Post hip fracture orthogeriatric care-a Canadian position paper addressing challenges in care and strategies to meet quality indicators.

Introduction

In response to the American Society for Bone and Mineral Research (ASBMR) [ 1 ], international call to action to address the low rate of diagnosis and treatment of osteoporosis post hip fracture a Canadian multi-disciplinary group has developed recommendations addressing post hip fracture care. The goal is to meet the Canadian quality indicators [ 2 ] and provide the best evidence-based strategies for care following a low trauma hip fracture from an orthopedic, geriatric medicine, and rehabilitation perspective. These recommendations are expected to reduce recurrent fractures and improve mobility and healthcare outcomes as well as healthcare costs.

This Canadian position paper outlining post hip fracture orthogeriatric care addresses the challenges and best practice strategies in Canada. It supports the global efforts of the International Osteoporosis Foundation (IOF) [ 3 ] in its goal to ensure effective pharmacologic intervention following fragility fracture with the launch of the IOF Capture the Fracture [ 4 ] initiative. The new Capture the Fracture Partnership in fact aims to reduce the incidence of hip and vertebral fractures due to osteoporosis by 25% by 2025 [ 4 ]. It also supports the initiatives of the Fragility Fracture Network (FFN) [ 5 ], which has emphasized the value of multi-disciplinary care with an orthogeriatric perspective focusing on early rehabilitation following a fragility fracture. The FFN also emphasizes the value of reliable secondary prevention, reducing falls risk and addressing bone health following a fragility fracture (FFN—four pillars).

This manuscript was developed by a team of multidisciplinary experts in post-fracture care. The patient perspective has also been captured and the document was reviewed and approved by the Bone Research and Education Center patient support program.

Key messages to enhance post-operative care are also provided.

Methodology

A comprehensive narrative review of the literature was conducted to identify and synthesize key articles on post hip fracture orthogeriatric care for each of the individual sections. Multiple search terms for each section were included (for example, emergency department, post hip fracture, and orthogeriatric care). Hand searching of reference lists of relevant articles was also conducted. We included articles with the following criteria (1) adults aged 50 years and older; (2) described care delivered to patients undergoing surgery for hip fracture including preoperative assessment, anesthesia management, surgery, pain management, post-operative management, osteoporosis management, nutrition, and rehabilitation; (3) randomized control trials (RCT), observational studies, systematic reviews, and guideline publications; and (4) English language articles. No limitations were placed on publication date to provide a comprehensive summary of current knowledge. Findings are summarized for each section below. This report is also guided by key quality indicators for hip fracture care provided by Health Quality Ontario (HQO) and Alberta Health Services (AHS) [ 2 , 6 ].

Results

Emergency department management

The early recognition and initiation of treatment of patients with hip fractures in the emergency room optimizes care. A number of “Fast-Track” pathways have been developed that allow patients with suspected hip fractures to receive adequate analgesia, early optimization and rapid diagnosis, and ensure timely care [ 7 ]. Early diagnosis and transfer to an appropriate inpatient bed is required, as it may reduce the risk of pressure ulcers from prolonged periods of immobilization in emergency room stretchers. Pre-operative traction in this setting is of no increased benefit [ 8 ].

Multi-disciplinary care in the preoperative setting allows for rapid medical optimization and has the potential to reduce delays to surgery, incidence of delirium, and in-patient mortality [ 9 , 10 ]. An orthogeriatric care model with co-management by orthopedic surgeons and clinicians with expertise in the care of geriatric patients has gained traction in recent years [ 11 – 13 ]. Co-management models have been shown to reduce the time to surgery and mortality rates in hip fracture patients [ 9 ]. Standardized pre-operative order sets should be initiated upon diagnosis in the emergency department. Standardized order sets and care pathways expedite care, reduce medical errors, and improve preoperative pain management [ 14 ]. Key pre-operative assessments should include a pre-fracture functional status, evaluation of fluid balance, cognitive and delirium screening, preoperative bloodwork, electrocardiography, and evaluation of home medications [ 15 ].

Surgery within 48 h

The evidence supporting timely surgery for patients with hip fractures has grown in recent years. Following a hip fracture, patients often experience significant pain, blood loss, and a period of immobilization. This inciting event leads to a hyper-coagulable, catabolic stress state that increases the risk of serious perioperative complications [ 16 – 18 ]. It is thought that timely surgical care shortens the exposure to this harmful state, reducing the risk of perioperative morbidity and mortality. Population-based cohort data from Ontario demonstrates that surgery within 24 h from presentation to hospital significantly reduces the overall mortality rate and risk of complications [ 19 ]. A recent RCT demonstrated that early surgery reduced mortality in high risk patients with elevated preoperative troponin levels [ 20 ]. If surgery is delayed for more than 12 h from the time of hospital admission, it is recommended that thromboprophylaxis be started pre-operatively with low molecular weight heparin (LMWH) [ 20 , 21 ].

Early surgery in this population requires coordination among several medical and surgical specialists and allied health staff and administrators. Standardized protocols, order sets, and dedicated hip fracture care pathways are imperative to ensure that patients who have sustained a hip fracture receive surgery within 48 h of arriving to the hospital and as soon as possible [ 10 ]. Although a recent RCT found that “accelerated surgery” for hip fracture, i.e., within 12 h of arrival at hospital, did not significantly result in a reduction in death or a composite of major complications compared with “standard care” [ 20 ], it has been established that early surgery within 24–48 h has proven benefits [ 10 , 19 ] and this approach has been widely adopted. Surgery should not be delayed if possible for patients on anticoagulation as the risks of delayed surgery outweigh the risks of intraoperative bleeding [ 22 , 23 ]. Recent meta-analyses have identified that hip fracture patients who present on oral anti-coagulants have significantly delayed time-to-surgery and this is related to higher mortality rates [ 24 , 25 ]. Hip fracture care pathways are being studied and there is increasing support for safe and early coordinated medical and surgical care for patients with hip fractures presenting on pre-injury anti-coagulation [ 26 ].

Multi-modal analgesia/nerve blocks

In addition to around the clock simple analgesia such as acetaminophen, regional nerve blocks can be a safe adjunctive method to improve pain management in patients with hip fractures. They have been shown to decrease opioid use and reduce the rate and length of delirium while also decreasing the length of stay in the hospital [ 27 – 29 ]. When done early, they can also assist with decreasing the time to mobility while also increasing functional walking distance [ 27 ]. This can be done and supplemented with other modes of analgesia as well to provide optimal pain relief for the patient.

The most common blocks are the femoral nerve block and the fascia iliaca compartment block (FICB). Both have been shown to be effective in providing analgesia to patients and can be done as a single-shot injection within the first few hours of presentation once the fracture is confirmed. These can be done under ultrasound guidance to help visualize the anatomy and target the specific region or using the landmark technique. These should be performed by a trained medical professional but can be done by providers of any specialty who have undergone sufficient training.

Typically, a long-acting anesthetic, such as ropivacaine or bupivacaine, is chosen. Pain relief can be felt up to 12 h or more, with the ability to repeat the block until surgery is performed. Patients should be monitored for 30–60 min after the block for signs of local systemic anesthetic toxicity (LAST). Absolute contraindications include patient refusal or allergy to local anesthetic agents. Patients on anticoagulation can receive regional nerve blocks for hip fractures with complications being rare but will need to be considered on an individual basis with risks such as hematoma or minor bleeding around the puncture site [ 30 ].

Surgery for stable intertrochanteric fractures

Inter-trochanteric hip fractures are extracapsular and have minimal risk of nonunion or subsequent osteonecrosis of the femoral head. Given this, they are treated with fixation with either a sliding hip screw (Fig. 1a ) or with an intramedullary nail (Fig. 1b ). The stability of inter-trochanteric fractures is generally determined by the fracture morphology and involvement of the post-eromedial calcar. Stable fracture patterns generally resist further fracture displacement following an adequate reduction and generally include two-part intertrochanteric fractures [ 31 ]. For stable intertrochanteric fractures, the clinical and radiographic outcomes are similar between sliding hip screws and intramedullary nails [ 32 , 33 ]. Sliding hip screws are significantly less expensive than intramedullary nails and are more cost-effective for stable inter-trochanteric hip fractures [ 34 ]. In the era of value-based healthcare, sliding hip screws should be utilized preferentially when indicated in this patient population. Fig. 1 ( a ) Sliding hip screw for intertrochanteric fracture. ( b ) Intra-medullary nail for inter-trochanteric fracture

Surgery for subtrochanteric or unstable intertrochanteric fractures

Sub-trochanteric and unstable inter-trochanteric hip fractures are a challenging entity that commonly present to orthopedic surgeons. Unstable intertrochanteric hip fractures include those with post-eromedial comminution, a reverse obliquity fracture pattern, sub-trochanteric extension, and lateral wall comminution [ 31 , 35 ] (Fig. 2 ). These unstable fracture patterns are associated with fixation failure and a cephalomedullary nail provides a more favorable biomechanical construct compared to a sliding hip screw in this setting. Patients with a sub-trochanteric or reverse obliquity inter-trochanteric fracture should be treated surgically with intramedullary nails to reduce complication rates [ 2 ]. Patients who are low demand with unstable inter-trochanteric fractures can be treated surgically with intra-medullary nails or sliding hip screws as the use of intramedullary nail fixation may be less beneficial in this setting and may not lead to improved functional outcomes [ 2 , 36 ]. Patients with unstable fracture patterns who are high demand and are able to ambulate without walking aids should be treated surgically with intra-medullary nails [ 37 ]. Fracture reduction and implant position are critical variables that play a large role in outcome for all methods of treatment [ 38 ]. Long intra-medullary nails are recommended over short nails by some authors, but most comparative studies show no advantage of one technique over the other [ 39 , 40 ]. Fig. 2 Unstable inter-trochanteric fracture of the right hip

Surgery for displaced intracapsular fractures

Displaced intra-capsular hip fractures (femoral neck fractures) (Fig. 3 ) are at a high risk of avascular necrosis (AVN) and nonunion due to disruption of the blood supply to the femoral neck and head. Surgical options for displaced femoral neck fractures include fixation with either a sliding hip screw or cannulated screws or hip arthroplasty (Fig. 4a ). In the elderly patient population, arthroplasty has demonstrated superior results compared to fixation. Arthroplasty results in lower reoperation rates and improved functional outcomes and higher patient satisfaction and quality of life when compared to fixation [ 41 ]. In young patients (< 60) who are high functioning and active, clinicians may choose to perform fixation in attempts to save the native joint after discussing the risks and benefits with the patient [ 42 ]. Given the risk of AVN, some experts advocate for expedited surgery early after diagnosis. However, there is growing evidence to suggest that the risk of AVN and poor outcomes is directly correlated with the initial fracture displacement and reduction, and surgical timing may not impact outcomes in this population [ 43 ]. Fig. 3 Femoral neck (intra-capsular) fracture of the left hip Fig. 4 ( a ) Sliding hip screw for intra-capsular fracture (femoral neck fracture). ( b ) Bipolar hemiarthroplasty of the left hip (cemented femoral stem). ( c ) Cemented left hip replacement (arthroplasty)

In patients undergoing arthroplasty for a displaced intra-capsular hip fracture, both hemiarthroplasty and total hip arthroplasty are surgical options [ 44 ] (Fig. 4b and c ). Hemiarthroplasty involves replacing the femoral head and neck with a prosthesis and total hip arthroplasty involves replacing both the femoral head and acetabular articular surface with prosthetic components. A recent large, international, RCT comparing hemiarthroplasty to total hip arthroplasty demonstrated similar outcomes between the two groups [ 44 ]. Total hip arthroplasty should be considered in patients with pre-existing arthritic hip pain or younger, active patients with a longer life expectancy. In considering the use of hemiarthroplasty, modern unipolar and bipolar implants may both be advantageous. When undergoing arthroplasty for a displaced intra-capsular hip fracture, cemented components for the femur should be used to reduce the risk of re-operation and periprosthetic fractures.

Weight-bearing as tolerated

Early post-operative mobilization in hip fracture patients reduces serious post-operative complications including pneumonia, thromboembolism, urinary tract infections, and pressure ulcers. Prolonged immobilization and lack of early weight-bearing have been shown to increase mortality in this patient population [ 45 , 46 ]. Older patients with hip fractures, particularly those with underlying dementia and delirium, may not be able to comply with weight-bearing restrictions in the postoperative period [ 47 ]. Weight-bearing restrictions have been shown to reduce overall mobility without actually reducing the load placed on the affected extremity [ 48 ]. Immediate post-operative weight-bearing after hip fracture surgery has not been shown to increase the rate of revision surgery [ 47 , 49 , 50 ]. Given the negative consequences and ineffectiveness of weight-bearing restrictions in hip fracture patients, they should be avoided, and the vast majority of patients should be allowed to mobilize and weight bear as tolerated. Weight-bearing restrictions may be warranted in younger patients who undergo fixation of intra-capsular hip fractures in attempts to salvage the native joint. In these rare situations in which restricted weight-bearing is warranted, a clear plan for progression of mobility and weight bearing should be in place prior to hospital discharge.

Screening for and managing delirium

Delirium, characterized by an acute onset and fluctuation in cognition, consciousness, disorganized thinking, and attention, is a common and serious complication in older patients after hip fracture surgery [ 51 , 52 ]. The incidence of delirium among hip fracture patients is 20–50% [ 53 ]. Post-operative delirium is often associated with falls, impaired functional and cognitive recovery, prolonged hospital stays, discharge to long-term care, and mortality compared to hip fracture patients without delirium, and it may also increase the risk of dementia [ 54 – 56 ]. See Tables 1 and 2 for risk factors and causes of delirium. Evaluating risk factors for delirium prior to hip fracture surgery can assist clinicians in identifying patients at risk and facilitating optimal use of preventative measures. Table 1 Risk factors for delirium in hip fracture patients Predisposing risk factors *Occurring prior to surgery Precipitating risk factors *Occurring during or after surgery High vulnerability *At baseline *Non-noxious events Advanced age Dehydration Pre-existing dementia Use of physical restraints Severe comorbidities Sepsis Frailty New psychoactive medication Vision impairment Infection Introduction of bladder catheter Low vulnerability *At baseline Healthy patient *Noxious events Sleep deprivation Intensive care stay Major surgery Multiple psychoactive medications Table 2 DIMES mnemonic for major causes of delirium [ 57 ] D Drugs -drug withdrawal I Infections -Three most common are PUS: pneumonia, UTI, and skin M Metabolic E Environmental S Structural -Central nervous system events (spontaneous or traumatic subdural bleeding, stroke, etc.) -Constipation -Urinary retention *UTI urinary tract infection

Hip fracture patients should be screened for delirium at admission and throughout the hospital stay as an important step in delirium management is early detection and prevention [ 58 ]. Routine laboratory tests, review of patient’s medical history and current illness, and the implementation of a screening test on admission can assist in evaluating a patient for delirium. The Confusion Assessment Method (CAM) is a quick, accurate, and commonly used tool for screening for delirium [ 59 , 60 ]. It can be incorporated into routine assessments of patients and has been shown to have high sensitivity and specificity (sensitivity of 94% (95% confidence interval (CI), 91–97%) and specificity of 89% (95% CI, 85–94%)) [ 59 , 61 ]. Diagnosis of delirium may also be completed according to the diagnostic criteria of the Diagnostic and Statistical Manual of Mental Disorders Fifth Edition (DSM-V) criteria, International Classification of Diseases (ICD-10), and the Delirium Rating Scale [ 51 , 62 , 63 ]. As delirium is often associated with pre-existing cognitive impairment, baseline cognitive assessment can be performed, using assessment tools such as the Standardized Mini-Mental State Examination (MMSE) [ 64 ], Montreal Cognitive Assessment (MoCA) [ 65 ], Mini-Cog [ 66 ], Short Portable Mental Status Questionnaire (SPMSQ) [ 67 ], and upon hospital admission [ 68 ]. Due to the high prevalence of post-operative delirium, hospitalized adult patients should be assessed at least daily for delirium [ 69 ].

Management strategies for delirium should be focused on prevention and symptom management. Once delirium has developed, there is limited evidence that pharmacologic therapy is beneficial [ 70 ]. A non-pharmacological multicomponent approach is highly effective to reduce the number and duration of delirium episodes [ 71 ]. Programs such as the Hospital Elder Life Program (HELP) is a multicomponent approach that uses delirium prevention strategies (such as maintaining orientation, reducing sensory deficits, ensuring adequate nutrition, and hydration) to reduce functional decline, placement in long-term care facilities, and improve overall quality of hospital care [ 72 , 73 ]. In-patient geriatric consultation as part of a multidisciplinary team has also been shown to decrease episodes of delirium by 40% in patients with hip fracture [ 74 ]. A comprehensive geriatric assessment focusing on evaluation of medications, alcohol intake, detailed patient history, early identification and treatment of complications, and mobilization has been shown to decrease the occurrence of delirium [ 75 ]. Physical exercise and rehabilitation can improve cognitive function among older adults and decrease the risk of delirium [ 76 – 78 ]. Prevention strategies should be prioritized in at-risk patients as such approaches can reduce the development of delirium but have no impact on duration of delirium once it develops.

Once delirium is diagnosed, it is important to identify and treat underlying causes, provide supportive care, and prevent complications. It should be noted that there no specific drugs that are approved the management of delirium. Drug treatments can lead to increased harm to patients, including increased morbidity (including falls and fractures) and mortality.

Pharmacological therapy should only be initiated if non-pharmacological strategies are not adequate to control symptoms and the patient is at risk of harm to themselves or others.

See Table 3 for pharmacologic therapy that may be initiated as indicated [ 2 , 6 , 58 ]. Table 3 Treatment for complications of hyperactive delirium Drug Dose Rout of administration Comments Atypical anti-psychotic Risperidone Initial dose range: 0.25 –0.50 mg every 4–6 h Suggested maximum dose in first 24 h: 2.0 mg Oral • May cause prolonged QT interval on EKG • FDA warning: increased risk of mortality in elderly patients with dementia-related psychosis Quetiapine Initial dose range: 12.50–50 mg every 8 h Suggested maximum dose in first 24 h: 100 mg Oral • May cause prolonged QT interval on EKG • Increased risk of sedation and orthostatic hypotension • FDA warning: increased risk of mortality in elderly patients with dementia-related psychosis Typical anti-psychotic Haloperidol Initial dose range: 0.25–1.0 mg every 2–4 h Suggested maximum dose in first 24 h: 2.0 mg Oral Intravenous Intramuscular Subcutaneous • May cause extrapyramidal side effects. Monitor QT interval on EKG • Increased risk of stroke • Increased risk of hyperglycemia • Common side effect: extra- pyramidal side effects including akathisia (i.e., restlessness) *Should not be confused with worsening agitation • FDA warning: increased risk of mortality in elderly patients with dementia-related psychosis Benzodiazepines Lorazepam Initial dose range: 0.50 –1.0 mg every 1–2 h Suggested maximum dose in first 24 h: 1.0 mg Oral/subcutaneous • May be used in patients with alcohol or substance withdrawal • May be used concomitantly with other anti-psychotics • FDA warning: not recommended for use in patients with primary depressive disorder or psychosis EKG , electrocardiogram; FDA , Food and Drug Administration; hrs , hours

Frailty is a clinical condition associated with increased vulnerability, which results from aging-related decline across psychological, physical, and social functioning [ 79 ]. Frail older adults undergoing hip fracture surgery are at increased risk of developing postoperative delirium, longer length of hospital stay, poor functional status, inability to recover pre-fracture mobility, and are more likely to be discharged to a long-term care facility [ 80 ]. Examples of frailty assessment methods include the Cardiovascular Health Study (CHS) frailty phenotype method (Fried’s phenotype method) [ 79 ] and the Frailty Index (FI) [ 81 ]. The Canadian Study of Health and Aging-Clinical Frailty Scale (CSHA-CFS) is a reliable tool to predict mortality or institutional care needs after hip fracture (available here: https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.htmll ) [ 82 ]. Evaluating frailty is essential in patients undergoing hip fracture surgery to prevent adverse outcomes and improve the overall health status of older adults at discharge.

In summary, delirium is a preventable clinical syndrome that is associated with multiple complications including dementia, functional impairment, prolonged length of stay, long-term care admission, and death [ 83 , 84 ]. Implementation of a multi-component non-pharmacological prevention program is effective in preventing delirium and improving outcomes for older adults.

Post-operative management

Hip fractures are associated with a high risk of post-operative complications including heart failure, chest infections, pressure injuries, and delirium [ 85 – 87 ]. Factors associated with increased risk of post-operative complications include three or more co-morbidities, frailty, underlying respiratory disease, and malignancy [ 85 , 88 ]. Cohesive, inter-disciplinary, orthogeriatric management has been recommended to optimize care [ 2 , 89 , 90 ].

A systematic approach to post-operative management is required to optimize recovery. Areas of focus should include the following: Nutritional assessment (see Sect. " Nutrition " for more detail) Nutritional assessment is essential. Malnutrition can be screened for using validated tools including the mini-nutritional assessment-short form (MNA-SF) [ 91 ] and malnutrition universal screening tool (MUST) [ 92 ]. Accurate assessment of muscle mass and body weight is advised. Protein and high-energy supplements should be provided if required. Pressure injury prevention and care Pressure injuries are common yet preventable [ 93 ]. They are associated with delayed rehabilitation, poorer prognosis, and increased risk of death [ 94 ]. Risk factors include poor nutritional status, low body weight, incontinence, diabetes, neuropathy, poor skin condition, and prolonged immobility. Pressure injury risk assessment should be undertaken using a validated tool such as the Braden Scale [ 95 ]. Skin care precautions should be taken, such as proper turning, repositioning, and use of pressure relieving equipment. Catheter care Urinary catheters should be removed by post-operative day 1. If post-operative catheterization is necessary beyond day 1, consider intermittent catheterization. Urinary retention is not uncommon with the addition of iron, calcium, decreased mobility, and constipation—consider post-void residuals if patient is not voiding, has delirium, and/or constipation. Fluid balance assessment Changes in fluid balance are common post-operatively. The goal of perioperative fluid management is to optimize cardiac output without precipitating cardiac failure. Dehydration can lead to hypotension, acute kidney injury, and delirium whereas fluid overload can lead to cardiac failure. Post-operative strategies to optimize fluid status include avoiding prolonged periods of fasting, assisting with oral fluid intake, monitoring fluid intake and output and the patient’s vital signs [ 87 ]. If dehydration cannot be rectified through oral rehydration, consider careful iv fluid administration with regular monitoring. Venous thromboprophylaxis In patients undergoing hip fracture surgery, the American College of Chest Physicians (CHEST) recommends the use of thromboprophylaxis for a minimum of 10 days post-operatively [ 21 ]. The National Institute for Health and Care Excellence (NICE) recommends the use of LMWH or fondaparinux for 28 to 35 days, while Thrombosis Canada similarly supports enoxaparin, dalteparin, tinzaparin, or fondaparinux for 14 to 35 days post-operatively [ 96 , 97 ]. Other subspecialty societies, including the Orthopedic Trauma Association (OTA) and the European Society of Anesthesiology also support aspirin use post-operatively for up to 35 days following hip fracture surgery [ 98 , 99 ]. Recent meta-analyses demonstrate equivalence for the use of Direct Oral Anti-Coagulants (DOACs), compared with other pharmacologic thromboprophylaxis [ 100 , 101 ]. Therefore, pharmacologic thromboprophylaxis using LMWH, aspirin (ASA), or DOACs are recommended for up to 35 days following hip fracture surgery (Table 4 ) [ 100 – 102 ]. Table 4 Summary of current thromboprophylaxis guidelines following hip fracture surgery Guideline Recommended thromboprophylaxis agents Recommended duration Publication year National Institute for Health and Care Excellence (NICE) Low molecular weight heparin; fondaparinux 28–35 days 2019 Orthopedic Trauma Association (OTA) Low dose aspirin (81 mg BID); low molecular weight heparin; fondaparinux 28–35 days 2019 American Society of Hematology Low molecular weight heparin; unfractionated heparin Not specified 2019 Thrombosis Canada Enoxaparin; dalteparin; tinzaparin; fondaparinux 14–35 days 2018 European Society of Anesthesiology Aspirin Not specified 2018 6. Fall risk assessment including medication review

A multi-factorial falls risk assessment should be performed including the following domains [ 103 ]. Focused fall history Detailed medication review including identification of fall risk inducing drugs (FRIDs) [ 104 ] Physical examination including gait, balance, mobility, neurological and cognitive function, muscle strength, cardiovascular status, visual acuity, and examination of feet and footwear Functional assessment Environmental assessment

Rehabilitation

Morbidity post-fracture is due to decreased mobility, impaired balance, and fear of falling [ 105 ], resulting in an increased risk of falls. These causes prevent approximately 40% of older people from returning to pre-fracture daily activity [ 106 ].

Cognitive impairment (dementia or delirium) does not preclude rehabilitation [ 78 , 107 ]. Delay in initiation of rehabilitation increases risk for hospital mortality (OR 2.2, 95% CI 1.06–4.42, p value 0.034) [ 108 ]. Appropriate adaptation of the program to meet individual patient’s needs is advised [ 109 ]. See Alberta Health Services regarding post-discharge instructions (available here: http://www.rehabcarealliance.ca/uploads/File/Initiatives_and_Toolkits/QBP/UPDATED_November_2017-_Hip_Fracture_QBP_Rehabilitative_Best_Practices_Framework.pdf ) [ 110 ]. It is important that rehabilitation happens not only acutely, but post-acutely (recovery hospital) and in the community after discharge. It can take up to 9 months for balance deficits and approximately 1 year for gait and walking speed to recover .

Mechanical load induced by exercise produces stress upon bones and enhances bone formation. Progressive resistance exercise, weight-bearing impact training, and functional balance training constitute most exercise programs. Resistance exercise and impact training promote the greatest bone formation. These recommendations have been developed in a pre-fragility fracture population [ 111 ] but are now being applied to post-fracture populations [ 112 ]. The general principles are correct technique, gradual loading increments, and avoiding activities that might increase risk for falls [ 113 ].

Rehabilitation should include balance training to reduce risk of future falls and fractures. A recent meta-analysis revealed that the balance training group had improved overall physical functioning, gait, lower limb strength, performance tasks, and activity of daily living compared with the control group [ 114 ]. More high-quality and large-scale RCTs are needed to identify the optimal regimen of balance training after hip fracture.

Individualized exercise approaches, considering patient preferences and integrating factors associated with patient adherence within the context of physiotherapy (such as counseling sessions, workbooks and goal setting, motivational interviewing, and cognitive behavioral therapy) will improve outcomes [ 109 ]. Recently published Clinical Practice Guidelines [ 115 ] in post-operative hip fracture patients included a multi-disciplinary approach, progressive resistance exercises, and balance training. Early ambulation, weight-bearing exercises, activities of daily living training, community-level rehabilitation, management of comorbidities/complication prevention, and nutritional support were also suggested [ 115 ]. However, in a Cochrane analysis [ 116 ] although number needed to treat was 25 patients (95% CI 15 to 100) to avoid one “poor outcome” (defined as mortality and decline in residential status at one year), results were generally borderline. In a hospital in-patient setting, there is moderate-certainty evidence that rehabilitation after hip fracture surgery, when delivered by a multidisciplinary team and supervised by an appropriate medical specialist, results in fewer cases of “poor outcome” (death or deterioration in residential status). However, there is low-certainty evidence that multi-disciplinary rehabilitation may result in fewer deaths in hospital and at 4 to 12 months; however, it may also result in slightly more. There is low-certainty evidence that multi-disciplinary rehabilitation may reduce the numbers of people with poorer mobility at 12 months. The borderline measurable effect of rehabilitation has prompted combination strategies-with nutrition (see section on nutrition) and/ or medications.

Encouraging data comparing in-hospital geriatric care and rehabilitation, to early discharge with a home-based rehabilitation program, has shown that in older people with hip fracture, early discharge followed by geriatric interdisciplinary home rehabilitation resulted in a comparable recovery of independence in activities of daily living (ADL) at 3 and 12 months [ 117 ]. A retrospective study also showed similar outcomes between home and in-patient rehabilitation, even though the inpatient group was more medically complex [ 118 ]. In addition, outpatient rehabilitation has been shown to be cost saving in one 10-week outreach rehabilitation intervention for nursing home residents who sustained a hip fracture, through reduced post-fracture hospital re-admissions [ 119 ]. In-patient clinical care pathways (CCPs) that extended to the outpatient setting showed greater improvements in Health-Related Quality of Life (HRQoL) and physical function compared to CCPs that were only inpatient or outpatient [ 120 ]. A feasibility trial also demonstrated that outreach participants achieved better locomotion by 3 months post-fracture compared with participants receiving usual post-fracture care; benefits were sustained to 12 months post-fracture. In adjusted analyses, outreach participants also showed sustained benefits in physical function and HRQoL [ 121 ]. See the Fresh Start program for hip fracture recovery guide (available here: https://vch.eduhealth.ca/PDFs/FB/FB.863.F73.pdf ) [ 122 ].

Inequity to access post hip fracture rehabilitation is an issue in most countries. Consistent decision criteria for access to hip fracture rehabilitation will assist in guiding a standard approach to providing rehabilitation, particularly for patients with cognitive impairment [ 107 , 113 ].

Recommendations: early mobilization post-operatively including strength, balance, and ADL exercises, home or hospital based are both feasible options; ideally, continuation of the program in the community; ensure equity with clinical practice guidelines; combine rehabilitation with nutritional support.

Osteoporosis management and fracture prevention

Osteoporosis is associated with an increased fracture risk. The estimated mortality rate within the first year following a hip fracture is approximately 37% and 28% in men and women, respectively [ 123 ]. Given the high risk of fracture among older adults, it is important to initiate pharmacologic therapy for osteoporosis to prevent fractures both in acute and long-term or outpatient care. Following a hip fracture, patients should undergo a comprehensive assessment by a clinician with osteoporosis expertise and be offered appropriate pharmacologic intervention. Currently, osteoporosis treatment rate following a major osteoporotic fracture is unacceptably low [ 124 , 125 ]. Pharmacotherapy can reduce the risk of subsequent clinical fractures, as well as improve survival [ 126 ]. BMD can be used to monitor treatment efficacy.

Hip and vertebral fractures confer a very high fracture risk and require pharmacologic therapy, preferably with an anabolic agent in order to improve the quality and microstructure of the skeleton [ 127 , 128 ]. After an initial fracture (spine, hip, pelvis, femur, or clavicle), women have an increased risk of fracture with as high as a 25% risk of second fracture within 2 years, and the risk increases with age [ 129 ]. Among women with a prior clinical fracture, 17.9% fractured again within 2-years following the initial fracture and 4.8% sustained a hip fracture [ 129 ]. This concept of imminent fracture risk, with an acute rise in fracture risk within the first two years following an index fragility fracture, supports the initiation of targeted therapeutic intervention as soon as possible after a fragility fracture [ 130 ]. Appropriate pharmacologic therapy for osteoporosis should be offered for patients, regardless of patient age.

Risk factors for osteoporosis include postmenopausal bone loss as well as age related declines in bone density [ 131 ]. Many other diseases and drugs may contribute to further bone loss [ 132 – 135 ]. A detailed evaluation with exclusion of secondary causes of bone loss prior to confirming a diagnosis of postmenopausal osteoporosis is essential (see Table 5 ). Table 5 Summary of the secondary causes of bone loss and relevant investigations [ 132 – 135 ] Causes Examples Investigations Drug-induced bone loss • Glucocorticoids (≥ 5 mg/day prednisone or equivalent for ≥ 3 months)/long-term inhaled corticosteroids • Androgen-deprivation therapy • Aromatase inhibitors • HIV therapy • Anti-convulsants • Chemotherapy • Selective serotonin reuptake inhibitors and SNRL Baseline laboratory test-to be completed upon admission to hospital • CBC • Serum calcium (corrected for albumin or ionized) • Serum phosphorus • Serum magnesium • Liver function tests • Serum creatinine, eGFR • Alkaline phosphatase • TSH • PTH • 25(OH)vitamin D • Serum immuno-electrophoresis Additional tests as required: • 24-h urine for free cortisol • 8 am total and free testosterone, FSH, LH in men • 24-h urine for calcium and creatinine clearance • TTG antibodies (if celiac disease is suspected) Endocrine disorders • Hyperthyroidism • Hyperparathyroidism (primary, secondary, or tertiary) • Hypercortisolism • Hypogonadism • Diabetes Vitamin D inadequacy Excess vitamin A • 25(OH)D < 75 nmol/L (< 30 ng/ml) Chronic renal failure Malabsorption • Celiac disease • Inflammatory bowel disease • Short gut syndrome • Post-gastric bypass Hypercalciuria Chronic lung disease Malignancy • Multiple myeloma • Bone metastasis Rheumatoid arthritis or ankylosing spondylitis Hepatic insufficiency Post-transplantation Lifestyle • Lack of exercise and reduced physical activity • Excessive alcohol use (more than 2 units/day) • Smoking (previous or active) Miscellaneous • Anorexia nervosa Abbreviations: CBC , complete blood count; eGFR , estimated glomerular filtration rate; FSH , follicle stimulating hormone; LH , luteinizing hormone; TSH , thyroid-stimulating hormone; PTH , parathyroid hormone; HIV , human immunodeficiency viruses; TTG , tissue transglutaminase; 25(OH)D , 25-hydroxyvitamin D

We recommend completing the following laboratory tests listed in Table 4 on admission to hospital in order to expedite initiation of appropriate pharmacologic intervention for the underlying osteoporosis.

General internal medicine (GIM) specialists are also closely involved in the care of hospitalized patients post hip fracture. Often, these patients are referred to internal medicine for pre-operative assessment and GIM is concurrently involved in the management of their medical concerns post-operatively. Unfortunately, osteoporosis care is often overlooked during these critical assessments. We strongly recommend internists address skeletal health and ensure exclusion of secondary causes of osteoporosis during the pre-operative assessment of hip fracture patients. It is essential to provide appropriate post-op follow-up with implementation of drug therapy for the underlying osteoporosis prior to discharge.

Renal osteodystrophy chronic kidney disease (CKD) stage 4 (eGFR < 30 ml/min) and 5 (eGFR < 15 ml/min) are associated with changes in serum calcium, phosphorus, parathyroid hormone (PTH), 1,25 dihydroxyvitamin D, and fibroblast growth factor-23 (FGF-23) resulting in abnormal bone structure and function [ 136 ]. Hip fracture risk increases dramatically with declines in eGFR. A careful evaluation of the biochemical profile is necessary prior to implementation of drug therapy. In the presence of CKD, osteoporosis may also be complicated by the presence of impaired bone mineralization or osteomalacia. Bone turnover may be elevated or suppressed, and this will impact the choice of drug therapy. It is necessary to normalize vitamin D levels as well as both serum calcium corrected for albumin as well as serum phosphate. PTH should be evaluated and is expected to be elevated with declines in eGFR below 60mls/min [ 136 ]. In patients with CKD stage 3a–5 not on dialysis, the optimal PTH level is not known. The Kidney Disease Improving Global Outcomes (KDIGO) guidelines suggest that patients with levels of intact PTH progressively rising or persistently above the upper normal limit for the assay be evaluated for modifiable factors, including hyperphosphatemia, hypocalcemia, high-phosphate intake, and vitamin D deficiency. The current KDIGO guidelines [ 136 ] suggest in stage 5 CKD that the PTH level be maintained in the 2–9 × the upper level of normal. Pharmacologic intervention with an anabolic agent may be appropriate off label in the presence of low turnover and an anti-resorptive agent may be suitable if remodeling is elevated. Bisphosphonates are contraindicated if the eGFR < 30-35mls/min.

Fracture risk assessment with and without BMD

High fracture risk is confirmed in the presence of a hip or vertebral fracture, OR > 1 fragility fracture, OR steroid use (prednisone ≥ 7.5 mg or equivalent for ≥ 3 months in the previous year) and concomitant history of a prior fragility fracture. All fragility fractures (low trauma) of the hip have a high fracture risk and require consideration of pharmacologic intervention regardless of the calculated fracture risk. Fracture risk can be calculated by the Fracture Risk Assessment Tool (FRAX) or Canadian Association of Radiologists and Osteoporosis Canada (CAROC) tool [ 137 – 140 ]. FRAX has been developed and validated in 11 different cohorts including the Canadian population and has been calibrated to fracture and mortality rates in Canada. FRAX can be used with or without BMD to predict the 10-year risk of hip and major osteoporotic fracture (MOF) [ 141 – 143 ]. FRAX with BMD (area under the curve (AUC) = 0.72) had a higher discriminative ability for osteoporotic fracture than FRAX without BMD (AUC = 0.69) [ 144 ].

Self-reported falls in the previous year are an additional risk factor, independent of FRAX, with a hazard ratio (HR) of 1.64 in women aged 70–90 [ 145 ].

Non-pharmacologic interventions and treatment of osteoporosis

Nutrition: see section on nutrition page 27 Calcium and vitamin D o Adults aged 50 years and older should ensure an adequate calcium intake of 1200 mg elemental calcium daily [ 146 ], ideally from dietary sources as there have been concerns regarding the association of calcium supplements and increased risk of cardiovascular disease and nephrolithiasis [ 147 , 148 ]. Estimation of dietary calcium intake can be performed using the Osteoporosis Canada calcium calculator, https://osteoporosis.ca/calcium-calculator [ 149 ]. If supplements are necessary, calcium carbonate or calcium citrate can be prescribed p Vitamin D adequacy is essential for optimal intestinal calcium absorption and may also improve balance and muscle strength and decrease the risk of falls [ 150 , 151 ]. A meta-analysis conducted in postmenopausal women showed a significant reduction in hip and non-vertebral fracture risk with vitamin D supplements at doses of 700–800 IU or more daily [ 151 ]. Vitamin D supplementation should be offered, targeting a serum 25 hydroxyvitamin D (25(OH)D) level of 75–125 nmol/L. It is important to ensure that the 25(OH) vitamin D levels are normal before initiating anti resorptive treatment. Vitamin D levels below 25 nmol/L may be associated with osteomalacia and may require replacement for several months prior to initiating additional pharmacologic intervention [ 152 ] Physical activity o A daily weight bearing exercise program should be emphasized, as regular physical activity has been shown to improve femoral neck (FN) and lumbar spine (LS) BMD in postmenopausal women [ 153 ] Lifestyle changes o Smoking cessation is advised as cigarette use has been reported to increase osteoporosis fracture risk [ 154 ] p Alcohol intake should be limited to no more than 2 units daily, as higher intake has been associated with an increased fracture risk [ 155 ] Fall prevention programs for the elderly Multiple risk factors for falls have been identified in elderly patients, including cognitive impairment, use of sedative medications, disabilities affecting the lower extremities, poor vision, and abnormalities of balance and gait [ 156 ]. Interventions targeting those risk factors may decrease the risk of falls and meta-analysis have proven fall prevention programs to be effective both in community dwelling elderly as well as nursing home residents [ 157 ]

Pharmacologic interventions

Osteoporosis treatment options include [ 128 , 158 – 160 ]: Bisphosphonates, oral (alendronate, risedronate), or intravenous (zoledronate) Denosumab Romosozumab Teriparatide/abaloparatide Selective estrogen receptor modulators (SERMS) (raloxifene or bazedoxifene) Menopausal hormonal therapy (MHT)

Treatment options

Anabolic therapy

An anabolic agent is the preferred option following a hip fracture due to greater impact on fracture risk reduction in comparison to bisphosphonate therapy, see Table 6 and Fig. 5 . This was demonstrated in the vertebral fracture treatment comparisons in osteoporotic women (VERO) study comparing the efficacy of teriparatide 20 µg sc daily versus risedronate 35 mg weekly in this head-to-head trial on the occurrence of new radiographic vertebral fractures [ 161 ]. Teriparatide decreased new vertebral fractures by 56%, relative risk (RR) 0.44, CI 0.29–0.68, p < 0.01, and clinical fractures (vertebral and non-vertebral) by 52% (hazard ratio (HR) 0.48, CI 0.32–0.74, p < 0.01) in comparison to risedronate [ 161 ]. The Active-Controlled Fracture Study in Postmenopausal Women with Osteoporosis at High Risk (ARCH) study compared romosozumab to alendronate in a head to head trial [ 162 ]. The romosozumab treated group had a 48% lower risk of new vertebral fractures and a 27% lower risk of clinical fractures when compared to alendronate [ 162 ]. Romosozumab: is a humanized monoclonal antibody to sclerostin. It increases bone formation and reduces bone resorption and is indicated in the presence of a very high fracture risk. The treatment dose is 210 mg subcutaneously (given as 2 injections of 105 mg each) monthly for up to 12 months. Romosozumab has been shown to reduce the risk of vertebral, hip, and non-vertebral fractures [ 162 , 163 ]. In the fracture study in postmenopausal women with osteoporosis (FRAME), study romosozumab was compared to placebo and was effective in reducing vertebral and clinical fracture risk [ 164 ]. It was well tolerated with no increase in the risk of major adverse cardiovascular events. In the ARCH trial, romosozumab was compared to alendronate [ 162 ]. Major adverse cardiovascular adverse events were seen more frequently in the romosozumab group (2.0%) than in the alendronate group (1.1%) [ 162 , 163 ]. Therefore, romosozumab is contraindicated in the presence of a prior myocardial infarct or stroke and clinicians should carefully consider the risks/benefits ratio in patients with multiple cardiovascular risk factors Teriparatide: is a recombinant human parathyroid hormone (rPTH) 1–34 and is an anabolic agent indicated in the presence of a very high fracture risk. It increases bone formation as well as bone resorption. The treatment dose is 20 mcg subcutaneously daily for up to 24 months. Teriparatide has been shown to reduce the risk of both vertebral and non-vertebral fragility fractures in post-menopausal women at high fracture risk [ 161 ]. In the Abaloparatide Comparator Trial In Vertebral Endpoints (ACTIVE) trial, the incidence of hypercalcemia was 6.4% in teriparatide treated patients [ 165 ]. It is important to ensure that the serum calcium corrected for albumin and PTH levels are normal prior to initiating therapy. Teriparatide is contraindicated in individuals with a prior history of malignancy or radiation therapy, as well as in patients with eGFR < 15 ml/min Abaloparatide: is a modified PTH-related peptide. It is an anabolic agent indicated in the presence of a very high fracture risk. It increases bone formation as well as bone resorption. The treatment dose is 80 mcg subcutaneously once daily for up to 24 months. It has been shown to reduce both vertebral and non-vertebral fragility fractures [ 165 ]. In the ACTIVE study, the incidence of hypercalcemia was 3.4% in abaloparatide treated patients and hypercalcemia and hyperparathyroidism need to be excluded prior to treatment initiation. It is also contraindicated in the presence of prior malignancy or radiation therapy [ 165 ] Anti-resorptive therapy If it is not possible to proceed with an anabolic after a hip fracture, then, denosumab or other anti-resorptive therapies such as IV zoledronate or an oral bisphosphonate such as alendronate or risedronate may be offered. Due to the high risk of fracture recurrence, it is advised that treatment be initiated prior to discharge from hospital if at all possible. Denosumab: is an anti-resorptive agent indicated in the presence of osteoporosis in postmenopausal women or men at a high fracture risk. Denosumab has been shown to reduce the incidence of vertebral, hip, and non-vertebral fracture by 68%, 40%, and 20%, respectively [ 166 ]. The treatment dose is 60 mg subcutaneously every 6 months and it can be given safely for up to 10 years. After therapy is discontinued, there is a rapid rebound in increase in osteoclastogenesis and bone resorption that is associated with an increased risk of fractures, and denosumab cessation should be followed by an anti-resorptive molecule such as bisphosphonates [ 167 ]. Osteonecrosis of the jaw (ONJ) and atypical femoral fracture (AFF) are rare complications of denosumab treatment, with incidence of 5.2/10,000 person years and 0.8/10,000 person years, respectively [ 168 ]. Prior to denosumab initiation, it is important to ensure that serum calcium corrected for albumin and vitamin 25(OH)D level is normal and eGFR should be > 15 ml/min in order to reduce the risk of hypocalcemia[ 169 ] Bisphosphonates: Intravenous zoledronate 5 mg is given as an infusion over 30–60 min. A single dose of IV zoledronate can provide long term skeletal protection and may be repeated in 2 yrs [ 170 ]. Prior to starting IV zoledronate, it is essential to ensure that serum calcium corrected for albumin and 25 (OH)D are normal and the eGFR must be ≥ 35 mls/min in order to avoid hypocalcemia. Rapid infusion of IV zoledronate may result in declines in renal function and must be avoided [ 136 ]. It is also important to ensure that individuals are well hydrated prior to the infusion of IV zoledronate. An acute phase reaction with myalgias, arthralgias, and fever and chills and flu like reaction may occur post-infusion and may last for a several days and is best treated with acetaminophen [ 171 ]. The oral bisphosphonate alendronate (70 mg once weekly) and risedronate (35 mg once weekly) are contraindicated in the presence of gastroesophageal reflux disease (GERD), stricture, achalasia, or impaired motility. They are also not suitable in the presence of malabsorption or prior bowel surgery. Patients are also required to sit and remain upright for 30–60 min after the oral bisphosphonate to ensure that the tablet does not reflux into the esophagus. If patients are not able to follow the dosing requirements for an oral bisphosphonate; then, parenteral anti-resorptive therapy should be considered with IV zoledronate or denosumab. Fractures may occur in patients who have been on drug therapy. In these situations, we would recommend a careful review ensuring that a secondary cause of osteoporosis has not been overlooked. Compliance with therapy should also be evaluated. If the patient was on a bisphosphonate, therapy may be switched to an anabolic agent or denosumab. If the patient was on denosumab then a switch to romosozumab or the addition of teriparatide may be considered [ 172 , 173 ]. Biomarkers are still being evaluated regarding their applicability in decision making post-fracture and are currently not recommended. There is no evidence that osteoporosis drug therapy will impact wound, or fracture healing and therapy should be initiated pre-discharge if at all possible. The options available will also be impacted by financial resources and provincial formularies. Table 6 Osteoporosis medications: special considerations and contraindications Name of drug Dose Adverse effects Contraindication Anabolic therapy Romosozumab 210 mg/mo SC (for 12 mo) Arthralgias, injection site reaction Prior MI or stroke, uncorrected hypocalcemia Teriparatide 20 μg/d SC (for up to 2 y) Nausea, orthostatic hypotension, leg cramps, mild hypercalcemia Cancer, external beam radiation therapy, hypercalcemia, Paget’s disease, bone metastases or skeletal malignancies, unexplained elevated ALP, prior radiation therapy involving the skeleton, severe renal impairment, b pregnancy, and breast feeding Abaloparatide a 80 μg/d SC (for up to 2 y) Nausea, orthostatic hypotension, leg cramps, mild hypercalcemia Hypercalcemia, Paget’s disease, bone metastases or skeletal malignancies, elevated ALP, prior radiation therapy involving the skeleton Anti-resorptive therapy Bisphosphonates (oral) Hypocalcemia, abdominal distention, GERD, constipation, diarrhea, musculoskeletal pain, ONJ (rare), AFF (rare) GERD, esophageal abnormalities, history of AFF, hypocalcemia, inability to stand or sit for at least 60 min Alendronate 70 mg/wk See above • See above • eGFR < 35 mL/min Risedronate 35 mg/wk 150 mg/mo See above • See above • eGFR < 30 mL/min Denosumab 60 mg SC every 6 mo Hypocalcemia, dermatitis, eczema, headaches, arthralgia, ONJ (rare), AFF (rare) • Hypocalcemia, history of AFF, pregnancy • Use with caution in severe renal impairment eGFR < 15 mL/min Zoledronic acid 5 mg IV (1 dose may provide skeletal protection for up to 5 y) Hypocalcemia, hypertension, nausea, acute phase reaction-like symptoms, fatigue, headache, arthralgia, myalgia, ONJ (rare), AFF (rare) • Hypocalcemia, pregnancy, breast feeding, history of AFF • eGFR < 35 mL/min SERMs Hot flashes, leg cramps, edema, infection, arthralgia, flu-like symptoms, muscle spasm Previous venous thromboembolic disorder (PE, DVT, retinal vein thrombosis), pregnancy Raloxifene 60 mg/d oral See above See above Bazedoxifene 20 mg/d oral See above See above MHT, suggested doses: Edema, breakthrough bleeding, breast tenderness, depression, arthralgia Prior MI, stroke or venous thromboembolic disorder, breast cancer, undiagnosed abnormal vaginal bleeding, estrogen-dependent tumors, hepatic impairment, thrombophilic disorders, breastfeeding, endometrial hyperplasia b Estrogen Conjugated estrogen 0.625 mg/d 17β-estradiol (oral) 1 mg/d 17β-estradiol (patch) 50 μg twice weekly 17β-estradiol (gel) 2 metered doses/actuation daily (Estrogel) 1 mg packets daily (Divigel) Progestogen Micronized progesterone 100 mg/d oral (continuous regimen) 200 mg/d oral for 12–14 d/mo (cyclic regimen) Medroxyprogesterone acetate 2.5 mg/d oral (continuous regimen) 5 mg/d oral for 12–14 d/mo (cyclic regimen) Combined patches 17β-estradiol/ norethindrone acetate 50/140 μg twice weekly patch (continuous regimen) 50/250 μg twice weekly patch for 12–14 d/mo (cyclic regimen) Abbreviations: SC , subcutaneous; mo , month; MI , myocardial infarction; ALP , alkaline phosphatase; GERD , gastroesophageal reflux disease; IV , intravenous; eGFR , estimated glomerular filtration rate; ONJ , osteonecrosis of the jaw; AFF , atypical femoral fracture; PE , pulmonary embolism; DVT , deep venous thrombosis; SERMs , selective estrogen receptor modulators; MHT , menopausal hormonal therapy Fig. 5 Treatment algorithm (reproduced with permission) [ 127 ]

Follow-up care

Following hip fracture surgery, patients should be followed up by their primary care provider within two-weeks of discharge from hospital as well as the orthopedic surgeon as advised. This timeframe is important as it embodies the fragmented period in the care transition from acute hospital care to the community where patients may experience poor satisfaction with care, unmet healthcare needs, medication discrepancy, and adverse clinical events [ 174 ]. As hip fracture patients may transition between a variety of healthcare settings (i.e., acute care, rehabilitation, home care, and long-term care), patients and families should be provided with standardized education and support on care transition processes.

Patients who experience a hip fracture are also at high risk of secondary fracture. In fact, one in three patients who experience a hip fracture will sustain another fracture within 12 months and over 50% of patients will experience another fracture within 5 years [ 175 ]. Although pharmacologic therapy and fall prevention strategies have been demonstrated to be effective in reducing the risk of secondary fractures, fall prevention counseling and osteoporosis treatment rates continue to be low following a hip fracture. Fewer than 20% of patients who sustain a fragility fracture receive pharmacologic treatment in the year following a fracture [ 176 ]. Therefore, secondary prevention methods should include treatment and management of osteoporosis and fall prevention. The National Hip Fracture Tool Kit (available here: http://boneandjointcanada.com/hip-fracture/ ) [ 177 ] recommends strategies for fall prevention including: Environment modifications to eliminate fall hazards (removing carpets, handrails, etc.) Physical activity Beware of medications that increase the risk of falling (due to dizziness, drowsiness, gait disturbance, etc.) Equipment such as mobility aids and hip protectors Counseling on fear of falling (which can lead to restricted activity and altered gait that increases the risk of future falls and injuries). Fear of falling can be evaluated using the Falls Efficacy Scale-International [ 178 ] (FES-I, short or long version) Healthcare provider and staff education on evidence-based fall prevention (e-learning available through the Canadian Falls Prevention Curriculum)

Educational resources for patient and family on fall prevention are important for secondary fracture prevention. Education and resources are available at Osteoporosis Canada ( https://osteoporosis.ca ) [ 179 ] and Public Health Agency of Canada ( http://www.phac-aspc.gc.ca/seniors-aines/publications/public/injuryblessure/falls-chutes/index-eng.php ) [ 180 ]

Nutrition

Malnutrition, in particular protein and caloric under-nutrition, is considered fracture risks by impairing muscle strength and function, thereby increasing the risk of falling. Compromised bone strength results in increased bone fragility and reduced soft tissue protection around the hip [ 181 ].

Malnutrition in older hip fracture patients is also associated with increased complication rates and mortality [ 182 ]. In those with malnutrition, mortality is increased more than two-fold [ 183 ]. Reported prevalence of malnutrition is common and ranges from 18 to 45% [ 184 ] to 85% in hip fracture patients [ 185 ]. Pre-fracture nutritional status also affects rehabilitation time and level of recovery [ 186 ]. Malnutrition (defined by Subjective Global assessment (SGA)) led to lower rehabilitation efficiency scores and poorer functional outcomes (OR 21.5) when correcting for all other confounders [ 186 ]. The global nutrition community is advocating for the Global Leadership Initiative on Malnutrition (GLIM) criteria to be the global standard of care [ 187 ]. The GLIM criteria include both phenotypic (weight loss, low body mass index (BMI), and reduced muscle mass) and etiologic (reduced food intake or assimilation and disease burden/inflammation) assessment criteria. However, the SGA is felt to be the most validated tool for diagnosing malnutrition, with a 2020 study suggesting the GLIM tool had low sensitivity compared to the SGA [ 188 ].

Serum albumin concentration < 3.5 g/l (< 35gm/L) was previously believed to be suggestive of malnutrition but is now felt to be more a marker of inflammation (along with C-reactive protein or pre-albumin). Hypoalbuminemia is a powerful independent risk factor for mortality following a surgical procedure for geriatric hip fracture [ 189 ]. Hypoalbuminemic patients had higher rates of death (9.94% compared with 5.53% (adjusted relative risk, 1.52 (95% CI, 1.37 to 1.70); p < 0.001)) and increased rates of sepsis, risk for intubation, and length of stay [ 189 ]. Despite this, correction of albumen in hip fracture patients has not been shown to improve outcomes.

Widespread, prolonged nil-by-mouth fasting (no food or fluids orally), is common [ 190 ], exceeding twice the recommended duration for solids and 4 times the recommended duration for fasting with clear fluids. Rates of supplementation remain low, with less than half of patients receiving snacks or nutritional supplements preoperatively, and only 56% of patients having received a solid meal prior to surgery in one region of the United Kingdom (UK). This is likely a common practice in many other regions and countries and has been reported by other groups [ 190 ]. Fasting periods regularly exceed 14 h, despite recommendation of 6 h for solid food by the European Society of Anaesthesiology [ 191 ], and 6 to 8 h by the American Society of Anesthesiologists, depending on the type of solid ingested [ 192 ]. This is often attributed to the common practice of prescribing nil-by-mouth fasting sting at midnight on the day of surgery [ 193 ]. The addition of 1 extra meal a day to hip fracture patients was shown to halve mortality across six National Health Service (NHS) trusts in northern England and Scotland [ 194 ].

A meta-analysis of pre-operative oral nutrition supplements on post-operative outcomes in geriatric hip fracture patients showed some lowering of post-operative complications (OR 0.48), but the studies available for review were few [ 195 ]. In addition, practically speaking, pre-operative supplementation is seldom realistic with the goal for surgery being within 24 h of fracture.

Early post-operative nutritional supplement utilization in malnourished hip fracture patients was associated with significantly shorter length of stay (5.8 (6.6) days vs. 7.6 (5.8) days; p < 0.001) [ 196 ] but there was no association between early nutritional supplementation and secondary outcomes, such as infectious complications, hospital mortality, intensive care unit (ICU) admission, and total hospital cost. However, early oral nutritional supplementation (protein intake approximately 70 g/day) reduced the incremental increase of postoperative IL-6 levels, with less time in bed, and better quality of life at 3 months, compared to controls [ 197 ].

Combining nutritional supplements and rehabilitation showed a significant reduction in mortality (RR 0.61, 95% CI 0.39, 0.93; I 2 = 0%) and complications (RR 0.67, 95% CI 0.44, 1.03; I 2 = 79%) and improved grip strength (mean difference = 2.01, 95% CI 0.81, 3.22; I 2 = 0%), with the caveat that the quality of the evidence in this meta-analysis was felt to be low [ 198 ].

Higher amounts of protein are recommended in older subjects, from a recommended daily allowance of 0.8 g /kg body weight to up to 1.3–1.5, in situations of stress or inflammation, where the needs are higher. PROT-AGE study group [ 199 ] recommends 1.0 to 1.2 g protein per kilogram of body weight per day to help older adults maintain and regain lean body mass and function, ≥ 1.2 g/kg body weight/day is recommended for older adults who are exercising, and 1.2–1.5 g/kg body weight/day is recommended for those with chronic disease [ 199 ]. Increased protein in those with baseline CKD remains unanswered [ 200 ]. But plant-based proteins are safer in those with baseline chronic renal impairment because of their lower bioavailability of phosphate and lower nonvolatile acid loads [ 201 ]. Therefore, recommendations are for close monitoring of CKD patients and balancing risks versus benefits in each case.

The effects of nutritional supplements in hip fracture patients have been evaluated in 2 meta-analyses including different numbers of studies [ 202 , 203 ]. Medical complications, wound, respiratory, and urinary infections were significantly reduced [ 202 ] as well as overall unfavorable outcomes including both deaths and medical complications [ 203 ].

The ESPEN guidelines on clinical nutrition and hydration in geriatrics [ 204 ] recommend routine screening for malnutrition in order to identify an existing risk early; oral nutrition including food modification and oral nutritional supplements, or enteral nutrition where indicated; to avoid dietary restrictions; to consider all to be at risk of low-intake dehydration and encourage adequate fluid intake (as measured by osmolality, 300 mOsm/kg) [ 204 ]. They do have recommendations specifically for post hip fracture and orthopedic surgery older adults with hip fracture which state, with good evidence, the benefit of oral nutritional supplements post-operatively to improve dietary intake and reduce risk of complications, regardless of the baseline nutritional state. Nutrition and hydration interventions have also been shown to be efficacious in the prevention of delirium.

Recommendations: objective assessment of nutritional status (e.g., SGA) and serum albumin; avoid unnecessarily prolonged nil-by-mouth fasting and follow evidence-based guidelines on fasting and clear-fluid restrictions; early post-operative nutritional supplementation including adequate calories and protein 1–1.5 g/kg/day; adequate hydration (maintaining serum osmolality < 300 mOsm/kg).

Patient perspective

Patients emphasize the need to provide easily accessible clear direction to physicians so that drugs associated with delirium and falls are avoided. Early surgical intervention should be prioritized with attention given to adequate pain control. Evaluation of skeletal health is seen as critical with identification of underlying metabolic bone disorders which may have contributed to the impaired bone strength and fragility fracture.

Summary

Currently, post hip fracture care in Canada is sub-optimal and a multi-disciplinary approach aimed at optimizing medical and surgical care as well as rehabilitation post hip fracture is expected to improve health care outcomes. It is also anticipated that this will lower morbidity and mortality following a hip fracture. Implementation of strategies designed to achieve the key quality indicators require further education and awareness as well as formal evaluation.

Key messages

Preoperative care: Multi-disciplinary care in the preoperative setting allows for rapid medical optimization and potentially reduces delays to surgery with prompt management of co-morbidities. For surgical candidates, hip fracture patients should undergo surgical intervention within 24 h of diagnosis, and those on pre-injury oral anti-coagulation should undergo surgical treatment within 48 h of diagnosis. If surgery is delayed for more than 12 h from the time of hospital admission, it is recommended that thromboprophylaxis be started pre-operatively. Regional nerve blocks are a safe adjunctive method to improve pain management in patients with hip fractures, leading to decreased opioid use, reduced rate and length of delirium, and decreased length of hospital stay.

Surgical care: 4. Sliding hip screws and cephalomedullary nails are both acceptable treatment options for stable intertrochanteric hip fractures, with sliding hip screws being the more cost-effective implant of choice. 5. Patients with a sub-trochanteric or reverse obliquity intertrochanteric fracture should be treated surgically with intramedullary nails to reduce complication rates. Patients with unstable intertrochanteric fractures who are higher demand (living independently and/or ambulating without assistive devices) should be treated surgically with intramedullary nails. 6. Arthroplasty is preferable over fixation for displaced femoral neck fractures in the elderly population because of the high incidence of avascular, nonunion necrosis, and femoral neck shortening, resulting in the need for revision surgery and/or limitations in function. 7. Whenever possible, hip fracture patients should be allowed to bear weight as tolerated after surgery in order to facilitate early mobilization.

Postoperative care: 8. Individuals who are over 75 years, those with dementia, vision impairment, and dehydration are at high risk for delirium—avoid physical restraints and psychoactive drugs. 9. Inter-disciplinary orthogeriatric care is recommended to optimize patient outcomes and care. 10. Rehabilitation is necessary acutely, post-acutely, and in the community after discharge. It should include progressive resistance, weight-bearing impact, and functional balance training. 11. A low trauma hip fracture denotes a high fracture risk regardless of bone mineral density (BMD) and requires aggressive medical therapy. 12. Home assessment post-discharge by an occupational/physical therapist and exercise should be focused on balance and resistance training. 13. Avoid prolonged nil-by-mouth fasting (no food or fluids orally). Early post-operative nutritional supplements reduce mortality and morbidity (medical complications, wound, respiratory, and urinary infections), especially when combined with rehabilitation. In patients undergoing hip fracture surgery, pharmacologic thromboprophylaxis is recommended for a minimum of 10 days and up to 35 days post-operatively.

Osteoporosis management and fracture prevention: 14. It is important to initiate pharmacologic therapy for osteoporosis to prevent fractures both in acute and long-term care as well as post-discharge. 15. Hip and vertebral fractures confer a very high fracture risk and require pharmacologic therapy, preferably with an anabolic agent followed by anti-resorptive therapy.

Abbreviations

Abaloparatide Comparator Trial in Vertebral Endpoints

Active-Controlled Fracture Study in Postmenopausal Women with Osteoporosis at High Risk

Activities of daily living

Alberta Health Services

Alkaline phosphatase

American College of Chest Physicians

American Society For Bone And Mineral Research

Area under the curve

Aspirin

Atypical femoral fracture

Avascular necrosis

Body mass index

Bone mineral density

Canadian Association of Radiologists and Osteoporosis Canada

Canadian Study of Health and Aging-Clinical Frailty Scale

Cardiovascular Health Study

Chronic kidney disease

Clinical care pathways

Complete blood count

Confidence interval

Confusion Assessment Method

Deep venous thrombosis

Diagnostic And Statistical Manual of Mental Disorders Fifth Edition

Direct oral anti-coagulants

Electrocardiogram

Estimated glomerular filtration rate

Falls Efficacy Scale-International

Fall risk inducing drugs

Fascia iliaca compartment block

Femoral neck

Fibroblast growth factor-23

Follicle stimulating hormone

Food And Drug Administration

Fracture Risk Assessment Tool Frax

Fracture study in postmenopausal women with osteoporosis

Fragility Fracture Network

Frailty Index

Gastroesophageal reflux disease

General internal medicine

Global Leadership Initiative on Malnutrition

Hazard ratio

Health Quality Ontario

Health-related quality of life

Hospital Elder Life Program

Hours

Human immunodeficiency viruses

Intensive care unit

International Osteoporosis Foundation

Intravenous

Kidney Disease Improving Global Outcomes

Local systemic anesthetic toxicity

Low molecular weight heparin

Lumbar spine

Luteinizing hormone

Major osteoporotic fracture

Malnutrition Universal Screening Tool

Menopausal hormonal therapy

Mini-Mental State Examination

Mini-Nutritional Assessment-Short Form

Month

Montreal Cognitive Assessment

Myocardial infarction

National Health Service

National Institute for Health and Care Excellence

Odds ratio

Osteonecrosis of the jaw

Parathyroid hormone

Pulmonary embolism

Randomized control trials

Recombinant human parathyroid hormone

Relative risk

Selective estrogen receptor modulators

Short portable mental status questionnaire

Subcutaneous

Subjective Global Assessment

Tenth International Classification of Diseases

The Orthopedic Trauma Association

Thyroid-stimulating hormone

Tissue transglutaminase

United Kingdom

Vertebral fracture treatment comparisons in osteoporotic women

Hydroxyvitamin D

This position paper has been endorsed by the Fragility Fracture Network and the International Osteoporosis Foundation as well as the Canadian Geriatric Association.

Aliya A Khan and Hajar AbuAlrob are first authors.

Publisher's note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Endorsement: This position paper has been endorsed by the Fragility Fracture Network and the International Osteoporosis Foundation as well as the Canadian Geriatric Society

Funding

We acknowledge unrestricted financial support from Amgen. They had no input into the planning or design of the project, the conduct of the reviews, evaluation of the data, writing or review of the manuscript, its content, conclusions, or recommendations contained herein.

Data Availability

Data sharing not applicable to this article as no datasets were generated or analysed during the current study.

Declarations

Conflict of interest

AK has received research grants from Alexion, Amgen, Ascendis, Chugai, Radius, Takeda, and Ultragenyx and is on the advisory board for Amgen, Amolyt, and Takeda. EB has received unrestricted research grant Amgen Canada and is on the advisory Board for Amgen Canada. AGJ is a consultant for Amgen and Paladin Lab and speaker for Amgen. ES has received a research grant from Amgen and is a consultant for Amgen. JT has received research funding and speaker honorarium from Amgen. AP has received grants, honorarium from Amgen and is on the advisory board for Amgen and Paladin Labs. The other authors declare no competing interests.

References

1. ASBMR initiates call to action to address the crisis in the treatment of osteoporosis - American Society for Bone and Mineral Research. https://www.asbmr.org/about/news-release-detail/asbmr-initiates-call-to-action-to-address-crisis-i . Accessed 18 Jul 2022

2. Health Quality Ontario (2017) Hip fracture: care for people with fragility fractures. Health QualOnt 1–49. https://www.hqontario.ca/portals/0/documents/evidence/quality-standards/qs-hip-fracture-clinical-guideen.pdf

3. International Osteoporosis Foundation | IOF. https://www.osteoporosis.foundation/ . Accessed 18 Jul 2022

4. Home | Capture the fracture. https://www.capturethefracture.org/ . Accessed 18 Jul 2022

5. Fragility Fracture Network (FFN). https://fragilityfracturenetwork.org/ . Accessed 18 Jul 2022

6. Health Services A (2019) Optimizing the post-acute continuum of care following a hip fracture a knowledge synthesis of clinical research interventions for post-acute care of hip fracture initiated within 14 days of surgical repair: A White Paper An Alberta Health Services (AHS) a. https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-bjh-hip-whitepaper.pdf

7. Larsson G Holgers KM Fast-track care for patients with suspected hip fracture Injury 2011 42 1257 1261 10.1016/j.injury.2011.01.001 21334620

8. Tosun B Aslan O Tunay S Preoperative position splint versus skin traction in patients with hip fracture: an experimental study Int J Orthop Trauma Nurs 2018 28 8 15 10.1016/J.IJOTN.2017.07.002 29398642

9. Forni S Pieralli F Sergi A Mortality after hip fracture in the elderly: the role of a multidisciplinary approach and time to surgery in a retrospective observational study on 23,973 patients Arch Gerontol Geriatr 2016 66 13 17 10.1016/j.archger.2016.04.014 27174126

10. Flikweert ER Izaks GJ Knobben BAS The development of a comprehensive multidisciplinary care pathway for patients with a hip fracture: design and results of a clinical trial BMC Musculoskelet Disord 2014 15 188 10.1186/1471-2474-15-188 24885674 PMC4053577

11. Folbert EC Hegeman JH Vermeer M Improved 1-year mortality in elderly patients with a hip fracture following integrated orthogeriatric treatment Osteoporos Int 2017 28 269 277 10.1007/S00198-016-3711-7 27443570

12. Grigoryan KV Javedan H Rudolph JL Orthogeriatric care models and outcomes in hip fracture patients: a systematic review and meta-analysis J Orthop Trauma 2014 28 e49 10.1097/BOT.0b013e3182a5a045 23912859 PMC3909556

13. Leung AHC Lam TP Cheung WH An orthogeriatric collaborative intervention program for fragility fractures: a retrospective cohort study J Trauma Inj Infect Crit Care 2011 71 1390 1394 10.1097/TA.0b013e31821f7e60 22002614

14. Casey SD Stevenson DE Mumma BE Emergency department pain management following implementation of a geriatric hip fracture program West J Emerg Med 2017 18 585 591 10.5811/WESTJEM.2017.3.32853 28611877 PMC5468062

15. British Geriatric Society (2007) Orthogeriatric models of care. Care Patients Fragility Fract. 7–36. https://www.bgs.org.uk/sites/default/files/content/attachment/2018-05-02/Blue%20Book%20on%20fragility%20fracture%20care.pdf

16. Chuang D Power SE Dunbar PR Hill AG Central nervous system interleukin-8 production following neck of femur fracture ANZ J Surg 2005 75 813 816 10.1111/j.1445-2197.2005.03530.x 16174000

17. Beloosesky Y Hendel D Weiss A Cytokines and C-reactive protein production in hip-fracture-operated elderly patients J Gerontol Ser A Biol Sci Med Sci 2007 62 420 426 10.1093/gerona/62.4.420 17452737

18. You D Skeith L Korley R Identification of hypercoagulability with thrombelastography in patients with hip fracture receiving thromboprophylaxis Can J Surg 2021 64 E324 E329 10.1503/CJS.021019 34085509 PMC8327983

19. Pincus D Ravi B Wasserstein D Association between wait time and 30-day mortality in adults undergoing hip fracture surgery JAMA J Am Med Assoc 2017 318 1994 2003 10.1001/jama.2017.17606 PMC5820694 29183076

20. Borges FK Bhandari M Guerra-Farfan E Accelerated surgery versus standard care in hip fracture (HIP ATTACK): an international, randomised, controlled trial The Lancet 2020 395 698 708 10.1016/S0140-6736(20)30058-1 32050090

21. Falck-Ytter Y Francis CW Johanson NA Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines Chest 2012 141 e278S e325S 10.1378/CHEST.11-2404 22315265 PMC3278063

22. Schermann H Gurel R Gold A Safety of urgent hip fracture surgery protocol under influence of direct oral anticoagulation medications Injury 2019 50 398 402 10.1016/j.injury.2018.10.033 30391072

23. Frenkel Rutenberg T Velkes S Vitenberg M Morbidity and mortality after fragility hip fracture surgery in patients receiving vitamin K antagonists and direct oral anticoagulants Thromb Res 2018 166 106 112 10.1016/j.thromres.2018.04.022 29727737

24. Xu Y You D Krzyzaniak H Effect of oral anticoagulants on hemostatic and thromboembolic complications in hip fracture: a systematic review and meta-analysis J Thromb Haemost 2020 18 2566 2581 10.1111/jth.14977 32574420

25. You D, Xu Y, Ponich B et al (2021) Effect of oral anticoagulant use on surgical delay and mortality in hip fracture a systematic review and meta-analysis. Bone Joint J 103 B:222–233. 10.1302/0301-620X.103B2.BJJ-2020-0583.R2 10.1302/0301-620X.103B2.BJJ-2020-0583.R2 33517730

26. You D, Xu Y, Krzyzaniak H et al (n.d.) Safety of expedited surgical protocols in anticoagulated patients with hip fracture: a systematic review and meta-analysis. In: Can J Surg. https://www.orthomedia.org.uk/Title/da5c6371-eb29-46c7-b1cb-c2bd741f5618 . (in press). 10.1503/cjs.010021 PMC10069416 37001973

27. Morrison RS, Dickman E, Hwang U, Akhtar S, Ferguson T, Huang J, Jeng CL, Nelson BP, Rosenblatt MA, Silverstein JH, Strayer RJ, Torrillo TM, Todd KH (2016) Regional nerve blocks improve pain and functional outcomes in hip fracture: a randomized controlled trial. J Am Geriatr Soc 64(12):2433–2439. 10.1111/jgs.14386 10.1111/jgs.14386 PMC5173407 27787895

28. Ritcey B Pageau P Woo MY Perry JJ Regional nerve blocks for hip and femoral neck fractures in the emergency department: a systematic review Can J Emerg Med 2016 18 37 47 10.1017/cem.2015.75 26330019

29. Mouzopoulos G Vasiliadis G Lasanianos N Fascia iliaca block prophylaxis for hip fracture patients at risk for delirium: a randomized placebo-controlled study J Orthop Traumatol 2009 10 127 133 10.1007/s10195-009-0062-6 19690943 PMC2744739

30. Joubert F Gillois P Bouaziz H Bleeding complications following peripheral regional anaesthesia in patients treated with anticoagulants or antiplatelet agents: a systematic review Anaesth Crit Care Pain Med 2019 38 507 516 10.1016/j.accpm.2018.12.009 30586601

31. Tawari AA Kempegowda H Suk M Horwitz DS What makes an intertrochanteric fracture unstable in 2015? Does the lateral wall play a role in the decision matrix? J Orthop Trauma 2015 29 S4 S9 10.1097/BOT.0000000000000284 25756825

32. Singh NK Sharma V Trikha V Is PFNA-II a better implant for stable intertrochanteric fractures in elderly population ? A prospective randomized study J Clin Orthop Trauma 2019 10 S71 S76 10.1016/j.jcot.2019.02.004 31700206 PMC6823828

33. Parker MJ Bowers TR Pryor GA Sliding hip screw versus the Targon PF nail in the treatment of trochanteric fractures of the hip: a randomised trial of 600 fractures J Bone Joint Surg Ser B 2012 94 B 391 397 10.1302/0301-620X.94B3.28406 22371549

34. Swart E Makhni EC Macaulay W Cost-effectiveness analysis of fixation options for intertrochanteric hip fractures J Bone Joint Surg Am 2014 96 1612 1620 10.2106/JBJS.M.00603 25274786

35. Haidukewych GJ Intertrochanteric fractures: ten tips to improve results Instr Course Lect 2010 59 503 509 20415401

36. Reindl R Harvey EJ Berry GK Rahme E Intramedullary versus extramedullary fixation for unstable intertrochanteric fractures: a prospective randomized controlled trial J Bone Joint Surg Am 2014 97 1905 1912 10.2106/JBJS.N.01007 26631990

37. Sanders D Bryant D Tieszer C A multicenter randomized control trial comparing a novel intramedullary device (InterTAN) versus conventional treatment (sliding hip screw) of geriatric hip fractures J Orthop Trauma 2017 31 1 8 10.1097/BOT.0000000000000713 27763958

38. Marmor M Guenthner G Rezaei A Reporting on quality of reduction and fixation of intertrochanteric fractures-a systematic review Injury 2021 52 324 329 10.1016/J.INJURY.2021.02.014 33612251

39. Sellan M Bryant D Tieszer C Short versus long InterTAN fixation for geriatric intertrochanteric hip fractures: a multicentre head-to-head comparison J Orthop Trauma 2019 33 169 174 10.1097/BOT.0000000000001409 30893216

40. Shannon SF Yuan BJ Cross WW Short versus long cephalomedullary nails for pertrochanteric hip fractures: a randomized prospective study J Orthop Trauma 2019 33 480 486 10.1097/BOT.0000000000001553 31232891

41. Gjertsen JE Vinje T Engesæter LB Internal screw fixation compared with bipolar hemiarthroplasty for treatment of displaced femoral neck fractures in elderly patients J Bone Joint Surg 2010 92 619 628 10.2106/JBJS.H.01750 20194320

42. Chan DS Femoral neck fractures in young patients: state of the art J Orthop Trauma 2019 33 S7 S11 10.1097/BOT.0000000000001366 30540666

43. Xu JL Liang ZR Xiong BL Risk factors associated with osteonecrosis of femoral head after internal fixation of femoral neck fracture:a systematic review and meta-analysis BMC Musculoskelet Disord 2019 20 20 10.1186/s12891-019-2990-5 31884960 PMC6935498

44. Investigators H Bhandari M Einhorn TA Total hip arthroplasty or hemiarthroplasty for hip fracture N Engl J Med 2019 381 2199 2208 10.1056/NEJMoa1906190 31557429

45. Warren J Sundaram K Anis H The association between weight-bearing status and early complications in hip fractures Eur J Orthop Surg Traumatol 2019 29 1419 1427 10.1007/s00590-019-02453-z 31134326

46. Siu AL Penrod JD Boockvar KS Early ambulation after hip fracture: effects on function and mortality Arch Intern Med 2006 166 766 771 10.1001/archinte.166.7.766 16606814 PMC3045760

47. Kammerlander C Pfeufer D Lisitano LA Inability of older adult patients with hip fracture to maintain postoperative weight-bearing restrictions J Bone Joint Surg Am 2018 100 936 941 10.2106/JBJS.17.01222 29870444

48. Pfeufer D Zeller A Mehaffey S Weight-bearing restrictions reduce postoperative mobility in elderly hip fracture patients Arch Orthop Trauma Surg 2019 139 1253 1259 10.1007/s00402-019-03193-9 31053870

49. Koval KJ Friend KD Aharonoff GB Zuckerman JD Weight bearing after hip fracture: a prospective series of 596 geriatric hip fracture patients J Orthop Trauma 1996 10 526 530 10.1097/00005131-199611000-00003 8915913

50. Turgut A, Kalenderer Ö, Karapınar L, Kumbaracı M, Akkan HA, Ağuş H (2016) Which factor is most important for occurrence of cutout complications in patients treated with proximal femoral nail antirotation? Retrospective analysis of 298 patients. Arch Orthop Trauma Surg 136(5):623–30. 10.1007/s00402-016-2410-3 10.1007/s00402-016-2410-3 26852380

51. DSM-V (2013) Diagnostic and statistical manual of Dsm-5 TM . Am Psychiatric Assoc 992. https://www.psychiatry.org/psychiatrists/practice/dsm

52. Wilson JE, Mart MF, Cunningham C et al () Delirium. Nat Rev Dis Primers 6:90. 10.1038/s41572-020-00223-4. https://www.nature.com/articles/s41572-020-00223-4#citeas 10.1038/s41572-020-00223-4 PMC9012267 33184265

53. Mosk CA Mus M Vroemen JPAM Dementia and delirium, the outcomes in elderly hip fracture patients Clin Interv Aging 2017 12 421 430 10.2147/CIA.S115945 28331300 PMC5354532

54. Marcantonio ER Flacker JM Michaels M Resnick NM Delirium is independently associated with poor functional recovery after hip fracture J Am Geriatr Soc 2000 48 618 624 10.1111/j.1532-5415.2000.tb04718.x 10855596

55. Kat MG de Jonghe JFM Vreeswijk R Mortality associated with delirium after hip-surgery: a 2-year follow-up study Age Ageing 2011 40 312 318 10.1093/AGEING/AFR014 21414946

56. Yang Y Zhao X Dong T Risk factors for postoperative delirium following hip fracture repair in elderly patients: a systematic review and meta-analysis Aging Clin Exp Res 2017 29 115 126 10.1007/s40520-016-0541-6 26873816

57. Cognitive G-EM impairment- causes of delirium. Available here https://geriem.com/cognitive-impairment/causes-of-delirium/

58. Grover S Avasthi A Clinical practice guidelines for management of delirium in elderly Indian J Psychiatry 2018 60 S329 10.4103/0019-5545.224473 29535468 PMC5840908

59. Waszynski C The Confusion Assessment Method (CAM) Hartford Inst Geriatr Nurs 2002 13 1 2

60. Inouye SK Van Dyck CH Alessi CA Clarifying confusion: the confusion assessment method. A new method for detection of delirium Ann Intern Med 1990 113 941 948 10.7326/0003-4819-113-12-941 2240918

61. Wei LA Fearing MA Sternberg EJ Inouye SK The Confusion Assessment Method: a systematic review of current usage J Am Geriatr Soc 2008 56 823 830 10.1111/J.1532-5415.2008.01674.X 18384586 PMC2585541

62. Kyziridis TC (2006) Post-operative delirium after hip fracture treatment - a review of the current literature. Psychosoc Med 3:Doc01 PMC2736510 19742275

63. Koskderelioglu A Onder O Gucuyener M Screening for postoperative delirium in patients with acute hip fracture: assessment of predictive factors Geriatr Gerontol Int 2017 17 919 924 10.1111/ggi.12806 27283273

64. Molloy DW Standish TIM A guide to the standardized Mini-Mental State Examination Int Psychogeriatr 1997 9 Suppl 1 87 94 10.1017/S1041610297004754 9447431

65. MoCA - cognitive assessment. https://www.mocatest.org/ . Accessed 19 Jul 2022

66. Mini-Cog© – quick screening for early dementia detection. https://mini-cog.com/ . Accessed 19 Jul 2022

67. The short portable mental status questionnaire (SPMSQ). https://geriatrics.stanford.edu/culturemed/overview/assessment/assessment_toolkit/spmsq.html . Accessed 19 Jul 2022

68. Tuch G Soo WK Luo KY Cognitive assessment tools recommended in geriatric oncology guidelines: a rapid review Curr Oncol 2021 28 3987 4003 10.3390/curroncol28050339 34677257 PMC8534877

69. Wong CL Holroyd-Leduc J Simel DL Straus SE Does this patient have delirium?: Value of bedside instruments JAMA J Am Med Assoc 2010 304 779 786 10.1001/jama.2010.1182 20716741

70. Flaherty JH, Gonzales JP, Dong B (2011) Antipsychotics in the treatment of delirium in older hospitalized adults: a systematic review. J Am Geriatr Soc 59(s2):S269–S276. 10.1111/j.1532-5415.2011.03675.x 10.1111/j.1532-5415.2011.03675.x 22091572

71. Hshieh TT Yue J Oh E Effectiveness of multicomponent nonpharmacological delirium interventions: a meta-analysis JAMA Intern Med 2015 175 512 520 10.1001/jamainternmed.2014.7779 25643002 PMC4388802

72. Inouye SK Bogardus ST Baker DI The hospital elder life program: a model of care to prevent cognitive and functional decline in older hospitalized patients J Am Geriatr Soc 2000 48 1697 1706 10.1111/j.1532-5415.2000.tb03885.x 11129764

73. Leslie DL Zhang Y Bogardus ST Consequences of preventing delirium in hospitalized older adults on nursing home costs J Am Geriatr Soc 2005 53 405 409 10.1111/J.1532-5415.2005.53156.X 15743281

74. Marcantonio ER Kiely DK Simon SE Outcomes of older people admitted to postacute facilities with delirium J Am Geriatr Soc 2005 53 963 969 10.1111/J.1532-5415.2005.53305.X 15935018

75. Shields L Henderson V Caslake R Comprehensive geriatric assessment for prevention of delirium after hip fracture: a systematic review of randomized controlled trials J Am Geriatr Soc 2017 65 1559 1565 10.1111/jgs.14846 28407199

76. Haley MN Casey P Kane RY Delirium management: let’s get physical? A systematic review and meta-analysis Australas J Ageing 2019 38 231 241 10.1111/AJAG.12636 30793460

77. Siddiqi N Harrison JK Clegg A Interventions for preventing delirium in hospitalised non-ICU patients Cochrane Database Syst Rev 2016 11 3 10.1002/14651858.CD005563.pub3 PMC10431752 26967259

78. Gual N García-Salmones M Brítez L The role of physical exercise and rehabilitation in delirium Eur Geriatr Med 2020 11 83 93 10.1007/s41999-020-00290-6 32297245 PMC7224129

79. Fried LP, Tangen CM, Walston J et al (2001) McBurnie MA; Cardiovascular Health Study Collaborative Research Group. Frailty in older adults: evidence for a phenotype 56:M146-56 10.1093/gerona/56.3.m146 11253156

80. Gandossi CM Zambon A Oliveri G Frailty, post-operative delirium and functional status at discharge in patients with hip fracture Int J Geriatr Psychiatry 2021 36 1524 1530 10.1002/gps.5561 33908103 PMC8518900

81. The frailty index - geriatric medicine research - Dalhousie University. https://www.dal.ca/sites/gmr/our-tools/the-frailty-index.html . Accessed 19 Jul 2022

82. Clinical frailty scale - geriatric medicine research - Dalhousie University. https://www.dal.ca/sites/gmr/our-tools/clinical-frailty-scale.html . Accessed 18 Jul 2022

83. Witlox J Eurelings LSM De Jonghe JFM Delirium in elderly patients and the risk of postdischarge mortality, institutionalization, and dementia: a meta-analysis JAMA J Am Med Assoc 2010 304 443 451 10.1001/jama.2010.1013 20664045

84. Inouye SK Westendorp RG Saczynski JS Delirium in elderly people Lancet 2014 383 911 922 10.1016/S0140-6736(13)60688-1 23992774 PMC4120864

85. Roche JJW Wenn RT Sahota O Moran CG Effect of comorbidities and postoperative complications on mortality after hip fracture in elderly people: prospective observational cohort study Br Med J 2005 331 1374 1376 10.1136/bmj.38643.663843.55 16299013 PMC1309645

86. Marcantonio ER Flacker JM John Wright R Resnick NM Reducing delirium after hip fracture: a randomized trial J Am Geriatr Soc 2001 49 516 522 10.1046/j.1532-5415.2001.49108.x 11380742

87. Falaschi P, Marsh D (eds) (2021) Orthogeriatrics: the management of older patients with fragility fractures [Internet], 2nd edn. Cham (CH): Springer. Available from: https://www.ncbi.nlm.nih.gov/books/NBK565581/ . 10.1007/978-3-030-48126-1 33347100

88. Kua J Ramason R Rajamoney G Chong MS Which frailty measure is a good predictor of early post-operative complications in elderly hip fracture patients? Arch Orthop Trauma Surg 2016 136 639 647 10.1007/s00402-016-2435-7 26980097

89. Ftouh S, Morga A (2011) Swift C; Guideline Development Group. Management of hip fracture in adults: summary of NICE guidance 342 10.1136/bmj.d3304 21693526

90. Australian and New Zealand Hip Fracture Registry (ANZHFR) Steering Group (2014) Australian and New Zealand guideline for hip fracture care improving outcomes in hip fracture management of adults. https://anzhfr.org/wp-content/uploads/sites/1164/2021/12/ANZ-Guideline-for-Hip-Fracture-Care.pdf

91. Murphy MC Brooks CN New SA Lumbers ML The use of the Mini-Nutritional Assessment (MNA) tool in elderly orthopaedic patients Eur J Clin Nutr 2000 54 555 562 10.1038/sj.ejcn.1601055 10918465

92. Stratton RJ King CL Stroud MA Malnutrition Universal Screening Tool (MUST) Oxf Handb Adult Nursing 2009 95 325 330 10.1093/med/9780199231355.005.0013 16469149

93. Baumgarten M Margolis DJ Orwig DL Pressure ulcers in elderly patients with hip fracture across the continuum of care: clinical investigations J Am Geriatr Soc 2009 57 863 870 10.1111/j.1532-5415.2009.02245.x 19484841 PMC3382012

94. Barrois B, Labalette C, Rousseau P et al (2008) A national prevalence study of pressure ulcers in French hospital inpatients. J Wound Care 17:378–379. 10.12968/jowc.2008.17.9.30934 10.12968/jowc.2008.17.9.30934 18833894

95. Bergstrom N Braden BJ Lacuzza A Holman V The braden scale for predicting pressure sore risk Nurs Res 1987 36 205 210 10.1097/00006199-198707000-00002 3299278

96. National Guideline Centre (UK) (2018) Venous thromboembolism in over 16s: reducing the risk of hospital acquired deep vein thrombosis or pulmonary embolism. London: National Institute for Health and Care Excellence (NICE). https://pubmed.ncbi.nlm.nih.gov/29697228/ 29697228

97. (2020) Thromboprophylaxis: orthopedic surgery. https://thrombosiscanada.ca/wp-uploads/uploads/2021/01/9.-Thromboprophylaxis-Orthopedic-Surgery_11May2020.pdf

98. Afshari A Ageno W Ahmed A European guidelines on perioperative venous thromboembolism prophylaxis Eur J Anaesthesiol 2018 35 77 83 10.1097/EJA.0000000000000729 29112553

99. Ricci WM Broekhuyse H Keating JF Thromboprophylaxis an update of current practice OTA Int 2019 2 e027 10.1097/OI9.0000000000000027 33937659 PMC7997114

100. Nederpelt CJ Bijman Q Krijnen P Schipper IB Equivalence of DOACS and LMWH for thromboprophylaxis after hip fracture surgery: systematic review and meta-analysis Injury 2022 53 1169 1176 10.1016/j.injury.2021.11.052 34916036

101. Wæver D Lewis D Saksø H The effectiveness and safety of direct oral anticoagulants following lower limb fracture surgery: a systematic review and meta-analysis J Orthop Trauma 2021 35 217 224 10.1097/BOT.0000000000001962 32956205

102. Anderson DR Morgano GP Bennett C American Society of Hematology 2019 guidelines for management of venous thromboembolism: prevention of venous thromboembolism in surgical hospitalized patients Blood Adv 2019 3 3898 3944 10.1182/BLOODADVANCES.2019000975 31794602 PMC6963238

103. Drootin M Summary of the Updated American Geriatrics Society/British Geriatrics Society clinical practice guideline for prevention of falls in older persons J Am Geriatr Soc 2011 59 148 157 10.1111/J.1532-5415.2010.03234.X 21226685

104. Lee J Negm A Peters R Deprescribing fall-risk increasing drugs (FRIDs) for the prevention of falls and fall-related complications: a systematic review and meta-analysis BMJ Open 2021 11 e035978 10.1136/BMJOPEN-2019-035978 33568364 PMC7878138

105. Johnell O Kanis JA Odén A Mortality after osteoporotic fractures Osteoporos Int 2004 15 38 42 10.1007/s00198-003-1490-4 14593451

106. Tang VL Sudore R Cenzer IS Rates of recovery to pre-fracture function in older persons with hip fracture: an observational study J Gen Intern Med 2017 32 153 158 10.1007/s11606-016-3848-2 27605004 PMC5264672

107. Mitchell R Fajardo Pulido D Ryder T Access to rehabilitation services for older adults living with dementia or in a residential aged care facility following a hip fracture: healthcare professionals’ views Disabil Rehabil 2021 43 834 845 10.1080/09638288.2019.1643418 31335212

108. Frenkel Rutenberg T Vitenberg M Haviv B Velkes S Timing of physiotherapy following fragility hip fracture: delays cost lives Arch Orthop Trauma Surg 2018 138 1519 1524 10.1007/s00402-018-3010-1 30054813

109. Pinto D, Alshahrani M, Chapurlat R et al (2022) Bruyere O; Rehabilitation Working Group of IOF Committee of Scientific Advisors. The global approach to rehabilitation following an osteoporotic fragility fracture: a review of the rehabilitation working group of the International Osteoporosis Foundation (IOF) committee of scientific advisors 33:527–540 10.1007/s00198-021-06240-7 35048200

110. Rehabilitative Care Alliance (2017) Rehabilitative care best practices for patients with hip fracture. 10.1002/14651858.CD007125.pub2

111. Daly RM Dalla Via J Duckham RL Exercise for the prevention of osteoporosis in postmenopausal women: an evidence-based guide to the optimal prescription Braz J Phys Ther 2019 23 170 180 10.1016/j.bjpt.2018.11.011 30503353 PMC6429007

112. Singh NA Quine S Clemson LM Effects of high-intensity progressive resistance training and targeted multidisciplinary treatment of frailty on mortality and nursing home admissions after hip fracture: a randomized controlled trial J Am Med Dir Assoc 2012 13 24 30 10.1016/j.jamda.2011.08.005 21944168

113. Sheehan KJ Smith TO Martin FC Conceptual framework for an episode of rehabilitative care after surgical repair of hip fracture Phys Ther 2019 99 276 285 10.1093/ptj/pzy145 30690532 PMC8055063

114. Wu JQ Mao LB Wu J Efficacy of balance training for hip fracture patients: a meta-analysis of randomized controlled trials J Orthop Surg Res 2019 14 1 10.1186/s13018-019-1125-x 30894205 PMC6425661

115. Min K Beom J Kim BR Clinical practice guideline for postoperative rehabilitation in older patients with hip fractures Ann Rehabil Med 2021 45 225 259 10.5535/ARM.21110 34233406 PMC8273721

116. Handoll HHG Cameron ID Mak JCS Multidisciplinary rehabilitation for older people with hip fractures Cochrane Database Syst Rev 2021 2021 11 10.1002/14651858.CD007125.pub3 PMC8586844 34766330

117. Karlsson Å Lindelöf N Olofsson B Effects of geriatric interdisciplinary home rehabilitation on independence in activities of daily living in older people with hip fracture: a randomized controlled trial Arch Phys Med Rehabil 2020 101 571 578 10.1016/j.apmr.2019.12.007 31935353

118. Levi Y, Punchik B, Zikrin E, Shacham D, Katz D, Makulin E, Freud T, Press Y (2020) Intensive inpatient vs. home-based rehabilitation after hip fracture in the elderly population. Front Med (Lausanne) 7:592693. 10.3389/fmed.2020.592693 10.3389/fmed.2020.592693 PMC7581791 33163503

119. Beaupre LA Lier D Magaziner JS An outreach rehabilitation program for nursing home residents after hip fracture may be cost-saving J Gerontol Ser A Biol Sci Med Sci 2020 75 E159 E165 10.1093/gerona/glaa074 32215562 PMC7750683

120. Talevski J Sanders KM Duque G Effect of clinical care pathways on quality of life and physical function after fragility fracture: a meta-analysis J Am Med Dir Assoc 2019 20 926.e1 926.e11 10.1016/j.jamda.2019.02.022 30975586

121. Beaupre LA Magaziner JS Jones CA Rehabilitation after hip fracture for nursing home residents: a controlled feasibility trial J Gerontol A Biol Sci Med Sci 2019 74 1518 1525 10.1093/GERONA/GLZ031 30753303 PMC7330465

122. Vacouver Coastal Health (2018) Fresh Start Toolkit. Fracture recovery for seniors at home: a hip fracture recovery guide for patients & families. https://vch.eduhealth.ca/media/vch/FB/FB.863.F73.pdf

123. Schnell S Friedman SM Mendelson DA The 1-year mortality of patients treated in a hip fracture program for elders Geriatr Orthop Surg Rehabil 2010 1 6 10.1177/2151458510378105 23569656 PMC3597289

124. Khan AA, AbuAlrob H, Tariq F, Tauqir M, Zalzal P, M'Hiri I, Khan M, Ginty M, Weening B (2021) Osteoporosis treatment rate following hip fracture in a community hospital. Arch Osteoporos 16(1):8. 10.1007/s11657-020-00861-x 10.1007/s11657-020-00861-x 33409668

125. Khosla S Cauley JA Compston J Addressing the crisis in the treatment of osteoporosis: a path forward J Bone Miner Res 2017 32 424 430 10.1002/JBMR.3074 28099754

126. Lyles KW Colón-Emeric CS Magaziner JS Zoledronic acid and clinical fractures and mortality after hip fracture N Engl J Med 2007 357 1799 1809 10.1056/NEJMOA074941 17878149 PMC2324066

127. Khan AA, Alrob HA, Ali DS et al (2022) Guideline no. 422 g: menopause and osteoporosis. J Obstet Gynaecol Can 44:527–536.e5. 10.1016/J.JOGC.2021.09.013 10.1016/j.jogc.2021.09.013 35577424

128. Shoback D, Rosen CJ, Black DM, Cheung AM, Murad MH, Eastell R (2020) Pharmacological management of osteoporosis in postmenopausal women: an endocrine society guideline update. J Clin Endocrinol Metab 105(3):587–594. 10.1210/clinem/dgaa048 10.1210/clinem/dgaa048 32068863

129. Balasubramanian A Zhang J Chen L Risk of subsequent fracture after prior fracture among older women Osteoporos Int 2019 30 79 92 10.1007/S00198-018-4732-1 30456571 PMC6332293

130. Schnell AD Curtis JR Saag KG Importance of recent fracture as predictor of imminent fracture risk Curr Osteoporos Rep 2018 16 738 745 10.1007/S11914-018-0487-Z 30368717

131. Kanis JA McCloskey EV Risk factors in osteoporosis Maturitas 1998 30 229 233 10.1016/S0378-5122(98)00090-5 9881321

132. Khan AA Hodsman AB Papaioannou A Management of osteoporosis in men: an update and case example CMAJ 2007 176 345 348 10.1503/CMAJ.050816 17261833 PMC1780100

133. Lan G bin, Xie XB, Peng LK et al (2015) Current status of research on osteoporosis after solid organ transplantation: pathogenesis and management. Biomed Res Int 2015:413169. 10.1155/2015/413169 10.1155/2015/413169 PMC4662986 26649301

134. Ebeling PR Clinical practice. Osteoporosis in men N Engl J Med 2008 358 1474 1482 10.1056/NEJMCP0707217 18385499

135. Sozen T Ozisik L Calik Basaran N An overview and management of osteoporosis Eur J Rheumatol 2017 4 46 56 10.5152/EURJRHEUM.2016.048 28293453 PMC5335887

136. KDIGO Clinical Practice Guideline Update for the Diagnosis, evaluation, prevention, and treatment of chronic kidney disease-mineral and bone disorder (CKD-MBD) Kidney Int Suppl 2017 2011 7 1 59 10.1016/J.KISU.2017.04.001 PMC6340919 30675420

137. Kanis JA McCloskey E Johansson H FRAX(®) with and without bone mineral density Calcif Tissue Int 2012 90 1 13 10.1007/S00223-011-9544-7 22057815

138. Kanis JA, Johansson H, Oden A, Cooper C, McCloskey EV (2014) Epidemiology and quality of life working group of iof. worldwide uptake of FRAX. Arch Osteoporos 9:166. 10.1007/s11657-013-0166-8 10.1007/s11657-013-0166-8 24420978

139. Leslie WD Majumdar SR Lix LM High fracture probability with FRAX usually indicates densitometric osteoporosis: implications for clinical practice Osteoporos Int 2012 23 391 397 10.1007/S00198-011-1592-3 21365460

140. Leslie WD Lix LM Simplified 10-year absolute fracture risk assessment: a comparison of men and women J Clin Densitom 2010 13 141 146 10.1016/J.JOCD.2010.02.002 20435264

141. Kanis JA Harvey NC Johansson H A decade of FRAX: how has it changed the management of osteoporosis? Aging Clin Exp Res 2020 32 187 196 10.1007/S40520-019-01432-Y 32043227

142. Hoff M Meyer HE Skurtveit S Validation of FRAX and the impact of self-reported falls among elderly in a general population: the HUNT study, Norway Osteoporos Int 2017 28 2935 2944 10.1007/S00198-017-4134-9 28668994

143. Sundh V Hange D Ahlqwist M FRAX and mandibular sparse trabeculation as fracture predictors: a longitudinal study from 1980 to 2002 Eur J Oral Sci 2017 125 135 140 10.1111/EOS.12341 28263008

144. Beaudoin C Moore L Gagné M Performance of predictive tools to identify individuals at risk of non-traumatic fracture: a systematic review, meta-analysis, and meta-regression Osteoporos Int 2019 30 721 740 10.1007/s00198-019-04919-6 30877348

145. Harvey NC Odén A Orwoll E Falls predict fractures independently of FRAX probability: a meta-analysis of the osteoporotic fractures in men (MrOS) study J Bone Miner Res 2018 33 510 516 10.1002/JBMR.3331 29220072 PMC5842893

146. Ross AC Manson JAE Abrams SA The 2011 report on dietary reference intakes for calcium and vitamin D from the Institute of Medicine: what clinicians need to know J Clin Endocrinol Metab 2011 96 53 58 10.1210/JC.2010-2704 21118827 PMC3046611

147. Bolland MJ, Grey A, Avenell A, Gamble GD, Reid IR (2011) Calcium supplements with or without vitamin D and risk of cardiovascular events: reanalysis of the Women's Health Initiative limited access dataset and meta-analysis. BMJ 342:d2040. 10.1136/bmj.d2040 10.1136/bmj.d2040 PMC3079822 21505219

148. Jackson RD LaCroix AZ Gass M Calcium plus vitamin D supplementation and the risk of fractures N Engl J Med 2006 354 669 683 10.1056/NEJMOA055218 16481635

149. Calcium Calculator | Osteoporosis Canada. https://osteoporosis.ca/calcium-calculator/ . Accessed 28 Nov 2022

150. Pfeifer M Begerow B Minne HW Effects of a long-term vitamin D and calcium supplementation on falls and parameters of muscle function in community-dwelling older individuals Osteoporos Int 2009 20 315 322 10.1007/S00198-008-0662-7 18629569

151. Bischoff-Ferrari HA Willett WC Wong JB Fracture prevention with vitamin D supplementation: a meta-analysis of randomized controlled trials JAMA 2005 293 2257 2264 10.1001/JAMA.293.18.2257 15886381

152. Minisola S, Colangelo L, Pepe J, Diacinti D, Cipriani C, Rao SD (2020) Osteomalacia and vitamin D status: a clinical update 2020. JBMR Plus 5(1):e10447. 10.1002/jbm4.10447 10.1002/jbm4.10447 PMC7839817 33553992

153. Kelley GA, Kelley KS, Kohrt WM (2012) Effects of ground and joint reaction force exercise on lumbar spine and femoral neck bone mineral density in postmenopausal women: a meta-analysis of randomized controlled trials. BMC Musculoskelet Disord 13:177. 10.1186/1471-2474-13-177 10.1186/1471-2474-13-177 PMC3489866 22992273

154. Kanis JA Johnell O Oden A Smoking and fracture risk: a meta-analysis Osteoporos Int 2005 16 155 162 10.1007/S00198-004-1640-3 15175845

155. Kanis JA Johansson H Johnell O Alcohol intake as a risk factor for fracture Osteoporos Int 2005 16 737 742 10.1007/S00198-004-1734-Y 15455194

156. Tinetti ME Speechley M Ginter SF Risk factors for falls among elderly persons living in the community N Engl J Med 1988 319 1701 1707 10.1056/NEJM198812293192604 3205267

157. Choi M Hector M Effectiveness of intervention programs in preventing falls: a systematic review of recent 10 years and meta-analysis J Am Med Dir Assoc 2012 13 188.e13 188.e21 10.1016/J.JAMDA.2011.04.022 21680249

158. Papaioannou A Morin S Cheung AM 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary CMAJ 2010 182 1864 1873 10.1503/CMAJ.100771 20940232 PMC2988535

159. Camacho PM Petak SM Binkley N American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis-2020 update Endocr Pract 2020 26 1 46 10.4158/GL-2020-0524SUPPL 32427503

160. Khan AA, Alrob HA, Ali DS, et al (2022) Guideline no. 422g: menopause and osteoporosis. J Obstet Gynaecol Can 44(5):527–536.e5. 10.1016/j.jogc.2021.09.013 10.1016/j.jogc.2021.09.013 35577424

161. Kendler DL Marin F Zerbini CAF Effects of teriparatide and risedronate on new fractures in post-menopausal women with severe osteoporosis (VERO): a multicentre, double-blind, double-dummy, randomised controlled trial Lancet 2018 391 230 240 10.1016/S0140-6736(17)32137-2 29129436

162. Saag KG Petersen J Brandi ML Romosozumab or alendronate for fracture prevention in women with osteoporosis N Engl J Med 2017 377 1417 1427 10.1056/NEJMOA1708322 28892457

163. Cosman F Crittenden DB Adachi JD Romosozumab treatment in postmenopausal women with osteoporosis N Engl J Med 2016 375 1532 1543 10.1056/NEJMOA1607948 27641143

164. Cosman F Crittenden DB Ferrari S FRAME study: the foundation effect of building bone with 1 year of romosozumab leads to continued lower fracture risk after transition to denosumab J Bone Miner Res 2018 33 1219 1226 10.1002/JBMR.3427 29573473

165. Miller PD Hattersley G Riis BJ Effect of abaloparatide vs placebo on new vertebral fractures in postmenopausal women with osteoporosis: a randomized clinical trial JAMA 2016 316 722 733 10.1001/JAMA.2016.11136 27533157

166. Cummings SR Martin JS McClung MR Denosumab for prevention of fractures in postmenopausal women with osteoporosis N Engl J Med 2009 361 756 765 10.1056/NEJMOA0809493 19671655

167. Everts-Graber J Reichenbach S Ziswiler HR A single infusion of zoledronate in postmenopausal women following denosumab discontinuation results in partial conservation of bone mass gains J Bone Miner Res 2020 35 1207 1215 10.1002/JBMR.3962 31991007

168. Bone HG Wagman RB Brandi ML 10 years of denosumab treatment in postmenopausal women with osteoporosis: results from the phase 3 randomised FREEDOM trial and open-label extension Lancet Diabetes Endocrinol 2017 5 513 523 10.1016/S2213-8587(17)30138-9 28546097

169. Tsvetov G Amitai O Shochat T Denosumab-induced hypocalcemia in patients with osteoporosis: can you know who will get low? Osteoporos Int 2020 31 655 665 10.1007/S00198-019-05261-7 31838550

170. Reid IR Brown JP Burckhardt P Intravenous zoledronic acid in postmenopausal women with low bone mineral density N Engl J Med 2002 346 653 661 10.1056/NEJMOA011807 11870242

171. Adami S Bhalla AK Dorizzi R The acute-phase response after bisphosphonate administration Calcif Tissue Int 1987 41 326 331 10.1007/BF02556671 3124942

172. Cosman F Nieves JW Dempster DW Treatment sequence matters: anabolic and antiresorptive therapy for osteoporosis J Bone Miner Res 2017 32 198 202 10.1002/JBMR.3051 27925287

173. Leder BZ Tsai JN Uihlein AV Denosumab and teriparatide transitions in postmenopausal osteoporosis (the DATA-Switch study): extension of a randomised controlled trial Lancet 2015 386 1147 1155 10.1016/S0140-6736(15)61120-5 26144908 PMC4620731

174. Health Services A (2019) Optimizing the post-acute continuum of care following a hip fracture a knowledge synthesis of clinical research interventions for post-acute care of hip fracture initiated within 14 days of surgical repair: A White Paper An Alberta Health Services (AHS) and Bone and Joint Health Strategic Clinical Network (BJH SCN) and Seniors Strategic Clinical Network (Seniors SCN) Workshop 2 Alberta Health Services BJH SCN Post-Acute Care of Hip Fracture White Paper. https://www.albertahealthservices.ca/assets/about/scn/ahs-scn-bjh-hip-white-paper.pdf

175. McGlasson R, Zellermeyer V, MacDonald V, Lo Nick, Spafford D, McMullan JL, Beaupre L, Gould JS, Saryeddine T, Scott V (2011) National Hip Fracture Toolkit. The Bone and Joint Decade. https://boneandjointcanada.com/wpcontent/uploads/2014/05/National-hip-fracture-toolkit-June-2011.pdf . Accessed 25 Mar 2022

176. Kanis JA Svedbom A Harvey N McCloskey EV The osteoporosis treatment gap J Bone Miner Res 2014 29 1926 1928 10.1002/JBMR.2301 24956507

177. McGlasson R, Zellermeyer V, MacDonald V et al (2011) National hip fracture toolkit. Bone Joint Decade

178. Dewan N MacDermid JC Fall efficacy scale - international (FES-I) J Physiother 2014 60 60 10.1016/j.jphys.2013.12.014 24856947

179. Osteoporosis Canada. https://osteoporosis.ca/ . Accessed 28 Nov 2022

180. Seniors’ Falls in Canada: Second Report - Canada.ca. https://www.canada.ca/en/public-health/services/health-promotion/aging-seniors/publications/publications-general-public/seniors-falls-canada-second-report.html . Accessed 28 Nov 2022

181. Rizzoli R Nutritional aspects of bone health Best Pract Res Clin Endocrinol Metab 2014 28 795 808 10.1016/J.BEEM.2014.08.003 25432353

182. Lim SL Ong KCB Chan YH Malnutrition and its impact on cost of hospitalization, length of stay, readmission and 3-year mortality Clin Nutr 2012 31 345 350 10.1016/J.CLNU.2011.11.001 22122869

183. Bell JJ Pulle RC Crouch AM Impact of malnutrition on 12-month mortality following acute hip fracture ANZ J Surg 2016 86 157 161 10.1111/ANS.13429 26748473

184. Malafarina V, Reginster JY, Cabrerizo S, Bruyère O, Kanis JA, Martinez JA, Zulet MA (2018) Nutritional status and nutritional treatment are related to outcomes and mortality in older adults with hip fracture. Nutrients 10(5):555. 10.3390/nu10050555 10.3390/nu10050555 PMC5986435 29710860

185. Koren-Hakim T Weiss A Hershkovitz A Comparing the adequacy of the MNA-SF, NRS-2002 and MUST nutritional tools in assessing malnutrition in hip fracture operated elderly patients Clin Nutr 2016 35 1053 1058 10.1016/J.CLNU.2015.07.014 26231340

186. Wong AM Xu BY Low LL Impact of malnutrition in surgically repaired hip fracture patients admitted for rehabilitation in a community hospital: a cohort prospective study Clin Nutr ESPEN 2021 44 188 193 10.1016/J.CLNESP.2021.06.024 34330464

187. Cederholm T Jensen GL Correia MITD GLIM criteria for the diagnosis of malnutrition - a consensus report from the global clinical nutrition community Clin Nutr 2019 38 1 9 10.1016/J.CLNU.2018.08.002 30181091

188. Allard JP Keller H Gramlich L GLIM criteria has fair sensitivity and specificity for diagnosing malnutrition when using SGA as comparator Clin Nutr 2020 39 2771 2777 10.1016/J.CLNU.2019.12.004 31918864

189. Bohl DD Shen MR Hannon CP Serum albumin predicts survival and postoperative course following surgery for geriatric hip fracture J Bone Joint Surg Am 2017 99 2110 2118 10.2106/JBJS.16.01620 29257017

190. Dixon J, Channell W, Arkley J, Eardley W (2019) Nutrition in Hip Fracture Units: Contemporary Practices in Preoperative Supplementation. Geriatr Orthop Surg Rehabil. 10.1177/2151459319870682 10.1177/2151459319870682 PMC6710709 31489253

191. Smith I Kranke P Murat I Perioperative fasting in adults and children: guidelines from the European Society of Anaesthesiology Eur J Anaesthesiol 2011 28 556 569 10.1097/EJA.0B013E3283495BA1 21712716

192. American Society of Anesthesiologists Committee (2011) Practice guidelines for preoperative fasting and the use of pharmacologic agents to reduce the risk of pulmonary aspiration: application to healthy patients undergoing elective procedures: an updated report by the American society of anesthesiologists committee on standards and practice parameters. Anesthesiology 114(3):495–511 10.1097/ALN.0b013e3181fcbfd9 21307770

193. Green CR Pandit SK Anthony Schork M Preoperative fasting time: is the traditional policy changing? Results of a national survey Anesth Analg 1996 83 123 128 10.1097/00000539-199607000-00022 8659722

194. HipQIP: scaling up project | RCP London. https://www.rcplondon.ac.uk/projects/outputs/hipqip-scaling-project . Accessed 28 Nov 2022

195. Lai WY, Chiu YC, Lu KC, Huang IT, Tsai PS, Huang CJ (2021) Beneficial effects of preoperative oral nutrition supplements on postoperative outcomes in geriatric hip fracture patients: a PRISMA-compliant systematic review and meta-analysis of randomized controlled studies. Medicine (Baltimore)100(47):e27755. 10.1097/MD.0000000000027755 10.1097/MD.0000000000027755 PMC8615416 34964732

196. Williams DGA Ohnuma T Haines KL Association between early postoperative nutritional supplement utilisation and length of stay in malnourished hip fracture patients Br J Anaesth 2021 126 730 737 10.1016/J.BJA.2020.12.026 33516455

197. Shi H Lu JH Wang SN Effect of early enteral nutrition in elderly patients with hip fracture during the perioperative period J Back Musculoskelet Rehabil 2020 33 109 117 10.3233/BMR-181191 31104006

198. Takahashi K Momosaki R Yasufuku Y Nutritional therapy in older patients with hip fractures undergoing rehabilitation: a systematic review and meta-analysis J Am Med Dir Assoc 2020 21 1364 1364.e6 10.1016/J.JAMDA.2020.07.005 32859299

199. Bauer J Biolo G Cederholm T Evidence-based recommendations for optimal dietary protein intake in older people: a position paper from the PROT-AGE Study Group J Am Med Dir Assoc 2013 14 542 559 10.1016/J.JAMDA.2013.05.021 23867520

200. Yan B, Su X, Xu B, Qiao X, Wang L (2018) Effect of diet protein restriction on progression of chronic kidney disease: A systematic review and meta-analysis. PLoS One 13(11):e0206134. 10.1371/journal.pone.0206134 10.1371/journal.pone.0206134 PMC6221301 30403710

201. Scialla JJ, Appel LJ, Wolf M, Yang W, Zhang X, Sozio SM, Miller ER 3rd, Bazzano LA, Cuevas M, Glenn MJ, Lustigova E, Kallem RR, Porter AC, Townsend RR, Weir MR, Anderson CA (2012) Chronic renal insufficiency cohort-cric study group: plant protein intake is associated with fibroblast growth factor 23 and serum bicarbonate levels in patients with chronic kidney disease: the Chronic Renal Insufficiency Cohort study. J Ren Nutr 22(4):379–388.e1. 10.1053/j.jrn.2012.01.026 10.1053/j.jrn.2012.01.026 PMC3383455 22480598

202. Liu M Yang J Yu X The role of perioperative oral nutritional supplementation in elderly patients after hip surgery Clin Interv Aging 2015 10 849 858 10.2147/CIA.S74951 26005339 PMC4433048

203. Avenell A, Smith TO, Curtain JP, Mak JC, Myint PK (2016) Nutritional supplementation for hip fracture aftercare in older people. Cochrane Database Syst Rev 11(11):CD001880. 10.1002/14651858.CD001880.pub6 10.1002/14651858.CD001880.pub6 PMC6464805 27898998

204. Volkert D Beck AM Cederholm T ESPEN guideline on clinical nutrition and hydration in geriatrics Clin Nutr 2019 38 10 47 10.1016/J.CLNU.2018.05.024 30005900