Surgical Treatment Options
For most elderly patients, surgery is the recommended course of action for a fractured hip to reduce pain and allow for early mobilization. The type of surgery performed is determined by several factors, including the location and type of fracture, whether the bone is displaced, the patient's age, and their pre-fracture health and activity level. The primary surgical options include internal fixation and hip replacement.
Internal Fixation
This procedure is often used for non-displaced or stable fractures where the bones can be held in place with hardware. The surgeon uses metal screws, pins, plates, or rods to secure the broken pieces together while the bone heals.
- Percutaneous Fixation: Involves screws or pins inserted through small incisions. This is typically used for less severe fractures.
- Compression Hip Screw: A large screw is inserted into the femoral head, with a side plate attached to the femur, allowing the fracture to compress as it heals.
- Intramedullary Nail: A rod is inserted into the marrow canal of the femur, passing through the fracture site. This is often used for fractures that occur further down the thigh bone, below the neck.
Hip Replacement (Arthroplasty)
For severe fractures, especially those that disrupt the blood supply to the femoral head, a hip replacement may be necessary.
- Partial Hip Replacement (Hemiarthroplasty): The femoral head and neck are replaced with a metal prosthesis. The natural socket (acetabulum) in the pelvis is left intact. This is a common choice for older, less active adults.
- Total Hip Replacement (THA): Both the femoral head and the acetabular socket are replaced with artificial components. This option is typically considered for younger, more active seniors who had good hip function before the fracture or those with pre-existing arthritis.
Non-Surgical Treatment
In rare instances, non-surgical treatment may be considered for elderly patients who are not candidates for surgery due to severe medical conditions or for isolated, very stable fractures. This approach carries significant risks due to prolonged immobilization and bed rest, such as deep vein thrombosis (DVT), pulmonary embolism, pneumonia, and bedsores. Treatment focuses on pain management and restricted weight-bearing, with the potential for a very long and challenging recovery.
Multimodal Pain Management
Effective pain control is vital throughout the entire recovery process to facilitate early mobility and rehabilitation. A multimodal approach is often used to minimize reliance on opioids, which can cause confusion, constipation, and other side effects in older adults.
- Regional Anesthesia: Nerve blocks, such as a fascia iliaca block, can provide effective pain relief in the emergency and preoperative settings, reducing the need for systemic opioids.
- Medications: Pain medication may include scheduled intravenous (IV) or oral acetaminophen, non-steroidal anti-inflammatory drugs (NSAIDs) if not contraindicated, and short-term use of opioids when necessary.
Post-Operative Rehabilitation
Rehabilitation begins almost immediately after surgery, often within 24 to 48 hours, to improve outcomes and prevent complications from immobility. A multidisciplinary team, including physical and occupational therapists, works with the patient. The process has several key phases:
- In-Hospital Phase: Early mobilization exercises to prevent muscle deconditioning and improve circulation. Patients learn how to safely get in and out of bed and use assistive devices like a walker or crutches.
- Rehabilitation Facility or Home: After hospital discharge, some patients may require a short-term stay in a rehabilitation facility for more intensive therapy. Others may receive in-home physical therapy. Exercises focus on strengthening the hip and leg muscles, improving balance, and increasing the range of motion.
- Functional Mobility Training: Occupational therapists help patients practice daily activities like dressing, bathing, and cooking to regain independence.
Comparison of Surgical Options
| Feature | Internal Fixation (Screws, Rods) | Partial Hip Replacement (Hemiarthroplasty) | Total Hip Replacement (THA) |
|---|---|---|---|
| Ideal For | Stable, non-displaced fractures; younger, healthier patients with displaced fractures | Displaced fractures in older, less active patients | Active patients with displaced fractures; those with pre-existing arthritis |
| Procedure | Stabilizes the patient's own femoral head with metal hardware | Replaces the femoral head and neck with an artificial prosthesis | Replaces both the femoral head and the hip socket |
| Recovery | Often quicker initial recovery, but can have a higher reoperation risk if it fails to heal | Good functional outcome with a lower reoperation rate compared to internal fixation in displaced fractures | Highest functional outcome, but with a higher initial complication and dislocation risk than hemiarthroplasty |
| Risks | Non-union, avascular necrosis (especially with displaced femoral neck fractures) | Acetabular erosion in active patients | Dislocation, higher initial surgical risk |
Conclusion
While a hip fracture is a significant event for an elderly person, rapid and effective treatment, primarily surgical intervention, can lead to positive outcomes. The specific treatment plan is highly individualized based on the patient's unique situation. Prompt surgery, followed by a dedicated and comprehensive rehabilitation program, is the standard of care for restoring mobility, managing pain, and enabling seniors to return to their highest possible level of function. Prevention strategies, including addressing bone density issues and fall risks, are also key to reducing the likelihood of a future fracture. To learn more about bone health and fracture prevention, visit the American Academy of Orthopaedic Surgeons (AAOS).
