Non‐operative management of hip fracture

We read with interest the systematic review by Winfield et al. [1] and the accompanying editorial by Foss et al. [2]. Both provide limited detail regarding the specific analgesic modalities and medical management employed in non-operative management of hip fractures. This omission is significant, as the nature of non-operative care, particularly the extent of palliation, can affect outcomes in this frail population substantially. In recent years, novel techniques have emerged that target anterior hip capsule innervation, offering promising avenues for pain control in patients deemed unsuitable for surgery following multidisciplinary team discussion. These include cryoneurolysis and chemical ablation (using alcohol and phenol) of the pericapsular nerve group [3, 4]. These interventions have established efficacy in alleviating pain associated with movement and in some cases have enabled ambulation 4 months following treatment [3, 4]. As these techniques gain traction, future studies should stratify non-operative management of hip fracture by modality and evaluate their respective outcomes to understand their true potential. Non-operative management, when tailored appropriately, may offer comparable benefits in quality of life in certain patient populations. The FRAIL-HIP study exemplified this approach, showing that health-related quality of life in patients managed non-operatively was non-inferior to those who underwent surgery, provided that decisions were made collaboratively and with full disclosure of available options [5]. This underscores the importance of aligning treatment plans with individual patient goals, medical status and values. It also highlights the need for clinicians to be well-versed in all available modalities, including newer interventions like cryoneurolysis and chemical denervation, to facilitate truly informed discussions and decisions. Future research should prioritise the development and evaluation of alternative treatments for patients who are poor surgical candidates. Comparative studies should assess these modalities against operative management using patient-centred metrics such as pain control; mobility; and quality of life. Subgroup analyses based on comorbidities, fracture type and functional status will be essential to identify which patients are most likely to benefit from specific approaches. A more nuanced understanding of non-operative strategies will enhance our ability to guide patients and their substitute decision-makers through complex choices. By expanding our knowledge of outcomes, we can better support individualised care that respects medical realities, personal preferences and goals of care.