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Hip Fracture and Surgery: Clinical Updates and Challenges

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A special issue of Journal of Clinical Medicine (ISSN 2077-0383). This special issue belongs to the section "Orthopedics".

Deadline for manuscript submissions: closed (20 January 2026) | Viewed by 15375

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Dr. Norio Imai

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Division of Comprehensive Musculoskeletal Medicine, Niigata University Graduate School of Medical and Dental Sciences, Niigata 951-8510, Japan
Interests: epidemiology of hip fracture; rate of antiosteoporosis medication; fracture liaison service; osteosynthesis; total hip arthroplasty; hemiarthroplasty
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Special Issue Information

Dear Colleagues,

Hip fractures, especially in the elderly, are a cause of decreased mortality and poor morbidity, and they are still increasing all over the world. A total of 14.2 million hip fractures occur all over the world per year, and a strong, positive correlation was observed between the incidence rate and the latitude of each country. Moreover, 1-year all-cause mortality rates are considered to be around 20% within a year of the injury. Therefore, high-quality clinical research and developing evidence-based management algorithms and guidelines aiming to decrease morbidity and mortality in this patient group are required to improve the outcome of severely injured patients. Studies on epidemiological findings, on diagnostic modalities, and on treatment options for different injury patterns are likewise essential to further improving the care of patients with hip fractures.

The present Special Issue aims to highlight the importance of clinical research of further advancing the standard of care in patients with hip fractures. All clinicians and researchers involved in the care of injured patients are invited to submit their original papers or review articles, focusing on any aspect of the entire field of fragility hip fractures.

Dr. Norio Imai
Guest Editor

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Submitted manuscripts should not have been published previously, nor be under consideration for publication elsewhere (except conference proceedings papers). All manuscripts are thoroughly refereed through a single-blind peer-review process. A guide for authors and other relevant information for submission of manuscripts is available on the Instructions for Authors page. Journal of Clinical Medicine is an international peer-reviewed open access semimonthly journal published by MDPI.

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Keywords

antiosteoporosis medication
fracture liaison service
osteosynthesis
total hip arthroplasty
hemiarthroplasty

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Related Special Issue

Hip Fracture and Surgery: Clinical Updates and Challenges: 2nd Edition in Journal of Clinical Medicine

Published Papers (8 papers)

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10 pages, 214 KB

Open AccessArticle

Risk Factors for Preoperative DVT in Elderly Patients with Hip Fractures

by Noratep Kulachote, Pheeraphat Phoophiboon, Pongsthorn Chanplakorn, Norachart Sirisreetreerux, Nachapan Pengrung and Paphon Sa-ngasoongsong

J. Clin. Med. 2026, 15(4), 1481; https://doi.org/10.3390/jcm15041481 - 13 Feb 2026

Viewed by 777

Abstract

Background: Deep vein thrombosis (DVT) is a common and potentially serious complication in elderly patients with hip fractures, as it may progress to pulmonary embolism. Despite advances in perioperative care, preoperative DVT remains an important clinical concern; therefore, in this study, we aimed to identify risk factors associated with preoperative DVT in elderly patients with hip fractures. Methods: A retrospective case–control study was conducted in patients aged > 60 years with hip fractures who had undergone preoperative Doppler ultrasonography between January 2015 and August 2024, while patients with prior or chronic DVT or incomplete medical records were excluded. Demographic, clinical, and laboratory data were collected, and uni- and multivariate logistic regression analyses were performed to identify independent predictors of preoperative DVT. Results: Of 669 eligible patients, 454 were included, and 23 (5.1%) were diagnosed with preoperative DVT. The mean age of the whole cohort was 79.5 years, and 70.7% were female. Univariate analysis revealed that thirteen predictors with p < 0.1 were associated with preoperative DVT, while through multivariate analysis, we identified four independent predictors: female sex (p = 0.02), active smoking (p = 0.01), Wells’ score ≥ 2 (p = 0.01), and elevated platelet-to-lymphocyte ratio (PLR) (p = 0.05). The model demonstrated good discriminative performance, with an AUC of 0.81. Conclusions: Preoperative DVT remains clinically significant in elderly patients with hip fractures. Female sex, active smoking, higher Wells’ score, and elevated PLR are independent predictors of this condition, so incorporating these factors into preoperative assessment may improve risk stratification and optimize Doppler ultrasonography use. Full article

(This article belongs to the Special Issue Hip Fracture and Surgery: Clinical Updates and Challenges)

12 pages, 444 KB

Open AccessArticle

Adjusting Iron Markers for Inflammation Reduces Misclassification of Iron Deficiency After Total Hip Arthroplasty

by Alexander Tham, Donald C. McMillan, Dinesh Talwar and Stephen T. McSorley

J. Clin. Med. 2026, 15(1), 259; https://doi.org/10.3390/jcm15010259 - 29 Dec 2025

Cited by 1 | Viewed by 788

Abstract

Background: Preoperative anemia is common among patients undergoing arthroplasty and is associated with increased transfusion requirements and worse outcomes. Current perioperative pathways rely on iron studies to guide intravenous iron supplementation, but systemic inflammation triggered by surgery profoundly alters iron markers, risking misclassification of iron deficiency. This study evaluated whether adjusting iron indices for inflammatory markers improves diagnostic accuracy after total hip arthroplasty (THA). Methods: In this prospective cohort study, 20 patients undergoing elective primary THA at a single center were enrolled. Patients with preoperative inflammation were excluded. Serum iron, transferrin, transferrin saturation (TSAT), CRP, and albumin were measured preoperatively and on postoperative days (PODs) 1, 2, 3, and 90. Serum iron was adjusted for systemic inflammation using a validated regression equation incorporating CRP and albumin, and adjusted TSAT was calculated accordingly. Absolute iron deficiency was defined as serum iron < 10 µmol/L, and functional iron deficiency was defined as TSAT < 20%. Comparisons were made using Wilcoxon’s signed-rank test and ANOVA. Results: In the 20 included patients, a pronounced systemic inflammatory response was observed, with CRP peaking on POD 2 (median, 162 mg/L) and albumin falling to 32 g/L on POD 1 (both p < 0.001). Unadjusted serum iron and TSAT fell sharply, with nearly all patients classified as iron-deficient in the first three postoperative days. Adjustment for CRP and albumin significantly attenuated these declines: on POD 2, median iron was 8.2 µmol/L adjusted versus 2.0 µmol/L unadjusted (p < 0.001), and TSAT was 19% versus 4% (p < 0.001). Misclassification of iron deficiency fell by 40–50% with adjustment, and by POD 90, adjusted indices approximated baseline values. Conclusions: Systemic inflammation after THA markedly suppresses iron indices, leading to widespread misclassification of iron deficiency. Adjustment for CRP and albumin reduces this misclassification and provides a more accurate assessment of perioperative iron status. These findings complement existing evidence supporting intravenous iron supplementation by highlighting a diagnostic refinement that could improve patient selection for therapy. Full article

(This article belongs to the Special Issue Hip Fracture and Surgery: Clinical Updates and Challenges)

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12 pages, 1256 KB

Open AccessArticle

Cementless Transtrochanteric Bipolar Hemiarthroplasty vs. Proximal Femoral Nailing for Unstable Intertrochanteric Fractures in the Elderly: A Retrospective Comparative Study

by Yusuf Polat, Tolga Keçeci, Murat Alparslan, Abdullah Alper Şahin, Alper Çıraklı and Serkan Sipahioğlu

J. Clin. Med. 2026, 15(1), 151; https://doi.org/10.3390/jcm15010151 - 25 Dec 2025

Cited by 1 | Viewed by 940

Abstract

Background/Objectives: Unstable intertrochanteric femur fractures (IFFs) in geriatric patients are associated with high rates of morbidity and mortality due to poor bone quality, multiple comorbidities, and limited functional capacity. This study aimed to compare the clinical outcomes of cementless bipolar hemiarthroplasty (BHA) performed via a transtrochanteric approach and proximal femoral nailing (PFN) in elderly patients with unstable IFFs. Methods: This retrospective comparative study included 131 patients aged ≥70 years who underwent surgery for AO/OTA 31-A2 and 31-A3 unstable fractures between January 2021 and July 2025 were retrospectively reviewed. 64 patients received cementless BHA and 67 underwent PFN. Eligible patients were ambulatory prior to fracture (independently or with a cane/walker); patients with pathological fractures/malignancy, alternative procedures (cemented or posterolateral BHA, total hip arthroplasty, tumor prosthesis, or other osteosynthesis methods), incomplete records, or <6 months of follow-up were excluded. Demographics, perioperative variables, mechanical complications, revision requirement, time to mobilization, and 1- and 6-month mortality rates were analyzed. Primary outcomes were mortality and perioperative clinical parameters. Results: The two groups were comparable in age, sex, ASA scores, and fracture patterns. Intraoperative blood loss and transfusion requirements were significantly higher in the BHA group (both p < 0.001). Mobilization was observed earlier in patients treated with BHA (1 [1,2] vs. 3 [2,3] days; p < 0.001). Mechanical complications were more frequently observed after PFN, which was associated with a higher revision requirement (17.9% vs. 4.7%; p = 0.018). Operative time, hospital stay, and 1- and 6-month mortality rates showed no significant differences between the groups. Conclusions: In geriatric patients with unstable IFFs, cementless BHA performed via a transtrochanteric approach may be considered a viable surgical option with appropriate patient selection, taking into account its association with earlier mobilization and the observed mechanical complication profile. PFN offers advantages of reduced blood loss and lower transfusion needs. Surgical decision-making should be individualized based on fracture morphology, bone quality, and the patient’s overall medical condition. Given the heterogeneity of unstable fractures within the AO/OTA classification and the retrospective nature of the present study, larger, multicenter prospective investigations incorporating functional outcomes are warranted to further clarify optimal treatment strategies. Full article

(This article belongs to the Special Issue Hip Fracture and Surgery: Clinical Updates and Challenges)

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16 pages, 750 KB

Open AccessArticle

Early Postoperative Mortality Risk Factors and Five- and Ten-Year Mortality Rates After Hip Arthroplasty for Femoral Neck Fracture

by Khalil Khalil, Youssef Jamaleddine, Ahmad Haj Hussein, Elio Daccache, Joseph Mouawad, Guillaume Fricault, Alfred Khoury and Nicolas Reina

J. Clin. Med. 2025, 14(23), 8263; https://doi.org/10.3390/jcm14238263 - 21 Nov 2025

Cited by 3 | Viewed by 1796

Abstract

Introduction: Femoral neck fractures in older adults are associated with appreciable short-term mortality, yet long-term survival after hip arthroplasty is incompletely characterized. We analyzed early mortality risk factors and 5- and 10-year mortality after hemi-arthroplasty or total hip arthroplasty (THA) for femoral neck fractures. Materials and Methods: In this single-center retrospective cohort, 397 consecutive patients underwent arthroplasty for femoral neck fracture in 2014 and 2015. Mean age was 83.3 years and 70.3% were women. Demographic data, Charlson Comorbidity Index, Parker Mobility Score, medication history, operative and anesthetic details, transfusion, and peri-operative complications were extracted. Survival status up to 10 years was obtained from hospital and civil registries. p-value < 0.05 was considered statistically significant. Results: A total of 397 patients were included. When categorized by age and ASA scores into low-, medium-, and high-risk groups, mortality rates increased with higher risk (p < 0.001). The mortality rate at 30 days, 90 days, 1 year, 5 years, and 10 years postoperatively was 3.5%, 7.1%, 14.1%, 48.36% and 71.03%, respectively; mean time-to-death was 3.3 years. At 30 days, mortality was higher in males, those on clopidogrel, in patients with lower mobility (lower Parker Score), higher morbidity (higher Charlson Score), NNIS score of 1, higher ASA, patient who underwent hemiarthroplasty, and patients with medical complications post-op. Additional 90-day risks were antivitamin K therapy, immunosuppressants, and continuous spinal anesthesia; 1-year risks also encompassed advanced age, prolonged hospital stay, and peri-operative transfusion. Conclusions: Arthroplasty after femoral neck fracture is associated with high mortality rate; only half of patients survive 5 years and fewer than one-third reach 10 years. Mortality rate is affected by many risk factors, both non-modifiable factors and modifiable peri-operative variables. Targeted optimization of modifiable peri-operative factors and multidisciplinary geriatric-orthopedic care may improve outcomes in this frail population. Full article

(This article belongs to the Special Issue Hip Fracture and Surgery: Clinical Updates and Challenges)

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9 pages, 762 KB

Open AccessArticle

Does a Dual-Mobility Cup Offer Better Stability than Conventional Bearings in Hip Arthroplasty Following Femoral Neck Fracture?

by Itay Ron, Itay Ashkenazi, Nimrod Snir, Yaniv Warschawski and Aviram Gold

J. Clin. Med. 2025, 14(16), 5613; https://doi.org/10.3390/jcm14165613 - 8 Aug 2025

Viewed by 2134

Abstract

Introduction: Instability following total hip arthroplasty (THA) remains a challenging complication. Dual-mobility (DM) hip components are aimed at improving joint stability by increasing the head-neck ratio and jump distance. However, data regarding the efficacy of these implants in the trauma setting are scarce. This study aimed to compare the dislocation rates of DM bearings with conventional THA in patients undergoing primary THA for the treatment of hip fractures. Methods: We retrospectively reviewed all patients who underwent THA for hip fractures between the years 2010–2022 and had a minimum follow-up of two years. Patient demographics and radiographic parameters, including cup version, leg length discrepancy (LLD) and femoral horizontal offset, were compared between patients who received DM bearings and patients who received conventional THA. Dislocation and revision surgery rates were also compared between the groups. Results: The study included 570 patients who met inclusion criteria, of which 82 patients were in the DM bearings group and 488 patients were in the conventional THA group. Baseline demographics and comorbidity profiles were comparable between the groups. Cup anteversion was significantly lower in the DM group (11.1° vs. 14.1°; p = 0.006), while no significant differences were observed in LLD nor femoral offset between the groups (p = 0.38, p = 0.69, respectively). Dislocation rates were similar between the DM and conventional THA groups (1.2% vs. 1.02%, respectively; p = 0.54). Furthermore, revision rates were similar between DM and conventional THA (1.22% vs. 2.87%, respectively; p = 0.387). Conclusions: While no significant differences in dislocation rates were observed between dual-mobility and conventional THA bearings, the significantly lower cup anteversion suggests a potential improvement in acetabular safe zone positioning, this could reflect a broader margin for error in implant positioning. Further prospective studies are needed to elucidate the biomechanical advantages of DM bearings in patients with hip fractures. Full article

(This article belongs to the Special Issue Hip Fracture and Surgery: Clinical Updates and Challenges)

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15 pages, 579 KB

Open AccessArticle

The Effect of Preoperative Intravenous Iron Supplementation on Mortality and Blood Transfusion Requirements in Elderly Patients Undergoing Hip Fracture Surgery: A Prospective Randomized Controlled Trial

by Taha Kizilkurt, Mustafa Ozkaya, Mert Balli, Mehmet Demirel and Mehmet Asik

J. Clin. Med. 2025, 14(13), 4713; https://doi.org/10.3390/jcm14134713 - 3 Jul 2025

Cited by 4 | Viewed by 3760

Abstract

Background/Objectives: Elderly patients who suffer a hip fracture often have a high risk of complications and mortality, which can be made worse by anemia during and after surgery. Although restrictive transfusion strategies are recommended, the role of preoperative intravenous iron, particularly ferric carboxymaltose (FCM), remains unclear. This study aimed to investigate whether preoperative IV FCM reduces mortality and transfusion requirements in geriatric hip fracture patients managed under a restrictive transfusion strategy. Methods: A study was conducted in which 220 patients aged 65 years and over who had undergone surgery for a hip fracture were included. These patients were allocated to receive either a single 1000 mg dose of intravenous FCM approximately 12 h before surgery or no iron supplementation. All the patients were managed with a standardized restrictive transfusion strategy. The primary outcome was all-cause mortality at 6 and 12 months. The secondary outcomes included perioperative transfusion requirement, hemoglobin trends, and length of hospital stay. Results: The FCM group demonstrated significantly lower mortality at both 6 months (22.9% vs. 39.0%, p = 0.011) and 12 months (28.4% vs. 42.9%, p = 0.028) compared to the control group. Multivariate logistic regression identified preoperative FCM administration as one of the independent protective factors for mortality. The FCM group had significantly lower transfusion rates (30.9% vs. 45.5%, p = 0.02). No significant difference was observed at the 6-week follow-up in terms of the higher discharge hemoglobin levels seen in the control group. The difference in hospital stay duration did not reach statistical significance. Conclusions: Preoperative intravenous FCM administration could reduce both short- and long-term mortality and transfusion needs in geriatric hip fracture patients managed under a restrictive transfusion protocol. These findings support further investigation of high dose IV iron as a component of perioperative blood management in this high-risk population. Full article

(This article belongs to the Special Issue Hip Fracture and Surgery: Clinical Updates and Challenges)

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13 pages, 515 KB

Open AccessArticle

The Impact of Total Hip Arthroplasty on the Incidence of Hip Fractures in Romania

by Flaviu Moldovan and Liviu Moldovan

J. Clin. Med. 2025, 14(13), 4636; https://doi.org/10.3390/jcm14134636 - 30 Jun 2025

Cited by 13 | Viewed by 1168

Abstract

Background/Objectives: The increase in life expectancy and the share of the elderly population has the effect of increasing the number of osteoporotic hip fractures. At the same time, the number of total hip arthroplasty (THA) interventions is continuously increasing. The objective of this study is to investigate the incidence rates of hip fractures during the period 2008–2019, in Romania, among people who are at least 40 years old, as well as to determine the extent to which the increase in the prevalence of people who have undergone THA has affected the incidence of hip fractures, given that the operated hip no longer presents a risk of fracture. Methods: We extracted the information, between 2008 and 2019, from nationwide retrospective studies about the incidence and time trend of hip fractures in Romania. Information on primary THA interventions during the period 2001–2019 was obtained from the Romanian Arthroplasty Register (RAR). We obtained the population size, by gender and age groups, from the reports of the National Institute of Statistics. For the period 2008–2019, we calculated the standardized annual hip fracture incidence rates by sex and by age. Given that each person has two hips at risk of fracture, we calculated hip fracture rates in a scenario without THA interventions. For this, we subtracted 0.5 people from the at-risk population for each prevalent hip prosthesis. Thus, we revealed the effects of decreasing fracture rates due to having hip prostheses. Results: From 2008 to 2019, age-standardized incidence rates of hip fractures increased by 10.8% in women, and by 2.8% in men. By excluding hips being replaced with prostheses in the at-risk population, we obtained higher hip fracture incidence rates. These recorded values were considerably higher for the elderly population. The variation in hip fracture rates during the observed period was 10.16% (9.76% in women and 11.68% in men) lower due to the increased prevalence of hip prostheses. Conclusions: Although the incidence of hip fractures has continued to rise, the growing number of people who have undergone THA and are living with hip prostheses has helped to blunt this increase. Full article

(This article belongs to the Special Issue Hip Fracture and Surgery: Clinical Updates and Challenges)

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14 pages, 406 KB

Open AccessSystematic Review

Comparison of Patient-Reported Outcome Measures Between Robotic-Assisted and Manual Total Hip Arthroplasty: A Systematic Review with a Minimum 2-Year Follow-Up

by Itay Ron, Jacob Shapira, Ady H. Kahana-Rojkind, Roger Quesada and Benjamin G. Domb

J. Clin. Med. 2025, 14(17), 6036; https://doi.org/10.3390/jcm14176036 - 26 Aug 2025

Cited by 4 | Viewed by 2986

Abstract

Background/Objectives: Since robotic THA is a relatively new procedure, there is a paucity of high-quality research evaluating long-term PROMs, and as such this study aimed to compare the long term outcomes in robotic and manual THA. To systematically review the literature comparing mid- to long-term patient-reported outcome measures (PROMs) between robotic-assisted and manual THA. Methods: This study focused specifically on full-body text of studies comparing robotic and manual THA and comparing PROMs with a minimum of 2 years follow-up. Inclusion criteria were studies comparing robotic THA and manual THA and showing at least 1 PROMs with a minimum follow-up period of 2 years. Results: Five studies reported higher scores in 2-year follow-up for patient undergone robotic surgery. In addition, most studies did not show significant difference in dislocation nor revision rate between robotic and manual THA. Six studies assessed limb-length discrepancy using radiographic measurements and found no evidence of superior outcomes in either group. Conclusions: Based on the current evidence, this review identified evidence suggesting a trend toward better PROMs in patients operated on robotically. However, there was not enough evidence to conclude a correlation between lower risks for post-operative complications, revisions, and dislocations and robotic surgery. Full article

(This article belongs to the Special Issue Hip Fracture and Surgery: Clinical Updates and Challenges)

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