Optimization of perioperative management of proximal femoral fracture in the elderly.

Abstract

Proximal femoral fracture in elderly subjects is a major event that is life-threatening in the medium-to-long term. Advanced age, male gender and number of comorbidities largely account for high mortality and require geriatric expertise. Protein-energy malnutrition and bone demineralization increase mortality. Mortality can, on the other hand, be reduced by acting on two variables accessible to medical intervention: daily activities and nutritional status. Functional and neurocognitive assessment allow the risk of dependency to be evaluated, and global geriatric work-up can prevent sudden breakdown of homeostasis. In the emergency setting, pain is to be alleviated, polymedication and anticoagulation therapy checked, and instability (notably cardiac and pulmonary) and confusion syndrome screened for on geriatric and anesthesiologic opinions. Surgery should be implemented without delay, within 48hours of admission, preferably using multimodal anesthesia. The technique should be geared to allow early weight-bearing and mobilization. The most comprehensive care plan involves team-work between emergency physicians, surgeons, orthopedic specialists, anesthesiologists, geriatricians, pharmacists, rehabilitation specialists and nursing staff, to reduce mortality and readmission and improve functional results. Post-fracture coordination seeks to prevent falls and further fractures and to treat bone demineralization.