-resorptive agent indicated in the presence of osteoporosis in postmenopausal women or men at a high fracture risk. Denosumab has been shown to reduce the incidence of vertebral, hip, and non-vertebral fracture by 68%, 40%, and 20%, respectively [166]. The treatment dose is 60 mg subcutaneously every 6 months and it can be given safely for up to 10 years. After therapy is discontinued, there is a rapid rebound in increase in osteoclastogenesis and bone resorption that is associated with an increased risk of fractures, and denosumab cessation should be followed by an anti-resorptive molecule such as bisphosphonates [167]. Osteonecrosis of the jaw (ONJ) and atypical femoral fracture (AFF) are rare complications of denosumab treatment, with incidence of 5.2/10,000 person years and 0.8/10,000 person years, respectively [168]. Prior to denosumab initiation, it is important to ensure that serum calcium corrected for albumin and vitamin 25(OH)D level is normal and eGFR should be > 15 ml/min in order to reduce the risk of hypocalcemia[169]

  • Bisphosphonates: Intravenous zoledronate 5 mg is given as an infusion over 30–60 min. A single dose of IV zoledronate can provide long term skeletal protection and may be repeated in 2 yrs [170]. Prior to starting IV zoledronate, it is essential to ensure that serum calcium corrected for albumin and 25 (OH)D are normal and the eGFR must be ≥ 35 mls/min in order to avoid hypocalcemia. Rapid infusion of IV zoledronate may result in declines in renal function and must be avoided [136]. It is also important to ensure that individuals are well hydrated prior to the infusion of IV zoledronate. An acute phase reaction with myalgias, arthralgias, and fever and chills and flu like reaction may occur post-infusion and may last for a several days and is best treated with acetaminophen [171]. The oral bisphosphonate alendronate (70 mg once weekly) and risedronate (35 mg once weekly) are contraindicated in the presence of gastroesophageal reflux disease (GERD), stricture, achalasia, or impaired motility. They are also not suitable in the presence of malabsorption or prior bowel surgery. Patients are also required to sit and remain upright for 30–60 min after the oral bisphosphonate to ensure that the tablet does not reflux into the esophagus. If patients are not able to follow the dosing requirements for an oral bisphosphonate; then, parenteral anti-resorptive therapy should be considered with IV zoledronate or denosumab.

    Fractures may occur in patients who have been on drug therapy. In these situations, we would recommend a careful review ensuring that a secondary cause of osteoporosis has not been overlooked. Compliance with therapy should also be evaluated. If the patient was on a bisphosphonate, therapy may be switched to an anabolic agent or denosumab. If the patient was on denosumab then a switch to romosozumab or the addition of teriparatide may be considered [172, 173].

    Biomarkers are still being evaluated regarding their applicability in decision making post-fracture and are currently not recommended.

    There is no evidence that osteoporosis drug therapy will impact wound, or fracture healing and therapy should be initiated pre-discharge if at all possible. The options available will also be impacted by financial resources and provincial formularies.

Table 6 Osteoporosis medications: special considerations and contraindications
Full size table
Fig. 5
figure 5

Treatment algorithm (reproduced with permission) [127]

Full size image

Follow-up care

Following hip fracture surgery, patients should be followed up by their primary care provider within two-weeks of discharge from hospital as well as the orthopedic surgeon as advised. This timeframe is important as it embodies the fragmented period in the care transition from acute hospital care to the community where patients may experience poor satisfaction with care, unmet healthcare needs, medication discrepancy, and adverse clinical events [174]. As hip fracture patients may transition between a variety of healthcare settings (i.e., acute care, rehabilitation, home care, and long-term care), patients and families should be provided with standardized education and support on care transition processes.

Patients who experience a hip fracture are also at high risk of secondary fracture. In fact, one in three patients who experience a hip fracture will sustain another fracture within 12 months and over 50% of patients will experience another fracture within 5 years [175]. Although pharmacologic therapy and fall prevention strategies have been demonstrated to be effective in reducing the risk of secondary fractures, fall prevention counseling and osteoporosis treatment rates continue to be low following a hip fracture. Fewer than 20% of patients who sustain a fragility fracture receive pharmacologic treatment in the year following a fracture [176]. Therefore, secondary prevention methods should include treatment and management of osteoporosis and fall prevention. The National Hip Fracture Tool Kit (available here: http://boneandjointcanada.com/hip-fracture/) [177] recommends strategies for fall prevention including:

  1. 1)

    Environment modifications to eliminate fall hazards (removing carpets, handrails, etc.)

  2. 2)

    Physical activity

  3. 3)

    Beware of medications that increase the risk of falling (due to dizziness, drowsiness, gait disturbance, etc.)

  4. 4)

    Equipment such as mobility aids and hip protectors

  5. 5)

    Counseling on fear of falling (which can lead to restricted activity and altered gait that increases the risk of future falls and injuries). Fear of falling can be evaluated using the Falls Efficacy Scale-International [178] (FES-I, short or long version)

  6. 6)

    Healthcare provider and staff education on evidence-based fall prevention (e-learning available through the Canadian Falls Prevention Curriculum)

Educational resources for patient and family on fall prevention are important for secondary fracture prevention. Education and resources are available at Osteoporosis Canada (https://osteoporosis.ca) [179] and Public Health Agency of Canada (http://www.phac-aspc.gc.ca/seniors-aines/publications/public/injuryblessure/falls-chutes/index-eng.php) [180]

Nutrition

Malnutrition, in particular protein and caloric under-nutrition, is considered fracture risks by impairing muscle strength and function, thereby increasing the risk of falling. Compromised bone strength results in increased bone fragility and reduced soft tissue protection around the hip [181].

Malnutrition in older hip fracture patients is also associated with increased complication rates and mortality [182]. In those with malnutrition, mortality is increased more than two-fold [183]. Reported prevalence of malnutrition is common and ranges from 18 to 45% [184] to 85% in hip fracture patients [185]. Pre-fracture nutritional status also affects rehabilitation time and level of recovery [186]. Malnutrition (defined by Subjective Global assessment (SGA)) led to lower rehabilitation efficiency scores and poorer functional outcomes (OR 21.5) when correcting for all other confounders [186]. The global nutrition community is advocating for the Global Leadership Initiative on Malnutrition (GLIM) criteria to be the global standard of care [187]. The GLIM criteria include both phenotypic (weight loss, low body mass index (BMI), and reduced muscle mass) and etiologic (reduced food intake or assimilation and disease burden/inflammation) assessment criteria. However, the SGA is felt to be the most validated tool for diagnosing malnutrition, with a 2020 study suggesting the GLIM tool had low sensitivity compared to the SGA [188].

Serum albumin concentration < 3.5 g/l (< 35gm/L) was previously believed to be suggestive of malnutrition but is now felt to be more a marker of inflammation (along with C-reactive protein or pre-albumin). Hypoalbuminemia is a powerful independent risk factor for mortality following a surgical procedure for geriatric hip fracture [189]. Hypoalbuminemic patients had higher rates of death (9.94% compared with 5.53% (adjusted relative risk, 1.52 (95% CI, 1.37 to 1.70); p < 0.001)) and increased rates of sepsis, risk for intubation, and length of stay [189]. Despite this, correction of albumen in hip fracture patients has not been shown to improve outcomes.

Widespread, prolonged nil-by-mouth fasting (no food or fluids orally), is common [190], exceeding twice the recommended duration for solids and 4 times the recommended duration for fasting with clear fluids. Rates of supplementation remain low, with less than half of patients receiving snacks or nutritional supplements preoperatively, and only 56% of patients having received a solid meal prior to surgery in one region of the United Kingdom (UK). This is likely a common practice in many other regions and countries and has been reported by other groups [190]. Fasting periods regularly exceed 14 h, despite recommendation of 6 h for solid food by the European Society of Anaesthesiology [191], and 6 to 8 h by the American Society of Anesthesiologists, depending on the type of solid ingested [192]. This is often attributed to the common practice of prescribing nil-by-mouth fasting sting at midnight on the day of surgery [193]. The addition of 1 extra meal a day to hip fracture patients was shown to halve mortality across six National Health Service (NHS) trusts in northern England and Scotland [194].

A meta-analysis of pre-operative oral nutrition supplements on post-operative outcomes in geriatric hip fracture patients showed some lowering of post-operative complications (OR 0.48), but the studies available for review were few [195]. In addition, practically speaking, pre-operative supplementation is seldom realistic with the goal for surgery being within 24 h of fracture.

Early post-operative nutritional supplement utilization in malnourished hip fracture patients was associated with significantly shorter length of stay (5.8 (6.6) days vs. 7.6 (5.8) days; p < 0.001) [196] but there was no association between early nutritional supplementation and secondary outcomes, such as infectious complications, hospital mortality, intensive care unit (ICU) admission, and total hospital cost. However, early oral nutritional supplementation (protein intake approximately 70 g/day) reduced the incremental increase of postoperative IL-6 levels, with less time in bed, and better quality of life at 3 months, compared to controls [197].

Combining nutritional supplements and rehabilitation showed a significant reduction in mortality (RR 0.61, 95% CI 0.39, 0.93; I2 = 0%) and complications (RR 0.67, 95% CI 0.44, 1.03; I2 = 79%) and improved grip strength (mean difference = 2.01, 95% CI 0.81, 3.22; I2 = 0%), with the caveat that the quality of the evidence in this meta-analysis was felt to be low [198].

Higher amounts of protein are recommended in older subjects, from a recommended daily allowance of 0.8 g /kg body weight to up to 1.3–1.5, in situations of stress or inflammation, where the needs are higher. PROT-AGE study group [199] recommends 1.0 to 1.2 g protein per kilogram of body weight per day to help older adults maintain and regain lean body mass and function, ≥ 1.2 g/kg body weight/day is recommended for older adults who are exercising, and 1.2–1.5 g/kg body weight/day is recommended for those with chronic disease [199]. Increased protein in those with baseline CKD remains unanswered [200]. But plant-based proteins are safer in those with baseline chronic renal impairment because of their lower bioavailability of phosphate and lower nonvolatile acid loads [201]. Therefore, recommendations are for close monitoring of CKD patients and balancing risks versus benefits in each case.

The effects of nutritional supplements in hip fracture patients have been evaluated in 2 meta-analyses including different numbers of studies [202, 203]. Medical complications, wound, respiratory, and urinary infections were significantly reduced [202] as well as overall unfavorable outcomes including both deaths and medical complications [203].

The ESPEN guidelines on clinical nutrition and hydration in geriatrics [204] recommend routine screening for malnutrition in order to identify an existing risk early; oral nutrition including food modification and oral nutritional supplements, or enteral nutrition where indicated; to avoid dietary restrictions; to consider all to be at risk of low-intake dehydration and encourage adequate fluid intake (as measured by osmolality, 300 mOsm/kg) [204]. They do have recommendations specifically for post hip fracture and orthopedic surgery older adults with hip fracture which state, with good evidence, the benefit of oral nutritional supplements post-operatively to improve dietary intake and reduce risk of complications, regardless of the baseline nutritional state. Nutrition and hydration interventions have also been shown to be efficacious in the prevention of delirium.

Recommendations: objective assessment of nutritional status (e.g., SGA) and serum albumin; avoid unnecessarily prolonged nil-by-mouth fasting and follow evidence-based guidelines on fasting and clear-fluid restrictions; early post-operative nutritional supplementation including adequate calories and protein 1–1.5 g/kg/day; adequate hydration (maintaining serum osmolality < 300 mOsm/kg).

Patient perspective

Patients emphasize the need to provide easily accessible clear direction to physicians so that drugs associated with delirium and falls are avoided. Early surgical intervention should be prioritized with attention given to adequate pain control. Evaluation of skeletal health is seen as critical with identification of underlying metabolic bone disorders which may have contributed to the impaired bone strength and fragility fracture.

Summary

Currently, post hip fracture care in Canada is sub-optimal and a multi-disciplinary approach aimed at optimizing medical and surgical care as well as rehabilitation post hip fracture is expected to improve health care outcomes. It is also anticipated that this will lower morbidity and mortality following a hip fracture. Implementation of strategies designed to achieve the key quality indicators require further education and awareness as well as formal evaluation.

Key messages

Preoperative care:

  1. 1.

    Multi-disciplinary care in the preoperative setting allows for rapid medical optimization and potentially reduces delays to surgery with prompt management of co-morbidities.

  2. 2.

    For surgical candidates, hip fracture patients should undergo surgical intervention within 24 h of diagnosis, and those on pre-injury oral anti-coagulation should undergo surgical treatment within 48 h of diagnosis. If surgery is delayed for more than 12 h from the time of hospital admission, it is recommended that thromboprophylaxis be started pre-operatively.

  3. 3.

    Regional nerve blocks are a safe adjunctive method to improve pain management in patients with hip fractures, leading to decreased opioid use, reduced rate and length of delirium, and decreased length of hospital stay.

Surgical care:

  1. 4.

    Sliding hip screws and cephalomedullary nails are both acceptable treatment options for stable intertrochanteric hip fractures, with sliding hip screws being the more cost-effective implant of choice.

  2. 5.

    Patients with a sub-trochanteric or reverse obliquity intertrochanteric fracture should be treated surgically with intramedullary nails to reduce complication rates. Patients with unstable intertrochanteric fractures who are higher demand (living independently and/or ambulating without assistive devices) should be treated surgically with intramedullary nails.

  3. 6.

    Arthroplasty is preferable over fixation for displaced femoral neck fractures in the elderly population because of the high incidence of avascular, nonunion necrosis, and femoral neck shortening, resulting in the need for revision surgery and/or limitations in function.

  4. 7.

    Whenever possible, hip fracture patients should be allowed to bear weight as tolerated after surgery in order to facilitate early mobilization.

Postoperative care:

  1. 8.

    Individuals who are over 75 years, those with dementia, vision impairment, and dehydration are at high risk for delirium—avoid physical restraints and psychoactive drugs.

  2. 9.

    Inter-disciplinary orthogeriatric care is recommended to optimize patient outcomes and care.

  3. 10.

    Rehabilitation is necessary acutely, post-acutely, and in the community after discharge. It should include progressive resistance, weight-bearing impact, and functional balance training.

  4. 11.

    A low trauma hip fracture denotes a high fracture risk regardless of bone mineral density (BMD) and requires aggressive medical therapy.

  5. 12.

    Home assessment post-discharge by an occupational/physical therapist and exercise should be focused on balance and resistance training.

  6. 13.

    Avoid prolonged nil-by-mouth fasting (no food or fluids orally). Early post-operative nutritional supplements reduce mortality and morbidity (medical complications, wound, respiratory, and urinary infections), especially when combined with rehabilitation.

    In patients undergoing hip fracture surgery, pharmacologic thromboprophylaxis is recommended for a minimum of 10 days and up to 35 days post-operatively.

Osteoporosis management and fracture prevention:

  1. 14.

    It is important to initiate pharmacologic therapy for osteoporosis to prevent fractures both in acute and long-term care as well as post-discharge.

  2. 15.

    Hip and vertebral fractures confer a very high fracture risk and require pharmacologic therapy, preferably with an anabolic agent followed by anti-resorptive therapy.