Abstract
Aims
Older adults with hip fractures are at high risk of experiencing complications after surgery, but estimates of the rate of specific complications vary by study design and follow-up period. The aim of this systematic review was to determine the prevalence of complications in older adults after hip fracture surgery.
Methods
MEDLINE, Embase, CINAHL, and CENTRAL databases were searched from inception until 30 June 2023. Studies were included if they reported prevalence data of complications in an unselected, consecutive population of older adults (aged ≥ 60 years) undergoing hip fracture surgery.
Results
A total of 95 studies representing 2,521,300 patients were included. For surgery-specific complications, the 30-day prevalence of reoperation was 2.31%, surgical site infection 1.69%, and deep surgical site infection 0.98%; the 365-day prevalence of prosthesis dislocation was 1.11%, fixation failure 1.77%, and periprosthetic or peri-implant fracture 2.23%. For general complications, the 30-day prevalence of acute kidney injury was 1.21%, blood transfusion 25.55%, cerebrovascular accident 0.79%, lower respiratory tract infection 4.08%, myocardial infarction 1.98%, urinary tract infection 7.01%, and venous thromboembolism 2.15%.
Conclusion
Complications are prevalent in older adults who have had surgery for a hip fracture. Studies reporting complications after hip fracture surgery varied widely in terms of quality, and we advocate for the routine monitoring of complications in registries and clinical trials to improve the quality of evidence.
Cite this article: Bone Joint J 2025;107-B(2):139–148.
Take home message
Complications are prevalent in older adults who have had surgery for a hip fracture.
Given the limitations associated with the current literature, the true real-world risks are likely to be higher than estimated.
Introduction
One-third of older adults with hip fractures experience a complication after surgery.1-5 This risk remains elevated beyond the immediate postoperative period.6,7 The development of postoperative complications is an important predictor of outcome in patients with a hip fracture, as they are associated with prolonged hospitalization,8 increased mortality,4 and higher healthcare and social care costs.9-11 Some of these complications are potentially preventable,12-14 and should be a priority area of research.
The existing literature on complications after a hip fracture surgery is limited for several reasons. Definitions of complications vary due to the lack of a defined core outcome set,15 and complications are infrequently reported in clinical databases and registries.16 Furthermore, data sources are often vulnerable to data collection or transcription errors that affect their accuracy.17 Finally, there is wide variation in the quality of data due to the methodological heterogeneity between studies, which may influence the precision of the reported estimates.18-27 Therefore, a summary of the literature-reported estimates for complications will act as an important benchmark for future research.
The aim of this systematic review was to estimate the prevalence of individual complications in older adults after hip fracture surgery.
Methods
This systematic review was reported according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines.28 The protocol was registered in the International Prospective Register of Systematic Reviews (PROSPERO) (reference: CRD42023456723). Ethics approval and informed consent were not required, as this study used publicly available data and did not involve patients in the conception, design, analysis, drafting, interpretation, or revision of the research.
Search strategy
The search was designed in conjunction with a specialist information librarian (KS), to capture any study that reported complications after surgery for a hip fracture in older adults (aged ≥ 60 years). Free-text terms and subject headings were used to create a database-specific search strategy for each of the following databases: MEDLINE (via Ovid), Embase (via Ovid), CINAHL (via EBSCO), and CENTRAL (via Wiley). The searches were performed on 30 June 2023, and all databases were searched from inception until 30 June 2023.
The search incorporated keywords and subject headings relating to hip and femoral fractures, postoperative complications, and older people. The postoperative complication terms included both general keywords and those specific to common complications following surgery for hip fractures.1 To narrow the search to the desired population (aged ≥ 60 years), the Wright and Jones age filter was adapted.29 Ovid’s expert search “elderly” filter was also consulted. No limits were applied to the search.
The reference lists of papers identified by the strategies described above were hand-searched, and snowballing was performed via CitationChaser to search for further reports of eligible studies.30 Additional searches were carried out in grey literature sources including the websites of national hip fracture registries worldwide.16
Eligibility criteria
Studies were included if they reported prevalence or incidence data for any of the prespecified complications in an unselected, consecutive population of older adults (aged ≥ 60 years) who had surgery for a hip fracture. Studies were excluded if they only included specific subgroups of patients who were unlikely to be representative of the general hip fracture population, composed of young patients with hip fractures, or had a population sample size of < 100 patients. The full inclusion and exclusion criteria are shown in Table I.
Table I.
Eligibility criteria.
| Inclusion criteria | Exclusion criteria |
|---|---|
| Studies with an experimental or observational design | Studies that reported specific subsets of a general population |
| Studies where the prevalence or incidence data for complications can be extracted or calculated | Studies with a population that included young patients (aged < 60 years) with a hip fracture |
| Studies that reported the prevalence or incidence of complications within the first year after surgery | Studies with a population sample size of < 100 patients |
| Studies that were not published in English | |
| Studies that were published as a letter, conference abstract, protocol, or infographic |
Outcome measures
The primary outcomes of interest were the prevalence of prespecified postoperative complications at each timepoint.1 These complications are listed in Table II. We pragmatically accepted any definition of these complications used by the study authors. The secondary outcome of interest was the prevalence of postoperative mortality at each timepoint.
Table II.
List of prespecified complications of interest.
| Classification | Complication |
|---|---|
| Surgery-specific complications | Prosthesis dislocation, fixation failure, periprosthetic or peri-implant fracture, reoperation (unspecified), reoperation for infection, and surgical site infection. |
| General complications | Acute kidney injury, blood transfusion, cerebrovascular accident, lower respiratory tract infection, myocardial infarction, urinary tract infection, venous thromboembolism, deep vein thrombosis, and pulmonary embolism. |
Assessment of methodological quality
The methodological quality of each included study was independently assessed by two reviewers (AK, AT). Disagreements were resolved by discussion with a third reviewer (ELG). The Joanna Briggs Institute (JBI) Critical Appraisal Checklist for studies reporting prevalence data was used for this assessment.31 This tool comprises nine questions with four standard answer options: “yes”, “no”, “unclear”, or “not applicable”; and a question for overall appraisal with three answer options: “include”, “exclude”, or “seek further information” based on rater judgement. Studies that scored “yes” in six or more questions were considered to be of high quality. Studies considered to be low-quality were included as part of the synthesis process, given that they may still add important data.
Selection process, data extraction, and data items
A data extraction form was used to extract equivalent information for each study. Two reviewers (AK, AT) independently extracted data for each study using this form. In case of disagreement, a consensus was sought following discussion with a third reviewer (ELG). The fields extracted are shown in Table III.
Table III.
Items included in the data extraction.
| Category | Items |
|---|---|
| Study details | Reviewer, study identification, date of data extraction, study title, author, year, and journal of publication |
| Study methodology | Setting, study design, study period, data source, and outcomes reported |
| Study population | Population size, population age, sex distribution, comorbidities, fracture type, and procedure type |
| Study results | Prevalence (number of events, number at risk) and timeframe (e.g. 30 days) |
Data synthesis
The prevalence of each complication was recorded for all included studies. Where two or more studies reported data from the same population, only data from the first study were used. The pooled prevalence and 95% CIs of each complication at different timepoints (e.g. 30 days) were estimated by fitting a random-effects model, as we anticipated substantial inter-study variability, with the results presented in Supplementary Table i.
Sensitivity analyses were undertaken using the fixed-effects model to compare the random- and fixed-effects estimates, and using different methods of back transformation: the harmonic mean and 1/σ2. The results of these analyses are presented in Supplementary Tables i and ii. The pooled prevalence for each complication at the timepoint with the most studies are presented in forest plots, which can be viewed in the Supplementary Material, while we have presented random effects calculations of the specific prevalence of complications with their 95% CIs in the Results (Supplementary Figures a to e). Subgroup analyses were performed based on the methodological variables; study quality and sample size and the results are presented in Supplementary Table iii.
Statistical analysis
The I2 statistic was used to assess the statistical heterogeneity of the prevalence values across the included studies. The threshold for statistical significance was set at the two-sided 5% significance level for the test of heterogeneity. Statistical heterogeneity was categorically defined as “low”, “moderate”, or “high” with an I2 of above 25%, 50%, and 75%, respectively, with results above 60% considered as substantial heterogeneity.32 Statistical analyses were performed with R statistical software (R Foundation for Statistical Computing, Austria), using the “metafor” and “meta” packages.33,34 The "metaprop" function within the "metafor" package was used for the subgroup analyses.
Results
Search results
The search identified a total of 38,269 records, of which 14,822 were duplicates. Abstracts of the remaining 23,447 records were screened against the prespecified eligibility criteria to assess potential for inclusion. Of these, 827 records were retrieved for full-text review after exclusion of 22,620 records. Following a search of the grey literature and citation searching, a further 3,284 records were identified and ten retrieved for full-text review. Following this, 95 records met the full inclusion and exclusion criteria and were deemed to be eligible for inclusion; the remaining 742 records were excluded. The PRISMA flowchart is presented in Figure 1.
Fig. 1
PRISMA flowchart showing the screening and selection process.
Characteristics of the included studies
There were 2,521,300 patients across the 95 included studies.1,8,14,35-126 These studies were published between 1985 and 2023, from Europe, North America, South America, Asia, and Australasia. The majority of studies were from the USA (39, 41.1%),35-38,40,42,44-46,48,50,53,56,57,62,64,70,72,74,75,87-92,95,96,99-104,108,109,111,114,118 Denmark (12, 12.6%),8,52,63,66,67,73,78-80,105-107 and the UK (10, 10.5%).1,54,68,69,71,76,97,98,119,122 The sample sizes ranged from 114 to 258,834 patients. Cohort studies made up all but one of the included studies (94, 98.9%).1,8,14,35-125 The remaining study was a randomized controlled trial (RCT).126 The majority of the studies were retrospective (72.6%) designs.8,39-42,45-48,53,55,60,65,68,69,74-76,82-86,90-94,96-98,100-102,108,110,112,113,115-117,119-122,124,125
The most frequently used source of registry data was the American College of Surgeons National Surgical Quality Improvement Program (22, 23.2%).35-38,44,50,56,62,64,70,72,87-89,95,99,103,104,109,111,114,118 Other registry sources included hip fracture-specific registers such as the Danish Multidisciplinary Hip Fracture Registry (11, 11.6%),52,63,66,67,73,78-80,105-107 Kaiser Permanente Hip Fracture Registry (2, 2.1%),53,101 Norwegian Hip Fracture Registry (2, 2.1%),65,77 Swedish National Registry for Hip Fractures (1, 1.1%),93 the National Hip Fracture Database (1, 1.1%) of England and Wales,98 and Irish Hip Fracture Database (1, 1.1%).98 Of the cohort studies, 43 studies used local hospital records,8,14,39,41-43,45-49,51,54,55,58-61,68,69,71,76,81-83,85,86,90,94,96,97,100,110,113,115-117,119-123,126 while one study used a hip-fracture specific national dataset.1
The reporting of the prevalence of surgery-specific and general complications and their respective timepoints varied across the included studies. Overall, 32 studies reported the prevalence of only one complication, and none reported the prevalence of all the complications from the prespecified list.35,38-41,44,47-49,51,52,55,65,66,72,74,76,77,82,98,102,105-108,110,121,123,125 A total of 11 studies reported the prevalence of complications at more than one timepoint.39,41,58,63,75,80,108,110,117,120,121 For the majority of complications, the most common reporting timepoint was 30 days after surgery. For surgery-specific complications such as prosthesis dislocation, fixation failure, and periprosthetic or peri-implant fracture, the most common reporting timepoint was 365 days. The characteristics of the included studies and their respective populations are presented in Supplementary Tables iv and v.
Quality assessment
In the overall appraisal, 60 (63.2%) studies met the criteria to be considered high-quality.1,8,35-38,40,41,44,46,48,50,52,53,56-59,62-67,70,73-80,84,87-89,91-93,95,98-109,111,112,114,118,121,124,125 Studies performed well across the following domains: sufficient coverage of the sample (93, 97.9%); appropriate statistical analysis (92, 96.8%); and response rate (91, 95.8%). They performed poorly across the following domains: measurement of the condition in a standard, reliable way (9, 9.5%); identification of the condition using valid methods (26, 27.4%); and detailed description of the study subjects and setting (49, 51.6%). The quality assessment for the included studies is described in detail in Supplementary Table vi.
Surgery-specific complications
Prosthesis dislocation: data pertaining to prosthesis dislocation were derived from studies reporting the use of hip hemiarthroplasty or total hip arthroplasty in hip fracture patients. The prevalence of prosthesis dislocation was reported in eight studies (n = 26,093).1,43,61,71,81,112,115,116 One study reported the prevalence at 30 days;43 one at 90 days; one at 120 days;1 one at 180 days;61 and four at 365 days.71,81,112,116 None of the studies reported the prevalence at more than one timepoint. The pooled prevalence of prosthesis dislocation was 1.11% (95% CI 0.75 to 1.52, I2 = 22%, p = 0.220) at 365 days.
Fixation failure: data pertaining to fixation failure were derived from studies reporting the use of internal fixation in hip fracture patients. The prevalence of fixation failure was reported in nine studies (n = 12,369).1,42,43,45,61,71,115,116 Two studies reported the prevalence at 30 days;42,43 one at 90 days;115 one at 120 days;1 two at 180 days;61,113 and three at 365 days.45,71,116 None of the studies reported the prevalence at more than one timepoint. The pooled prevalence of fixation failure was 1.77% (95% CI 0.51 to 3.74, I2 = 86%, p = 0.004) at 365 days.
Periprosthetic or peri-implant fracture: the prevalence of periprosthetic or peri-implant fracture was reported in six studies (n = 11,376).1,45,85,113,115,116 One study reported the prevalence at 30 days;85 one at 90 days;115 one at 120 days;1 one at 180 days;113 and two at 365 days.45,116 None of the studies reported the prevalence at more than one timepoint. The pooled prevalence of periprosthetic or peri-implant fracture was 2.23% (95% CI 0.01 to 7.56, I2 = 96%, p < 0.001) at 365 days.
Reoperation (unspecified): where the indication for reoperation on the previously operated hip was not reported, we labelled this “unspecified”. The prevalence of reoperation (unspecified) was reported in 30 studies (n = 570,635).8,14,36,37,42,43,45,46,50,56,57,61,62,65,70,72,76,77,87,88,95,98,103,104,111,112,115,116,121,123 A total of 18 studies reported the prevalence at 30 days;36,37,42,43,46,50,56,62,70,72,87,88,95,98,103,104,111,121 one at 90 days;115 one at 120 days;121 four at 180 days;8,14,61,76 and seven at 365 days.45,57,65,77,112,116,123 One study reported the prevalence at more than one timepoint.121 Four studies reported the prevalence in the same population; two at 30 days;87,88 and two at 180 days.14,61 The pooled prevalence of reoperation (unspecified) was 2.31% (95% CI 1.85 to 2.81, I2 = 98%, p < 0.001) at 30 days.
Reoperation (infection): the prevalence of reoperation for infection was reported in seven studies (n = 316,215).8,60,61,63,67,78,80 One study reported the prevalence at 15 days;80 four at 30 days;63,67,78,80 one at 90 days;80 one at 120 days;60 two at 180 days;8,61 and two at 365 days.63,80 Two studies reported the prevalence at more than one timepoint.63,80 Two studies reported the prevalence at 30 days in the same population.78,80 The pooled prevalence of reoperation for infection was 0.45% (95% CI 0.35 to 0.56, I2 = 94%, p < 0.001) at 30 days.
Surgical site infection (SSI) (all): the prevalence of SSI was reported in 33 (n = 604,912).1,36,42,45,49,51,56,59,64,70,71,75,81,85-90,95,99,103,109-116,118,120,126 In total, 22 studies reported the prevalence at 30 days;36,42,49,51,56,64,70,75,85,87-89,95,99,103,109-111,114,118,120,126 one at 42 days;110 three at 90 days;75,90,115 two at 120 days;1,59 two at 180 days;113,120 and six at 365 days.45,71,81,86,112,116 Three studies reported the prevalence at more than one timepoint.75,110,120 Three studies reported the prevalence at 30 days in the same population.87-89 The pooled prevalence of SSI was 1.69% (95% CI 1.14 to 2.35, I2 = 99%, p < 0.001) at 30 days.
Surgical site infection (superficial): the prevalence of superficial SSI was reported in 20 studies (n = 262,862).36,45,47,51,55,59,64,81,85-89,95,99,103,109,111,114,115 In total, 16 studies reported the prevalence at 30 days;36,47,51,55,64,85-89,95,99,103,109,111,114 one at 90 days;115 one at 120 days;59 and three at 365 days.45,81,86 One study reported the prevalence at more than one timepoint.86 Three studies reported the prevalence at 30 days in the same population.87-89 The pooled prevalence of superficial SSI 0.77% (95% CI 0.47 to 1.13, I2 = 98%, p < 0.001) at 30 days.
Surgical site infection (deep): the prevalence of deep SSI was reported in 20 studies (n = 260,675).36,43,45,51,59,61,64,81,85-89,95,99,103,109,111,114,115 A total of 14 studies reported the prevalence at 30 days;36,43,51,64,85,87-89,95,99,103,109,111,114 one at 90 days;115 one at 120 days;59 one at 180 days;61 and three at 365 days.45,81,86 None of the studies reported the prevalence at more than one timepoint. Three studies reported the prevalence at 30 days in the same population.87-89 The pooled prevalence of deep SSI was 0.98% (95% CI 0.40 to 1.81, I2 = 100%, p < 0.001) at 30 days.
General complications
Acute kidney injury (AKI): the prevalence of AKI was reported in 24 studies (n = 529,361).1,37,43,45,56,58,59,64,70,71,75,82,87,88,95,99,103-105,107,111,114,119,122 Three studies reported the prevalence at seven days;82,105,107 16 at 30 days;37,43,56,64,70,75,87,88,95,99,103,104,111,114,119,122 one at 90 days;75 three at 120 days;1,58,59 and two at 365 days.45,58 Two studies reported the prevalence at more than one timepoint.58,75 Four studies reported the prevalence in the same population; two at seven days;105,107 and two at 30 days.87,88 The pooled prevalence of AKI was 1.21% (95% CI 0.37 to 2.52, I2 = 100%, p < 0.001) at 30 days.
Blood transfusion: the prevalence of blood transfusion was reported in 24 studies (n = 879,028).1,35,36,38,43,46,48,52,56,60,64,66,68,69,71,75,81,87,95,103,106,114,126 Four studies reported the prevalence at seven days;48,52,66,106 15 at 30 days;35,36,38,43,46,56,64,68,69,75,87,95,103,114,126 one at 90 days;75 two at 120 days;1,60 and two at 365 days.71,81 None of the studies reported the prevalence at more than one timepoint. Two studies reported the prevalence at seven days from the same population.52,66 The pooled prevalence of blood transfusion was 25.55% (95% CI 20.26 to 31.23, I2 = 100%, p < 0.001) at 30 days.
Cerebrovascular accident (CVA): the prevalence of CVA was reported in 31 studies (n = 547,183).1,37,39,42,43,45,46,50,56,58-60,70,71,73,85,87-89,93,95,99,103,108,111,114,118-120,122,125 A total of 21 studies reported the prevalence at 30 days;37,42,43,46,50,56,70,85,87-89,95,99,103,108,111,114,118-120,122 four at 120 days;1,58-60 two at 180 days;39,120 and eight at 365 days.39,45,58,71,73,93,108,125 Four studies reported the prevalence at more than one timepoint.39,58,108,120 Three studies reported the prevalence at 30 days in the same population.87-89 The pooled prevalence of CVA was 0.79% (95% CI 0.69 to 0.90, I2 = 79%, p < 0.001) at 30 days.
Lower respiratory tract infection (LRTI): the prevalence of LRTI was reported in 44 studies (n = 1,527,931).1,14,36,37,43-45,50,53,54,56-59,61,63,64,67,70,71,75,78,79,85,87-93,95,99-101,103,109,111,114,117-120,122 One study reported the prevalence at seven days;100 31 at 30 days;36,37,43,44,50,54,56,63,64,67,70,75,78,79,85,87-89,91,92,95,99,103,109,111,114,117-120,122 six at 90 days;53,57,75,90,101,117 three at 120 days;1,58,59 three at 180 days;14,61,120 and six at 365 days.45,58,63,71,93,117 Five studies reported the prevalence at more than one timepoint.58,63,75,117,120 Nine studies reported the prevalence in the same population; seven at 30 days;78,79,87-89,91,92 and two at 180 days.14,61 The pooled prevalence of LRTI was 4.08% (95% CI 3.50 to 4.70, I2 = 99%, p < 0.001) at 30 days.
Myocardial infarction (MI): the prevalence of MI was reported in 33 studies (n = 523,354).1,36,37,40,42,45,46,50,53,58-60,64,70,71,74,85,87-89,93,95,99-101,103,104,111,114,117-119,122 Two studies reported the prevalence at seven days;74,100 21 at 30 days;36,37,42,46,50,64,70,85,87-89,95,99,103,104,111,114,117-119,122 three at 90 days;53,101,117 four at 120 days;1,58-60 and six at 365 days.40,45,58,71,93,117 Two studies reported the prevalence at more than one timepoint.58,117 Three studies reported the prevalence at 30 days in the same population.87-89 The pooled prevalence of MI was 1.98% (95% CI 1.71 to 2.28, I2 = 95%, p < 0.001) at 30 days.
Urinary tract infection (UTI): the prevalence of UTI was reported in 32 studies (n = 892,248).1,36,37,43,46,50,54,56,58,59,63,64,67,70,71,75,78,79,85,87-89,95,99,103,104,111,114,118-120,122 Overall, 28 studies reported the prevalence at 30 days;36,37,43,46,50,54,56,63,64,67,70,75,78,79,85,87-89,95,99,103,104,111,114,118-120,122 one at 90 days;75 three at 120 days;1,58,59 one at 180 days;120 and three at 365 days.58,63,71 Four studies reported the prevalence at more than one timepoint.58,63,75,120 Five studies reported the prevalence at 30 days in the same population.78,79,87-89 The pooled prevalence of UTI was 7.01% (95% CI 5.50 to 8.69, I2 = 100%, p < 0.001) at 30 days.
Venous thromboembolism (VTE): the prevalence of VTE was reported in 47 studies (n = 1,149,504).1,36,37,41,43,45,46,50,53,54,56,58-60,62,68-71,73,75,83,84,87-92,94-97,101-104,109,111,114,117-120,122,124,126 One study reported the prevalence at seven days;96 29 at 30 days;36,37,41,43,46,50,56,62,68-70,75,87-89,91,92,95,103,104,109,111,114,117,118,120,122,124,126 two at 60 days;54,119 11 at 90 days;41,53,75,83,84,90,94,97,101,102,117 four at 120 days;1,58-60 one at 180 days;120 and five at 365 days.45,58,71,73,117 Five studies reported the prevalence at more than one timepoint.58,75,117,120 Five studies reported the prevalence at 30 days in the same population.87-89,91,92 The pooled prevalence of VTE was 2.15% (95% CI 1.54 to 2.86, I2 = 100%, p < 0.001) at 30 days.
Deep vein thrombosis (DVT): the prevalence of DVT was reported in 30 studies (n = 509,841).36,37,46,50,56,58-60,68,69,71,83-85,87-90,94-97,109,111,114,117,119,120,124,126 One study reported the prevalence at seven days;96 19 at 30 days;36,37,46,50,56,68,69,85,87-89,95,109,111,114,117,120,124,126 one at 60 days;119 six at 90 days;83,84,90,94,97,117 three at 120 days;58-60 one at 180 days;120 and three at 365 days.58,71,117 Three studies reported the prevalence at more than one timepoint.58,117,120 Three studies reported the prevalence at 30 days in the same population.87-89 The pooled prevalence of DVT was 1.43% (95% CI 0.69 to 2.43, I2 = 100%, p < 0.001) at 30 days.
Pulmonary embolism (PE): the prevalence of PE was reported in 34 studies (n = 748,179).36,37,42,43,46,50,56,58-60,64,68,69,71,83,84,87-90,93-97,99,109,111,114,117,119,120,124,126 One study reported the prevalence at seven days;96 22 at 30 days;36,37,42,43,46,50,56,64,68,69,87-89,95,99,109,111,114,117,120,124,126 one at 60 days;119 six at 90 days;83,84,90,94,97,117 three at 120 days;58-60 one at 180 days;120 and four at 365 days.58,71,93,117 Three studies reported the prevalence at more than one timepoint.58,117,120 Three studies reported the prevalence at 30 days in the same population.87-89 The pooled prevalence of PE was 0.67% (95% CI 0.58 to 0.77, I2 = 84%, p < 0.001) at 30 days.
Mortality
The prevalence of mortality was reported in 64 studies (n = 1,145,400).1,8,14,35-38,40-46,48-50,52-54,56,58-60,62,65,68-74,76-78,81,87-90,93,95,98-101,103-105,107,109,111-121,123 One study reported the prevalence at seven days;100 42 at 30 days;8,35-38,42-44,48-50,52,54,56,59,62,68-70,72,77,78,87-89,95,98-101,103-105,107,109,111,113,114,117-119,121 seven at 90 days;41,48,53,81,90,101,112 five at 120 days;1,54,58-60 six at 180 days;8,46,76,113,120,123 and 17 at 365 days.14,40,45,58,65,71,73,74,77,81,93,101,105,107,115,116,123 There were 12 studies that reported the prevalence at more than one timepoint.8,48,54,58,59,81,101,105,107,113,123 Seven studies reported on the same population.52,78,87-89,105,107 The pooled prevalence of mortality was 6.19% (95% CI 5.45 to 6.97, I2 = 99%, p < 0.001) at 30 days and 21.8% (95% CI 19.1 to 24.6, I2 = 100%, p < 0.001) at 365 days.
Discussion
This review provides a comprehensive overview of all studies that reported the prevalence of complications after surgery in older adults with a hip fracture, using data from 2,521,300 patients.
There was a high prevalence of postoperative complications in this population. Approximately 2% of patients had further surgery for any cause on their previously operated hip in the first month, and 5% in the first year after surgery. The main indications were prosthesis dislocation, fixation failure, and deep SSI. These are higher than estimates from hip fracture registries in which reoperation rates are around 1% at 30 days to 2% at 120 days.127-129 It is likely that the true risk of reoperation is higher than that reported from registry sources. The data at one year also provide insight into the trajectory of reoperation rates beyond the routinely used follow-up points of 30 and 120 days.
A consistent pattern in the timing of the onset of complications was observed. Blood transfusion, AKI, and MI were the most common complications observed in the first week, while UTI and LRTI typically occurred in the first month. In contrast, prosthesis dislocation, fixation failure, and periprosthetic or peri-implant fracture were more frequent beyond this point. These findings are consistent with studies that investigated the timing of complications after hip fracture surgery but lacked data on late complications due to the short follow-up period.75,89
As expected, the pooled prevalence of complications increased at each subsequent timepoint in the meta-analysis. This is important to appreciate, as many of the observational studies of larger hip fracture populations have focused on complications occurring only during the index hospital admission.2,4,130 Recent work indicates that such studies under-report certain complications.1 It is evident that patients with a hip fracture continue to remain at high risk of developing complications after discharge from hospital and, in the case of further surgery related to the hip fracture, for at least one year after the first surgery. This has important implications for clinicians, who are likely to be involved in the care of these patients in the hospital and community setting.9
Strengths and limitations
The key strength of this systematic review is the systematic search of the worldwide literature on complications among older adults with hip fractures. Approximately two-thirds of studies were assessed to be of high quality, but there are some caveats to this. Studies that reported complications with hard endpoints such as reoperation tended to score higher than those which reported complications with soft endpoints, such as UTI. Therefore, the quality of reporting is likely to vary between complications. Furthermore, there are a number of limitations that may have biased the pooled estimates. First, the study populations were highly varied in terms of geography, demographics, fracture type, and operation. Second, different definitions of each complication were used between studies, which introduces inconsistency in measurement. Third, the results are vulnerable to surveillance bias and so the pooled prevalence is likely to underestimate the true prevalence of the complication. Fourth, there is uncertainty whether or not all patients were followed up, with increased rates of missing data, and hence lower follow-up rates, observed for studies with longer durations. Fifth, studies with higher mortality rates may report fewer complications, given that death is a competing risk for the development of complications. Finally, acute conditions diagnosed as postoperative complications may have existed preoperation but only detected later. These inherent limitations of the studies included in this systematic review may influence the pooled estimates, which should be acknowledged. After consideration of the aforementioned strengths and limitations, we postulate that the complication rates reported still underestimate the true real-world risks, which should be taken into account when using these results as a benchmark.
In conclusion, there is a high prevalence of complications in older adults who have had surgery for a hip fracture. However, there was substantial variation in the reporting of complications, with some complications better reported than others. This highlights the need for routine collection of complication data in registries and core outcome sets for clinical trials. Nonetheless, the summary statistics generated for each complication will be useful to clinicians and patients, as part of informed consent. Furthermore, they provide a reference range against which future studies can be assessed and inform power calculations for new studies of interventions in hip fracture.
References
1. Goh EL , Lerner RG , Achten J , Parsons N , Griffin XL , Costa PML . Complications following hip fracture: results from the World Hip Trauma Evaluation cohort study . Injury . 2020 ; 51 ( 6 ): 1331 – 1336 . Crossref PubMed Google Scholar
2. Prieto-Alhambra D , Reyes C , Sainz MS , et al. In-hospital care, complications, and 4-month mortality following a hip or proximal femur fracture: the Spanish registry of osteoporotic femur fractures prospective cohort study . Arch Osteoporos . 2018 ; 13 ( 1 ): 96 . Crossref PubMed Google Scholar
3. Hansson S , Rolfson O , Åkesson K , Nemes S , Leonardsson O , Rogmark C . Complications and patient-reported outcome after hip fracture. A consecutive annual cohort study of 664 patients . Injury . 2015 ; 46 ( 11 ): 2206 – 2211 . Crossref PubMed Google Scholar
4. Roche JJW , Wenn RT , Sahota O , Moran CG . Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study . BMJ . 2005 ; 331 ( 7529 ): 1374 . Crossref PubMed Google Scholar
5. Inacio MCS , Weiss JM , Miric A , Hunt JJ , Zohman GL , Paxton EW . A community-based hip fracture registry: population, methods, and outcomes . Perm J . 2015 ; 19 ( 3 ): 29 – 36 . Crossref PubMed Google Scholar
6. Pedersen AB , Ehrenstein V , Szépligeti SK , Sørensen HT . Hip fracture, comorbidity, and the risk of myocardial infarction and stroke: a Danish nationwide cohort study, 1995-2015 . J Bone Miner Res . 2017 ; 32 ( 12 ): 2339 – 2346 . Crossref PubMed Google Scholar
7. Protty MB , Aithal S , Hickey B , Pettit R , Johansen A . Mechanical prophylaxis after hip fracture: what is the risk of deep vein thrombosis? A retrospective observational study . BMJ Open . 2015 ; 5 ( 2 ): e006956 . Crossref PubMed Google Scholar
8. Foss NB , Palm H , Krasheninnikoff M , Kehlet H , Gebuhr P . Impact of surgical complications on length of stay after hip fracture surgery . Injury . 2007 ; 38 ( 7 ): 780 – 784 . Crossref PubMed Google Scholar
9. Leal J , Gray AM , Prieto-Alhambra D , et al. Impact of hip fracture on hospital care costs: a population-based study . Osteoporos Int . 2016 ; 27 ( 2 ): 549 – 558 . Crossref PubMed Google Scholar
10. Cuesta-Peredo D , Arteaga-Moreno F , Belenguer-Varea Á , et al. Influence of hospital adverse events and previous diagnoses on hospital care cost of patients with hip fracture . Arch Osteoporos . 2019 ; 14 ( 1 ): 88 . Crossref PubMed Google Scholar
11. Zeelenberg ML , Den Hartog D , Panneman MJM , Polinder S , Verhofstad MHJ , Van Lieshout EMM . Trends in incidence, health care consumption, and costs for proximal femoral fractures in the Netherlands between 2000 and 2019: a nationwide study . Osteoporos Int . 2023 ; 34 ( 8 ): 1389 – 1399 . Crossref PubMed Google Scholar
12. Kamel HK , Iqbal MA , Mogallapu R , Maas D , Hoffmann RG . Time to ambulation after hip fracture surgery: relation to hospitalization outcomes . J Gerontol A Biol Sci Med Sci . 2003 ; 58 ( 11 ): 1042 – 1045 . Crossref PubMed Google Scholar
13. Merten H , Johannesma PC , Lubberding S , et al. High risk of adverse events in hospitalised hip fracture patients of 65 years and older: results of a retrospective record review study . BMJ Open . 2015 ; 5 ( 9 ): e006663 . Crossref PubMed Google Scholar
14. Flikweert ER , Wendt KW , Diercks RL , et al. Complications after hip fracture surgery: are they preventable? Eur J Trauma Emerg Surg . 2018 ; 44 ( 4 ): 573 – 580 . Crossref PubMed Google Scholar
15. Haywood KL , Griffin XL , Achten J , Costa ML . Developing a core outcome set for hip fracture trials . Bone Joint J . 2014 ; 96-B ( 8 ): 1016 – 1023 . Crossref PubMed Google Scholar
16. Johansen A , Hall AJ , Ojeda-Thies C , Poacher AT , Costa ML , Global Fragility Fracture Network Hip Fracture Audit Special Interest Group . Standardization of global hip fracture audit could facilitate learning, improve quality, and guide evidence-based practice . Bone Joint J . 2023 ; 105-B ( 9 ): 1013 – 1019 . Crossref PubMed Google Scholar
17. No authors listed . American College of Surgeons National Surgical Quality Improvement Program: User Guide for the 2022 ACS NSQIP Participant Use Data File (PUF) . 2023 . https://www.facs.org/media/1nrdyqmr/nsqip_puf_userguide_2022.pdf ( date last accessed 17 December 2024 ). Google Scholar
18. Furey JG . Complications following hip fractures . J Chronic Dis . 1967 ; 20 ( 2 ): 103 – 113 . Crossref PubMed Google Scholar
19. Edelmuth SVCL , Sorio GN , Sprovieri FAA , Gali JC , Peron SF . Comorbidities, clinical intercurrences, and factors associated with mortality in elderly patients admitted for a hip fracture . Rev Bras Ortop . 2018 ; 53 ( 5 ): 543 – 551 . Crossref PubMed Google Scholar
20. Myers AH , Palmer MH , Engel BT , Warrenfeltz DJ , Parker JA . Mobility in older patients with hip fractures: examining prefracture status, complications, and outcomes at discharge from the acute-care hospital . J Orthop Trauma . 1996 ; 10 ( 2 ): 99 – 107 . Crossref PubMed Google Scholar
21. Memon K , Heer RS , Raza N , Moiz M . Reducing surgical site infections in fractured neck of femur patients: a closed loop audit and literature review . J Liaq Uni Med Health Sci . 2019 ; 18 ( 4 ): 258 – 261 . Crossref Google Scholar
22. Malkin S , Frankenburg F . Fractures of the hip: a three‐year survey in one hospital, including experience with the pugh nail procedure . J Am Geriatr Soc . 1978 ; 26 ( 11 ): 506 – 509 . Crossref PubMed Google Scholar
23. Jamal Sepah Y , Umer M , Khan A , Ullah Khan Niazi A . Functional outcome, mortality and in-hospital complications of operative treatment in elderly patients with hip fractures in the developing world . Int Orthop . 2010 ; 34 ( 3 ): 431 – 435 . Crossref PubMed Google Scholar
24. Dash SK , Panigrahi R , Palo N , Priyadarshi A , Biswal M . Fragility hip fractures in elderly patients in Bhubaneswar, India (2012-2014): a prospective multicenter study of 1031 elderly patients . Geriatr Orthop Surg Rehabil . 2015 ; 6 ( 1 ): 11 – 15 . Crossref PubMed Google Scholar
25. Duque-Sánchez J-D , Toro L-Á , González-Gómez F-I , Botero-Baena S-M , Duque G , Gómez F . One-year mortality after hip fracture surgery: urban-rural differences in the colombian andes . Arch Osteoporos . 2022 ; 17 ( 1 ): 111 . Crossref PubMed Google Scholar
26. Walter N , Szymski D , Kurtz SM , et al. Complications and associated risk factors after surgical management of proximal femoral fractures . Bone Jt Open . 2023 ; 4 ( 10 ): 801 – 807 . Crossref PubMed Google Scholar
27. Ogawa T , Onuma R , Kristensen MT , et al. Association between additional weekend rehabilitation and in-hospital mortality in patients with hip fractures . Bone Joint J . 2023 ; 105-B ( 8 ): 872 – 879 . Crossref PubMed Google Scholar
28. Moher D , Shamseer L , Clarke M , et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement . Syst Rev . 2015 ; 4 ( 1 ): 148 – 160 . Crossref PubMed Google Scholar
29. Wright J , Jones D . Search strategies to investigate decision making by older adults and appraisal by GPs following cancer symptoms . Research Data Leeds Repository . 2021 . https://archive.researchdata.leeds.ac.uk/904/ ( date last accessed 17 December 2024 ). Google Scholar
30. Haddaway NR , Grainger MJ , Gray CT . citationchaser: An R package and Shiny app for forward and backward citations chasing in academic searching . 2021 . https://estech.shinyapps.io/citationchaser/ ( date last accessed 19 November 2024 ). Google Scholar
31. Munn Z , Moola S , Lisy K , Riitano D , Tufanaru C . Methodological guidance for systematic reviews of observational epidemiological studies reporting prevalence and cumulative incidence data . Int J . 2015 ; 13 ( 3 ): 147 – 153 . Crossref PubMed Google Scholar
32. Deeks JJ , Higgins JPT , Altman DG . Analysing data and undertaking meta-analyses . Cochrane Handb Syst Rev Interv . 2019 ; 241 – 284 . Crossref Google Scholar
33. Viechtbauer W . Conducting meta-analyses in R with the metafor package . J Stat Soft . 2010 ; 36 ( 3 ): 1 – 48 . Crossref Google Scholar
34. Wang N . Conducting Meta-analyses of Proportions in R . JBDS . 2023 ; 3 ( 2 ): 1 – 61 . Crossref Google Scholar
35. Agrawal S , Turk R , Burton BN , Ingrande J , Gabriel RA . The association of preoperative delirium with postoperative outcomes following hip surgery in the elderly . J Clin Anesth . 2020 ; 60 : 28 – 33 . Crossref PubMed Google Scholar
36. Aldebeyan S , Nooh A , Aoude A , Weber MH , Harvey EJ . Hypoalbuminaemia-a marker of malnutrition and predictor of postoperative complications and mortality after hip fractures . Injury . 2017 ; 48 ( 2 ): 436 – 440 . Crossref PubMed Google Scholar
37. Arshi A , Lai WC , Iglesias BC , et al. Blood transfusion rates and predictors following geriatric hip fracture surgery . Hip Int . 2021 ; 31 ( 2 ): 272 – 279 . Crossref PubMed Google Scholar
38. Arshi A , Su L , Lee C , Sassoon AA , Zeegen EN , Stavrakis AI . Comparison of complication profiles for femoral neck, intertrochanteric, and subtrochanteric geriatric hip fractures . Arch Orthop Trauma Surg . 2023 ; 143 ( 1 ): 49 – 54 . Crossref PubMed Google Scholar
39. Atzmon R , Sharfman ZT , Efrati N , et al. Cerebrovascular accidents associated with hip fractures: morbidity and mortality-5-year survival . J Orthop Surg Res . 2018 ; 13 ( 1 ): 161 . Crossref PubMed Google Scholar
40. Batsis JA , Huddleston JM , Melton LJ 4th , et al. Body mass index and risk of adverse cardiac events in elderly patients with hip fracture: a population-based study . J Am Geriatr Soc . 2009 ; 57 ( 3 ): 419 – 426 . Crossref PubMed Google Scholar
41. Beauchamp-Chalifour P , Belzile ÉL , Michael R , et al. The risk of venous thromboembolism in surgically treated hip fracture: a retrospective cohort study of 5184 patients . Orthop Traumatol Surg Res . 2022 ; 108 ( 1 ): 103142 . Crossref PubMed Google Scholar
42. Bindner CT , Wester CJ , Ghanta RB , et al. Standardized protocol for hip fracture care leads to similar short-term outcomes despite socioeconomic differences in patient populations: a retrospective cohort study . Curr Orthop Pract . 2022 ; 33 ( 5 ): 428 – 433 . Crossref Google Scholar
43. Blanco JF , da Casa C , Pablos-Hernández C , González-Ramírez A , Julián-Enríquez JM , Díaz-Álvarez A . 30-day mortality after hip fracture surgery: influence of postoperative factors . PLoS One . 2021 ; 16 ( 2 ): e0246963 . Crossref PubMed Google Scholar
44. Bohl DD , Sershon RA , Saltzman BM , Darrith B , Della Valle CJ . Incidence, risk factors, and clinical implications of pneumonia after surgery for geriatric hip fracture . J Arthroplasty . 2018 ; 33 ( 5 ): 1552 – 1556 . Crossref PubMed Google Scholar
45. Bosch LC , Nathan K , Lu LY , Campbell ST , Gardner MJ , Bishop JA . Do-Not-Resuscitate status is an independent risk factor for medical complications and mortality among geriatric patients sustaining hip fractures . J Clin Orthop Trauma . 2021 ; 14 : 65 – 68 . Crossref PubMed Google Scholar
46. Bub C , Stapleton E , Iturriaga C , et al. Implementation of a geriatrics-focused orthopaedic and hospitalist fracture program decreases perioperative complications and improves resource utilization . J Orthop Trauma . 2022 ; 36 ( 4 ): 213 – 217 . Crossref PubMed Google Scholar
47. Capdevila A , Navarro M , Bori G , et al. Incidence and risk factors for infection when teicoplanin is included for prophylaxis in patients with hip fracture . Surg Infect . 2016 ; 17 ( 4 ): 381 – 384 . Crossref PubMed Google Scholar
48. Carson JL , Duff A , Berlin JA , et al. Perioperative blood transfusion and postoperative mortality . JAMA . 1998 ; 279 ( 3 ): 199 – 205 . Crossref PubMed Google Scholar
49. Charles-Lozoya S , Cobos-Aguilar H , Manilla-Muñoz E , De La Parra-Márquez ML , García-Hernández A , Rangel-Valenzuela JM . Survival at 30 days in elderly patients with hip fracture surgery who were exposed to hypothermia: survival study . Medicine . 2021 ; 100 ( 39 ): e27339 . Crossref PubMed Google Scholar
50. Chung AS , Hustedt JW , Walker R , Jones C , Lowe J , Russell GV . Increasing severity of malnutrition is associated with poorer 30-day outcomes in patients undergoing hip fracture surgery . J Orthop Trauma . 2018 ; 32 ( 4 ): 155 – 160 . Crossref PubMed Google Scholar
51. Cuchí E , García LG , Jiménez E , et al. Relationship between skin and urine colonization and surgical site infection in the proximal femur fracture: a prospective study . Int Orthop . 2020 ; 44 ( 6 ): 1031 – 1035 . Crossref PubMed Google Scholar
52. Daugaard C , Pedersen AB , Kristensen NR , Johnsen SP . Preoperative antithrombotic therapy and risk of blood transfusion and mortality following hip fracture surgery: a Danish nationwide cohort study . Osteoporos Int . 2019 ; 30 ( 3 ): 583 – 591 . Crossref PubMed Google Scholar
53. Desai V , Chan PH , Prentice HA , et al. Is anesthesia technique associated with a higher risk of mortality or complications within 90 days of surgery for geriatric patients with hip fractures? Clin Orthop Relat Res . 2018 ; 476 ( 6 ): 1178 – 1188 . Crossref PubMed Google Scholar
54. Doherty WJ , Stubbs TA , Chaplin A , et al. Prediction of postoperative outcomes following hip fracture surgery: independent validation and recalibration of the nottingham hip fracture score . J Am Med Dir Assoc . 2021 ; 22 ( 3 ): 663 – 669 . Crossref PubMed Google Scholar
55. Du P , Zhu Y , Guo J , et al. Incidence and risk factors associated with surgical site infection after surgically treated hip fractures in older adults: a retrospective cohort study . Aging Clin Exp Res . 2022 ; 34 ( 5 ): 1139 – 1148 . Crossref PubMed Google Scholar
56. Durand WM , Goodman AD , Johnson JP , Daniels AH . Assessment of 30-day mortality and complication rates associated with extended deep vein thrombosis prophylaxis following hip fracture surgery . Injury . 2018 ; 49 ( 6 ): 1141 – 1148 . Crossref PubMed Google Scholar
57. Dy CJ , Lane JM , Pan TJ , Parks ML , Lyman S . Racial and socioeconomic disparities in hip fracture care . J Bone Joint Surg Am . 2016 ; 98-A ( 10 ): 858 – 865 . Crossref PubMed Google Scholar
58. Ekström W , Al-Ani AN , Sääf M , Cederholm T , Ponzer S , Hedström M . Health related quality of life, reoperation rate and function in patients with diabetes mellitus and hip fracture--a 2 year follow-up study . Injury . 2013 ; 44 ( 6 ): 769 – 775 . Crossref PubMed Google Scholar
59. Ekström W , Samuelsson B , Ponzer S , Cederholm T , Thorngren KG , Hedström M . Sex effects on short-term complications after hip fracture: a prospective cohort study . CIA . 2015 ; 10 : 1259 . Crossref PubMed Google Scholar
60. Elete AR , Panwar Y , Dannaway J , Chen J , Thomas B . Assessing operative delay and complications in hip fracture patients on anticoagulants and antiplatelets . SAGE Open Med . 2023 ; 11 : 20503121231162410 . Crossref PubMed Google Scholar
61. Flikweert ER , Diercks RL , Izaks GJ , Wendt KW , Stevens M , Reininga IHF . Strict adherence to evidence-based protocol in choice of implants and surgical technique leads to fewer hip fracture reoperations . PLoS One . 2019 ; 14 ( 1 ): e0210239 . Crossref PubMed Google Scholar
62. Fu MC , Boddapati V , Gausden EB , Samuel AM , Russell LA , Lane JM . Surgery for a fracture of the hip within 24 hours of admission is independently associated with reduced short-term post-operative complications . Bone Joint J . 2017 ; 99-B ( 9 ): 1216 – 1222 . Crossref PubMed Google Scholar
63. Gadgaard NR , Varnum C , Nelissen RGHH , Vandenbroucke-Grauls C , Sørensen HT , Pedersen AB . Comorbidity and risk of infection among patients with hip fracture: a Danish population-based cohort study . Osteoporos Int . 2023 ; 34 ( 10 ): 1739 – 1749 . Crossref PubMed Google Scholar
64. Galivanche AR , Kebaish KJ , Adrados M , et al. Postoperative pressure ulcers after geriatric hip fracture surgery are predicted by defined preoperative comorbidities and postoperative complications . J Am Acad Orthop Surg . 2020 ; 28 ( 8 ): 342 – 351 . Crossref PubMed Google Scholar
65. Gjertsen JE , Dybvik E , Furnes O , et al. Improved outcome after hip fracture surgery in Norway . Acta Orthop . 2017 ; 88 ( 5 ): 505 – 511 . Crossref PubMed Google Scholar
66. Glassou EN , Kristensen N , Møller BK , Erikstrup C , Hansen TB , Pedersen AB . Impact of preadmission anti-inflammatory drug use on the risk of RBC transfusion in elderly hip fracture patients: a Danish nationwide cohort study, 2005-2016 . Transfusion . 2019 ; 59 ( 3 ): 935 – 944 . Crossref PubMed Google Scholar
67. Glassou EN , Kjørholt KK , Hansen TB , Pedersen AB . Delay in surgery, risk of hospital-treated infections and the prognostic impact of comorbidity in hip fracture patients. A Danish nationwide cohort study, 2005–2016 . Clin Epidemiol . 2019 ; 11 : 383 – 395 . Crossref PubMed Google Scholar
68. Goh EL , Gurung PK , Ma S , et al. Direct oral anticoagulants in the prevention of venous thromboembolism following surgery for hip fracture in older adults: a population-based cohort study . Geriatr Orthop Surg Rehabil . 2020 ; 11 : 2151459319897520 . Crossref PubMed Google Scholar
69. Goh EL , Chidambaram S , Rai S , Kannan A , Anand S . Timing of surgery for hip fracture in patients on direct oral anti-coagulants: a population-based cohort study . Geriatr Orthop Surg Rehabil . 2022 ; 13 : 1 – 6 . Crossref PubMed Google Scholar
70. Golinvaux NS , Bohl DD , Basques BA , Baumgaertner MR , Grauer JN . Diabetes confers little to no increased risk of postoperative complications after hip fracture surgery in geriatric patients . Clin Orthop Relat Res . 2015 ; 473 ( 3 ): 1043 – 1051 . Crossref PubMed Google Scholar
71. Griffin XL , Parsons N , Achten J , Fernandez M , Costa ML . Recovery of health-related quality of life in a United Kingdom hip fracture population. The Warwick Hip Trauma Evaluation--a prospective cohort study . Bone Joint J . 2015 ; 97-B ( 3 ): 372 – 382 . Crossref PubMed Google Scholar
72. Haynes MS , Alder KD , Toombs C , Amakiri IC , Rubin LE , Grauer JN . Predictors and sequelae of postoperative delirium in a geriatric patient population with hip fracture . J Am Acad Orthop Surg Glob Res Rev . 2021 ; 5 ( 5 ): e20.00221 . Crossref PubMed Google Scholar
73. Hjelholt TJ , Johnsen SP , Brynningsen PK , Pedersen AB . Association of CHA2DS2-vasc score with stroke, thromboembolism, and death in hip fracture patients . J Am Geriatr Soc . 2020 ; 68 ( 8 ): 1698 – 1705 . Crossref PubMed Google Scholar
74. Huddleston JM , Gullerud RE , Smither F , et al. Myocardial infarction after hip fracture repair: a population‐based study . J Am Geriatr Soc . 2012 ; 60 ( 11 ): 2020 – 2026 . Crossref PubMed Google Scholar
75. Kammien AJ , Ratnasamy PP , Caruana DL , Grauer JN . Timing of adverse events within 90 days of hip fracture surgery: a database study . J Am Acad Orthop Surg . 2023 ; 31 ( 5 ): 245 – 251 . Crossref PubMed Google Scholar
76. Khunda A , Jafari M , Alazzawi S , Mountain A , Hui ACW . Mortality and re-operation rate after proximal femoral fracture surgery by trainees . J Orthop Surg (Hong Kong) . 2013 ; 21 ( 1 ): 87 – 91 . Crossref PubMed Google Scholar
77. Kjærvik C , Stensland E , Byhring HS , Gjertsen JE , Dybvik E , Søreide O . Hip fracture treatment in Norway: deviation from evidence-based treatment guidelines: data from the Norwegian Hip Fracture Register, 2014 to 2018 . Bone Jt Open . 2020 ; 1 ( 10 ): 644 – 653 . Crossref PubMed Google Scholar
78. Kjørholt KE , Kristensen NR , Prieto-Alhambra D , Johnsen SP , Pedersen AB . Increased risk of mortality after postoperative infection in hip fracture patients . Bone . 2019 ; 127 : 563 – 570 . Crossref PubMed Google Scholar
79. Kjørholt KE , Johnsen SP , Kristensen NR , Prieto-Alhambra D , Pedersen AB . Increasing risk of hospital-treated infections and community-based antibiotic use after hip fracture surgery: a nationwide study 2005-2016 . J Bone Miner Res . 2019 ; 34 ( 3 ): 437 – 446 . Crossref PubMed Google Scholar
80. Kristensen NK , Lange J , Frøslev T , Pedersen AB . Risk of reoperation due to surgical site infection in 74,771 hip fracture patients: a Danish nationwide cohort study . Acta Orthop . 2022 ; 93 : 760 – 766 . Crossref PubMed Google Scholar
81. Kulshrestha V , Sood M , Kumar S , Sharma P , Yadav YK . Outcomes of fast-track multidisciplinary care of hip fractures in veterans: a geriatric hip fracture program report . Clin Orthop Surg . 2019 ; 11 ( 4 ): 388 – 395 . Crossref PubMed Google Scholar
82. Küpeli İ , Ünver S . The correlation between preoperative and postoperative hypoalbuminaemia and the development of acute kidney injury with respect to the KDIGO criteria in the hip fracture surgery in elderly patients . Turk J Anaesthesiol Reanim . 2020 ; 48 ( 1 ): 38 – 43 . Crossref PubMed Google Scholar
83. Lee Y-K , Choi Y-H , Ha Y-C , Lim J-Y , Koo K-H . Does venous thromboembolism affect rehabilitation after hip fracture surgery? Yonsei Med J . 2013 ; 54 ( 4 ): 1015 – 1019 . Crossref PubMed Google Scholar
84. Lin Y-C , Lee S-H , Chen I-J , et al. Symptomatic pulmonary embolism following hip fracture: a nationwide study . Thromb Res . 2018 ; 172 : 120 – 127 . Crossref PubMed Google Scholar
85. Ling XW , Howe TS , Koh JSB , Wong MK , Ng ACM . Preoperative thyroid dysfunction predicts 30-day postoperative complications in elderly patients with hip fracture . Geriatr Orthop Surg Rehabil . 2013 ; 4 ( 2 ): 43 – 49 . Crossref PubMed Google Scholar
86. Ma T , Lu K , Song L , et al. Modifiable factors as current smoking, hypoalbumin, and elevated fasting blood glucose level increased the SSI risk following elderly hip fracture surgery . J Invest Surg . 2020 ; 33 ( 8 ): 750 – 758 . Crossref PubMed Google Scholar
87. Malik AT , Quatman CE , Phieffer LS , Ly TV , Wiseman J , Khan SN . The impact of metabolic syndrome on 30-day outcomes in geriatric hip fracture surgeries . Eur J Orthop Surg Traumatol . 2019 ; 29 ( 2 ): 427 – 433 . Crossref PubMed Google Scholar
88. Malik AT , Quatman CE , Phieffer LS , Ly TV , Jain N , Khan SN . Transfer status in geriatric hip fracture surgery - an independent risk factor associated with 30-day mortality, re-operations and complications . J Clin Orthop Trauma . 2019 ; 10 ( Suppl 1 ): S65 – S70 . Crossref PubMed Google Scholar
89. Malik AT , Quatman CE , Phieffer LS , Ly TV , Khan SN . Timing of complications following surgery for geriatric hip fractures . J Clin Orthop Trauma . 2019 ; 10 ( 5 ): 904 – 911 . Crossref PubMed Google Scholar
90. McDonald M , Ward L , Wortham H , Sorenson B , Jarski R , El-Yussif E . Effect of a 6 AM–9 AM dedicated orthopaedic trauma room on hip fracture outcomes in a community level II trauma center . J Orthop Trauma . 2021 ; 35 ( 5 ): 245 – 251 . Crossref PubMed Google Scholar
91. Metcalfe D , Salim A , Olufajo O , et al. Hospital case volume and outcomes for proximal femoral fractures in the USA: an observational study . BMJ Open . 2016 ; 6 ( 4 ): e010743 . Crossref PubMed Google Scholar
92. Metcalfe D , Olufajo OA , Zogg CK , et al. Are older adults with hip fractures disadvantaged in level 1 trauma centers? Med Care . 2016 ; 54 ( 6 ): 616 – 622 . Crossref PubMed Google Scholar
93. Meyer AC , Eklund H , Hedström M , Modig K . The ASA score predicts infections, cardiovascular complications, and hospital readmissions after hip fracture - a nationwide cohort study . Osteoporos Int . 2021 ; 32 ( 11 ): 2185 – 2192 . Crossref PubMed Google Scholar
94. Millar JS , Lawes CM , Farrington B , et al. Incidence of venous thromboembolism after total hip, total knee and hip fracture surgery at Waitemata District Health Board following a peer-reviewed audit . N Z Med J . 2020 ; 133 ( 1511 ): 52 – 60 . PubMed Google Scholar
95. Mitchell SM , Chung AS , Walker JB , Hustedt JW , Russell GV , Jones CB . Delay in hip fracture surgery prolongs postoperative hospital length of stay but does not adversely affect outcomes at 30 days . J Orthop Trauma . 2018 ; 32 ( 12 ): 629 – 633 . Crossref PubMed Google Scholar
96. Montrey JS , Kistner RL , Kong AY , et al. Thromboembolism following hip fracture . J Trauma . 1985 ; 25 ( 6 ): 534 – 537 . Crossref PubMed Google Scholar
97. Mula V , Parikh S , Suresh S , Bottle A , Loeffler M , Alam M . Venous thromboembolism rates after hip and knee arthroplasty and hip fractures . BMC Musculoskelet Disord . 2020 ; 21 ( 1 ): 95 . Crossref PubMed Google Scholar
98. Murray CE , Fuchs A , Grünewald H , Godkin O , Südkamp NP , Konstantinidis L . Identifying disparities in the management of hip fractures within europe: a comparison of 3 health-care systems . Geriatr Orthop Surg Rehabil . 2019 ; 10 : 2151459319872941 . Crossref PubMed Google Scholar
99. Nayar SK , Marrache M , Ali I , et al. Racial disparity in time to surgery and complications for hip fracture patients . Clin Orthop Surg . 2020 ; 12 ( 4 ): 430 – 434 . Crossref PubMed Google Scholar
100. O’Hara DA , Duff A , Berlin JA , et al. The effect of anesthetic technique on postoperative outcomes in hip fracture repair . Anesthesiology . 2000 ; 92 ( 4 ): 947 – 957 . Crossref PubMed Google Scholar
101. Okike K , Chan PH , Paxton EW . Effect of surgeon and hospital volume on morbidity and mortality after hip fracture . J Bone Joint Surg Am . 2017 ; 99-A ( 18 ): 1547 – 1553 . Crossref PubMed Google Scholar
102. Oster G , Ollendorf DA , Vera-Llonch M , Hagiwara M , Berger A , Edelsberg J . Economic consequences of venous thromboembolism following major orthopedic surgery . Ann Pharmacother . 2004 ; 38 ( 3 ): 377 – 382 . Crossref PubMed Google Scholar
103. Ottesen TD , McLynn RP , Galivanche AR , et al. Increased complications in geriatric patients with a fracture of the hip whose postoperative weight-bearing is restricted: an analysis of 4918 patients . Bone Joint J . 2018 ; 100-B ( 10 ): 1377 – 1384 . Crossref PubMed Google Scholar
104. Patterson JT , Bohl DD , Basques BA , Arzeno AH , Grauer JN . Does preoperative pneumonia affect complications of geriatric hip fracture surgery? Am J Orthop . 2017 ; 46 ( 3 ): E177 – E185 . PubMed Google Scholar
105. Pedersen AB , Christiansen CF , Gammelager H , Kahlert J , Sørensen HT . Risk of acute renal failure and mortality after surgery for a fracture of the hip: a population-based cohort study . Bone Joint J . 2016 ; 98-B ( 8 ): 1112 – 1118 . Crossref PubMed Google Scholar
106. Pedersen AB , Cronin Fenton D , Nørgaard M , Kristensen NR , Kuno Møller B , Erikstrup C . Body mass index, risk of allogeneic red blood cell transfusion, and mortality in elderly patients undergoing hip fracture surgery . Osteoporos Int . 2016 ; 27 ( 9 ): 2765 – 2775 . Crossref PubMed Google Scholar
107. Pedersen AB , Gammelager H , Kahlert J , Sørensen HT , Christiansen CF . Impact of body mass index on risk of acute kidney injury and mortality in elderly patients undergoing hip fracture surgery . Osteoporos Int . 2017 ; 28 ( 3 ): 1087 – 1097 . Crossref PubMed Google Scholar
108. Popa AS , Rabinstein AA , Huddleston PM , Larson DR , Gullerud RE , Huddleston JM . Predictors of ischemic stroke after hip operation: a population-based study . J Hosp Med . 2009 ; 4 ( 5 ): 298 – 303 . Crossref PubMed Google Scholar
109. Porter SB , Pla R , Chow JH , et al. Preoperative pressure ulcers, mortality, and complications in older hip fracture surgery patients . J Am Acad Orthop Surg Glob Res Rev . 2022 ; 6 ( 11 ): e22.00117 . Crossref PubMed Google Scholar
110. Probert N , Andersson ÅG , Magnuson A , Kjellberg E , Wretenberg P . Surgical-site infection after hip fracture surgery: preoperative full-body disinfection compared to local disinfection of the surgical site-a population-based observational cohort study . Eur Geriatr Med . 2022 ; 13 ( 5 ): 1089 – 1097 . Crossref PubMed Google Scholar
111. Pugely AJ , Martin CT , Gao Y , Klocke NF , Callaghan JJ , Marsh JL . A risk calculator for short-term morbidity and mortality after hip fracture surgery . J Orthop Trauma . 2014 ; 28 ( 2 ): 63 – 69 . Crossref PubMed Google Scholar
112. Ravi B , Pincus D , Wasserstein D , et al. Association of overlapping surgery with increased risk for complications following hip surgery: a population-based, matched cohort study . JAMA Intern Med . 2018 ; 178 ( 1 ): 75 – 83 . Crossref PubMed Google Scholar
113. Rincón-Hoyos JA , Vallejo-Yepes P , Restrepo-Giraldo JN , et al. Morbidity and mortality in hip surgery patients due to fracture during the COVID-19 pandemic . Injury . 2023 ; 54 Suppl 6 : 110731 . Crossref PubMed Google Scholar
114. Rodkey DL , Pezzi A , Hymes R . Effects of spinal anesthesia in geriatric hip fracture: a propensity-matched study . J Orthop Trauma . 2022 ; 36 ( 5 ): 234 – 238 . Crossref PubMed Google Scholar
115. Frenkel Rutenberg T , Vitenberg M , Haviv B , Velkes S . Timing of physiotherapy following fragility hip fracture: delays cost lives . Arch Orthop Trauma Surg . 2018 ; 138 ( 11 ): 1519 – 1524 . Crossref PubMed Google Scholar
116. Frenkel Rutenberg T , Vintenberg M , Khamudis A , et al. Outcome of fragility hip fractures in elderly patients: does diabetes mellitus and its severity matter? Arch Gerontol Geriatr . 2021 ; 93 : 104297 . Crossref PubMed Google Scholar
117. Shen C-Y , Hsiao C-H , Tsai W , Chang W-H , Chen T-H . Associations between hip fracture operation waiting time and complications in Asian geriatric patients: a Taiwan medical center study . Int J Environ Res Public Health . 2021 ; 18 ( 6 ): 2848 . Crossref PubMed Google Scholar
118. Stahl CC , Funk LM , Schumacher JR , Zarzaur BL , Scarborough JE . The relative impact of specific postoperative complications on older patients undergoing hip fracture repair . Jt Comm J Qual Patient Saf . 2021 ; 47 ( 4 ): 210 – 216 . Crossref PubMed Google Scholar
119. Stubbs TA , Doherty WJ , Chaplin A , et al. Using pre-fracture mobility to augment prediction of post-operative outcomes in hip fracture . Eur Geriatr Med . 2023 ; 14 ( 2 ): 285 – 293 . Crossref PubMed Google Scholar
120. Sun L , Wang C , Zhang M , Li X , Zhao B . The surgical timing and prognoses of elderly patients with hip fractures: a retrospective analysis . Clin Interv Aging . 2023 ; 18 : 891 – 899 . Crossref PubMed Google Scholar
121. Tarrant SM , Attia J , Balogh ZJ . The influence of weight-bearing status on post-operative mobility and outcomes in geriatric hip fracture . Eur J Trauma Emerg Surg . 2022 ; 48 ( 5 ): 4093 – 4103 . Crossref PubMed Google Scholar
122. Tsang STJ , Aitken SA , Golay SK , Silverwood RK , Biant LC . When does hip fracture surgery fail? Injury . 2014 ; 45 ( 7 ): 1059 – 1065 . Crossref PubMed Google Scholar
123. Weatherall M . One year follow up of patients with fracture of the proximal femur . N Z Med J . 1994 ; 107 ( 983 ): 308 – 309 . PubMed Google Scholar
124. Yhim H‐Y , Jang M‐J , Bang S‐M , et al. Incidence of venous thromboembolism following major surgery in Korea: from the health insurance review and assessment service database . J Thromb Haemost . 2014 ; 12 ( 7 ): 1035 – 1043 . Crossref PubMed Google Scholar
125. Yu L , Zhu Y , Chen W , Bu H , Zhang Y . Incidence and risk factors associated with postoperative stroke in the elderly patients undergoing hip fracture surgery . J Orthop Surg Res . 2020 ; 15 ( 1 ): 429 . Crossref PubMed Google Scholar
126. Zheng X , Jia R , Li Y , Liu T , Wang Z . Omega-3 fatty acids reduce post-operative risk of deep vein thrombosis and pulmonary embolism after surgery for elderly patients with proximal femoral fractures: a randomized placebo-controlled, double-blind clinical trial . Int Orthop . 2020 ; 44 ( 10 ): 2089 – 2093 . Crossref PubMed Google Scholar
127. Ellanti P , Cushen B , Galbraith A , Brent L , Hurson C , Ahern E . Improving hip fracture care in Ireland: a preliminary report of the Irish hip fracture database . J Osteoporos . 2014 ; 2014 : 1 – 7 . Crossref PubMed Google Scholar
128. No authors listed . 15 Years of Quality Improvement: The 2023 National Hip Fracture Database Report on 2022 . National Hip Fracture Database , 2023 . https://www.nhfd.co.uk/reportopen/NHFD-2023+Annual+Report ( date last accessed 17 December 2024 ). Google Scholar
129. No authors listed . Annual Report 2023 . Australian & New Zealand Hip Fracture Registry , 2023 . https://anzhfr.org/wp-content/uploads/sites/1164/2023/09/ANZHFR-2023-Annual-Report-%E2%80%93-Clinical-Care-Standard-Report-Print-Version-%E2%80%93-FINAL.pdf ( date last accessed 17 December 2024 ). Crossref PubMed Google Scholar
130. Lawrence VA , Hilsenbeck SG , Noveck H , Poses RM , Carson JL . Medical complications and outcomes after hip fracture repair . Arch Intern Med . 2002 ; 162 ( 18 ): 2053 – 2057 . Crossref PubMed Google Scholar
Author contributions
E. L. Goh: Conceptualization, Formal analysis, Investigation, Methodology, Writing – original draft, Writing – review & editing, Data curation, Project administration
A. Khatri: Investigation, Writing – original draft, Data curation
A. B. Costa: Investigation, Writing – original draft, Data curation
A. Ting: Investigation, Writing – original draft, Data curation
K. Steiner: Methodology, Writing – original draft, Resources, Software
M. E. Png: Conceptualization, Methodology, Writing – original draft, Resources, Software, Supervision, Validation, Writing – review & editing
D. Metcalfe: Conceptualization, Methodology, Writing – original draft, Supervision, Writing – review & editing
J. A. Cook: Conceptualization, Methodology, Writing – original draft, Formal analysis, Supervision, Validation, Writing – review & editing
M. L. Costa: Conceptualization, Methodology, Writing – original draft, Project administration, Supervision, Validation, Visualization, Writing – review & editing
Funding statement
The authors disclose receipt of the following financial or material support for the research, authorship, and/or publication of this article: National Institute for Health and Care Research (NIHR) institutional research grant.
ICMJE COI statement
E. L. Goh reports an institutional research grant from National Institute for Health and Care Research (NIHR) which enabled research for this study. M. L. Costa's employer, the University of Oxford, receives research grant funding from NIHR and Wellcome for research into musculoskeletal trauma. D. Metcalfe reports an institutional research grant from NIHR and an institutional programme grant from the Kadoorie Charitable Foundation, neither of which are related to this study.
Data sharing
All data generated or analyzed during this study are included in the published article and/or in the supplementary material.
Open access funding
The open access fee for this article was funded by the NIHR Oxford Biomedical Research Centre.
Open access statement
This article is distributed under the terms of the Creative Commons Attributions (CC BY 4.0) licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium or format, provided the original author and source are credited.
Supplementary material
Search strategies, characteristics of the included studies and their populations, forest plots, and results of the meta-analysis including sensitivity and subgroup analyses.
Social media
Follow E. L. Goh on X @gohenlin
Follow D. Metcalfe on X @TraumaDataDoc
Follow M. L. Costa on X @Oxford_Trauma
This article was primary edited by G. Scott.
