Hip Fractures Kill 1 in 5 Patients Within a Year. Most Are Getting Suboptimal Secondary Prevention.

More than 14 million hip fractures occur worldwide each year, and in the United States alone, the 1-year mortality after hip fracture exceeds 22%. In older adults, a hip fracture is frequently the clinical event that separates independence from institutionalization. A comprehensive narrative review published in JAMA on August 11, 2026 synthesized the current evidence on diagnosis, surgical management, rehabilitation, and prevention.[1]

The review makes clear that outcomes after hip fracture are largely a function of what happens in the first 48 hours. Time to surgery matters. Among patients fit for the operating room, repair within 24–48 hours of admission is associated with reduced 30-day mortality, lower rates of pneumonia and pressure ulcers, shorter hospital stays, and superior functional recovery.[1] This is not a surgical preference — it is an evidence-based target that medicine and anesthesia teams should jointly prioritize.

Surgical choice between hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures depends primarily on patient activity level and baseline function. THA is preferred for active, community-dwelling patients without significant medical comorbidity; hemiarthroplasty is appropriate for those with limited ambulation or significant comorbidity. Intramedullary nailing remains the standard for intertrochanteric and subtrochanteric fractures.[1]

Tranexamic acid consistently reduced intraoperative and postoperative blood loss by up to 46% compared with controls in hip fracture repair, across multiple dosing strategies, without a significant increase in thromboembolic events — making it a standard perioperative agent.[1,2]

Secondary Prevention Is Consistently Neglected

The review highlights a persistent and well-documented failure: most patients who survive a hip fracture never receive osteoporosis pharmacotherapy before discharge. Yet the risk of a second fracture is highest in the year after the first. Bisphosphonates (alendronate, zoledronic acid), denosumab, and — for high-risk patients — anabolic agents (teriparatide, abaloparatide, romosozumab) all reduce subsequent fracture risk significantly.[1]

Zoledronic acid given within 90 days of hip fracture repair reduced mortality by 28% in the HORIZON Recurrent Fracture Trial — an effect not seen with any other drug in this population.[3] And yet initiation rates remain below 30% in most health systems.

Clinical Context

The orthogeriatric co-management model — in which geriatric medicine is involved from the moment of admission — is now strongly supported and associated with reduced complications and shorter length of stay. Vitamin D insufficiency (25-OH-D <30 ng/mL) is near-universal in hip fracture patients and should be corrected before discharge. Calcium supplementation through diet is preferred over high-dose supplements, which have been associated with cardiovascular risk in some analyses.

Limitations

This is a narrative review, not a systematic review or meta-analysis. The studies cited vary in design, patient population, and follow-up duration. Some surgical outcome data predate modern anesthesia and pain management protocols. Fall prevention interventions show inconsistent benefit across RCTs, and the review notes that fall prevention likely contributes to fracture prevention without definitive RCT evidence.