Hip Fracture in the Elderly: What Happens Next and What Determines Recovery

Research-informed explainer — last updated April 12, 2026

A hip fracture in an elderly person is not just a broken bone — it is a systemic medical event that carries a 20-30% mortality rate within one year, and the factors that determine survival are as much about medical management and rehabilitation as they are about the surgery itself. Surgery within 48 hours, optimized perioperative care, and early mobilization are the most evidence-backed interventions for improving outcomes.

This article draws on research from four orthopaedic trauma specialists. Joseph Zuckerman, M.D., at NYU Langone, published the definitive hip fracture review in the New England Journal of Medicine (604 citations), the predictors of one-year mortality after hip fracture (313 citations), and a broader mortality risk analysis (316 citations). William Macaulay, MD, also at NYU Langone, co-led the FOCUS trial in the New England Journal of Medicine (1,292 citations) — the landmark randomized comparison of liberal versus restrictive transfusion strategy after hip surgery — and published a prospective RCT comparing hemiarthroplasty to total hip arthroplasty for displaced femoral neck fractures. Sean Nork, MD, Professor at the University of Washington School of Medicine at Harborview Medical Center, published the definitive internal fixation versus arthroplasty RCT for displaced femoral neck fractures (595 citations). Julius Bishop, MD, Associate Professor at Stanford, published the epidemiology and financial aspects of delayed union and nonunion (619 citations).

Who is at risk and why hip fractures are dangerous

Approximately 300,000 hip fractures occur in the United States annually, predominantly in people over 65. The 20-30% one-year mortality figure cited in Joseph Zuckerman's original NEJM hip fracture review has remained essentially unchanged over decades despite improvements in surgical technique — because the mortality is driven by the patient's underlying medical status, not primarily by the surgery.

His mortality predictor studies identified the following as the strongest predictors of one-year mortality after hip fracture:

• Older age (each decade over 70 increases risk substantially)
• Male sex (men have higher post-fracture mortality than age-matched women)
• Pre-existing institutionalization (nursing home residence before fracture)
• Significant comorbidities — cardiac disease, dementia, pulmonary disease, renal failure
• Poor pre-fracture functional status
• Delay to surgery beyond 48 hours

Types of hip fractures and how surgery choice differs

Hip fractures are broadly divided into two anatomical groups:

Femoral neck fractures (intracapsular): The break is within the hip joint capsule. The blood supply to the femoral head (the ball) is at risk, which can lead to avascular necrosis (bone death) if the fracture is displaced and treated with internal fixation.

Intertrochanteric / subtrochanteric fractures (extracapsular): Below the femoral head; blood supply to the head is generally preserved; internal fixation is typically the treatment of choice.

The key decision for femoral neck fractures: fixation vs. arthroplasty

For nondisplaced femoral neck fractures (the bone is cracked but not shifted), internal fixation with screws preserves the native hip and is the standard approach.

For displaced femoral neck fractures (Garden III-IV), the treatment choice is more complex:

Sean Nork's 2003 Journal of Bone and Joint Surgery RCT randomized 192 patients with displaced femoral neck fractures to internal fixation versus arthroplasty (hemiarthroplasty or total hip replacement). Key findings:

• Arthroplasty significantly reduced the risk of reoperation (9% vs. 42% at 12 months, p<0.001)
• Internal fixation carried higher rates of fixation failure, femoral head collapse, and need for revision surgery
• Arthroplasty was associated with slightly higher early complication rates (more blood loss, longer operative time, higher infection rate) — a tradeoff that favors arthroplasty for physiologically fit patients

Hemiarthroplasty vs. total hip arthroplasty for displaced femoral neck fractures:

William Macaulay's prospective RCT comparing hemiarthroplasty to THA for displaced femoral neck fractures found that THA produced better functional outcomes and Harris Hip Scores at 2 years in physiologically fit patients (those expected to survive more than 1-2 years and who are ambulatory). Hemiarthroplasty remains preferred for frail patients with limited life expectancy and those with pre-existing cognitive impairment where the activity restrictions of THA are difficult to follow.

Current AO/OTA and AAOS guidance recommends THA for medically fit, community-dwelling patients under approximately 80-85 years; hemiarthroplasty for frail or less physiologically robust patients.

The FOCUS trial: transfusion strategy matters

Blood transfusion after hip surgery has been a major area of uncertainty — how low can hemoglobin go before transfusion is needed? The FOCUS trial, co-led by William Macaulay, enrolled 2,016 hip fracture surgical patients with known cardiovascular disease or risk factors and randomized them to a liberal (hemoglobin threshold 10 g/dL) versus restrictive (threshold 8 g/dL or symptoms) transfusion strategy. At 60 days, there was no significant difference in death or independent walking ability between groups, validating a restrictive transfusion strategy as safe — even in high-risk cardiac patients. This finding changed peri-operative management practice at many centers.

The 3-year follow-up confirmed that survival and functional outcomes were equivalent between groups, with no evidence of harm from the more restrictive strategy.

When do hip fractures not heal? The nonunion risk

Julius Bishop's epidemiology review documented that delayed union and nonunion of hip fractures — where the bone fails to knit — carry substantial clinical and economic consequences. Risk factors for nonunion include osteoporosis, smoking, malnutrition, poor fracture reduction, and excessive motion at the fracture site. The estimated annual cost of fracture nonunion in the United States is $2-3 billion.

For femoral neck fractures treated with internal fixation, nonunion rates of 10-30% are reported — substantially higher than arthroplasty (where there is no bone healing required). This is one of the key drivers of the shift toward arthroplasty for displaced fractures.

Perioperative management priorities

The evidence base for hip fracture care emphasizes several factors beyond the choice of implant:

Surgical timing: Multiple prospective studies show that surgery within 24-48 hours of injury is associated with lower 30-day and 1-year mortality, fewer pulmonary complications, less delirium, and shorter hospital stays. Delays beyond 48 hours for medical optimization should only occur if the patient has a genuinely reversible medical issue (unstable cardiac arrhythmia, active anticoagulation requiring reversal) — not for chronic conditions already at baseline.

VTE prophylaxis: Deep venous thrombosis and pulmonary embolism are major causes of mortality after hip fracture surgery. Chemical thromboprophylaxis (low-molecular-weight heparin, DOACs) should begin within 12-24 hours of surgery.

Delirium prevention: Elderly hip fracture patients have very high rates of postoperative delirium — up to 50% in some series. Early mobilization, pain management (including fascia iliaca nerve blocks to reduce systemic opioid requirements), minimizing polypharmacy, and orienting interventions reduce delirium incidence.

Rehabilitation: Early weight-bearing and mobilization — ideally beginning the day after surgery — is the strongest predictor of functional recovery. Patients who return to full weight-bearing within the first week have substantially better 1-year functional outcomes than those who are kept non-weight-bearing.

Bone health and fall prevention: A hip fracture should trigger evaluation for osteoporosis and initiation of bisphosphonate or denosumab therapy to reduce the approximately 2-3 times elevated risk of a second fracture in the contralateral hip within 1-2 years.

Questions to ask your doctor

• Is this a femoral neck fracture or an intertrochanteric fracture, and does that change the surgical plan?
• If it is a displaced femoral neck fracture, is my family member a better candidate for hemiarthroplasty or total hip replacement given their health status and life expectancy?
• What is causing any delay to surgery, and is it truly necessary?
• Will they be on blood thinners immediately after surgery, and at what hemoglobin level would a transfusion be given?
• What is the rehabilitation plan — will they start physical therapy the day after surgery?
• Who is managing the medical aspects of care (internist, hospitalist, or geriatrician) alongside the orthopaedic surgeon?
• After discharge, what osteoporosis treatment will they receive to prevent the next fracture?

The bottom line

A hip fracture in an elderly person is a medical emergency that requires surgical treatment within 24-48 hours whenever medically feasible. For displaced femoral neck fractures, arthroplasty (hemiarthroplasty or total hip replacement for fit patients) substantially reduces the risk of reoperation compared to internal fixation. The FOCUS trial established that a restrictive transfusion threshold (8 g/dL) is safe even in high-risk cardiac patients, reducing unnecessary transfusion. Recovery is determined as much by early mobilization, delirium prevention, and osteoporosis treatment as by the surgical procedure itself.