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

Abstract

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

Keywords: Delirium prevention; Frailty; Garden classification; Surgical management.

Fig. 1

Bony and vascular anatomy of the proximal femur (adapted from [8])

Fig. 2

The Garden classification of non-displaced (Garden type I and II) and displaced (Garden type III and IV) femoral neck fractures. Incomplete or impacted fractures, including a valgus dislocation, are classified as type I. If neither impaction nor dislocation occurs, the fracture is classified as type II. Type III refers to a dislocated fracture with existing bony contact in the calcar femoris region, including the retinacula of Weitbrecht being still 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 neck’s blood supply

Fig. 3

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

Fig. 4

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

Fig. 5

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

Fig. 5

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