Anabolic-steroid therapy after geriatric proximal femur fracture: a level I evidence systematic review and meta-analysis of bone density, functional recovery, and safety

Abstract

Older adults often face rapid loss of bone and muscle after a hip fracture, which can hinder recovery and independence. Anabolic steroid therapy increased bone mineral density and enhanced functional performance without notable side effects, showing potential as an adjunct to rehabilitation to support musculoskeletal recovery in postoperative elderly patients.

Introduction: Proximal femur ("hip") fractures are associated with high complication rates and challenging rehabilitation courses in the geriatric population. These patients can develop rapid sarcopenia and bone loss. Anabolic agents such as androgenic anabolic steroids (AAS) might counteract this catabolic state, but their efficacy remains uncertain. The purpose of this systematic review and meta-analysis was to evaluate whether postoperative AAS improves the outcomes in geriatric hip fractures.

Methods: A systematic search of MEDLINE, Embase, CENTRAL, Web of Science, Google Scholar, ClinicalTrials.gov, and Wiley (inception to June 1, 2025) identified randomized controlled trials (RCTs) comparing an AAS with placebo/standard care after hip fracture. After record screening and data extraction, the data from studies evaluating AAS were analyzed using fixed-effect modeling. In addition, studies were assessed descriptively. The certainty of evidence was graded using the GRADE system.

Results: Nine RCTs (466 total participants; 214 received anabolic agents) met the inclusion criteria. AAS therapy significantly increased hip bone mineral density (BMD) z-score (d = 1.29, 95% CI 1.04-1.55; moderate certainty). The Harris Hip Score (HHS) (d = 2.85, 95% CI 2.52-3.17) and Katz Activities of Daily Living (KADL) index (d = 0.95, 95% CI 0.71-1.19) also improved with anabolic therapy. HHS and KADL index findings had very low certainty due to a high risk of bias and imprecision. No significant gain was observed in operative-leg strength versus the contralateral leg. Thirteen mild, transient adverse events (liver-enzyme elevation, sweating, hirsutism) occurred among AAS patients (13/214, 6.1%). No serious androgen-related complications were reported.

Conclusion: Low-dose AAS after hip fracture surgery increased BMD and improved patient-reported function without significant safety concerns. Still, evidence of functional benefits is limited by small, often unblinded trials. Larger, multicenter RCTs using standardized treatment protocols and functional endpoints will help better determine the benefits of AAS after proximal femur fractures.

Level of evidence: Level I, Systematic Review and Meta-analysis.

Keywords: Anabolic agents; Bone mineral density; Geriatric; Hip fractures; Randomized controlled trials; Rehabilitation.