Hip Fractures

Importance: More than 14.2 million people worldwide and 280 000 in the US experience a hip fracture each year. The median 1-year mortality rate after a hip fracture is 22% and approximately 42% to 71% of patients regain their prefracture level of basic activities of daily living within 6 months. Observations: Hip fractures are classified as intracapsular or extracapsular and most commonly occur after a fall. Intracapsular hip fractures include femoral neck (34%) and femoral head (rare). Extracapsular fractures consist of intertrochanteric (48%) and subtrochanteric fractures (5.8%). In the US, between 2008 and 2017, hip fractures were associated with 1-year mortality rates of 26.9% among men and 18.5% among women. Older age is a major risk factor for hip fracture, with a hazard ratio of 1.35 (95% CI, 1.25-1.47) per 5-year increase in age. Women have higher incidence of hip fractures than men due to accelerated bone loss after menopause and higher incidence of falls. Other risk factors for hip fractures include low bone mineral density (bone density of 1 SD or below that of healthy young adults measured by dual-energy x-ray absorptiometry), prior fracture, and factors contributing to falls, such as weak muscles, poor visual acuity, and smoking. Surgery for hip fracture typically consists of hip joint replacement or hip joint stabilization, using embedded hardware (open reduction and internal fixation). Patients with hip fracture benefit from physical therapy and fall reduction strategies, such as muscle-strengthening exercises and modifying medications associated with increased fall risk, such as antidepressants, and should be treated with antiresorptive medications, such as bisphosphonates (alendronate, zoledronic acid) or denosumab to prevent subsequent fracture. To prevent a hip fracture, patients with vertebral osteoporosis at the spine may require anabolic therapy, such as teriparatide, abaloparatide, or romosozumab, before starting an antiresorptive. Hip fractures may lead to mobility limitations; declines in physical, emotional, and social functioning; and reduced health-related quality of life. Conclusions and Relevance: Hip fractures are common among older people and are associated with a 1-year mortality rate of 22% and with reduced mobility and quality of life. Surgical repair for hip fracture typically consists of joint replacement or open reduction and internal fixation. Hip fracture treatment also includes physical therapy, fall reduction strategies, and medications to protect against fracture, such as bisphosphonates; denosumab; or anabolic drugs, such as parathyroid hormone analogues or romosozumab.