what are the important properties to consider for when picking a material for this femoral head?

• Journal List
• Eur J Med Res
• v.26; 2021
• PMC8335457

Eur J Med Res. 2021; 26: 86.

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

H. Fischer

ⁱDepartment of Oral and Maxillofacial Surgery, Charité–Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany

²Julius Wolff Institute, Berlin Institute of Wellness at Charité– Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Germany

T. Maleitzke

ⁱⁱJulius Wolff Institute, Berlin Constitute of Health at Charité– Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Frg

³Center for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Augustenburger Platz i, 13353 Berlin, Germany

⁴BIH Biomedical Innovation University, BIH Charité Clinician Scientist Program, Berlin Institute of Wellness at Charité–Universitätsmedizin Berlin, Charitéplatz 1, 10117 Berlin, Germany

C. Eder

^threeCenter for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Augustenburger Platz ane, 13353 Berlin, Germany

Southward. Ahmad

³Center for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Augustenburger Platz i, 13353 Berlin, Germany

U. Stöckle

^threeMiddle for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Augustenburger Platz ane, 13353 Berlin, Germany

One thousand. F. Braun

ⁱⁱⁱCenter for Musculoskeletal Surgery, Charité–Universitätsmedizin Berlin, Augustenburger Platz 1, 13353 Berlin, Frg

^vKlinik Und Poliklinik Für Unfallchirurgie, Klinikum Rechts Der Isar der TU München, Ismaninger Street 22, 81675 München, Germany

Received 2021 Mar 10; Accepted 2021 Jul nineteen.

Abstract

As one of the leading causes of elderly patients' hospitalisation, proximal femur fractures (PFFs) will present an increasing socioeconomic problem in the near futurity. This is a consequence of the demographic change that is expressed by the increasing proportion of elderly people in gild. Peri-operative management must be handled attentively to avoid complications and decrease mortality rates. To deal with the infrequent needs of the elderly, the evolution of orthogeriatric centres to back up orthogeriatric co-management is mandatory. Adequate pain medication, balanced fluid management, delirium prevention and the operative handling choice based on comorbidities, individual demands and biological rather than chronological age, all deserve particular attending to meliorate 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 onetime patients and displaced fractures. In bedridden patients, osteosynthesis might be an pick to establish transferability from bed to chair and the restroom. Postoperatively, the patients do good from early on 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.

Keywords: Garden nomenclature, Frailty, Surgical direction, Delirium prevention

Introduction

The majority of proximal femur fractures (PFFs) affects the elderly every bit more than three quarters of PFFs occur in patients over the age of 75 in Germany [1]. While around 1.iii million hip fractures were reported globally in 1990 [two], the number is estimated to range between 7.3 and 21.3 meg by 2050 [2].

For elderly patients, a PFF often represents a life-irresolute event, stripping patients of their already potentially impaired self-sustainability. Within 1 year after a hip fracture, simply xl–sixty% of elderly patients regain their pre-fracture level of mobility and ability to perform daily living activities [3].

Comorbidities are high in patients with PFFs, with 50% of PFFs occurring in people with pre-existing nursing care needs [4]. A geriatric patient is divers as a patient above the age of 80 or a patient with typical geriatric multimorbidity in combination with an age of > 70 years [v].

Around 25–50% of people anile 85 and older are considered to be delicate [6], significant iii or more than of the post-obit factors apply according to the definition of Fried et al.:

1. Unintentional weight loss;

2. Low grip strength;

3. Cocky-written report of exhaustion;

4. Deadening walking speed;

5. Low physical activity level [7].

Frailty describes a state of increased vulnerability to stressors, mostly due to a lack of resource [vi]. Fifty-fifty a small event (east.g., minor infections like a urinary tract infection or minor surgery) may result in a hit and disproportional deterioration of the individual's wellness status, due to the low resolution of homeostasis [six].

PFFs in frail patients are associated with a pronounced chance of cardiovascular, pulmonary, thrombotic, infectious, or bleeding complications [8] with further surgical delay increasing the take chances of bloodshed [9].

Ideally, operative treatment should take place within the first 24 h [10]. Surgery subsequently more 24 h raises the hazard for peri-operative complications such equally pulmonary embolism, pneumonia, deep vein thrombosis, urinary tract infections and pressure level ulcers. If surgery is delayed for more than 48 h, the mortality risk rises significantly. Patients operated within 48 h show a xx% lower take chances of dying within the next twelvemonth, and especially patients with comorbidities benefit significantly from surgery within 24 h [9].

There is evidence for reduced in-hospital complication rates, shorter hospital stays and fewer readmissions, too as lower inability and in-hospital bloodshed when implementing interdisciplinary geriatric care in trauma management [11].

The aim of this article is to provide a comprehensive review of crucial aspects in the treatment of PFFs in elderly patients and to bespeak out how to avoid complications in the peri-operative and postoperative periods.

Delay of operative treatment increases complications and mortality

Anatomy of the femoral neck

In the hip joint, the almost spherical femoral caput articulates with the hollow sphere of the facies lunata of the acetabulum. The articular cavity's surface takes up but 50% of the femoral head'due south surface [12]. The femoral neck connects the femoral head with the shaft, forming an angle of approximately 127° [13], while its radiological outline shows compressive and tensile trabeculae, that characteristically form the ward triangle as a zone of low trabecular density [12]. For vertical reinforcement of the trabecular bone, the calcar femorale provides an essential contributor to stability [xiv]. Thus, a correct reduction of the calcar femorale is a key factor in the operative treatment of PFFs.

With age, the trabecular structure degenerates [15] and, concomitantly, reinforcements like the calcar femorale lose structural integrity. It was hypothesized that the neck-shaft-angle increases with historic period [16], notwithstanding data on more than 8000 cervix-shaft-angles showed no meaning differences betwixt the age groups [17, 13].

Low energy falls, which become more frequent with historic period, are the leading cause of hip fractures. During such falls, compressive stress is applied to the femoral cervix'south superolateral cortex, existence considered the main machinery of injury of PFFs [18]. Osteoporosis, loss of dumbo trabecular networks, an increased bore and a thinner cortex of the femoral neck enhance buckling susceptibility [10, 19].

Bone healing is dependent on the femoral head'southward vascular supply which might hands be disrupted by fracture dislocation or increased intracapsular pressure, and cellular coverage of the femoral head, which deteriorates with age, thus limiting osteoprogenitor cell influx post-obit a femoral neck fracture. In adults, only twenty% of the femoral neck'southward surface is covered past cellular periosteum [twenty]. The femoral head receives its primary blood supply from the superior, inductive, and inferior retinacular arteries arising from the deep branch of the medial circumflex femoral avenue every bit well every bit the round ligament arteries [21] (Fig.1).

Bony and vascular anatomy of the proximal femur

(adjusted from [8])

The development of a posttraumatic femoral head necrosis is highly correlated with disrupted retinacular arteries, which pose the principal claret supply for the femoral head [22]. In Garden Blazon 4 fractures, all retinacular arteries appear disrupted as a result of gross dislocation [21]. The retinacula of Weitbrecht are intraarticular synovial plicae protecting the retinacular arteries within [23]. Amidst the anatomical variances, the medial retinaculum is constantly present [23], extending from the base of operations of the lesser trochanter to the edge of the acetabular cartilage (Fig.2) [23].

The poor vascular supply and a limited regenerative potential of the femur neck'southward periosteum may cause impaired bone regeneration

The Garden classification of non-displaced (Garden type I and Two) and displaced (Garden type 3 and Four) femoral cervix fractures. Incomplete or impacted fractures, including a valgus dislocation, are classified every bit type I. If neither impaction nor dislocation occurs, the fracture is classified as type II. Type 3 refers to a dislocated fracture with existing bony contact in the calcar femoris region, including the retinacula of Weitbrecht being yet intact [77]. Type IV indicates a complete disassociation of the femoral head from capsule and vessels. A higher dislocation grade is associated with a higher probability of disruption of the femoral cervix's blood supply

Classification of femoral neck fractures

PFFs are divided into intracapsular and extracapsular femoral neck fractures, including intertrochanteric and subtrochanteric fractures (Fig.1). Depending on their location, femoral neck fractures are identified as sub-capital, mid-cervical, and basicervical fractures. Peculiarly in the elderly, the mid-cervical femoral fracture is the most common by far, with a frequency of over 86% [24].

At that place are three common classifications for femoral neck fractures: The Garden, the Pauwels and the AO classification. First published by R.S. Garden in 1961, the Garden nomenclature is the one most widely used. Femur cervix fractures are classified by the fracture displacement based on an ap radiogram into non-displaced (Garden type I and Ii) and displaced fractures (Garden blazon III and Four). Garden type I describes an incomplete or impacted fracture, Garden type Ii a complete fracture without displacement, Garden blazon III a consummate fracture with partial displacement, and Garden type IV a complete fracture with full displacement [25] (Fig.2).

The Garden nomenclature has only a fair inter-observer reliability when all four types are assessed, merely a moderate to substantial 1 if fractures are but classified as undisplaced or displaced [26]. Fracture displacement correlates with interruption of the vascular supply, as described above; therefore, Garden classification relates to the risk of femoral head necrosis. Due to the disrupted blood supply to the femoral head [21], Garden type Iv fractures are not suitable for osteosynthesis. However, if the fracture line is located at the very basis of the femoral cervix, it decreases the adventure of femoral head necrosis regardless of dislocation, considering the fracture might be lateral to the vascular supply.

The Pauwels classification concentrates on the biomechanical forces adding pressure on the fracture line. Type I describes a dominating pinch force, with a fracture line of upwardly to xxx° to the horizontal plane. In type II, shearing stress is present; the fracture line lies between 30° and 50° [27]. Shearing stress has a possible negative impact on os healing [28]. In the tertiary type with a fracture line above l°, shearing stress is predominant, leading to fracture displacement [27]. In the inter-observer reliability, the Pauwels classification shows just weak reliability and reproducibility [26].

Equally the most circuitous classification, the AO classification combines the fracture level, the degree of displacement, and the angle of the fracture line (Fig.3). Because of its complexity, the AO nomenclature serves mainly for academic purposes.

The Garden classification describes the risk of necrosis of the femoral head

AO classification of femoral neck fractures. AO 31-B1 includes impacted fractures. With decreasing impaction from grade i to form iii, B2 consists of a larger femoral head fragment with a fracture line increasing in gradient from grade 1 to class 3, and B3 describes a small-scale head fragment with increasing dislocation and instability with increasing class

Peri-operative direction

Frailty fractures are classified as fractures in the absence of adequate trauma or a autumn from standing meridian or less with hip fractures stand for the most common frailty fracture types [29].

A comprehensive geriatric cess helps to identify treatable geriatric conditions to forbid complications in elderly patients. Evidence suggests that comprehensive geriatric cess improves the outcome of people above the age of 65 with a hip fracture [30]. This can be done afterward surgery, since older people receiving comprehensive geriatric cess are less likely to die and more than likely to render to their previous environs.

For the radiological confirmation of the diagnosis of a PFF, an ap Ten-ray is sufficient. A second aeroplane X-ray in most cases does not contain additional information only is oftentimes very painful for the patient. If available, a planning body for preoperative determination of the prosthesis size should be added if a prosthesis is needed. If an X-ray cannot ostend the diagnosis, but a hip fracture is highly suspected, information technology is recommended to perform a computed tomography (CT).

Sufficient pain management is mandatory and its importance needs to be expressed. Not simply is it humane, merely information technology is also an essential factor in the prevention of delirium [31]. In the peri-operative pain management of elderly patients, NSAIDs are not recommended. However, it is advised to offer not-NSAIDs such as paracetamol every 6 h unless contraindicated [32]. If no sufficient pain control is accomplished, i.v. or oral opioids tin can be titrated according to the patient's constitution accompanied past a routine constipation prophylaxis [10].

If non-NSAIDs and opioids are non sufficient, femoral nerve blocks may be considered [32]. Guay et al. stated in a Cochrane review that there is moderate quality bear witness for reducing pneumonia hazard, decreased fourth dimension to starting time mobilisation, and cost reduction in pain medication after single-shot blocks [33]. Loftier-quality testify suggests that a regional blockade reduces hurting on movement within 30 min after cake placement [33].

Routine laboratory tests should be performed on all patients, including consummate blood count, inflammation markers, INR, partial thromboplastin fourth dimension, and a basic metabolic contour [10]. Every bit hip fracture patients tend to be dehydrated, i.v. hydration might exist needed with the amount depending on clinical judgment. A flow charge per unit of 100–200 ml/h for isotonic crystalloids is estimated to be prophylactic [10]. Volume status needs to be monitored advisedly, still, as many elderly patients take cardiac diseases, making them predisposed to heart failure triggered by volume overload [10].

With historic period, the incidence of urinary tract infections increases [34]. In addition to symptomatic urinary tract infections, asymptomatic bacteriuria is common amongst the elderly. It is estimated that asymptomatic bacteriuria is present in effectually xx% of salubrious women over the age of 80 years [35].

The link between hardware infection and asymptomatic bacteriuria has been investigated, especially in the context of arthroplasty. Even though at that place is a correlation between an increased occurrence of prosthetic joint, superficial wound infections and the presence of asymptomatic bacteriuria, Zhang et al. showed in a systematic review that the incidence of postoperative infectious complications did not decrease when the asymptomatic bacteriuria is treated before arthroplasty [35]. In hip fracture patients, screening for urinary tract infections is recommended, although those should only be treated if symptomatic [10].

Proper pain direction plays a crucial role in preventing complications

Prevention of bleeding complications

Approximately 40% of elderly patients presenting with hip fracture are under anticoagulant or antiplatelet therapy [36]. Managing anticoagulants and antiplatelets requires close coordination with anaesthesiology. For patients receiving antiplatelet therapy, it is recommended to go along with surgery directly rather than delaying surgery to restore platelet part [37]. In the instance of dual antiplatelet therapy, spinal anaesthesia is contraindicated. The utilise of clopidogrel and peculiarly the combination of clopidogrel and aspirin might lead to increased peri-operative blood loss [38]. Nevertheless, information technology has also been shown that those patients can nevertheless safely undergo hip fracture surgery without delay [38].

INR values beneath 1.5 are desired in patients receiving vitamin K antagonists, including warfarin and phenprocoumon. This may be accomplished by either waiting, i.v. vitamin K substitution or the administration of fresh frozen plasma before surgery [x]. A bridging strategy based on either treatment-dose subcutaneous low-molecular-weight heparin or intravenous unfractionated heparin should exist considered for patients with mechanical valves, atrial fibrillation with recent history of stroke, deep vein thrombosis, or pulmonary embolism [39].

For the anti-Xa-agents (Apixaban, Edoxaban, Rivaroxaban), a plasma drug level of nether l pg/ml is deemed safe for surgery [40]. If there is no possibility of measuring the plasma level, a gap of 24 h between the last dose and surgery should exist considered.

For patients anti-coagulated with Dabigratran, in that location is a gamble to determine the plasma level and use the directly anti-agent Idarucizumab for neutralisation [41]. The elimination of directly oral anticoagulants can be compromised, depending on renal and hepatic part (Table ​ 1) [39].

Tabular array 1

Anticoagulants and antiplatelets summarised [39]

Drug	Emptying half-life	Management	Adequate to continue with spinal
Aspirin	Irreversible effect on platelets	Continue with surgery	Go on
Clopidogrel	Irreversible consequence on platelets	Keep with surgery, monitor for claret loss, consider platelet transfusion if concerns regarding bleeding	If anti-platelet monotherapy. General anesthesia if dual therapy
Ticagrelor	viii–12 h	Proceed with surgery with full general anaesthetic. Monitor for blood loss. Consider platelet transfusion if concerns regarding bleeding	5 days or mail service platelet transfusion at least 6 h post last dose
Warfarin	four–5 days	5 mg vitamin K i.v. and repeat INR after 4–six h. This can be repeated or consider Beriplex for immediate reversal	If INR < i.five
Apixaban	12 h	Surgery and anesthesia 24h later on last dose if renal function is normal	2 half-lives/24 h after final dose if renal function is normal
Dabigatran	12–24 h	Surgery and anesthesia if thrombin time normal or idarucizumab for immediate reversal if thrombin time prolonged	If thrombin time normal or 30 min following idarucizumab infusion
Rivaroxaban	7–x h	Surgery and anesthesia 24 h afterwards last dose if renal part normal	2 half-lives/24 h after terminal dose if renal function normal
Low-molecular weight heparin sub-cutaneous prophylactic dose	iii–7 h	Final dose 12 h pre-op	12 h
Low-molecular weight heparin sub-cutaneous handling dose	3–vii h	Last dose 12–24 h pre-op. Monitor for blood loss	24 h
Unfractionated i.v. heparin	1–2 h	Stop i.v. heparin 2–4 h pre-op	4 h

Systemic administration of tranexamic acid can reduce blood loss and transfusion rates and tin be used for control of bleeding in anti-coagulated patients. Yet, a contempo meta-assay showed that there is yet a lack of testify apropos the optimal regimen, timing, and dosage of tranexamic acid [42].

Preventing delirium

Hypoactive delirium is present more often and frequently remains unrecognised in the elderly [43, 44]. Information technology is associated with a higher charge per unit of complications and mortality, so prevention plays a vital function [45].

For the screening of delirium in hospitalised older people, the 4AT is a sensitive and specific tool which is validated for hip fractures [46]. To determine mental condition changes, it is important to institute a baseline status, for case using routine screening at admission.

For delirium prevention, multicomponent non-pharmacological approaches have been proven to be a practiced strategy [44]. Those approaches include early mobilisation, acceptable hydration, sleep enhancement, orientation in time and place, hearing and vision optimisation also as therapeutic activities such as reminiscence [44]. To additionally prevent delirium, a one face up policy for visitors tin be established alongside stress reduction and daytime activity to allow sleep at dark in support of a normal night–24-hour interval rhythm.

If delirium occurs, it is important to search for a possible reason in need of handling, such as electrolyte derangements, metabolic derangements, infection, organ failure, pain, or anticholinergic load. With the help of an anticholinergic burden scale, due east.thou., the anticholinergic drug calibration, inappropriate medication in elderly patients can be identified [47]. Using drugs with anticholinergic properties in the elderly increases the risk of delirium, cognitive impairment, falls, fractures, and mortality [48]. Nosotros recommend evaluating the indication and modalities of drug therapy for delirium together with a geriatrician (Tabular array ​ 2).

Table 2

Acceptable reasons for delaying surgery in hip fracture patients co-ordinate to the guideline for the management of hip fractures 2020 past the Clan of Anaesthetists [39, 49]

Acceptable	Unacceptable
Haemoglobin concentration < 8 yard dL	Lack of facilities or theatre space
Plasma sodium concentration < 120 or > 150 mmol/l	Awaiting echocardiography
Potassium concentration < 2.viii or > 6.0 mmol/50	Unavailable surgical expertise
Uncontrolled diabetes	Minor electrolyte abnormalities
Uncontrolled or acute onset left ventricular failure
Correctable cardiac arrhythmia with a ventricular charge per unit > 120 min
Chest infection with sepsis
Reversible coagulopathy

Operative management

The goal for the treatment should ever exist the render to the previous level of activity and full weight bearing.

Intertrochanteric and subtrochanteric fractures

Both in intertrochanteric and subtrochanteric fractures, the treatment of choice is intramedullary nailing as information technology decreases soft tissue damage and permits early weight bearing. For intertrochanteric fractures, the option of implant depends on the stability of the fracture blueprint defined past the lateral cortical wall [50]. Extramedullary devices like the sliding hip screw can be chosen if the lateral cortical wall is intact [50], making a thorough evaluation of the fracture design essential when an extramedullary device is considered.

In comparison to extramedullary devices such every bit the sliding hip screw, an intramedullary device is located closer to the vector of strength line, equalising a shorter lever arm compared to extramedullary devices, thus giving intramedullary nails a biomechanical advantage [fifty].

Cheng and Sheng compared 8 treatment options for intertrochanteric fractures [dynamic hip screw, pinch hip, percutaneous compression plate, Medoff sliding plate, less invasive stabilisation system, gamma blast, proximal femoral blast, and proximal femoral nail anti-rotating (PFNA)] and identified PFNA as the preferable surgical method with fewer claret loss and high functional outcomes, according to the Harris hip score [51]. When using intramedullary nails, the use of a helical bract in comparison to a lag screw is associated with a higher charge per unit of collapse of the neck-shaft bending and the concomitant dislocation of the screw (cut-out) in the femoral head [50].

Subtrochanteric fractures are a less common type of hip fracture. In subtrochanteric fractures, intramedullary nailing (long nail) is considered the gold standard, because it decreases operation time, fixation failure and length of infirmary stay in comparison to extramedullary devices [52].

To reduce the hazard of cut-out in screws and blades in osteoporotic os, cement augmentation can be used in osteosynthesis, although it may risk thermal harm, osteonecrosis and cement leaking to the fracture region. In particular for PFNA, significantly improved rotational stability and pull-out resistance were shown biomechanically [53]. Information technology was clearly demonstrated that cement augmentation enhances implant anchorage in osteoporotic bone [53]. A systematic review by Namdari et al. of the clinical results of cement augmentation indicated that the master benefits lie in improved radiographic parameters and lower complication rates when using cement augmentation. Still, larger systematic studies are needed to further investigate the extent of the do good [54].

Femoral neck fractures

Femoral cervix fractures can either be treated with osteosynthesis, total hip arthroplasty or hemiarthroplasty. In patients with more one comorbidity above the age of 70, at that place is an 83% risk of secondary fracture dislocations when treated conservatively [55], making surgery the handling of option for elderly patients. When choosing the implant, two main aspects demand to be kept in mind: older patients are less likely to follow weight-bearing restrictions [56], while, on the other hand, the indication for osteosynthesis needs to exist advisedly considered. Due to biomechanical aspects, according to Pauwels classification, any femoral neck fracture classified as type I or Two is an indication for internal fixation. Due to the blood supply of the femoral head, femoral neck fractures classified equally Garden type III and 4 are, in nearly cases, not suitable for osteosynthesis. Confused femoral neck fractures are related to a high incidence of interrupted blood supply of the femoral caput (as described in a higher place), and therefore, predisposed for fixation failure. Existing osteoporosis and age-related changes in os structure might pb to an increased gamble of non-unions in elderly patients [57]. Osteosynthesis is, therefore, suggested in either biologically young patients with non-dislocated fractures or every bit a salvage choice, if the patient is bed-bound and operative therapy is only indicated for pain management.

Even though this review focuses on frail elderly patients, betwixt 50 and 75% of elderly patients are not fragile. Information technology needs mentioning that in healthy and active patients, biological age should determine the selection of implant. The high functional requirements and lower biological age, in comparison to the chronological age of the so-called "golden-ager", accept led to a image-shift towards total arthroplasty instead of hemiarthroplasty in good for you elderly patients [58].

In that location is good testify that in hip arthroplasties, cemented implants pb to less postoperative hurting and thereby ameliorate mobility [59]. A cemented femoral stem leads to a meliorate fixation in osteoporotic bone [60]. Because no cortical printing-fit needs to be achieved, only a reduced stem preparation is necessary, leaving a thicker cortical wall. This results in a potentially reduced periprosthetic fracture hazard and lower loosening rates. In a German registry report, Konow et al. showed a two times higher risk of a periprosthetic femoral fracture in uncemented versus in cemented stems with a significantly increased risk for patients to a higher place the age of 60 when uncemented stems were used [61]. Therefore, a standard process should include a cemented shaft and, depending on the patient´s activity, a hemiarthroplasty or a total arthroplasty should be chosen. In active patients, a total arthroplasty is the implant of selection due to a ameliorate functionality and lower long-term reoperation rate in comparing to hemiarthroplasty. Nevertheless, total hip arthroplasty might be linked to a higher rate of dislocation [60]. Procedure-related factors such as the surgical approach, the positioning of the components, the soft tissue tension, the surgeon´due south experience, just as well implant-related factors play a major office in the gamble for dislocation post-obit total hip arthroplasty [62]. Sarcopenia, the loss of proprioception, and an increased risk of falls are described equally typical take chances factors in the elderly [62]. For patients who are not able to follow precautions to lower the take a chance of dislocation, hemiarthroplasty might exist the better option. For those with an elevated risk contour and suitable bone quality, a non-cemented shaft should be considered to lower the adventure of bone cement implantation syndrome during the operation. Risk factors for suffering from bone cement implantation syndrome include impaired cardiopulmonary function, grade III and IV ASA levels, pre-existing pulmonary hypertension, poor pre-existing physical reserve and bony metastases [63].

The Dorr type and the cortical thickness are key factors in estimating the chance of an intraoperative fracture when placing the prosthesis and can thus assistance guiding the selection of the fixation method. The Dorr description of the proximal femoral morphology correlates with a low cortical thickness alphabetize [64]. In comparison to blazon A, Dorr blazon B and C bespeak a college risk of intraoperative fracture [64].

The advantages of hemiarthroplasty are a shorter operation time and a lower incidence of dislocation [58]. The Health-Trial compared patients with displaced femoral cervix fractures undergoing either total hip arthroplasty or hemiarthroplasty in a multicentre randomised controlled trial. No significant difference in the incidence of secondary procedures could be found, while functional endpoints co-ordinate to the WOMAC score favoured total hip arthroplasty over hemiarthroplasty [65]. A slightly higher incidence of serious adverse effects could be seen in the grouping that underwent total hip replacement [65]. In biologically immature patients, utilize of a hemiarthroplasty is linked to high rates of acetabular erosion and the need for conversion to full hip arthroplasty due to secondary osteoarthritis [66].

Accounting for merely 1.eight% of all PFFs, basicervical femoral neck fractures are quite uncommon [67]. The treatment options include both a cephalomedullary nail, a dynamic hip screw and cancellous screws. When the latter were used, a college failure rate was observed [67]. Reviewing treatments and failures of basicervical femoral cervix fractures, Yoo et al. stated that farther enquiry with a homogenous definition on treatment results or fixation failure are needed to perform a meta-analysis for clear recommendations [67].

The surgical handling should focus on the biological and not on the chronological age (Figs. ​ 4 and ​ v) [30].

Option of the implant in the operative treatment for femoral neck fractures in the elderly

Unlike hip fractures and treatment options. A Displaced fracture at the very footing of the femoral neck in a 71-year-old male (cemented total hip arthroplasty). B Non-displaced femoral cervix fracture in a 78-year-old female person patient, treated with a total hip replacement. C Displaced femoral neck fracture in an 85-year-old female person, treated with cemented hemiarthroplasty. Options in osteosynthesis for femoral neck fractures (D) and intertrochanteric fractures (E)

Postoperatively

Patients benefit from early mobilisation, since the process reduces complication rates, and minimises the risk of pneumonia, thromboembolism, pressure ulcers, and delirium [68].

Patients with ane fracture are at an increased risk of suffering some other [69]. Therefore, it is essential to investigate the reasons for falling to prevent further fractures. Amongst the near common reasons are syncope, Parkinson'south disease and polypharmacy. Polypharmacy in general and drugs related to an increased take a chance of falling can present a preventable reason for fractures in the elderly [70].

Standard postoperative care should include mechanical thromboembolism prophylaxis such every bit early mobilisation, regular physiotherapy and pharmacological prophylaxis. According to Flevas et al., the utilise of low-molecular-weight heparin is preferable and should be connected for 28–35 days co-ordinate to product characteristics (Table ​ 3) [71].

Table 3

The big five in direction of geriatric patients with femoral cervix fractures (compiled from the AO-guidelines)

The big five in management of a geriatric patient with a femoral fracture to avoid the most common complications
Time to surgery	The less time passes from admission to surgery, the fewer complications
Pain management	Pain management can be accomplished by a stable fixation, paracetamol, oral or parenteral opioids and regional nerve blockades
Delirium prevention	Prevention is the best strategy apropos delirium. Thorough fluid management (pre and postoperatively), aid with orientation, avoiding of tethers such as tubes (urine catheter removal on the second twenty-four hour period postoperatively if possible), help with orientation like for example hearing aids, proper hurting management and hydration direction contribute to lower the incidences of delirium
Early on mobilisation	Physiotherapy and respiratory therapy prevent pneumonia and thrombotic events. Anticoagulation is needed for 28–35 days
Patient care	A proper postoperative bowel regimen prevents obstipation, pressure soars can exist avoided by early surgery and frequent repositioning

The affect of COVID-19 on hip fractures in the elderly

While the total number of fracture patients was significantly reduced during the COVID-19 pandemic globally, the number of fragility fractures remained stable [72].

Concerning COVID-19, most hip fracture patients comprise a high-risk population. Therefore, in COVID-xix-negative patients, preventing COVID-nineteen infections in hospitals is of utter importance.

A systematic review and meta-analysis from Lim and Pranata reported a seven-fold increased risk of mortality for COVID-xix-positive patients with hip fractures and, correspondingly, the take chances of postoperative complications increased [73]. COVID-19-associated changes inside the infirmary led to additional challenges in medical care for elderly people. For example, waiting for COVID-nineteen tests, limited operating capacity, and the shortage of infirmary staff in particular all affect both COVID-19-positive and COVID-19-negative patients. A Spanish multicentre study concerning the treatment of PFFs during the COVID-19 outbreak showed a hateful delay of 2.iv days to surgery with a minimum of 0 days and a maximum of xiii days [74]. As well, data from Argentine republic confirmed a significantly prolonged time from admission to surgery during the COVID-19 pandemic in COVID-19-negative patients [75].

Cheung and Forsh stated that asymptomatic and mildly symptomatic COVID-19-positive patients with PFF might crave preoperative medical optimisation, only that they can safely undergo early on surgery. Both asymptomatic and mildly symptomatic COVID-19-positive patients might accept an increased oxygen demand postoperatively [76].

Conclusion

Providing medical care to elderly patients with hip fractures remains a bully challenge. Interdisciplinary orthogeriatric management reduces the length of hospital stay, the number of complications and mortality.

The about critical peri-operative management aspects include proper pain management, early mobilisation, a thorough fluid management, the prevention of delirium and the pick of operative treatment depending on comorbidities, demands, and biological rather than chronological age. For elderly patients, directly weight bearing and as little delay as possible in operative treatment are of groovy importance. While inter- or subtrochanteric fracture requires intramedullary nailing, the handling options for femoral neck fractures include osteosynthesis, total hip arthroplasty and hemiarthroplasty. The Garden classification and the patient'southward activeness level may allow osteosynthesis treatment for a biologically young patient with a non-dislocated fracture showing no signs of osteoarthritis. Full hip arthroplasty is recommended for agile patients with dislocated fractures, and hemiarthroplasty for frail patients.

The COVID-xix pandemic brings additional obstacles in medical care for elderly hip fracture patients, leading to a delay in surgery, corresponding to a higher complexity charge per unit.

Acknowledgements

Not applicative.

Authors' contributions

HF: writing—original draft; TM: writing—review and editing; CE: writing—review and editing; SA: writing—review and editing; US: conceptualization, supervision, writing—review and editing; KFB: conceptualization, supervision, writing—review and editing. All authors read and approved the final manuscript.

Funding

Open up Access funding enabled and organized by Projekt Bargain.

Availability of information and materials

Not applicative.

Declarations

Ethics approval and consent to participate

Non applicable.

Consent for publication

Not applicative.

Competing interests

Non applicative.

Footnotes

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