Hip Replacement at Age 80 and Older — How Geriatric Co-Management Reduces Risk

A total hip replacement replaces both parts of the damaged joint: the femoral head on the thighbone and the acetabulum in the pelvis. The artificial joint consists of:

• Shaft (titanium or cobalt-chromium alloy) — anchored in the femur
• Head (ceramic or metal) — replaces the femoral head
• Acetabular cup (metal with a plastic, ceramic, or metal insert) — located in the pelvic bone

Anchoring is either cemented (especially in older patients with softer bone) or cementless (in patients with good bone quality). The surgeon makes this decision on a case-by-case basis—cemented implants are more commonly used in older patients with age-related osteoporosis.

→ For an overview of joint replacement in older adults: Joint Replacement in Older Adults.

Two completely different clinical situations lead to total hip replacement in older adults:

Elective hip TEP for coxarthrosis

The typical scenario: long-standing, progressively worsening hip pain, limited walking distance, nighttime pain, and conservative treatment options exhausted. The surgery is scheduled, and the timing can be chosen. This allows for structured prehabilitation—and thus significantly better outcomes. The basis for this is a geriatric assessment.

Hip TEP Following a Proximal Femoral Fracture

The other scenario: a fall, a fracture, and the need for rapid treatment within 24 to 48 hours. No time for prehabilitation; patients are often in fragile health and have frequent comorbidities. Mortality is significantly higher in this scenario—not because of the implant, but due to the initial condition and systemic stress.

The SOG study (Surgery in the Oldest-Old) reports a one-year mortality rate of 26.5 percent for patients over 90 years of age following a proximal femoral fracture. For elective total hip replacement in patients over 80, the rate ranges from 2 to 5 percent, depending on the quality of care. This difference speaks volumes about the importance of the patient’s baseline condition and the care system.

At my own hospital, the Main-Kinzig-Kliniken Schlüchtern, the number of hip-related fractures nearly doubled between 2019 and 2025—from 109 to 217 cases per year. A significant proportion of these patients undergo joint replacement surgery. We have expanded our orthogeriatric services accordingly: geriatric co-management from admission, standardized delirium screening, systematic medication review, and early mobilization on the first postoperative day.

→ Femoral neck fractures in older adults are the most common indication for hip replacement in this age group.

Surgical techniques have made significant advances in recent years. Three surgical approaches are used:

• Anterior approach (Direct Anterior Approach, DAA): Minimally invasive to muscles, faster mobilization in the first few days, and good outcomes in experienced hands.
• Lateral approach (anterolateral): A classic alternative; involves slightly more muscle dissection but is very well-established.
• Posterior approach (posterior): The most common approach worldwide; provides good visibility for the surgeon; carries a slightly higher risk of posterior dislocation in the first few months.

The choice of approach depends on the surgeon’s experience, the patient’s anatomy, and the surgical plan. For the patient, the choice is usually less important than the surgical team’s experience with the respective approach.

For patients over 75—and especially those over 80—a structured geriatric preoperative evaluation is standard practice:

• Frailty assessment: Clinical Frailty Scale (CFS). Caution is advised starting at a CFS score of 5; at a CFS score of 7 or higher, the indication for surgery should generally be reconsidered. More on frailty syndrome. A structured frailty screening is also recommended.
• Cognitive Test: MMSE or MoCA. Pre-existing dementia in older adults is the strongest single predictor of postoperative delirium.
• Nutritional status: MNA. Malnutrition in older adults is an independent risk factor for wound healing and infection.
• Medication review: Anticoagulants, benzodiazepines, anticholinergic agents—each medication should be evaluated for necessity and alternatives. Keywords: deprescribing and polypharmacy in older adults.
• Social environment: Who provides support at home? Is the home barrier-free? Are there stairs? Is there a bathtub instead of a shower?

→ For a comprehensive assessment of surgical risk in older adults: Surgical Risk in Older Adults.

The first three days after total hip replacement (THR) are key to the patient’s subsequent recovery. In modern fast-track protocols, the following applies:

• Mobilization on the day of surgery or by Day 1 at the latest—first at the edge of the bed, then with a walker
• Multimodal pain management with minimal opioid use—this reduces the risk of delirium
• Delirium screening at least once daily by the nursing team
• Glasses, hearing aids, and dentures should be available—sensory impairments can contribute to delirium
• Actively ensure hydration and nutrition—dehydration is a common trigger for delirium
• Thrombosis prophylaxis, respiratory therapy, secretion clearance

→ For detailed information on the recognition and treatment of postoperative delirium: Delirium in Older Adults.

???? When an elderly family member is admitted for a planned total hip replacement (THR): Bring their current medication list, glasses, hearing aid, and a photo of their familiar surroundings. These seemingly small things measurably reduce the risk of delirium.

The acute phase in the hospital is typically followed by:

• Early geriatric rehabilitation: for complex or multimorbid patients, directly in the acute care hospital. More on this: Early geriatric rehabilitation.
• Follow-up rehabilitation (AHB): three weeks of inpatient rehabilitation at a specialized facility.
• Outpatient physical therapy: Continued treatment over several weeks to further improve mobility—particularly important for preventing falls in older adults and as part of fall prevention.

The surgeon determines when weight-bearing on the operated leg is permitted—for cemented prostheses, full weight-bearing is usually allowed from the first day; for cementless prostheses, weight-bearing is often restricted for several weeks.

The prognosis for modern total hip replacements (THRs) is very good with careful selection and follow-up care:

• Long-term prosthesis survival: 90 to 95 percent after 15 years
• Patient satisfaction: over 90 percent report a significant improvement in pain and function after one year
• Revision rate: about 1 percent per year, mostly due to aseptic loosening

Key complications to keep in mind:

• Dislocation (prothesis dislocation): Risk of 2 to 5 percent, especially in the first few months. Strict adherence to positioning guidelines is important.
• Periprosthetic fracture: a fracture of the bone surrounding the prosthesis; rare but serious. Prevention involves treating underlying osteoporosis in older patients.
• Periprosthetic infection: 1 to 2 percent risk; often difficult to treat. Oral hygiene and dental checkups before and after surgery are important.
• Postoperative delirium and POCD: 20 to 40 percent in this age group—our strongest lever for improvement through targeted delirium prevention.
• Thrombosis and pulmonary embolism: Rare with adequate prophylaxis.

In modern orthopedic centers, geriatric co-management for patients over 75 is standard practice. Where this does not happen automatically, you should actively request it—at the latest when one of the following situations arises:

• Pre-existing cognitive impairment or suspected dementia in older adults
• Five or more long-term medications—keyword: polypharmacy in older adults
• Falls in older adults within the last twelve months
• Malnutrition in older adults or unintentional weight loss
• Multimorbidity involving heart failure in older adults, COPD, or kidney failure
• Desire for a structured risk-benefit assessment prior to the procedure — based on a geriatric assessment

Leading Medicine Guide features a team of experienced orthopedic surgeons and trauma surgeons specializing in joint replacement. The combination of orthopedic excellence and geriatric co-management is a proven and evidence-based foundation for good outcomes in modern healthcare systems—especially among older adults. Geriatric traumatology provides the structural framework for this.