- Germany: Around 150,000 proximal femoral fractures per year.
- Age distribution: Over 80 percent of those affected are over 75 years of age.
- Sex ratio: Women are affected three times as often as men, primarily because of postmenopausal osteoporosis in old age.
- Lifetime risk: About one in four women and one in ten men over 70 will suffer a hip-related fracture in the course of their life.
In my own clinic, the Main-Kinzig-Kliniken Schlüchtern, the number of cases almost doubled between 2019 and 2025 — from 109 to 217 cases per year. That corresponds to an increase of 99.1 percent in six years. The demographic aging of our catchment area explains only part of this curve; the other part is due to avoidable falls in old age. These figures have two consequences: we have expanded our geriatric early rehabilitation accordingly — and we have made delirium prevention, medication review and the preoperative assessment structure a standard process, not an exception.
→ Why falls in old age are rarely “just” falls — and what lies behind them: falls in old age.
A femoral neck fracture is a serious injury at any age, but in older people something else is added: the fracture itself is usually the visible event — the actual challenge begins afterward. The relevant figures:
- 1-year mortality: 20 to 30 percent, depending on the starting condition and the quality of care. That is higher than after most tumor diseases in geriatric medicine.
- Functional loss: Only about 40 to 50 percent of patients fully regain their pre-fracture level of mobility.
- Need for care: 20 to 30 percent of previously independently living patients move into residential care after the fracture.
- Delirium rate: 30 to 50 percent of patients develop signs of delirium postoperatively — more on this: delirium prevention.
- Re-fracture risk: After a hip-related fracture, the risk of a second fracture on the opposite side is markedly increased within a few years.
These figures sound alarming — and they are. But they are not unchangeable laws of nature. They differ considerably depending on the quality of care. The frailty syndrome is a central factor here: patients with pre-existing frailty have a markedly higher risk of complications.
Surgical treatment is the standard today in geriatric traumatology. Non-surgical treatment only comes into question for clearly defined exceptions (patients in a palliative situation, conditions not fit for surgery). The choice of procedure depends on the fracture location and the activity level:
Total hip replacement (hip TEP)
The damaged femoral head is replaced by a prosthesis made of metal and plastic. Preferred in active patients with a good life expectancy and pre-existing hip osteoarthritis. Long-lasting treatment, high functional resilience.
Hemiarthroplasty (bipolar prosthesis)
Only the femoral head is replaced, the hip socket is preserved. Shorter operation time, smaller procedure. Preferred in older, less active patients without pre-existing osteoarthritis.
Osteosynthesis (screwing or intramedullary nail)
The fracture is stabilized with screws, plates or an intramedullary nail, the patient’s own bone is preserved. For stable, non-displaced fractures and for fractures in the trochanteric region.
The decision between these procedures is made individually by the operating team. Important for patients and relatives to know: the choice of implant does not alone determine the course. Postoperative mobilization and geriatric support are at least as important.
→ In depth on joint replacement in old age — what older patients should know.
→ Specifically on hip joint replacement: hip TEP from 80.
One of the best-documented findings of recent years: the time until the operation is an independent predictor of mortality and loss of function. The S3 guideline of the AWMF and international guidelines recommend surgical treatment within 24 hours, but at the latest within 48 hours after admission. Reasons:
- A longer waiting time increases the rate of pneumonias, thromboses, delirium and pressure sores
- Extended bed rest before the operation leads to muscle loss (sarcopenia) and cardiovascular deconditioning
- The pain is often considerable at rest, even when lying down — pain relief comes primarily through the operation
In Germany, 24-hour care is not yet achieved everywhere across the board, even though it is increasingly becoming the standard in specialized centers of geriatric medicine.
Orthogeriatrics — the structured cooperation of trauma surgery and geriatrics — is one of the best-documented organisational forms of modern geriatric medicine. Studies show:
- Reduction of 1-year mortality by up to 30 percent
- Shorter length of stay
- Marked reduction of postoperative complications (delirium, pneumonia, thrombosis)
- Higher rate of return to one’s own home
The geriatrician does not take over the operation, but the overall management of the secondary aspects that determine the actual course: pain therapy, fluid and nutrition management, delirium prevention, mobilization planning, medication review to address polypharmacy in old age, secondary prevention of further fractures.
???? With every clinic admission for a hip-related fracture: actively ask whether geriatric co-care is offered. In centers with an orthogeriatric structure this is standard — in other hospitals it has to be requested explicitly.
After the operation, the geriatric early rehabilitation ideally begins on the first postoperative day. The typical course:
Day 1–2: First mobilization to the edge of the bed, breathing therapy, secretion mobilization, thrombosis prophylaxis. Painkillers in sufficient amounts, but opioids as sparingly as possible.
Day 3–7: First attempts at walking with a rollator or walking frame. Start of occupational therapy for everyday activities. Admission assessment with Barthel and Tinetti. Delirium screening.
Day 8–14: Extension of the walking distance. Training of everyday functions (dressing, washing, going to the toilet). Climbing stairs. Planning of discharge.
Day 14–21: Discharge preparation with a final assessment. Provision of aids, home adaptation, organization of a care service or physiotherapy at home, secondary prevention plan.
→ In detail on the procedure: geriatric early rehabilitation.
A hip-related fracture considerably increases the risk of a second fracture. This is not medically inevitable — it is avoidable. Three building blocks belong to secondary prevention:
- Osteoporosis diagnostics and therapy: Bone density measurement, vitamin D determination, laboratory tests. When indicated: bisphosphonates, denosumab or, in severe osteoporosis in old age, romosozumab. Antiresorptive therapy reduces the re-fracture risk by 40 to 50 percent.
- Fall clarification and prevention: Systematic analysis of the causes of falls — medications, vision, mobility, living environment — and targeted interventions. More on this: fall prevention.
- Muscle and strength building: Continuation of training beyond the rehabilitation. Without structured strength and balance training, the risk of relapse is high — closely linked to the prevention of sarcopenia.
→ On osteoporosis and antiresorptive therapy: osteoporosis in old age.
→ On structured fall prevention: fall prevention — what really works.
→ On the role of medication review after a fracture: polypharmacy in old age.
- Invest time in the first days: Familiar faces reduce delirium and provide motivation.
- Bring glasses, hearing aid, dentures: Sensory impairments intensify confusion and hinder mobilization.
- Bring the current medication list to admission: including over-the-counter and herbal preparations. Especially in polypharmacy, the complete list is decisive.
- Ask about delirium screening and geriatric co-care: Both should be a topic from the very beginning. More on this: delirium prevention.
- Take part in discharge planning: The earlier you are involved, the better the transition home succeeds.
- Prepare the living environment: Grab rails, night lighting, removing tripping hazards — this is often sensible in parallel with the rehabilitation and part of fall prevention.
In clinics with an orthogeriatric structure, the geriatrician is automatically involved. In other hospitals — and especially after discharge — a geriatric follow-up is part of good care. Specifically:
- During the clinic stay, if no automatic co-care takes place
- After discharge in case of persistent unsteadiness, weakness or confusion
- Three to six months after the fracture to evaluate the secondary prevention
- In case of newly occurring falls in old age after the operation
- If the medication was not systematically reviewed after the fracture
→ How a comprehensive geriatric assessment supports further planning.
