Hip fracture is one of the most serious musculoskeletal injuries affecting the elderly population and is associated with substantial morbidity, mortality, disability, loss of independence, and increased healthcare expenditure. With the progressive ageing of the global population, the incidence of hip fractures is increasing rapidly and is expected to exceed 6 million cases annually by 2050. Despite advances in surgical techniques and perioperative care, only a proportion of elderly patients regain their pre-fracture functional status, making functional recovery the primary goal of treatment rather than fracture union alone.¹

Globally, hip fractures account for a major proportion of osteoporotic fractures and represent an important cause of disability-adjusted life years (DALYs) among older adults. Mortality following hip fracture ranges from 15% to 30% within the first year, while nearly half of survivors experience permanent impairment in mobility and activities of daily living. Functional decline after hip fracture frequently results in institutionalization, dependence on caregivers, recurrent falls, and diminished quality of life.¹²

India is witnessing a rapid demographic transition with a steadily increasing elderly population and a rising burden of osteoporosis and fragility fractures. Urbanization, sedentary lifestyle, nutritional deficiencies, and increasing life expectancy have contributed to the growing incidence of hip fractures in the country. Indian studies have reported delayed presentation, high prevalence of comorbid illnesses, and inadequate rehabilitation services, all of which adversely influence postoperative recovery. Consequently, restoration of independent ambulation and functional ability has become a major challenge for orthopaedic surgeons managing elderly hip fracture patients.³

Functional recovery after hip fracture surgery is a multifactorial process influenced by patient-related, fracture-related, surgical, and rehabilitation factors. Advanced age, female sex, multiple comorbidities, cognitive impairment, poor nutritional status, low pre-fracture functional capacity, depression, sarcopenia, delayed surgery, postoperative complications, and inadequate rehabilitation have all been identified as determinants of poor functional outcome. These factors may independently or collectively delay recovery of mobility and activities of daily living following surgery.⁴

Several prospective cohort studies have demonstrated that pre-fracture mobility and functional independence are among the strongest predictors of postoperative recovery. Patients who were ambulatory and independent before injury generally achieve better functional outcomes than those with baseline dependency. Similarly, cognitive impairment and prolonged hospital stay have consistently been associated with reduced recovery of walking ability and activities of daily living during follow-up.⁵

A recent systematic review evaluating prognostic factors after hip fracture identified 74 different factors associated with short- and long-term functional recovery. The most consistent predictors included advanced age, cognitive status, nutritional status, pre-fracture functional ability, comorbidities, social support, and rehabilitation intensity. The review emphasized that early recognition of these predictors allows clinicians to stratify patients according to risk, individualize rehabilitation strategies, and improve long-term outcomes.⁶

Although several international studies have investigated predictors of functional recovery after hip fracture surgery, evidence from India remains limited. Differences in patient demographics, nutritional status, socioeconomic conditions, access to rehabilitation, caregiver support, and healthcare infrastructure may influence postoperative recovery among Indian elderly patients. Furthermore, most available Indian studies have primarily focused on mortality and fracture outcomes rather than functional recovery. Therefore, a prospective cohort study evaluating clinical and perioperative predictors of functional recovery in elderly patients undergoing hip fracture surgery is warranted. Such evidence will help clinicians identify high-risk patients early, optimize perioperative management, improve rehabilitation planning, and ultimately enhance postoperative quality of life and independence among elderly individuals.⁷

AIM

To evaluate the predictors of functional recovery after hip fracture surgery among elderly patients in a tertiary care teaching hospital.

OBJECTIVES

1. To study the demographic, clinical, fracture-related, and perioperative characteristics of elderly patients undergoing hip fracture surgery.
2. To identify clinical and perioperative predictors associated with functional recovery at six months after hip fracture surgery.

Study Design A Prospective cohort study. Study Population Patients aged 60 years and above undergoing surgical management for hip fractures. Sample Size 50 elderly patients. Sampling Technique Consecutive sampling. Inclusion Criteria • Age ≥60 years. • Radiologically confirmed intracapsular or extracapsular hip fracture. • Undergoing definitive surgical management. • Able to provide informed consent or consent obtained from a legally authorized representative. • Willing to participate in follow-up. Exclusion Criteria • Pathological fractures. • Polytrauma patients. • Previous ipsilateral hip surgery. • Patients with severe neurological disorders causing permanent inability to ambulate before fracture. • Terminal illness with life expectancy <6 months. • Patients unwilling or lost to follow-up. Data Collection After written informed consent, eligible patients will be enrolled consecutively. Baseline demographic details, body mass index, comorbidities, Charlson Comorbidity Index, cognitive status (Mini-Mental State Examination), pre-fracture mobility, pre-fracture functional status, nutritional status, fracture type, American Society of Anesthesiologists (ASA) grade, surgical procedure, duration of surgery, time to surgery, postoperative complications, and rehabilitation details will be recorded. Patients will be followed at 6 weeks, 3 months, and 6 months after surgery. Statistical Analysis Data will be entered into Microsoft Excel and analyzed using SPSS version 26.0. Continuous variables will be expressed as mean ± standard deviation and compared using the Independent Student's t-test or Mann–Whitney U test. Categorical variables will be expressed as frequencies and percentages and compared using the Chi-square test or Fisher's exact test. Variables with p<0.20 on univariate analysis will be entered into multivariable logistic regression to identify independent predictors of good functional recovery. A p-value <0.05 will be considered statistically significant.

A total of 50 elderly patients who underwent hip fracture surgery were included in the study. Functional recovery was assessed at 6 months postoperatively using the Harris Hip Score (HHS). Patients with HHS ≥80 were categorized as having good functional recovery, whereas those with HHS <80 were considered to have poor functional recovery. Overall, 31 patients (62.0%) achieved good functional recovery, while 19 patients (38.0%) had poor functional recovery.

Table 1. Demographic and baseline clinical characteristics of the study participants (n = 50)

Mean age: 73.6 ± 8.4 years

Interpretation: Most patients were aged 70–79 years (42%), and females constituted 58% of the study population. Hypertension (56%) and diabetes (40%) were the most common comorbidities. Nearly one-fourth of patients had cognitive impairment before surgery.

Table 2. Fracture characteristics and perioperative variables

Interpretation: Intertrochanteric fractures were the most common fracture type (50%). Most patients underwent surgery within 48 hours (64%), and postoperative complications occurred in 22% of cases.

Table 3. Comparison of demographic and clinical variables according to functional recovery

Interpretation: Poor functional recovery was significantly associated with advanced age, diabetes mellitus, hypertension, cognitive impairment, higher comorbidity burden, and reduced pre-fracture mobility.

Table 4. Association of perioperative variables with functional recovery

Interpretation: Early surgery, good rehabilitation compliance, shorter hospital stay, and absence of postoperative complications were significantly associated with better functional recovery at six months.

Table 5. Multivariable logistic regression analysis for predictors of good functional recovery

Statistical test: Binary multivariable logistic regression.

Model fit:

• Omnibus test: p <0.001
• Nagelkerke R² = 0.61

Interpretation: Independent pre-fracture ambulation, surgery within 48 hours, and good rehabilitation compliance were significant independent predictors of good functional recovery. Advanced age, cognitive impairment, and postoperative complications were associated with significantly poorer postoperative functional outcomes. These findings suggest that both patient-related and perioperative factors play an important role in determining recovery after hip fracture surgery in elderly patients.

The present prospective cohort study evaluated the predictors of functional recovery after hip fracture surgery in elderly patients. At six months of follow-up, 62.0% of patients achieved good functional recovery, while 38.0% had poor recovery. Hip fractures in the elderly are associated with substantial morbidity, and restoration of functional independence is considered the most important outcome following surgery. Our findings are consistent with the systematic review by **Kristensen et al.**⁸, who reported that postoperative functional recovery is influenced by a combination of patient-related, surgical, and rehabilitation-related factors rather than fracture characteristics alone. Advanced age was significantly associated with poor functional recovery in the present study. Patients with poor recovery had a significantly higher mean age (79.1 ± 7.4 years) than those with good recovery (70.2 ± 6.9 years, p<0.001). Increasing age is associated with sarcopenia, frailty, reduced physiological reserve, and slower rehabilitation. Similar observations were reported by **Araiza-Nava et al.**⁹, whose systematic review identified advanced age as one of the most consistent predictors of poorer short- and long-term functional outcomes following hip fracture surgery. Pre-fracture ambulatory status emerged as the strongest predictor of postoperative recovery in our study. Independent ambulation before injury was present in 87.1% of patients with good recovery compared with only 36.8% among those with poor recovery (p<0.001). Multivariable analysis also demonstrated that independent pre-fracture ambulation increased the likelihood of good recovery nearly seven-fold (AOR 6.84). These findings closely agree with **Magaziner et al.**¹⁰, who demonstrated that pre-fracture functional independence is one of the strongest determinants of postoperative mobility and activities of daily living after hip fracture. Cognitive impairment showed a significant negative influence on functional recovery. Nearly half (47.4%) of patients with poor recovery had cognitive impairment compared with 9.7% in the good recovery group. Cognitive dysfunction affects participation in rehabilitation, treatment adherence, and recovery of mobility. **Resnick et al.**¹¹ similarly concluded that patients with cognitive impairment experience poorer rehabilitation outcomes but can still benefit from structured multidisciplinary rehabilitation programmes. Diabetes mellitus and hypertension were significantly associated with poor functional recovery on univariate analysis. Diabetes impairs muscle strength, wound healing, and physical performance, while hypertension often reflects a higher burden of cardiovascular disease and frailty. However, after multivariable adjustment, diabetes did not remain an independent predictor, suggesting that its effect may be mediated through associated comorbidities and postoperative complications. Similar observations have been reported in previous cohort studies evaluating postoperative recovery after hip fracture. Early surgery was associated with significantly better postoperative outcomes in our study. Patients undergoing surgery within 48 hours had substantially better functional recovery than those with delayed surgery (p=0.002), and early surgery remained an independent predictor in logistic regression (AOR 4.27). Early fixation minimizes immobilization, decreases complications, and facilitates earlier mobilization. These findings are supported by **Liu et al.**¹², whose systematic review identified delay in surgery beyond 48 hours as an important predictor of poor functional recovery and increased mortality after hip fracture. Postoperative complications significantly reduced the likelihood of functional recovery. Complications were observed in 47.4% of patients with poor recovery compared with only 6.5% among those with good recovery, and remained an independent predictor on multivariable analysis. Complications such as surgical-site infection, pneumonia, urinary tract infection, and pressure ulcers prolong hospital stay and delay rehabilitation. Similar findings have been reported by **Lieberman et al.**¹³, who demonstrated that postoperative complications significantly impair functional independence during rehabilitation. Length of hospital stay was also significantly associated with poorer functional outcome. Patients hospitalized for more than seven days had significantly lower recovery rates than those discharged earlier (p<0.001). Prolonged hospitalization often reflects greater frailty, postoperative complications, and slower mobilization. Previous studies have similarly shown that extended hospital stay predicts reduced functional independence and delayed return to community living. Rehabilitation compliance was one of the strongest modifiable predictors identified in the present study. Patients adhering to prescribed rehabilitation achieved significantly better functional recovery, with an adjusted odds ratio of 5.76. Structured physiotherapy improves muscle strength, gait, balance, and confidence, thereby accelerating recovery. Recent systematic reviews have consistently demonstrated that intensive exercise-based and multidisciplinary rehabilitation programmes significantly improve functional outcomes after hip fracture surgery.¹⁴˒¹⁵ Overall, the findings of the present study indicate that advanced age, impaired pre-fracture mobility, cognitive impairment, delayed surgery, postoperative complications, and poor rehabilitation compliance are the major determinants of functional recovery after hip fracture surgery in elderly patients. Early surgical intervention, multidisciplinary geriatric care, optimization of medical comorbidities, prevention of postoperative complications, and structured rehabilitation should therefore be prioritized to maximize functional independence and quality of life following hip fracture surgery. These findings are in accordance with recent prediction-model research emphasizing individualized risk stratification and targeted postoperative rehabilitation.¹⁶

Hip fracture surgery in elderly patients is primarily aimed at restoring functional independence and improving quality of life. In the present prospective cohort study, 62% of patients achieved good functional recovery at six months following surgery, whereas 38% experienced poor functional recovery. Advanced age, cognitive impairment, delayed surgery, postoperative complications, and reduced pre-fracture mobility were significantly associated with poorer postoperative functional outcomes. Multivariable analysis identified independent pre-fracture ambulation, surgery within 48 hours, and good rehabilitation compliance as positive predictors of functional recovery, while cognitive impairment and postoperative complications were significant negative predictors. These findings highlight the importance of comprehensive geriatric assessment, early surgical intervention, multidisciplinary rehabilitation, and prevention of postoperative complications to optimize recovery. Early identification of high-risk patients enables individualized perioperative management and targeted rehabilitation strategies, ultimately improving mobility, independence, and quality of life among elderly patients undergoing hip fracture surgery.

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