A broken hip is rarely just a broken hip. For older patients, it can signal a broader decline in health, with complications that become more dangerous the longer surgery is delayed. Yet for decades, hospitals routinely kept these patients waiting while physicians determined whether they were healthy enough to undergo an operation.
Scott Ryan, MD, chief of orthopedic trauma and vice chair of clinical affairs at Boston-based Tufts Medical Center, believes that approach has overlooked a fundamental risk: The waiting itself can make patients sicker.
“Having a hip fracture is like having a heart attack,” Dr. Ryan told Becker’s. “The bone is alive. It’s an organ and has a blood flow. It is not just a piece of wood that we put back together.”
At Tufts, rethinking how orthopedic surgeons, anesthesiologists and medical teams approach hip fracture patients has helped shorten hospital stays, Dr. Ryan said.
The improvement did not come from a new implant or surgical technique. It came from changing how the hospital delivers care around the operation.
When caution becomes the greater risk
Twenty years ago, surgeons generally aimed to repair hip fractures within four days. As evidence evolved, that window narrowed to 48 hours. Today, the emphasis is on operating within 24 to 48 hours when medically appropriate, Dr. Ryan said.
But meeting that standard requires challenging long-standing assumptions about surgical risk. Patients taking blood thinners, for example, have historically faced delays over concerns about excessive bleeding, he added. Those taking clopidogrel, commonly known as Plavix, could wait five to seven days for the medication’s effects to diminish.
Dr. Ryan said accumulating evidence has changed how he weighs those risks. “I would not delay surgery because a patient is on blood thinners,” he said.
Although anticoagulation can increase bleeding concerns, he argues that routine delays often pose greater risks than proceeding with appropriately managed surgery.
Similar questions arise when patients have elevated troponin levels, which can indicate cardiac injury but may also reflect physiological stress from the fracture itself.
Tufts participated in the international HIP ATTACK trial, published in The Lancet in 2020, which found that accelerated hip fracture surgery did not significantly reduce mortality or major complications overall. However, a separate 2024 analysis published in The Journal of Bone and Joint Surgery found lower 90-day mortality among patients with elevated troponin levels who underwent accelerated surgery, raising questions about whether delaying surgery benefits some medically vulnerable patients.
The experience helped change Dr. Ryan’s thinking about preoperative decision-making, including the language physicians use.
“I’m not a big fan of the word ‘clearance’ with hip fractures,” he said. “I think we should use the word optimized. Clearance is like passing the blame if someone were to have a complication. This isn’t about blame.”
The distinction matters because many older patients have chronic conditions that cannot be resolved before surgery. The objective is not to eliminate every risk, but to determine which problems can meaningfully be improved before an operation.
Acute respiratory distress, significant fluid overload or certain cardiac emergencies may warrant additional treatment. But Dr. Ryan believes most hip fracture patients can be prepared for surgery within the recommended window.
How Tufts took a day off hospital stays
Getting patients to surgery sooner requires more than an available operating room. Emergency physicians, hospitalists, anesthesiologists and orthopedic surgeons all influence when an operation can proceed. Without agreement on what constitutes adequate medical optimization, patients can face delays even when every team is acting in their best interest.
“Having alignment with all of the services involved with these patients is really key,” Dr. Ryan said.
Participation in HIP ATTACK helped Tufts establish a more consistent approach to preoperative decisions. Rather than treating each medical concern as a potential reason to postpone surgery, teams focused on whether additional intervention would meaningfully change a patient’s readiness.
Dr. Ryan said the changes substantially reduced time to surgery and shortened hospital stays by about one day. Physical therapy also became involved earlier, helping patients regain mobility sooner. For hospital leaders, the implications extend beyond clinical outcomes. Avoiding unnecessary delays can improve patient flow, reduce inpatient bed utilization and make care delivery more efficient.
The experience also illustrates how improvements in surgical care can emerge from better coordination rather than additional technology.
The next opportunity lies beyond surgery
Once patients reach the operating room, Dr. Ryan said treatment largely depends on fracture location and displacement. Displaced femoral neck fractures generally require some form of hip replacement, while other proximal femur fractures are commonly treated with intramedullary nails or plates and screws.
The objective is to provide enough stability for patients to begin walking as soon as possible. But Dr. Ryan sees some of the greatest remaining opportunities in what happens afterward.
At Tufts, his team is focusing on reducing postoperative delirium, improving pain management and limiting narcotic exposure among older patients. Nerve blocks and earlier physical therapy are among the approaches being considered.
Ideally, patients would begin physical therapy on the day of surgery, although late-day operations can make that difficult. Prioritizing hip fracture cases earlier in the operating room schedule could help.
Dr. Ryan is also working to strengthen fracture liaison services involving specialties such as endocrinology to address osteoporosis and prevent subsequent fractures. Better communication with primary care physicians and patients’ families is another priority.
Together, these efforts reflect a shift toward treating hip fractures as an episode of care rather than an isolated surgical procedure.
“The implants that we have have not changed in a long time,” Dr. Ryan said. “Arthroplasty is arthroplasty. Nails are nails, and plates and screws are plates and screws.”
What surrounds those procedures, he believes, offers the greatest opportunity for improvement.
For hospitals, the lesson is that better hip fracture outcomes may depend less on developing the next surgical innovation than on removing the barriers that prevent patients from receiving timely, coordinated care. The tools to repair a broken hip are already well established. The challenge is building a system that gets patients to those tools, and through recovery, without unnecessary delays.
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