experimental hip surgery

5 Things to Know About Mako Robotic Hip Replacement Surgery

Your hip joint can experience wear-and-tear due to degenerative conditions like arthritis or from overuse or traumatic injury. Without a healthy hip joint, your movements are constrained and uncomfortable.

Surgical hip replacement is an effective way to revitalize your hip joint, keeping you moving and comfortable for years to come. At Twin Palm Orthopedics , located in Ocala, Florida, our team stays at the front of surgical medicine and robotic surgery to give you the best possible post-procedure outcome.

Our team, led by Dr. Derek Farr and Dr. Nirav Gupta , uses Mako® robotic-arm-assisted technology during hip replacement surgeries. Mako robotic hip replacement surgery offers several improvements over traditional techniques. Here’s what you need to know about Mako robotic hip replacement surgery.

1. Computer imaging assistance

Before your hip replacement procedure at Twin Palm Orthopedics, our team uses a CT scan to make an accurate 3D model of your affected hip. We place virtual implants on the computer model of your hip, creating a perfect match. Then, we send the enhanced model to the robotic arm of the Mako system.

During your robotic hip replacement surgery, also known as Makoplasty , your surgeon uses computer screens to review live feedback of your implant placements. Everyone’s hips are slightly different, so perfect placement of your hip joint implants makes a significant difference in your post-procedure hip replacement outcomes.

2. High degree of accuracy

Mako robotic-arm technology helps our team work through a smaller incision with a high degree of accuracy. During your hip replacement procedure, robotic monitoring technology ensures that bone ends, cartilage, and joints are all completely and effectively replaced with implants before our team closes your incisions to complete your surgery.

3. Minimally invasive surgery

Robotic-assisted surgery combines human expertise with computer precision for your benefit. We keep your Makoplasty as minimally invasive, with as little tissue and muscle damage as possible.

In some cases, our team may be able to perform your hip replacement surgery using a less invasive approach known as an Anterolateral approach. Instead of creating a long incision in the back of your leg or posterior, the anterolateral approach avoids cutting your leg muscles, shortening your recovery time.

4. Lower risks of complications

With less trauma to tissue and muscle, your robotic hip replacement surgery has fewer risks of complications than traditional, non-robotic surgery. Your procedure at Twin Palm Orthopedics is typically performed on an outpatient basis, so you can head home the day of your surgery.

5. Reduced recovery time

The benefits of Mako robotic hip replacement surgery include faster recovery times. Your provider at Twin Palm Orthopedics can help you understand what you’ll need to plan on for your post-surgery recovery.

Another benefit of Mako robotic-assisted surgery is a lower revision rate and a greater likelihood of total comfort once you’ve completed your full recovery.

Learn more about robotic-assisted hip surgery by getting in touch with our team at Twin Palm Orthopedics. Schedule your appointment online or call now to book.

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Doctors Find Alternative to Total Hip Replacement

The procedure uses a cement-like material to repair damaged pelvic bones.

More than 300,000 patients in the U.S. have hip-replacement surgery each year, which can require grueling rehabilitation and months of recovery before they can get back to normal. But now, orthopedic surgeons are employing a new, easier alternative called subchondroplasty , in which a damaged hip is strengthened by injecting a cement-like material.

W. Kelton Vasileff, an orthopedic surgeon at the Ohio State University Wexner Medical Center, says the procedure originally was developed to treat ailing knees. It usually begins with surgeons performing an arthroscopy, in which they reshape the hip socket to eliminate any pinching, clean up damaged cartilage and resolve other problems. Then they inject the cement-like material, which solidifies within minutes.

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Eventually, after a couple of years, the patient’s body will replace the material by growing new bone, he says.

According to Vasileff, recovering from a subchondroplasty is far less arduous than a total hip replacement, in which surgeons completely remove the damaged femoral head and the cartilage surface of the socket and replace them with artificial parts.

“Usually, you’re up walking quickly and pretty normally within a month, without crutches or a walker ,” he said of the new procedure. A return to full activity, including playing sports, can take six to nine months, he said. 

Vasileff says he has used the procedure to repair the hips of patients from their 20s to 50s, but he thinks it also would work on older patients as long as they don’t already have a lot of arthritis. 

Subchondroplasty also eliminates the risk of implants wearing out, requiring additional surgery, a problem that younger and physically active hip-replacement patients can face.

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Landmark study approved to evaluate Hip Innovation Technology’s Reverse Hip Replacement System

Home / News / Landmark study approved to evaluate Hip Innovation Technology’s Reverse Hip Replacement System

HIT’s Reverse Hip Replacement System could revolutionise total hip replacement surgery

Hip Innovation Technology, LLC (HIT), a medical device company developing innovative orthopaedic device solutions to advance the quality of life and quality of care for patients, has received FDA (Food and Drug Administration) Investigational Device Exemption (IDE) approval to initiate a pivotal clinical study to further evaluate the company’s Reverse Hip Replacement System (Reverse HRS) for use in primary total hip arthroplasty (THA).

The clinical study objective is to evaluate the safety and effectiveness of the Reverse HRS in patients undergoing THA. Safety will be assessed through the collection of device-related adverse events and patient quality of life metrics. Effectiveness will be evaluated using clinical, radiologic, and patient-reported outcomes.

“The Reverse HRS is a unique hip implant design that represents a significant advancement for patients requiring total hip arthroplasty,” said George Diamantoni, Hip Innovation Technology’s Co-Founder and Chief Executive Officer. “In our pivotal study we will further evaluate potential Reverse HRS patient benefits including hip stability at extended ranges of motion, reduced risk of device dislocation, and greater latitude for placement of hip components.”

In an ongoing 100-patient clinical study, the company has collected outcomes data from multiple sources including radiostereometric analysis (RSA). RSA is a state-of-the-art x-ray technique used to evaluate device micro-motion and wear. Data from the first 21 patients demonstrates minimal migration between 12 and 24 months for both the femoral and acetabular components. Mean migration was below detection and no migration concern was identified among all study patients. Importantly, patient Recorded Outcome Measure (PROM) data suggest significant improvement from pre- to post-operative patient and physician perspectives.

“The Reverse HRS first phase RSA clinical data evaluating implant micro-motion of the acetabular and femoral components has demonstrated each to be at a “not at risk” category for aseptic loosening indicating predictable long-term fixation,” said Steve MacDonald, MD, Professor and JC Kennedy Chairman of Orthopaedic Surgery at the University of Western Ontario in London, Ontario, Canada. “The FDA IDE trial that will begin in 2022 will further assess the Reverse HRS clinical performance in multiple sites, in the U.S.”

Total hip replacements are one of the most effective ways to reduce joint pain and improve functioning for patients with advanced hip problems. According to the American Academy of Orthopaedic Surgeons (AAOS), over 450,000 hip replacements are performed each year in the U.S.

For more information, visit: http://www.hipinnovationtechnology.com/

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Total Hip Arthroplasty — New Advance Changes the Game

Hip Innovation Technology Advances Reverse Hip Replacement System

February 9, 2023 – OrthoSpineNews –

• What are some of the shortcomings of current Total Hip Arthroplasty?

Total Hip Arthroplasty (THA) was introduced in the late 1950s by the innovative surgeon John Charnley, MD. Since that time, only minor incremental improvements in THA device concepts and refinements have been made.

While numerous Hip Implant Systems are available, all possess the same functional designs with minimal differentiation. All systems maintain a femoral stem with an attached ball and an acetabular cup component.

Although skilled surgeons have optimized existing Hip Implant System offerings, significant challenges associated with THA remain. Primary complications are instability and dislocation, component positioning / placement and edge loading. Unfortunately, all these potential THA complications can be serious.

The most significant THA complications causing the greatest physician concern, increased health care costs and reduced patient satisfaction are dislocation and instability. Certain component positions can cause the ball of the hip prosthesis to sublux and/or dislocate. To avoid this, patients are sometimes advised after surgery not to bend more than 90 degrees at the hip and to not let their leg cross the midline of the body. The risk for dislocation is greatest in the first few months after surgery while the tissues are healing.

Accurate positioning of implant components during total hip arthroplasty is a challenging and critical step in hip replacement. Placement of the acetabular cup is of immense importance since nearly every deviation from the ideal center of rotation negatively influences endoprosthesis survival, polyethylene wear and hip load. Unfortunately, malposition of acetabular cups is quite common. In some cases, it may be unavoidable due to anatomical limitations that can affect cup placement (e.g. hip dysplasia, obesity, etc.).

Edge loading is a chiseling effect that can occur when the ball of the implant presses on the socket edge. Edge loading is associated with acetabular cup malposition and may cause accelerated component wear and increased debris particles that heighten the likelihood of osteolysis and subsequent loosening and failure of the implant.

• How does the Reverse Hip Replacement System (Reverse HRS) overcome the challenges of traditional THA?

The Hip Innovation Technology (HIT) Reverse Hip Replacement System (Reverse HRS) possesses unique design features that may reduce or potentially eliminate common complications associated with THA. The Reverse HRS is a unique hip implant design that the company believes represents breakthrough technology and a significant advancement for THA.

The Reverse HRS is a unique hip implant design that possesses a ball at the center of the acetabular cup, which articulates with a femoral cup attached to the femoral stem. During motion, the edge of the femoral cup will interlock in the space situated between the acetabular ball and the acetabular cup.  The Reverse HRS can be implanted in accordance with current surgical technique, to be compatible with posterior, lateral or anterior approaches and to provide a greater degree of latitude for placement of hip components relative to current designs.

• Who invented this technology?

Zafer Termanini, MD, an orthopedic surgeon, invented and designed the HIT Reverse Hip Replacement System (Reverse HRS).

• What stage of development is Reverse HRS?

Hip Innovation Technology , has initiated its pivotal Investigational Device Exemption (IDE) clinical study to evaluate the Reverse HRS in primary total hip arthroplasty (THA). This study has started and is currently enrolling patients.

• If available, will all THA patients be candidates for Reverse HRS? Or is this option only for certain patients?

The Reverse HRS is designed for use in all patients who are eligible for THA.  The Reverser HRS allows forgiving placement of the acetabular cup which means patients suffering from spinal-pelvis disorders may be ideally suited for this reverse design.

Josh Sandberg

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Mayo Clinic's approach

Mayo Clinic doctors with training in bone and joint surgery (orthopedic surgeons), arthritis (rheumatologists), physical medicine and rehabilitation, and imaging techniques (radiologists) work together as a team to treat people who have hip replacement surgery.

This becomes particularly important in surgeries to correct complex problems in hip joints that have significant deformities.

The Mayo Clinic Total Joint Registry contains information on every joint replacement surgery performed at Mayo Clinic. The registry helps Mayo Clinic doctors determine which surgical technique and prosthesis type will be the most effective for you. It also has led to many improvements in surgical techniques and prosthesis designs.

Advanced technology

Techniques for hip replacement are evolving. As surgeons continue to develop less invasive surgical techniques, these techniques might reduce recovery time and pain.

Orthopedic surgeons at Mayo Clinic use new combinations of regional anesthesia and pain relief techniques that can reduce the need for general anesthesia and intravenous narcotic pain medications, which can speed recovery.

Recent research published by Mayo Clinic doctors include studies that examine:

• Different types of artificial joint components
• Techniques that reduce the risk of leg lengths not matching
• Ways to reduce blood loss during hip replacement surgery
• Strategies to reduce the risk of the prosthesis becoming infected

Nationally recognized expertise

Mayo Clinic in Rochester, Minnesota, Mayo Clinic in Phoenix/Scottsdale, Arizona, and Mayo Clinic in Jacksonville, Florida, are ranked among the Best Hospitals for orthopedics by U.S. News & World Report.

• Hip replacement. National Institute of Arthritis and Musculoskeletal and Skin Diseases. https://www.niams.nih.gov/health-topics/hip-replacement-surgery/advanced. Accessed Nov. 2, 2021.
• Erens GA, et al. Total hip arthroplasty. https://www.uptodate.com/contents/search. Accessed Nov. 2, 2021.
• Total hip replacement. American Academy of Orthopaedic Surgeons. https://orthoinfo.aaos.org/en/treatment/total-hip-replacement. Accessed Nov. 2, 2021.
• Goldman L, et al., eds. Surgical treatment of joint diseases. In: Goldman-Cecil Medicine. 26th ed. Elsevier; 2020. https://www.clinicalkey.com. Accessed Nov. 2, 2021.
• Erens GA, et al. Complications of total hip arthroplasty. https://www.uptodate.com/contents/search. Accessed Nov. 2, 2021.
• Azar FM, et al. Arthroplasty of the hip. In: Campbell's Operative Orthopaedics. 14th ed. Elsevier; 2021. https://www.clinicalkey.com. Accessed Nov. 2, 2021.
• Office of Patient Education. Total hip replacement surgery. Mayo Clinic; 2018.
• Sierra RJ (expert opinion). Mayo Clinic. Dec. 8, 2021.
• Jensen NA. Allscripts EPSi. Mayo Clinic. Dec. 10, 2021.
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A NEW, MINIMALLY INVASIVE HIP REPLACEMENT TECHNIQUE (ANTERIOR APPROACH)

Hip Replacement Surgery

Anterior Hip Replacement Surgery

How Is Anterior Hip Replacement Done?

Anterior Hip Replacement Surgery vs. Posterior Hip Replacement Surgery

Considering a hip replacement surgery can be scary, after all, it is your central and core joint. Thankfully, recent advances in surgical techniques enable a minimally invasive approach that offers the benefits of faster recovery, reduced pain, and significantly less trauma.

Hip replacement surgery is one of the most performed orthopedic procedures around the globe. In Germany alone, approximately 200,000 hip replacements are performed every year and in terms of incidence, according to a study by market and consumer data firm Statista, Germany ranks first among European nations. Research suggests that increasing life expectancy as well as the prevalence of a growing older population, are the main reasons for the increasing patient numbers.

There is more than one surgical approach to replace a damaged hip joint. Traditionally orthopedic surgeons have used the posterior hip replacement approach.

However, more recently, the anterior approach is becoming increasingly popular. It is considered minimally invasive and promises quicker recovery and fewer complications compared to the posterior approach. It is also referred to as Muscle Sparing Hip Replacement Surgery.

A posterior approach is when your orthopedic surgeon replaces the hip through an incision on the backside of your thigh, while the anterior approach is when your surgeon replaces the damaged joint through an incision on the front side of your thigh.

The anterior hip replacement is more technically challenging and choosing an orthopedic surgeon experienced in this technique is crucial for a successful surgery.

What Is Hip Replacement Surgery?

A hip replacement procedure, also known as hip arthroplasty, is often performed to treat hip fractures or degenerative joint disease (osteoarthritis).

Hip replacement involves the insertion of a metallic or plastic joint prosthesis. It will allow you to walk again, reduce hip pain, and improve mobility.

Up until recently, almost all hip replacements were done using a posterior approach. With this approach, a six to 12-inch incision is made, cutting through the pelvic and buttock muscles to reach the hip joint, in order to replace the joint. The cutting of muscles generally necessitates certain precautions after surgery and can also cause functional weaknesses.

What Is Anterior Hip Replacement Surgery?

The anterior approach is a newer minimally invasive technique now being performed by some surgeons. This approach uses a smaller incision near the front of the hip and avoids muscle cutting to access and replace the joint. Although anterior hip replacement is considered minimally invasive, as mentioned, you’ll need to choose a surgeon with experience performing this technique to avoid any complications.

Who Is a Candidate for Anterior Hip Replacement?

If you have a damaged hip joint due to osteoarthritis or a femoral neck fracture, then you will probably need a hip replacement.

You will be considered for a minimally invasive anterior hip replacement if you meet the following criteria:

• You are not obese (or moderately overweight)
• Your pelvis is not too wide (determined during a physical exam)
• You don’t already have certain types of hip implants

The eligibility for minimally invasive hip replacement is determined in a case-by-case manner. You will be examined, and if you’re suitable for the procedure, you will be given the option.

Both the anterior and posterior hip replacement techniques involve removing the old damaged joint and replacing it with a round metallic or plastic hip prosthesis.

The hip prosthesis replaces the head of the femur (thigh bone). It has a ball-like shape that fits right into the hip socket, allowing your hip bone to move in a full range of motion. It reduces friction and improves mobility.

Anterior hip replacement is usually performed under general anesthesia. This means that you will be put to sleep and won’t feel anything during the surgery. In this method, the patient is placed in the supine position.

The total surgical time of anterior hip replacement is on average 2-3 hours. Since the anterior approach is much more technically demanding, it takes longer than the traditional approach which is usually performed in 1-2 hours.

Once you are asleep, a vertical 5-6 cm skin incision is performed on your upper thigh. The muscles and soft tissue are moved (not cut) to gain visual access to the hip joint. This key element makes the surgery minimally invasive - with minimal muscle cutting.

The old, damaged femur head is then cut and removed. The metallic or plastic prosthesis is attached atop the femur, and the joint is slid back into its socket.

The soft tissue and skin are then closed with sutures.

Benefits of Anterior Hip Replacement

The new anterior approach for hip surgery is slowly becoming more popular among surgeons as it has several benefits:

Less Invasive and Not as Traumatic

In the anterior approach, no major muscles are cut. The surgeon will move the muscles covering the hip joint and work around them. This also means that there is less blood loss. This is probably the top advantage of anterior hip replacement. It involves less trauma compared to the traditional posterior technique.

In a posterior approach, the gluteal (buttocks) muscles are detached from the bone and cut. This can lead to more pain and a longer recovery time.

Reduced Pain

Pain after hip replacement can deter some patients from getting a prosthesis. Since the anterior hip replacement technique is minimally invasive involving less soft tissue trauma, post-op pain is less.

Quicker Recovery

Recovery after hip replacement surgery can take several months. You will have to use a walker or cane for several weeks during recovery before you can walk on your own.

Researchers have found that patients who get anterior hip replacement can leave the hospital in as little as 4 days and can stop using a walker 1 to 3 weeks earlier than those who get a posterior hip replacement. In some cases patients can walk without crutches as early as the next day

Additionally because patients recover quicker, and can keep their pelvis in a horizontal position, there is not as much need to compensate with the upper body.

Moreover, anterior hip replacement requires less precautions and physical limitations postoperatively. This can be attributed to the less traumatic and less invasive nature of this new hip replacement technique.

Easier Second Surgery

A prosthetic hip joint is very durable, but it can sometimes fail. Approximately 1 in 10 people will need hip replacement revision after 10 years of their first surgery. Since the posterior approach involves muscle cutting and more trauma, it causes more fibrosis and soft tissue scarring which makes it more challenging to perform a second surgery.

The advantage of anterior hip replacement makes for a smoother second surgery if you ever need it as no major muscles are cut.

Orthopedic surgeons are always searching for the least traumatic way to treat a damaged hip. So far, research shows that anterior hip replacement might be the way to go. Less trauma, reduced pain and a faster recovery, without compromising the results.

Anterior vs Posterior Hip Replacement - Which Is Better for You?

This depends on who you ask. The anterior minimally invasive hip replacement is probably better as long as it's being performed by an experienced surgeon. A surgeon that has already done this procedure numerous times. With the highest incidence of hip replacement per capita globally, Germany is well-positioned in terms of experience, research, and advancements in this field.

The sooner you get back to walking and moving, the more your surgery is considered successful. Researchers have already established that anterior hip replacement is less traumatic and leads to faster recovery without compromising the results.

However, if you don’t meet the criteria for anterior hip replacement, then the surgery might not be for you. A posterior approach might be the better choice in such cases.

For info on the areas of expertise of the clinic for Children, Adolescents, and Neuro-orthopedics at Rummelsberg Hospital, visit this  page .

For more details on the team at the Children, Adolescents, and Neuro-orthopedics clinic at Rummelsberg Hospital, click  here .

Prof. Dr. med. Wolf Drescher  is a specialist in endoprosthetics and the chief physician for orthopedic surgery of the lower extremities and endoprosthetics at the Rummelsberg Hospital in Schwarzensbruck near Nuremberg in Bavaria, Germany. He is an internationally recognized expert in joint-preserving hip surgery and femoral head necrosis. As a specialist in minimally invasive and muscle-sparing hip arthroplasty, Prof. Wolf Drescher has done the anterior hip replacement procedure more than 2000 times and has been applying it for over 10 years, making him one of the first doctors in the country to perform it.

• https://www.statista.com/statistics/283234/number-of-knee-replacements-in-selected-countries/
• https://link.springer.com/chapter/10.1007/978-3-030-61830-8_2
• https://www.hss.edu/conditions_anterior-hip-replacement-overview.asp
• https://pubmed.ncbi.nlm.nih.gov/24500832/
• https://pubmed.ncbi.nlm.nih.gov/25007723/
• https://pubmed.ncbi.nlm.nih.gov/23464946/
• https://www.sana.de/rummelsberg/medizin-pflege/kinder-jugend-und-neuroorthopaedie
• Drescher, W. R., Kyung-Hoi, K., Windsor, R. E. (2021): Advances in special hip surgery, 1st ed.

Disclaimer: Please note that Mya Care does not provide medical advice, diagnosis, or treatment. The information provided is not intended to replace the care or advice of a qualified healthcare professional. The views expressed are those of the author and do not necessarily reflect the opinion of Mya Care. Always consult your doctor for all diagnoses, treatments, and cures for any diseases or conditions, as well as before changing your healthcare regimen. Do not reproduce, copy, reformat, publish, distribute, upload, post, transmit, transfer in any manner or sell any of the materials in this blog without prior written permission from myacare.com

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What is the new technology for hip replacement 2024?

by Addison Maynard | Feb 2, 2024 | Uncategorized

You’ve probably heard about all the crazy new medical tech that’s coming soon, but have you wondered how your future hip replacement might be different? With life expectancies rising, joint replacements are becoming more and more common. Hip surgery has come a long way since its inception, with continuous advancements in medical technology enhancing the efficacy and safety of procedures. While current designs involve metal and plastic, futuristic materials like ceramics and highly- crosslinked plastics are already being tested. 

Surgical techniques are rapidly advancing too. Robotic surgery and personalized 3D-printed implants tailored to your exact anatomy could enable faster recovery and better function. Even injectable biomaterials that regenerate cartilage and bone are on the horizon! What does this all mean for you? 

A Look at Cutting-Edge Hip Replacement Technology in 2024

By 2024, hip replacement technology and surgical techniques will have advanced in exciting new ways:

• Hip implants will utilize newer materials like ceramic-on- ceramic or highly cross-linked plastics to reduce wear and last longer. These improved bearings can better withstand everyday use and may delay the need for revision surgery down the road. Minimally invasive techniques will continue improving. Muscle- sparing approaches through smaller incisions lessen trauma to soft tissues while still allowing accurate component positioning. This further speeds recovery with less post-op pain. 
• Patient-specific instrumentation will create customized cutting guides from 3D CT scans of each patient’s unique bone anatomy. This tailors the procedure and enhances accuracy in implant positioning without needing to extensively expose or detach muscle tissues.
• Robot-assisted systems can autonomously handle surgical tools like a highly precise extension of the surgeon’s hands. This augments their abilities and skills beyond human limitations. Robots allow for even more accurate planning and execution.
• New tools will enable tissue regeneration instead of traditional hardware implantation. Stem cells, growth factors, or special biologic meshes could regrow a biological joint surface without using typical artificial implants. This concept remains highly experimental but shows incredible promise. 

Ultimately, the goal is to make procedures less invasive and traumatic while improving accuracy, longevity, and patient outcomes. Advanced computing power and emerging nanotechnologies will open new possibilities in 2024 and beyond. The future looks bright for those needing hip replacement!

How 3D Printing Is Revolutionizing Hip Implants

3D printing technology is revolutionizing the world of hip replacement surgery and implants. By 2024, a large percentage of hip implants will be made using 3D printers, customized to match each patient’s unique bone structure. Here’s what you can expect:

Also called patient- matched devices, the implants are designed using 3D models from CT scans and X-rays of your actual hip structure. This allows for a perfect fit, promoting faster healing. No more one-size- fits-all implants that never feel quite right!

Improved Materials

New metals like titanium and cobalt- chromium alloys can be 3D printed to be porous, promoting bone growth into the implant. This anchors it firmly and reduces loosening over time. Non-metal options like ceramic and special plastics are also being developed.

Less Invasive Placement

The custom fit and improved “grip” of 3D printed components lends itself well to smaller incisions and less invasive surgery. For some minimally invasive procedures, the socket can be pressed into place rather than hammered. This causes less trauma and quicker recovery times.

Reduced Dislocation Risk

With components designed to your specific anatomy and range of motion, 3D printed implants stay put! This may reduce the risk of post-surgery dislocation, especially for people with complex needs.

Fewer Revisions Down the Road

Personalized components that integrate with your bone and soft tissues better than ever before mean your new hip should last 15-20 years or longer before needing replaced again.

While not yet mainstream, customized 3D printed implants are the way of the near future. By 2024 many surgeons predict a majority of their hip replacement components will be printed, not mass produced. This futuristic tech offers the potential for life-changing outcomes!

Hip Replacement FAQs: Your Top Questions About the Future of Hip Surgery Answered

Wonder what hip replacements will be like in just a couple years? As technology rapidly advances, you may be surprised at the innovative new techniques and equipment set to revolutionize hip surgery by 2024. Let’s explore some frequently asked questions about the future of hip replacements.

Will the surgery be less invasive?

Yes! One exciting area of development is less invasive surgical methods that require smaller incisions. Some techniques may use only one 3 to 5 inch incision instead of the traditional 10- 12 inch cut. This leads to less soft tissue trauma, reduced blood loss, shorter hospital stays, and faster recovery times.

How long will the artificial joint last?

Current hip implants last 15- 20 years on average. However, with improved materials and design, the latest generation of artificial joints can potentially last 25- 30 years or longer before needing replaced again. This means fewer repeat replacement surgeries for most patients.

Will I have increased range of motion and mobility?

Absolutely! With innovative materials like porous titanium that better integrates with your bone, future hip implants will likely provide improved functionality and stability. This leads to greater mobility and flexibility for activities requiring hip range of motion like bending down, reaching overhead, golfing or gardening.

While hip surgery will continue advancing rapidly, it’s still major surgery with a lengthy recovery. But you’ll be walking easier and getting back to activities you love sooner than ever thanks to the amazing innovations on the horizon! AOA Arlington Ortho is committed to offering the greatest care in the ever-changing field of orthopedic technology, embracing the most recent developments in hip surgery. Robotics, 3D printing, artificial intelligence, and other simple approaches are combining, offering a new age in the sector that will improve patient outcomes and quality of life. As 2024 comes to a close, AOA Arlington Ortho continues to acknowledge and profit from these advancements. If you’re considering hip surgery, you may be confident that the future is brighter than ever.

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Surgical Realignment of the Hip (Osteotomy)

Key points about surgical realignment of the hip.

• Surgical realignment of the hip surgery is performed to align the bones and tissues in the hip.
• You may be a candidate for a surgical hip realignment if you are not a candidate for a hip replacement surgery.
• Complications associated with a surgical hip realignment include blood clots, infection, inability to heal, and nerve damage.
• During a surgical hip realignment, your doctor will move the hip bone into the correct place and remove any bone fragments that are causing issues in the hip.
• It can take as long as six months to return to normal activity levels after the procedure. Follow your doctor’s recovery instructions to ensure proper healing. 

Candidates for surgical hip realignment

If you are not a candidate for a hip replacement, your doctor may recommend a surgical realignment of the hip.  Fractures or dislocations and associated damage that may require a medical hip realignment include:

• Industrial accidents
• Automobile accidents
• Falling from a high place, such as from a ladder.

When performed early, realignment surgery can reduce pain and delay the onset of arthritis in the hip.

Risks associated with surgical realignment of the hip

Complications related to surgical hip realignment include:

• Blood clots. You will be given a blood thinner, compression stockings, and compression boots to avoid the risk of blood clots. 
• Infection. You will be given IV antibiotics before and after surgery to prevent infection.
• Inability to heal. You may need additional surgery if the bone does not heal correctly.
• Nerve palsy. In rare cases, nerves can be damaged.

Preparing for surgical realignment of the hip

In preparation for surgery, your doctor will take X-rays and MRIs to evaluate the severity of your case.  Before you undergo a hip surgical realignment, your doctor will advise you to do the following:

• If you are overweight, lose extra weight. 
• Stop smoking.
• Stretch and strengthen your muscles in your abdomen and legs.
• Arrange to have a driver for three or four weeks after surgery.
• Do not take any blood thinners before surgery.
• Prepare your home for after surgery when you are not able to move around as well.

What to expect during a surgical realignment of the hip

Your doctor will perform surgical realignment of the hip under general anesthesia. During the surgery, your orthopedic surgeon will:

• Make an incision approximately six to eight inches long at the hip joint. 
• Using X-ray guidance, your surgeon will cut out the damaged bone and tissue to free it from its original position.
• Prepare the bone graft that will be used in the hip joint. 
• Place the bone graft in place and stabilize the joint with metal screws, plates, and pins. 

Once the area is located, your doctor will cut out the damaged bone and tissue. 

Recovery after surgical hip realignment 

Recovery from a hip medical realignment procedure is lengthy. For approximately six weeks after surgery, you will take a blood thinner, wear a compression hose, and walk with crutches. Your doctor will give you pain medication, if necessary. You can typically begin driving again three to four weeks after surgery after you get off narcotics. Six weeks after surgery, you will transition to using one crutch and may start stretching or strengthening exercises. After three months, you may return to work as tolerated. Your doctor will encourage you to do gentle exercises or walk. Six months after surgery, as bone cuts heal, you can return to your normal activity level, except for running and jumping activities.

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Less-invasive approaches to hip replacement surgery gaining popularity

Regardless of the type of approach used, the results are all very similar, with less than 3% having significant issues. It is important to discuss the various approaches with your doctor.

Robert Olseski Jr. realized last year that his right hip pain, due to osteoarthritis, was affecting the quality of his life. He found it difficult to get in and out of the car easily, an important part of his job for his family-owned food distribution business, W.E. Ryan Co.

He could no longer take walks with his wife in Valley Forge Park. Doing yard work and shoveling snow were becoming painful. He also developed a limp.

“I had my left hip done 15 years ago and they told me then that I would need to have the other hip done eventually,” recalled Olseski, 58, from Wayne. “For the last year and a half it was bothering me but with the pandemic I had to put it off until January.”

The experience was easier this time around, Olseski said. He discussed his options with Charles L. Nelson, an orthopedic surgeon at Penn Medicine, and decided to have a total hip replacement with a less-invasive technique than when he had his left-hip surgery.

Olseski spent one night in the hospital and then started physical therapy to help strengthen his new hip. He used a walker for a couple days, then a cane for a few weeks. After five weeks, he returned to work with full mobility.

“I was amazed,” he said. “My hip is great.”

Roughly a half-million people in the United States had hip replacement surgery in 2019, according to C. Lowry Barnes, president of the Association of Hip and Knee Surgeons, based in Little Rock, Ark. That’s up from about 375,000 just five years earlier. He estimates that about one million hips will be replaced annually by 2030, due in part to Americans’ increasingly active lifestyle and confidence in new medical technologies.

Significant developments have been made in surgical approaches to hip replacements, with some doctors now using robotic assistance to ensure precision.

Like Olseski, more patients who qualify for it are opting for the anterior approach, where patients are lying on their back and the surgeon comes in from the front in between muscle groups.

“It’s just like you’re parting curtains, so it gives you a window into the hip without detaching muscles,” said Nelson, chief of adult reconstruction and professor of orthopaedic surgery at Penn Medicine.

Some studies suggest that this approach may result in less damage to major muscles, less postoperative pain, a smaller scar, and a quicker recovery than more traditional approaches, in which a larger incision is made from the side or from behind.

Other studies don’t bear out that the anterior approach yields superior results, Barnes said, noting that long-term outcomes will help create a clearer picture. Barnes estimated that the anterior approach is now being used in 10% to 15% of hip replacement surgeries.

‘A muscle-friendly approach’

The typical hip replacement recipients are in their mid-60s and suffer from arthritis of the hip, though other reasons for replacement include fractures and loss of blood supply, Barnes said. The surgical procedure involves replacing the damaged hip joint — the ball and socket — with a prosthetic implant.

“The person commonly has groin pain that interferes with his or her activities of daily living – pain getting up from a chair, going up and down stairs, walking or sleeping,” Barnes said. Often, the pain prevents them from their favorite activity, such as golf or tennis.

The modern hip replacement was developed in the 1960s with a lateral approach, in which the doctor makes a long incision at the side of the hip, splitting the abductor muscles, allowing the hip to be dislocated and viewed by the surgeon. Most common today is the posterior approach, in which patients are lying on their side and the surgeon comes in behind the abductor muscles. But the anterior method is gaining popularity as more surgeons train to use it.

“You come into the hip from the front, in the interval between two groups of muscles,” Nelson said. “It’s a very muscle-friendly approach to get into the hip.”

Of the roughly 650 hip and knee replacements Nelson performed last year, about 300 were first-time hip replacements, 100 of which he performed with the direct anterior approach. That’s up from 60 to 75 five years ago.

Yet this less-invasive surgery isn’t appropriate for all hip-replacement patients.

“I don’t use that approach when cases are complex with prior hardware or [with] patients who are morbidly obese,” he said.

Jeremy J. Reid, attending orthopedic surgeon at Virtua Health, was trained using the anterior approach before starting his practice in 2014, and uses it in about 90% of his hip replacement surgeries.

Reid is also an advocate of robotic surgery.

The robot helps the surgeon prepare the bone for prosthetics, he said, by helping guide removal of diseased bone and cartilage. It also aids in determining the final depth and orientation of the replacement of the prosthetic component, he said. Robotics also help measure limb length and the position of the femur relative to the pelvis.

“Studies show about 97% of plans are executed within one to two millimeters of target, which is well above what can be executed with the naked eye or with instruments alone,” he said.

Along with other approaches to hip replacement, the anterior approach is covered by Medicare and most insurance plans. The use of robotics is similarly covered, Reid said.

Nelson said that he uses robots in the posterior approach, but not the anterior. In those cases, he uses fluoroscopy, which he described as real time X-ray with computer-assisted image navigation.

When considering hip replacement surgery, it is important to discuss the various approaches with your doctor.

“The data show that regardless of the type of approach used to do the hip replacement, the results are all very similar, with less than 3% having significant issues,” Barnes said. “After a while you forget you ever had a hip replacement because it’s so normal.”

Olseski is thrilled with his surgery and recovery. “I came home the next day and now I have no pain and a more positive outlook,” he said. “I feel like a new man.”

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Hip Labrum Surgery: Is It the Right Treatment?

Hip arthroscopy, frequently asked questions.

A hip labral tear can cause hip joint discomfort and pain, and it can be repaired surgically or managed with non-surgical treatment, Surgical repair of a hip labral tear is usually done through a minimally invasive arthroscopic procedure . The decision about which approach is right for you depends on several factors, including how well it's already healing, the type of tear, and whether you have arthritis.

This article describes the factors to consider when thinking about surgical treatment for a hip labral tear.

The Hip Labrum

The hip labrum is a ring of cartilage that surrounds the socket of the ball-and-socket hip joint. Unlike other ball and socket joints, such as the shoulder, the hip has a very deep and stable socket.

The hip labrum helps to deepen the socket, while also being flexible to allow for some movement.

The hip labrum, like other types of cartilage, lacks a good blood supply and therefore does not have a strong capacity to heal after damage.

Once the labrum has been damaged, it tends to show signs of damage that may not repair over time.

Hip Labrum Tears

Hip labral tears come in a variety of shapes, sizes, and types, and the treatment can differ significantly.

Most importantly, labral tears are often seen in the setting of other damage to the hip joint including arthritis and bone spurs . A labral tear in the setting of arthritis of the hip is nothing like a labral tear as an isolated injury.

But labral tears are very common, and they don't usually cause symptoms. Often, labral tears do not need treatment. In one study, a labral tear was detected in 41 to 43% of asymptomatic hips. Another study found that over 90% of patients age 50 and older had some degree of hip labral tear discovered on MRI.

Between 1999 and 2009, arthroscopic surgery of the hip joint increased 18-fold, with a 365% increase between 2004 and 2009.  

Arthroscopic hip surgery is an outpatient surgery that is often performed under general anesthesia. During the procedure, a surgeon places a small camera with an attached light source into the hip joint and places the surgical instruments through another small incision.

Techniques used during surgery may include:

• Repair of the damaged cartilage
• Trimming out the torn portion
• Reconstructing the labrum

The decision of how to address the tear usually depends on factors including the tear type and location.

Arthroscopic hip surgery has potential risks:

• Persistent pain
• Nerve or blood vessel injury

When considering any surgical treatment, it is important to weigh the risks and the benefits of surgery.

Results of Surgical Treatment

A number of studies have reported good short-term results following arthroscopic hip surgery. Most of these studies find that people who undergo hip arthroscopy have good pain relief in the months and years to follow surgical treatment.

Especially when there are no signs of arthritis, these results tend to hold up well over time, and people are satisfied with their treatment.

Only a few studies have compared surgical treatment to nonsurgical treatment.

One study of about 100 military recruits who had hip labral tears randomly assigned them to either get surgery or nonsurgical treatment. Two years after treatment was completed, there was no significant difference between the groups of individuals treated surgically versus those treated nonsurgically.

That is not to say that everyone got better, it just means that an approximately equal number of patients got better with nonsurgical treatment as with surgical treatment. However, 70% of the patients who didn't have surgery ended up undergoing surgery later.

In almost all situations, nonsurgical treatment should be attempted before surgery.

Labral Tears After Age 40

There has been controversy regarding the treatment of patients over the age of 40 who have labral tears.

Studies have shown that people over the age of 40 have a higher rate of progressive arthritis of the hip joint, and the labral tear is likely an early sign of arthritis in the hip. Almost 20% of these patients ultimately end up having  hip replacement surgery within a year and a half of undergoing arthroscopic hip surgery.

It is clear that not every individual who has a hip labral tear needs arthroscopic hip surgery. In fact, nonsurgical treatment in many cases may be just as effective, and sometimes even more effective, than surgical intervention. Working to define which patients are most likely to benefit is an ongoing process.

A Word From Verywell

Arthroscopic hip surgery undoubtedly plays an important role in the treatment of hip labral injuries. That said, many patients can find equally effective treatment with nonsurgical treatment. In almost all scenarios, nonsurgical treatment should be attempted before considering arthroscopic surgery.

Studies have shown that when nonsurgical and surgical treatment are compared, the results are not too different between these groups; both treatments tend to lead to an improvement in symptoms. There are situations when nonsurgical treatments are not effective, and surgery can be considered.

The ideal candidate for surgical treatment is under the age of 40 years old and does not have signs of arthritis in their hip joint.

It depends. Surgery is not always required or recommended for a labrum tear. A person’s age, the extent of the injury, and overall hip health are factors to consider. 

Surgery is not typically recommended for people ages 40 and up. This is because a hip labrum tear is often an early sign of arthritis. If you have osteoarthritis , a hip replacement may be needed in the future.

In addition, other treatments, including physical therapy, may be equally as effective as surgery for a minor tear.

It can take several months to fully return to normal after hip labrum tear surgery. You can expect to walk with crutches for the first week or two. After that, at least six weeks of physical therapy will be needed to help restore strength and flexibility. 

On average, it takes about six months to fully recover after hip labral tear surgery. Some people recover in as little as three months, while others take longer to heal. As long as there aren't any complications or other problems with the hip joint, you should be fully recovered within nine months.

In the immediate aftermath of hip labrum arthroscopy, you will not be able to put any weight on the leg for the first week or so.

Other things to watch out for:

• Avoid sitting on low, soft surfaces as they may be difficult to get up from.
• Don't sit cross-legged or with your ankle resting on your knee.
• Do not lift the leg straight up or pivot over the leg that was operated on. 

Once you start physical therapy, it will still be a while until you are able to exercise independently. You will need to avoid high-impact activities like jumping or running for at least 12 weeks—and not until your physical therapist or surgeon approves it.

American Academy of Orthopaedic Surgeons. Osteoarthritis of the hip .

Vahedi H, Aalirezaie A, Azboy I, Daryoush T, Shahi A, Parvizi J. Acetabular labral tears are common in asymptomatic contralateral hips with femoroacetabular impingement . Clin Orthop Relat Res . 2019 May;477(5):974-979. doi:10.1097/CORR.0000000000000567

Jayakar R, Merz A, Plotkin B, Wang D, Seeger L, Hame SL. Magnetic resonance arthrography and the prevalence of acetabular labral tears in patients 50 years of age and older . Skeletal Radiol. 2016 Aug;45(8):1061-7. doi:10.1007/s00256-016-2392-9

Gwathmey FW, Jones KS, Thomas byrd JW. Revision hip arthroscopy: findings and outcomes . J Hip Preserv Surg . 2017;4(4):318-323. doi:10.1093/jhps/hnx014

American Academy of Orthopaedic Surgeons. Hip arthroscopy .

Menge TJ, Briggs KK, Dornan GJ, Mcnamara SC, Philippon MJ. Survivorship and outcomes 10 years following hip arthroscopy for femoroacetabular impingement: labral debridement compared with labral repair . J Bone Joint Surg Am . 2017;99(12):997-1004. doi:10.2106/JBJS.16.01060

Mansell NS, Rhon DI, Meyer J, Slevin JM, Marchant BG. Arthroscopic surgery or physical therapy for patients with femoroacetabular impingement syndrome: a randomized controlled trial with 2-year follow-up . Am J Sports Me d. 2018;46(6):1306-1314. doi:10.1177/0363546517751912

Griffin DW, Kinnard MJ, Formby PM, Mccabe MP, Anderson TD. Outcomes of hip arthroscopy in the older adult: a systematic review of the literature . Am J Sports Med . 2017;45(8):1928-1936. doi:10.1177/0363546516667915

Haefeli PC, Albers CE, Steppacher SD, Tannast M, Büchler L. What are the risk factors for revision surgery after hip arthroscopy for femoroacetabular impingement at 7-year followup ? Clin Orthop Relat Res . 2017 Apr;475(4):1169-1177. doi:10.1007/s11999-016-5115-6

Horner NS, Ekhtiari S, Simunovic N, Safran MR, Philippon MJ, Ayeni OR. "Hip Arthroscopy in Patients Age 40 or Older: A Systematic Review" Arthroscopy. 2017 Feb;33(2):464-475.e3.

By Jonathan Cluett, MD Dr. Cluett is board-certified in orthopedic surgery. He served as assistant team physician to Chivas USA (Major League Soccer) and the U.S. national soccer teams.

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Discharge transitional care programme for older adults after hip fracture surgery: a quasi-experimental study

Affiliations.

• 1 Associate Professor, Department of Nursing, Daegu Haany University, South Korea.
• 2 Assistant Professor, Department of Rehabilitation Medicine, Kyungpook National University Hospital, South Korea.
• 3 Associate Professor, Department of Orthopedic Surgery, Kyungpook National University Hospital, South Korea.
• PMID: 38162723
• PMCID: PMC10756176 (available on 2024-12-01 )
• DOI: 10.1177/17449871231204499

Background: Hip fractures require extended periods of recovery and rehabilitation, subjecting older adults to discontinuous care. Discharge transition is a critical point of heightened vulnerability for older adults.

Aims: This study aimed to evaluate the effectiveness of a transitional care programme on the physical functions and quality of life (QOL) of older adults after hip fracture surgery.

Methods: Seventy-five older adults were assessed from pre-discharge to 6 weeks after hip surgery, and their physical functions, including walking status and activities of daily living, were measured. The QOL was measured using the European Quality of life-5 Dimensions-5 Levels (EQ 5D 5L).

Results: There was a significant strong effect of time ( B = 10.565; 95% CI = 2.584-18.547; p = 0.009) on the EuroQol Visual Analog Scale (EQ-VAS) for the experimental group. However, there were no significant effects of time on physical functions and EQ-5D-5L scores.

Conclusions: The discharge transitional care programme improved the EQ-VAS of older adults following hip fracture surgery 6 weeks post-surgery. However, there were no significant differences in physical functions and EQ-5D between the groups.

Keywords: hip fractures; older adults; patient discharge; quality of life; surgery; transitional care.

© The Author(s) 2023.

PubMed Disclaimer

Conflict of interest statement

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

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Characterization of micro-threaded stem taper surfaces of cementless hip endoprostheses.

1. Introduction

2. materials and methods, 2.1. materials, 2.2. methods, 3.1. microstructure of ti6al7nb and ti6al4v stem tapers, 3.2. the estimation of microstructure alpha- and beta-phase contents in ti6al7nb and ti6al4v alloys, 3.3. sem/ebsd characterization of stem taper phase microstructure, 3.4. sem/eds characterization of stem taper new implants’ microstructure, 3.5. sem/eds characterization of prematurely failed implants, 3.6. stem taper morphology: surface roughness, 3.7. corrosion properties of investigated new and retrieved stem taper samples, 4. discussion, 5. conclusions, author contributions, institutional review board statement, informed consent statement, data availability statement, conflicts of interest.

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Share and Cite

Dolinar, D.; Kocjančič, B.; Avsec, K.; Šetina Batič, B.; Kocijan, A.; Godec, M.; Sedlaček, M.; Debeljak, M.; Grant, J.T.; Zupanc, T.; et al. Characterization of Micro-Threaded Stem Taper Surfaces of Cementless Hip Endoprostheses. Materials 2024 , 17 , 2751. https://doi.org/10.3390/ma17112751

Dolinar D, Kocjančič B, Avsec K, Šetina Batič B, Kocijan A, Godec M, Sedlaček M, Debeljak M, Grant JT, Zupanc T, et al. Characterization of Micro-Threaded Stem Taper Surfaces of Cementless Hip Endoprostheses. Materials . 2024; 17(11):2751. https://doi.org/10.3390/ma17112751

Dolinar, Drago, Boštjan Kocjančič, Klemen Avsec, Barbara Šetina Batič, Aleksandra Kocijan, Matjaž Godec, Marko Sedlaček, Mojca Debeljak, John T. Grant, Timon Zupanc, and et al. 2024. "Characterization of Micro-Threaded Stem Taper Surfaces of Cementless Hip Endoprostheses" Materials 17, no. 11: 2751. https://doi.org/10.3390/ma17112751

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Combined nutritional status and activities of daily living disability is associated with one-year mortality after hip fracture surgery for geriatric patients: a retrospective cohort study

• Original Article
• Open access
• Published: 08 June 2024
• Volume 36 , article number  127 , ( 2024 )

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• Ying Chen 1 ,
• Ying Guo 1 ,
• Gang Tong 2 ,
• Ruihua Zhang 1 &

We aimed to explore the association combined nutritional status and activities of daily living disability with all-cause mortality of older adults with hip fracture in the first year after hospitalization.

This is a single-center retrospective cohort study in older adults with hip fracture patients. Clinical data and laboratory results were collected from electronic medical record system of our hospital (2014–2021). The endpoint of this study was all-cause mortality in the first year after hospitalization.

A total of 303 older adults were enrolled and all-cause mortality was 21.8%. The study population was categorized by CONUT score. Patients in CONUT score 5–12 had a higher age, ASA status, CRP and creatinine level, more patients with history of fracture, pneumonia and delirium, meanwhile, lower BMI and ADL score, lower hemoglobin, lymphocyte, total protein, albumin, triglyceride, total cholesterol and one year survival than those in CONUT score 0–4 (all P  < 0.05). Multivariable Cox analysis showed that BMI, ADL score and CONUT score were independent risk factors for all-cause mortality of hip fracture in older adults (HR (95% CI):2.808(1.638, 4.814), P  < 0.001; 2.862(1.637, 5.003), P  < 0.001; 2.322(1.236, 4.359), P  = 0.009, respectively). More importantly, the combined index of CONUT and ADL score had the best predictive performance based on ROC curve (AUC 0.785, 95% CI: 0.734–0.830, P  < 0.0001). Kaplan-Meier survival curves for all-cause mortality showed that patients with CONUT score increase and ADL score impairment had a higher mortality rate at 1 year compared to CONUT score decrease and ADL score well (Log Rank χ2 = 45.717, P  < 0.0001).

Conclusions

Combined CONUT and ADL score is associated with one-year mortality after hip fracture surgery for geriatric patients.

Avoid common mistakes on your manuscript.

Introduction

Due to population ageing, estimated hip fracture patients would grow exponentially worldwide, which is expected to be 2.6 million by 2025 and 6.3 million by 2050 [ 1 , 2 ].

Hip fractures have a significant impact on the health of elderly people, and are known as the “last fracture in life” due to their high disability and mortality rates. About 35% of hip fracture survivors are unable to resume independent walking, and 25% of patients require long-term home care. The one-year mortality rate after fractures is as high as 20–30%, and medical expenses are expensive [ 3 , 4 , 5 ]. Surgery-related factors, including the delay of surgery, among others, and non-surgery-related factors, such as age, sex and BMI (body mass index), comorbidities, and special laboratory test results, were identified as risk factors [ 6 ]. Several predictive models were constructed based on these risk factors [ 7 , 8 ]. However, the simplicity and practicality of the models for stratifying the mortality risk after hip fracture surgery was not satisfactory [ 9 ].

More and more evidence implicates that malnutrition, a crucial and modifiable risk factor, is associated with multiple unfavorable outcomes after hip fracture, such as increased risk of pneumonia, delirium, readmission, and mortality, etc. [ 10 , 11 ]. In fact, nutritional intervention can help reduce complications after hip fracture surgery and improve daily living activities, which has been confirmed by randomized controlled trials or other high-level evidence [ 12 , 13 ].

Meanwhile, the improvement of daily living activities is crucial for the outcomes of hip fractures, as individuals with decreased functional Status have an increased risk of disability and mortality [ 14 , 15 , 16 ].In addition, loss of mobility can lead to increased nursing costs and greater burden on the long-term care insurance system [ 17 ].

However, to our knowledge, existing research rarely has combined nutritional and functional status indicators as a composite parameter to explore and quantify the prognosis of patients with hip fractures.

This study aimed to explore whether combined nutritional status and activities of daily living disability is associated with one-year mortality after hip fracture surgery for geriatric patients.

Materials and methods

Study population.

This was a single-center retrospective cohort study which was approved by the Clinical Research Ethics Committee of Beijing Tongren Hospital, Capital Medical University (TREC2023-KY026). A total of 303 older patients with a diagnosis of fragility (osteoporotic) hip fracture in our hospital from January 2014 to December 2021 were enrolled. Fragility hip fracture was defined as a hip fracture occurring after a minimal trauma, such as a fall from standing height or lower. Written informed consent was obtained from all patients. Clinical Trials.gov Identifier: NCT05814172.

The patients were divided into two groups according to Controlling nutritional status (CONUT) score: CONUT score 0–4 ( n  = 209) and CONUT score 5–12 ( n  = 94).

Inclusion criteria: (1) patients ≧ 65 years old; (2) patients diagnosed with hip fracture, including femoral neck fracture, femoral pertrochanteric fracture, and femoral subtrochanteric fracture; (3) patients whose injury was within 21 days of presentation; and (4)patients who had undergone surgery.

Exclusion criteria: (1) patients with pathological fractures due to tumor metastasis or infection or inherited bone disorder; (2) patients with avascular necrosis of femoral head; (3) patients with periprosthetic fractures; (4) patients with severe trauma or fracture in other parts; (5)patients died in hospital; (6) loss to follow-up. The flow of patients through the study was shown in Fig.  1 .

Flow of patients through the study

Variables and follow up

Variables extracted were divided in several groups, including demographic characteristics, comorbidities, complications, parameters related to surgery and laboratory parameters.

Demographic characteristics were age, gender and body mass index (BMI). Comorbidities included hypertension, coronary heart disease, diabetes, chronic kidney disease, cerebrovascular disease and previous fracture history. Postoperative complications included deep vein thrombosis (DVT), delirium and pneumonia which have a relatively high incidence rate. Functional independence status was evaluated by activities of daily living (ADL). Parameters related to surgery meaned American Society of Anesthesiologists (ASA) status. Laboratory parameters included hemoglobin (Hb), lymphocytes (Lyc), C-reactive protein (CRP), fasting blood glucose (Glu), serum creatinine (sCr), total protein (TP), albumin Alb), triglycerides (TG) and total cholesterol (TC). Those were collected from the electronic medical record system.

BMI was calculated as the weight in kilograms divided by the square of the height in metres, based on data from the medical records on admission. A BMI value of 18.5 kg/m 2 was used as a cutoff for underweight, as suggested by the World Health Organization [ 18 ].

The ADL score assessment uses the Barthel Index, which is one of the most widely used tools assessing functional independence. The 10 performance items addressed by the Barthel index are presence or absence of fecal and urinary incontinence, and presence or absence of help needed with grooming, toilet use, feeding, transfers (i.e., from chair to bed), walking, dressing, climbing stairs, and bathing. The final score ranges from 0 (completely dependent patient) to 100 (totally independent patient) in 5-point intervals. The higher the score, the greater the activities of daily living. The ADL score assessment was performed for each patient before discharge by a trained nurse [ 19 , 20 , 21 , 22 ]. Severe functional impairment or dependency was defined as ADL score ≦ 50 based on previous literature.

ASA status graded physical status from 1 (normal) to 4 (severe systemic disease) [ 23 ].

In the present analysis, cut-off points of CRP, TP, TG were proposed by Youden’s index of ROC curve.

Anaemia is defined as a haemoglobin level two standard deviations below the normal for age and sex by the United Kingdom (UK) laboratory. This correlates as the following: Hb of men below 130 g/l, Hb of women below 120 g/l [ 24 ].

Our outcome was death from any cause within one year of surgery. After discharge, all enrolled patients were followed-up in an outpatients setting. Survival data were obtained via direct contact with patients or patients’ caregiver by their physicians at the hospital, or via telephone interview of their family by dedicated coordinators and investigators. The follow-up lasted for one year and the last follow-up was ended on December 31, 2022.

Controlling nutritional status (CONUT) score

CONUT score was calculated from 3 variables: serum albumin concentration, total cholesterol concentration, and lymphocyte count. In this scoring system, point values are assigned to different ranges of the laboratory measures as follows: serum albumin score (1):≥35 g/L, 0 points; 34–30 g/L, 2 points; 29–25 g/L, 4 points; and < 25 g/L, 6 points; lymphocytes score (2):≥1.6*10 9 /L, 0 points; 1.2–1.59*10 9 /L, 1 point; 0.8–1.19*10 9 /L, 2 points; and < 0.8*10 9 /L, 3 points; and total cholesterol score (3): ≥4.65 mmol/L, 0 points; 3.62-4.64mmol/L, 1 point; 2.59-3.61mmol/L, 2 points; and < 2.59mmol/L, 3 points, CONUT score=(1)+(2)+(3). We defined normal and mild malnutrition as CONUT score 0–4 and moderate to severe malnutrition as CONUT score 5–12, as previously reported [ 25 , 26 ].

Statistical analysis

All continuous data were expressed in terms of the mean and the standard deviation of the mean or median and interquartile range (IQR) when not normally distributed. Normal distributional data were compared between two groups using independent-samples t test. The rank sum test was used to compare differences in nonnormally distributed data. Categorical data were expressed as frequencies and percentages and compared by the Chi-square. Cox proportional hazards regression models were used to identify patients at risk of all-cause mortality to calculate the multivariable-adjusted HRs and 95% CIs. Moreover, to check the predictive value of the model, a receiver operator characteristic (ROC) curve analysis was carried out. Kaplan-Meier survival curves and a log-rank test were used to compare mortality among risk-stratified groups. All analyses were performed using SPSS version 19.0 (SPSS, Chicago, IL, USA). A p value of < 0.05 was considered to be statistically significant.

Baseline characteristics

As shown in Fig.  1 , a total of 354 older patients with hip fracture were initially selected, and 51 were excluded according to the exclusion criteria. In the excluded patients, 21patients patients did not receive surgical treatment.

Finally, 303 eligible patients were included in this study, with a median age of 82 (78, 87) years, a predominance of female (69%), moderate to severe malnutrition rate of 31%. During one year follow up 66 patients (21.8%) died. The study population was categorized by CONUT score as follows: CONUT score 0–4, normal and mild malnutrition risk group ( n  = 209), and CONUT score 5–12, moderate to severe malnutrition risk group ( n  = 94). BMI could only be evaluated in 288 patients. Patients in CONUT score 5–12 had a higher age, ASA status, CRP and creatinine level, more patients with history of fracture, pneumonia and delirium, meanwhile, lower BMI and ADL score, lower hemoglobin, lymphocyte, total protein, albumin, triglyceride, total cholesterol and one year survival than those in CONUT score 0–4 (all P  < 0.05), as shown in Table  1 .

Clinical outcomes and prognostic analysis

All patients were discharged and followed up for at least one year. All-cause 1-year-mortality was 21.8%. Univariable Cox proportional hazards analysis revealed that age (HR 2.876, P  = 0.001), BMI (HR 3.194, P  < 0.001), ADL score (HR 3.894, P  < 0.001), with pneumonia (HR 2.099, P  = 0.020), with delirium (HR 1.99, P  = 0.008), Hb (HR 2.232, P  = 0.001), CRP (HR 2.239, P  = 0.001), TP (HR 3.432, P  < 0.001), TG (HR 2.782, P  < 0.001) and CONUT score (HR 4.361, P  < 0.001) were significantly associated with all-cause mortality. Multivariable Cox proportional hazards analysis allowed us to identify a total of three independent predictive factors after adjusted for age, delirium, pneumonia, anemia, CRP, TP and TG. Being low BMI (HR 2.808, P  < 0.001), having less ADL score (HR 2.862, P  < 0.001) and higher CONUT score (HR 2.322, P  < 0.001) were found to be statistically significant predictive factors of one year mortality after surgery (Table  2 ).

ROC curve results

The Fig.  2 showed that the the sensitivity, pecificity and AUC of ROC curve for BMI, ADL score and CONUT score predicting patients’ prognosis. When CONUT score was combined with ADL, the AUC was 0.785, with a sensitivity of 71.21% and a specificity of 73.00% ( P  < 0.0001), which was higher than for CONUT score, ADL score or BMI, a single characteristic (Fig.  2 ).

ROC Curve of the predictive model of all-cause mortality in patients with hip fractures. BMI, body mass index; ADL, daily of activity ability; CONUT, controlling nutritional status

Survival analysis results

Kaplan-Meier survival curves for all-cause mortality showed that patients with CONUT score increase and ADL score impairment had a higher mortality rate at one year compared to CONUT score decrease and ADL score well (HR 5.17, 95% CI 3.088–8.662, Log Rank χ2 = 45.717, P  < 0.0001) (Fig.  3 ).

Kaplan–Meier estimates of all-cause mortality with patients stratified by different indicators Log-rank test was used to compare survival between groups. BMI, body mass index; ADL, daily of activity ability; CONUT, controlling nutritional status

In this observational cohort study on the one-year mortality following hip fractures in older adults, we observed that combined index of CONUT score increase and ADL score impairment has good clinical value. To our knowledge, this study is the first exploring the relationship between a comprehensive index of nutritional status and autonomous mobility and mortality after hip fracture.

Firstly, high prevalence of malnutrition among older patients with hip fracture has been well documented, as well as its consequences on length of hospital stay, functional recovery, disability and in-hospital mortality [ 10 , 27 , 28 ]. This is because the nutritional status may further deteriorate after fracture surgery due to increased catabolism and reduced dietary intake. Even without the impact of surgery, malnutrition can lead to frailty and sarcopenia, which are common in elderly patients. Because muscles require sufficient protein and other nutrients to maintain their mass and function. Individuals with frailty may experience a decrease in muscle mass due to insufficient energy and nutrient intake, leading to the development of sarcopenia. Conversely, sarcopenia may also exacerbate frailty, as muscles are crucial tissues for maintaining daily activities and bodily functions. Frailty and sarcopenia affect the patient’s mobility and functional recovery. Malnutrition can also lead to a decline in the patient’s immune function, increase the risk of postoperative complications such as infection, resulting in prolonged hospital stays and increased mortality [ 29 , 30 , 31 ].

Considering the relevance of a correct identification of malnutrition in this population, the use of the most adequate screening tool should be warranted. In this study we used CONUT. Our study demonstrates the strong adverse impact of malnutrition on one year mortality in this population. The higher the CONUT score, the higher the risk of death within one year, consistent with previous reports [ 32 , 33 ]. This information is important, because it allows clinicians to identify high risk patients, improve outcomes and healthcare efficiency and to target treatment to the most effective intervention.

More importantly, the combined index of ADL score and CONUT score had the best predictive performance. Due to the prolonged immobilisation required and to possible post-operative complications, hip fracture has a greater impact than other acute events on the functional decline of older patient. Therefore, on the contrary, the functional autonomy of older aduits reflects their postoperative prognosis well. In the study of 60,111 U.S. long-term nursing home residents, function declined substantially after fracture across all ADL score domains assessed, including transferring, mobility in bed, personal hygiene and toileting and increasing baseline ADL score dependence were all associated with decreased survival after hip fracture [ 34 ]. Ceolin’s study also suggested that functional loss in older adults hospitalised for proximal femur fractures was greatest in the first 6 months after discharge, and this increased the risk of death at 1 year [ 35 ]. However, malnutrition is related to losing walking independence (LWI) after hip fracture surgery. Cheng et al. evaluated the relationship between preoperative nutritional status assessed by CONUT score and postoperative 180 day walking independence in elderly Chinese patients with hip fractures. This study suggests that preoperative malnutrition is an important risk factor for postoperative loss of non independence in hip fractures, and nutritional screening at admission may have potential health benefits [ 36 ].

This study is the first exploring the relationship between a comprehensive index of nutritional status and autonomous mobility and mortality after hip fracture. A multidimensional assessment may be superior to considering a single aspect. CONUT, as an objective biomarker of nutritional status, although its detection method is simple, it reflects multiple physiological functions such as nutrition, inflammation, and immunity in the body, and complements the functional indicator ADL score to achieve complementary advantages. Our study clearly extends previous findings and reflects the role of multidisciplinary teams in postoperative rehabilitation of older fracture patients.

Indeed, there have been many developed nutrition screening tools, such as Mini Nutrition Assessment Short Form (MNA-SF), Nutrition Risk Screening 2002 (NRS 2002), and Subjective Global As assessment (SGA), which are often used in comprehensive assessment of older adults in recent years. While there are many screening tools available in the form of questionnaires, they heavily rely on subjective information provided by patients or their relatives. These tools can be influenced by subjective factors and compromised by cognitive impairments. Objective nutritional indicators are becoming a more and more frequently used tool in clinical work. Therefore, as a comprehensive nutritional scoring tool, CONUT score is an objective, easily obtainable and highly reproducible biomarker. Compared to other nutritional indicators, it may be more suitable for accurate nutritional assessment in fracture patients and provide stronger prognostic information for older adults fracture patients.

Secondly, except for CONUT and ADL score, this study also found that BMI was one of prognostic factors for all-cause mortality in elderly patients one year after surgery. BMI is a commonly available clinical parameter. Although pre-obesity and obesity as measured by BMI are associated with a higher risk of death in the general population, they are also associated with increased survival in various diseases, a phenomenon known as the ‘obesity paradox’, although its interpretation is a matter of debate. Some scholars believe that, the obesity paradox may be an artifact of selection bias for healthier patients in the preplanned surgical setting [ 37 , 38 ]. However, in many studies analyzing survival in older adults, being overweight or obese has been found to be a beneficial factor. Theoretically, excess adipose tissue may provide for a metabolic reserve to be used in stress conditions, either chronic ones such as cancer or acute ones such as a fracture of a long bone and its surgical treatment. Overweight patients may thus be more tolerant of the internal and external stress that is coupled with traumatic injury and critical illness [ 39 ]. Consequently, a higher BMI could provide protection against acute muscle loss and, later on, frailty [ 40 ]. And underweight is the opposite, especially in old age, underweight status appears to be a stronger predictor for risk of death than is being overweight or obese [ 41 , 42 ]. This study also supports that low BMI is an unfavorable factor for one-year overall mortality following hip surgery. However, in some older patients with spinal kyphosis or impaired cardiac and renal function, there may be difficulties in accurately measuring height and dry body weight, leading to potential deficiencies or errors in calculating BMI. This is a practical challenge.

This study has certain limitations. First, this was a single center, retrospective and observational study, which was subject to the clinical data of patients to a certain extent. The sample size of this study was limited, and the follow-up time was relatively short, which may cause a potential selection bias and center-specific to the research results. Secondly, weight refers to preoperative weight, and the acquisition of CONUT score is based on laboratory indicators at discharge. This study did not provide dietary information or changes in weight, CONUT score, and ADL score for each patient after discharge. Given the impact of hospital stay, postoperative ADL score and CONUT score may underestimate the patient’s condition. In order to clarify the answer to this question, further longitudinal research is needed.

The combined index of CONUT score increase and ADL score impairment has good clinical value in assessing 1-year postoperative prognosis in older adults after hip fracture.

Going forward, intervention plans that use CONUT score as an objective detection indicator, ADL score as an outcome measure and BMI as a self-monitoring target may become practical standards for improving quality of life in geriatric patients with hip fractures after surgery.

Data availability

The data that support the fingdings of this study are available from the first author or cooresponding author upon reasonable request. This study has been registered on Clinical Trials.gov, and relevant data can be obtained from the website after the study is published.

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Acknowledgements

The authors would like to thank the staff of the Department of Orthopedics, Beijing Tongren Hospital and our colleagues on the Department of Geriatrics. We also thank all those involved in collecting the data.

This study was supported by Beijing Municipal Health Commission (2019–2024) No.2020 − 641.

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Ying Chen, Ying Guo, Yu He, Ruihua Zhang & Qi Liu

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Q.L conceived the study.Y.C conducted analysis and wrote the paper. Y.G supervised data collection, and supported data interpretation. G.T supported data interpretation. Y. H was responsible for statistical data.RH. Z supervised data collectionAll authors revised the manuscript for intellectual content.

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Chen, Y., Guo, Y., Tong, G. et al. Combined nutritional status and activities of daily living disability is associated with one-year mortality after hip fracture surgery for geriatric patients: a retrospective cohort study. Aging Clin Exp Res 36 , 127 (2024). https://doi.org/10.1007/s40520-024-02786-8

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Perioperative interventions to improve early mobilisation and physical function after hip fracture: a systematic review and meta-analysis

Mitchell n sarkies.

School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney NSW 2006, Australia

Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia

Ann Carrigan

Natalie roberts.

James Paget University Hospital Foundation Trust, Norfolk NR31, UK

Catherine Sherrington

Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney NSW 2006, Australia

School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney NSW 2006, Australia

Rebecca Mitchell

Jacqueline c t close.

Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney NSW 2031, Australia

Prince of Wales Clinical School, University of New South Wales, Sydney NSW 2052, Australia

Catherine McDougall

The University of Queensland, Brisbane 4072, Australia

The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane 4032, Australia

Katie Sheehan

Department of Population Health Sciences, School of Life Course and Population Sciences, King’s College London, London WC2R, UK

Associated Data

Data is available from the corresponding author upon reasonable request.

Perioperative interventions could enhance early mobilisation and physical function after hip fracture surgery.

Determine the effectiveness of perioperative interventions on early mobilisation and physical function after hip fracture.

Ovid MEDLINE, CINAHL, Embase, Scopus and Web of Science were searched from January 2000 to March 2022. English language experimental and quasi-experimental studies were included if patients were hospitalised for a fractured proximal femur with a mean age 65 years or older and reported measures of early mobilisation and physical function during the acute hospital admission. Data were pooled using a random effect meta-analysis.

Twenty-eight studies were included from 1,327 citations. Studies were conducted in 26 countries on 8,192 participants with a mean age of 80 years. Pathways and models of care may provide a small increase in early mobilisation (standardised mean difference [SMD]: 0.20, 95% confidence interval [CI]: 0.01–0.39, I 2  = 73%) and physical function (SMD: 0.07, 95% CI 0.00 to 0.15, I 2  = 0%) and transcutaneous electrical nerve stimulation analgesia may provide a moderate improvement in function (SMD: 0.65, 95% CI: 0.24–1.05, I 2  = 96%). The benefit of pre-operative mobilisation, multidisciplinary rehabilitation, recumbent cycling and clinical supervision on mobilisation and function remains uncertain. Evidence of no effect on mobilisation or function was identified for pre-emptive analgesia, intraoperative periarticular injections, continuous postoperative epidural infusion analgesia, occupational therapy training or nutritional supplements.

Conclusions

Perioperative interventions may improve early mobilisation and physical function after hip fracture surgery. Future studies are needed to model the causal mechanisms of perioperative interventions on mobilisation and function after hip fracture.

• The primary goal of hip fracture surgery is to optimise health-related quality of life by alleviating pain and restoring physical function.
• The effect of perioperative interventions on the ability to mobilise early postoperatively and restoration of physical function is relatively unknown.
• Pathways, models of care and analgesia interventions may improve early mobilisation and physical function.

Introduction

Hip fracture is a life changing injury for older people that is associated with considerable morbidity, mortality, loss of independence and reduced health-related quality of life (HRQoL) [ 1–3 ]. Approximately 25% of hip fracture patients die within 12 months of injury; [ 4 ] of those who survive, around 40–70% fail to regain their previous level of physical function and 10–20% require new residential aged care facility accommodation [ 5 ]. By 2050, hip fractures are expected to affect 4.5 million people per year, representing considerable personal, health and societal cost from hospitalisation, rehabilitation and long-term support [ 6 , 7 ].

The primary goal of treatment is to optimise HRQoL by alleviating pain and restoring physical function. For most hip fracture patients, this is best achieved with surgery followed by early mobilisation and rehabilitation [ 8 , 9 ]. Early mobilisation is recommended in clinical practice guidelines usually by day 1 postoperatively [ 10 , 11 ]. However, despite best efforts, only 20–50% of patients achieve first day walking and less than half receive physiotherapy for greater than two hours in the first 7 days after surgery [ 11 , 12 ]. Factors thought to contribute to delay in first day walking include postoperative delirium, haemodynamic instability, pain, restricted weight bearing instructions, post-operative anaemia and patient expectations, [ 13 ] all of which are potentially amenable to interventions in the perioperative care period.

Perioperative interventions, such as analgesia regimens, timing of surgery and type of anaesthesia are recommended in clinical practice guidelines to address barriers to early mobilisation and optimise physical function outcomes [ 14–16 ]. However, the delivery of these perioperative interventions varies substantially between hospital sites and their impact on the ability to mobilise early postoperatively and restoration of physical function is not yet well understood. The aim of this systematic review is to determine the effectiveness of perioperative interventions on achieving early mobilisation and improving physical function after hip fracture.

A systematic review was undertaken and reported in accordance with the Preferred Reporting Items for Systematic Review and Meta-Analyses statement (PRISMA) [ 17 ]. The protocol was registered with Prospero (CRD42022313693) [ 18 ].

Search strategy and selection criteria

Five academic databases (Ovid MEDLINE, CINAHL, Embase, Scopus and Web of Science) were searched for peer-reviewed English language articles published between 1 January 2000 and 4 March 2022. Searches were supplemented by snowballing the reference lists of included articles, and relevant reviews and protocols identified, as well as forward citation tracking of articles citing those included in the review. The search strategy was created in collaboration with a medical librarian ( Supplementary 1 ).

Study selection

Four reviewers (LT, SS, AC and NR) independently assessed the eligibility of title/abstract and full text articles for inclusion in pairs using Rayyan [ 19 ]. The inclusion criteria for the review are presented in Box 1 . Any disagreements during screening were discussed and a third independent reviewer was consulted for the final decision where consensus could not be achieved (MS). Authors of studies where relevant data could not be obtained were contacted and excluded if no response was received.

Systematic review inclusion criteria

Participants

Mean age of 65 years and older and admitted to hospital with a fractured proximal femur.

Intervention

Perioperative interventions were defined as those delivered in preparation for surgery and during the operative period to recovery. This excluded the operation or procedure performed. Where one of the perioperative interventions also included early mobilisation, we considered the protocolised early mobilisation as the intervention, and whether it was achieved as the outcome.

Any control conditions, including usual care or alternative interventions or exposures.

Measures of both early mobilisation and physical function were included, considering the potential relationship between perioperative interventions on the ability to mobilise early and then improve eventual physical function outcomes.

• Early mobilisation: Timing of commencement, proportion of patients mobilised early, or total amount of early postoperative mobilisation activity achieved postoperatively during the acute hospital admission.
• Physical function: Any measure of function collected postoperatively during the acute hospital admission, including functional outcome assessments, distance walked and achievement of functional tasks, and level of independence during ambulation.

Types of study

Experimental and quasi-experimental studies.

Date of publication

Published between 1 January 2000 and 4 March 2022.

Data extraction

Data relating to study characteristics, interventions and outcomes were independently extracted to a customised Excel spreadsheet by reviewers in pairs (LT, SS, AC and NR), which was piloted before use. Risk of bias was assessed using the JBI Checklist for Randomised controlled trials (RCTs) or Checklist for Quasi-Experimental Studies ( Supplement 2 ) [ 20 ]. Disagreements were resolved by discussion and a third independent reviewer was consulted for the final decision where consensus was not achieved (MS). Authors were contacted to request additional data as needed.

Data synthesis

Random effect meta-analysis was conducted where data were available for the same intervention and outcomes in two or more studies. Standardised mean difference (SMD) effect size was used for measures of early mobilisation and physical function with different scales and was interpreted according to Cohen’s d (0.2 = small, 0.5 = moderate and 0.8 = large) [ 21 ]. The mean and standard deviation were estimated for studies reporting medians and ranges, [ 22–26 ] using methods described by Wan et al. [ 27 ]. Dichotomous and continuous outcomes were combined using methods described by the Cochrane Handbook for Systematic Reviews of Interventions, which involved re-expressing odds ratios as SMDs [ 28 ]. Effect size directions were transformed to standardise positive effects as favouring the intervention and negative effects favouring the control. The I -squared statistic ( I 2 ) was used to represent heterogeneity in the study findings, with >50% considered substantial [ 29 ]. A leave-one-out sensitivity analysis was undertaken where overall heterogeneity levels were above 50% to further explore how each individual study affected the overall estimate of the rest of the studies. Analysis was performed using STATA Version 18 [ 30 ].

Early mobilisation: In studies where multiple measures of mobilisation were evaluated, time to first mobilisation was prioritised for the mobilisation outcome meta-analysis. Where not reported, number of patients mobilised on the earliest reported postoperative day (e.g. day 1) was used. Where activity during admission was reported, the number of mobilisation events was used instead of time spent mobilising.

Physical function: For studies with multiple functional outcomes assessed, the cumulated ambulation score (CAS) was prioritised as the functional outcome assessment for the meta-analysis. Totals or averages of functional outcomes over multiple inpatient days were used where reported; otherwise, the latest follow-up period was used (e.g. day of discharge). Distance walked was selected over achievement of tasks (e.g. walking beyond bedside chair) and ability to walk independently was selected over ability to walk with assistance. Ambulation capability over multiple distance categories were pooled to greater than 10 metres. The functional independence measure (FIM) motor function score was used over the locomotion sub-score.

A formal meta-regression was not planned, as it was anticipated that a small number of the included studies could be included in meta-analyses. A narrative synthesis was used to describe the data for the remaining studies.

Study flow and characteristics of included studies

Twenty-eight studies were included in the review, from 1,327 identified citations ( Figure 1 ). Eighteen studies were RCTs, five were non-randomised trials and five were controlled before and after studies. Studies were conducted in Sweden ( n  = 4), USA ( n  = 2), Australia ( n  = 3), China ( n  = 2), Denmark ( n  = 2), Japan ( n  = 2), Norway ( n  = 2), UK ( n  = 2), Korea ( n  = 1), Israel ( n  = 1), Italy ( n  = 1), Russia ( n  = 1), Spain ( n  = 1), Taiwan ( n  = 1), Ukraine ( n  = 1) and multinational ( n  = 2). Studies were conducted at a single ( n  = 22) or multiple hospital sites ( n  = 6). There were 8,192 participants across the included studies (range 41–781) with a mean age of 80 years. Interventions were grouped into six categories: analgesia, pathways and models of care, rehabilitation delivery modes, surgical protocols, nutritional supplements and clinical supervision. Early mobilisation outcomes were collected between postoperative days 1 and 7 or upon discharge. Physical function outcomes were collected between days 1 and 14 or upon discharge. Risk of bias assessment is reported in Supplement 2 . Characteristics of the included studies are presented in Supplement 3 , and the outcomes of perioperative interventions on early mobilisation and physical function after hip fracture surgery are presented in Supplement 4 .

PRISMA flow diagram of studies in the review.

Ten RCTs ( n  = 843) and one non-RCT ( n  = 103) reporting the effects of analgesia interventions in the perioperative period were identified. Six studies ( n  = 705) [ 22 , 31–36 ] compared ultrasound guided peripheral nerve blocks to conventional pain management. Two studies ( n  = 104) [ 37 , 38 ] compared active TENS to a sham device. One study ( n  = 82) [ 39 ] compared pre-emptive analgesic medication and intraoperative periarticular injections to standard care and another study ( n  = 55, 40) compared continuous postoperative epidural infusion to a placebo. Analgesia interventions had no clear overall effect on early mobilisation (SMD: 0.39, 95% CI: –0.35 to 1.13, I 2  = 84%; Figure 2 ) or physical function (SMD: 0.64, 95% CI: –0.07 to 1.35, I 2  = 96%; Figure 3 ). Subgroup analysis showed that TENS provided a moderate improvement in physical function (SMD: 0.65, 95% CI: 0.24–1.05, I 2  = 96%; Figure 3 ). Leave-one-out sensitivity analysis suggested the absence of an effect persists irrespective of the omission of any one trial, with the exception of Foss et al. [ 40 ], where removed there was a large beneficial effect of analgesia interventions on physical function ( Supplement 5-A and B ).

Forest plot of comparison: analgesia interventions versus control on mobilisation.

Forest plot of comparison: analgesia interventions versus control on function.

Pathways and models of care

Six RCTs ( n  = 1,210) [ 23 , 41–45 ], one non-RCT ( n  = 244) [ 46 ] and two controlled before and after studies ( n  = 1,262) [ 47 , 48 ] reporting the effects of perioperative pathways and models of care were identified. Four studies ( n  = 840) [ 23 , 41 , 42 , 46 ] compared orthogeriatric models of care to conventional care. Five studies ( n  = 881) [ 43–45 , 47 , 48 ] compared Enhanced Recovery After Surgery (ERAS) care pathways to conventional postoperative care. Perioperative pathways and models of care produced a small positive effect on early mobilisation (SMD: 0.20, 95% CI: 0.01–0.39, I 2  = 73%; Figure 4 ) and physical function (SMD: 0.07, 95% CI: 0.00–0.15, I 2  = 0%; Figure 5 ). Leave-one-out sensitivity analysis suggested the small effect noted persisted following the removal of Gonzalez-Montalvo [ 46 ], Kang [ 43 ], Roberts [ 47 ] or Panella [ 45 ]. The effect did not persist following removal of remaining three studies ( Supplement 5-C ).

Forest plot of comparison: pathways and models of care versus control on mobilisation.

Forest plot of comparison: pathways and models of care versus control on function.

Rehabilitation delivery modes

One RCT ( n  = 100) [ 49 ] compared patients receiving occupational therapy training to those receiving conventional nursing care only, finding no significant difference in early mobilisation physical function. One RCT ( n  = 51) [ 24 ] compared recumbent cycling to usual care reporting similar between group function. One non-RCT ( n  = 150) [ 50 ] compared a preoperative mobilisation program with usual care finding significant improvements in physical function using the modified Barthel Index on admission day 3 and at discharge. One controlled before and after study ( n  = 155) [ 51 ] examined the effect of a multidisciplinary rehabilitation program compared to usual care, reporting significantly earlier ability to mobilise and less mobility decline (relative to pre-fracture mobility status).

Surgical protocols

One RCT ( n  = 2,970) [ 26 ] compared accelerated surgery (goal of surgery within 6 hours of diagnosis) to standard care, reporting reduced time to first mobilisation following surgery and no difference in physical function, time to first standing and weight bearing. One RCT ( n  = 162) [ 25 ] compared liberal transfusion thresholds to restrictive transfusion thresholds finding no significant difference in physical function on days 1–3.

Nutritional supplements

One controlled before and after study ( n  = 209) [ 52 ] compared nutritional supplements with usual care finding no significant improvement in walking assistance levels measured at day 5.

Clinical supervision

One controlled before and after study ( n  = 290) [ 53 ] compared the addition of direct face to face supervision of physiotherapists by an experienced orthopaedic physiotherapist external to the department to an existing reflective clinical supervision program. Patients receiving care from physiotherapists under the direct supervision program were more likely to mobilise day 1 and by day 2 postoperatively, and walked further day 5 with less assistance.

This systematic review identified perioperative interventions that improved postoperative early mobilisation and physical function for hip fracture patients. TENS analgesia may provide a moderate improvement to physical function, and pathways and models of care may provide a small improvement in function, particularly orthogeriatric models. One study was identified supporting pre-operative mobilisation compared to bed rest for post-operative physical function when surgery was delayed beyond 48 hours. However, the average pre-operative waiting time in this study was greater than 6 days, limiting the generalisability to settings where operative waiting time is usually less than 48 hours. Other single studies supported improved early mobilisation for multidisciplinary rehabilitation delivery modes compared to usual care and direct clinical supervision of physiotherapists compared to usual reflective supervision. Multiple studies indicated less clear results for peripheral nerve blocks, and ERAS care pathways on early mobilisation and physical function, and orthogeriatric models and recumbent bike cycling on function. Single studies evaluating pre-emptive analgesia and intraoperative periarticular injections, continuous postoperative epidural infusion analgesia, indicated benefits for postoperative mobilisation and function. No improvement in physical function was identified from occupational therapy training rehabilitation delivery modes and nutritional supplements.

The proportion of patients achieving early mobilisation has been relatively resistant to improvement in the UK, Australia and New Zealand, despite increases in the proportion of hip fracture patients offered the opportunity to mobilise day 1 postoperatively [ 12 , 54 ]. Several factors contribute to the inability to mobilise early, including the presence of delirium, low levels of pre-morbid mobility, older age, more days with a fever, urinary catheter or incontinence and non-use of anti-decubitus mattresses [ 13 , 55 ]. Further barriers have been identified by treating physiotherapists, such as manual handling risks, patient declining rehabilitation, hypotension and pain [ 13 ]. Increasing opportunities for hip fracture patients to mobilise is important but other perioperative interventions are needed to overcome these barriers to improving physical function through early and ongoing rehabilitation in the acute phase postoperatively.

Peripheral nerve blocks and TENS analgesia interventions are thought to work by reducing reliance on opioids, which may avoid complications impacting the ability to mobilise including confusion, nausea, hemodynamic instability and chest infection [ 56 , 57 ]. This mechanism is supported by Guay et al. who reported peripheral nerve blocks reduce pain, risk of acute confusion and probably reduce the risk of chest infection and time to first mobilisation [ 58 ]. There is a close bidirectional relationship between delirium and physical function [ 59 ], as immobility can be both a risk factor and a direct consequence of delirium [ 60–63 ]. Therefore, perioperative interventions that reduce the risk of delirium could also deliver dividends through earlier mobilisation and improved physical function.

Pathways and models of care may help to reduce variation by systematising the delivery of care [ 64 ]. Cooperation between orthopaedic surgeons, geriatricians and other multidisciplinary team members can lead to early identification of hip fracture patients for discharge planning and rehabilitation regimes [ 65 ]. Identifying and addressing comorbidities early is thought to optimise medical stability [ 66 ]; thereby reducing the risk of postoperative complications [ 67 ]. A study by Van Heghe et al. suggests that while there is evidence that orthogeriatric models of care reduce mortality and delirium and may reduce complications, the effect on functional outcome is inconsistent [ 68 ]. There is no ideal model identified to improve early postoperative mobilisation and physical function that is generalisable across different hospital sites with different contextual circumstances. The study by Snowdon et al. [ 53 ] evaluating clinical supervision of physiotherapists by an external senior orthopaedic physiotherapist could point to a potential mechanism for multidisciplinary team models improving mobility outcomes in an Australian context.

Mobilising hip fracture patients postoperatively can be resource intensive, often requiring two health professionals. Recumbent cycling offers an additional alternative mode to exercise that could be less resource intensive for therapists. However, the benefits on physical function were mixed, with the study authors suggesting benefits might not be expected to occur in the acute postoperative period and recommended a fully powered follow up trial [ 24 ]. Multidisciplinary rehabilitation programs were posited to offer more opportunities for early rehabilitation via nursing staff in addition to physiotherapists. Collaboration between members of the multidisciplinary team has been shown to result in fewer cases of death or loss of ability to live independently, although there is lower certainty of reductions in poorer functional outcomes at 12 months [ 69 ]. Pre-operative mobilisation targeted a different mechanism for improved post-operative early mobilisation, by preventing deconditioning and complications due to immobility while awaiting surgery. Immobilisation after fracture is a substantial contributor to poor prognosis and therefore efforts should be directed to improving time to surgery [ 70 ]. However, it is not uncommon for hip fracture patients to wait more than 48 hours for surgery [ 71 ]. Mobilisation during this pre-operative period could prevent functional deterioration, counter impaired ventilation and impaired cough reflex to reduce risk of pneumonia [ 72 , 73 ], and prevent delirium and sleep disorders by helping to create a day and night routine [ 74 ].

Accelerated surgery reduces delirium, urinary tract infection and moderate to severe pain, which are closely related to early mobilisation [ 26 ]. However, the direction of this association between early mobilisation and these complications in the context of accelerated surgery is unclear. It is possible that early mobilisation itself reduces these complications rather than the absence of complications being a facilitator of early mobilisation. Foss et al. demonstrated that liberal transfusion thresholds did not affect physical function. Previous research has shown associations between postoperative anaemia and decreased mobilisation postoperatively [ 75–77 ]; however, correction via red blood cell transfusion has not previously been shown to improve rehabilitation outcomes [ 78 ].

Strengths and limitations

This review included only experimental and quasi-experimental study designs according to Cochrane Effective Practice and Organisation of Care study design criteria [ 79 ]. Most identified studies were RCTs, limiting the risk of confounding variables influencing the study findings. To ensure the capture of articles, forward and backward citation tracking snowballing of both included articles and other potentially relevant articles identified in the screening process was conducted. The included studies provided a relatively diverse sample ( n  = 8,192) from 26 countries and allowed comparisons across multiple studies evaluating similar perioperative interventions. However, the heterogeneity between methods, interventions and outcomes constrained our ability to examine pooled estimates across all included studies. Inclusive definitions of compared interventions and outcomes may have contributed to high levels of heterogeneity in our meta-analysis. Furthermore, some of the included studies did not restrict their inclusion criteria to older patient cohorts and reported on all patients over 18 years. These studies did not appear to have a younger average sample when compared to those with inclusion criteria selective of older age groups, but we were unable to examine the potential effect of age on the outcomes of interest. It is difficult to provided definitive recommendations for perioperative interventions with uncertain findings within and between studies, as well as those with only one study identified.

For analyses of analgesic approach, leave-one-out sensitivity analysis suggested the absence of an effect persists irrespective of the omission of any one trial. In contrast, the results of analyses of pathways and models of care varied with the omission of individual studies, but this did not appear to be related to underlying study quality.

The effect of several perioperative interventions on early mobilisation and physical function after hip fracture were identified in this systematic review. TENS, and orthogeriatric models and ERAS care pathways may improve physical function after hip fracture surgery. The benefit of peripheral nerve blocks, pre-operative mobilisation, multidisciplinary rehabilitation, recumbent cycling and clinical supervision is less certain. No improvement was identified for pre-emptive analgesia and intraoperative periarticular injections, continuous postoperative epidural infusion analgesia, occupational therapy training and nutritional supplements. Many barriers to early mobilisation are potential amenable to perioperative interventions. Yet, despite the importance of achieving early mobilisation and restoring physical function after hip fracture surgery, relatively few studies were identified. There is a lack of standardisation in outcome measurement and reporting practices that limits the ability to synthesise findings across studies. Future aetiologic studies are required to understand and model the causal mechanisms by which early mobilisation and physical function after hip fracture can be improved by perioperative interventions.

Supplementary Material

Aa-23-0319-file006_afad154, acknowledgements.

The authorship team wish to acknowledge the contributions of Sonia Singh to the screening of titles and abstracts for inclusion in this review.

Contributor Information

Mitchell N Sarkies, School of Health Sciences, Faculty of Medicine and Health, University of Sydney, Sydney NSW 2006, Australia.

Luke Testa, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia.

Ann Carrigan, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia.

Natalie Roberts, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia.

Rene Gray, James Paget University Hospital Foundation Trust, Norfolk NR31, UK.

Catherine Sherrington, Institute for Musculoskeletal Health, The University of Sydney and Sydney Local Health District, Sydney NSW 2006, Australia. School of Public Health, Faculty of Medicine and Health, The University of Sydney, Sydney NSW 2006, Australia.

Rebecca Mitchell, Australian Institute of Health Innovation, Faculty of Medicine, Health and Human Sciences, Macquarie University, Macquarie Park NSW 2113, Australia.

Jacqueline C T Close, Falls, Balance and Injury Research Centre, Neuroscience Research Australia, Sydney NSW 2031, Australia. Prince of Wales Clinical School, University of New South Wales, Sydney NSW 2052, Australia.

Catherine McDougall, The University of Queensland, Brisbane 4072, Australia. The Prince Charles Hospital, Metro North Hospital and Health Service, Brisbane 4032, Australia.

Katie Sheehan, Department of Population Health Sciences, School of Life Course and Population Sciences, King’s College London, London WC2R, UK.

Declaration of Conflicts of Interest

Declaration of sources of funding.

This study received funding from an NHMRC Investigator Grant (CIA Sarkies 2007970).

Data Availability Statement