Beyond the Operation: The Future of Orthopaedic Surgery, Fragility Fracture Care and Orthogeriatrics

Imagine an 84-year-old person arriving at hospital after a fall in 2035.

Within minutes, digital systems recognise the fracture, review previous imaging, identify frailty, flag delirium risk and retrieve the patient’s medications and previously expressed wishes. The orthopaedic surgeon, orthogeriatric clinician and anaesthetist agree a personalised plan before the patient leaves the emergency department.

Surgery provides a stable construct that permits early mobilisation. Rehabilitation begins the following day and continues at home through a combination of face-to-face therapy, remote monitoring and support for the family. Bone protection is started, falls risks are addressed and follow-up continues until treatment, mobility and recovery goals have been achieved.

This may sound futuristic. In reality, nearly every part of this pathway already exists somewhere.

The challenge is no longer inventing the components. The challenge is bringing them together reliably for every patient.

The next revolution in fracture care will not simply be a better implant.

It will be a better system.

Why Fragility Fracture Care Must Change

Fragility fractures are not minor injuries caused by unfortunate falls. They are often visible signs of underlying osteoporosis, frailty, sarcopenia, multimorbidity and declining physiological reserve.

More than 70,000 people sustain a hip fracture each year in England, Wales and Northern Ireland. The National Hip Fracture Database recorded 71,885 cases in 2024, compared with 67,673 in 2019. Hip fracture care occupies approximately one in every 30 hospital beds and costs the health service around £2 billion annually. Current projections suggest that the number of hip fractures could double by 2060. [1] (nhfd.co.uk)

Globally, the number of hip fractures is projected to almost double between 2018 and 2050 as populations live longer. [2] (International Osteoporosis Foundation)

This is not merely a problem of increasing numbers. The patients themselves are becoming more complex.

Many older fracture patients live with cognitive impairment, frailty, cardiovascular disease, renal dysfunction, polypharmacy, malnutrition or limited mobility. The fracture may be surgically treatable, but the patient’s outcome depends on far more than the technical quality of fixation.

That is precisely why orthogeriatrics has moved from being an optional consultation service to becoming a central part of modern fracture care.

What Is Orthogeriatrics?

Orthogeriatrics is the coordinated management of older people with fractures by orthopaedic, geriatric and multidisciplinary teams.

It is not simply a geriatrician reviewing a patient when a medical problem occurs. True orthogeriatric care begins early and continues throughout the pathway.

It brings together:

• orthopaedic surgery;
• geriatric and perioperative medicine;
• anaesthesia;
• specialist nursing;
• physiotherapy and occupational therapy;
• pharmacy;
• nutrition;
• falls assessment;
• osteoporosis treatment;
• discharge planning;
• primary and community care.

NICE recommends that hip fracture care should be delivered through a coordinated multidisciplinary Hip Fracture Programme, with early surgery, orthogeriatric assessment, delirium prevention and rehabilitation beginning no later than the day after surgery. [3] (NICE)

Research has associated structured orthogeriatric care with improvements in mortality, delirium, hospital length of stay, complications and elements of quality of life, although the exact benefits vary according to the model and how reliably it is implemented. [4,5] (OUP Academic)

The important question for the future is therefore not whether orthogeriatrics works.

It is whether healthcare systems can deliver it consistently, across the entire week, and beyond hip fracture alone.

1. The Focus Will Move From Repairing the Bone to Restoring the Person

Traditional orthopaedic thinking understandably concentrates on the fracture:

• What is the fracture pattern?
• Which implant should be used?
• When should surgery occur?
• Is the fixation satisfactory?

These remain essential questions. However, the older patient usually asks something different:

• Will I walk again?
• Will I return home?
• Will I remain independent?
• Will I become confused?
• Will I suffer another fracture?
• Will I recover a life that is meaningful to me?

The future of fragility fracture care will therefore measure more than mortality, complications and radiographic union.

Successful care will increasingly be judged by:

• recovery of mobility;
• return to the previous residence;
• independence in daily activities;
• freedom from delirium and pressure injury;
• quality of life;
• carer burden;
• avoidance of another fracture;
• achievement of the patient’s own goals.

A technically successful operation that leaves a patient immobile, delirious, medically unstable or without a rehabilitation plan cannot be regarded as a complete success.

2. Surgery Will Become More Personalised—but Also More Function-Focused

Surgical innovation will continue. Implant design, imaging, navigation, biomaterials and operative planning will improve.

However, the most valuable surgical advance for frail older adults may be a change in objective rather than a new device.

The future operation should aim to provide a construct sufficiently stable to support safe early mobilisation whenever clinically achievable.

For many older patients, prolonged restrictions on weight-bearing are difficult to understand and almost impossible to follow. They may lead to immobility, deconditioning, chest infection, pressure injury, thrombosis, loss of confidence and delayed discharge.

The 2025 National Hip Fracture Database report highlighted continued variation in whether patients were permitted to fully weight-bear after surgery. It recommended that surgical planning and supervision should support early mobilisation and recovery. [1] (nhfd.co.uk)

Future surgical decision-making will increasingly consider:

• pre-fracture mobility;
• cognition and ability to follow restrictions;
• bone quality;
• frailty;
• life expectancy;
• rehabilitation potential;
• patient priorities;
• the consequences of fixation failure;
• the consequences of immobility.

The technically most sophisticated operation is not automatically the best operation. The best procedure is the one that offers the patient the most realistic path towards comfort, mobility and meaningful recovery.

3. Frailty Will Become as Important as the Fracture Classification

Fracture classifications help surgeons understand anatomy, select implants and communicate clearly. But they do not fully describe the patient’s risk.

Two patients with an identical fracture can have completely different outcomes because their physiological reserve is different.

Future fragility fracture pathways will increasingly incorporate structured assessment of:

• frailty;
• cognition and delirium risk;
• multimorbidity;
• sarcopenia;
• nutritional status;
• renal and cardiac risk;
• medication burden;
• falls history;
• functional reserve;
• social support;
• realistic rehabilitation potential.

This does not mean using frailty to deny surgery.

It means using frailty to identify what the patient needs before, during and after surgery.

A patient at high risk of delirium may need a quieter environment, careful medication review, hydration, pain control and family involvement. A patient with malnutrition may require immediate nutritional intervention. A patient with severe frailty may need early discussions about realistic goals, escalation plans and the balance between operative and non-operative care.

The future will be personalised not because every patient receives something different, but because every patient receives what matters most to their recovery.

4. Artificial Intelligence Will Detect Fractures Before Clinicians Are Looking for Them

Some of the most important fragility fractures are already visible on imaging—but remain unrecognised.

Vertebral fractures may be present on chest X-rays or CT scans performed for cancer, abdominal pain or respiratory disease. They may never be formally reported, communicated or connected to an osteoporosis pathway.

Artificial intelligence could help change this.

AI systems are being developed to:

• identify vertebral fractures on routine imaging;
• recognise possible hip and pelvic fractures;
• estimate bone quality from existing scans;
• support fracture classification;
• predict complications, delirium or readmission;
• identify patients at high risk of future fracture;
• detect delays or failures within clinical pathways.

In October 2025, NICE published early value assessment guidance supporting the use of selected AI technologies as options—while further evidence is generated—to assist healthcare professionals in detecting vertebral fragility fractures on imaging undertaken for other reasons. [6] (NICE)

This represents an important change. Osteoporosis detection may gradually move from depending only on patients attending dedicated bone-health services to opportunistic case-finding from imaging that already exists.

However, AI must remain a clinical assistant, not an unaccountable decision-maker.

Algorithms require external validation, monitoring for bias and integration into pathways that guarantee human review. Detecting a fracture without ensuring assessment, communication and treatment would simply create a more sophisticated version of the same care gap.

The value of AI will not be measured by how many abnormalities it identifies. It will be measured by how many fractures it helps prevent.

5. Rehabilitation Will No Longer Stop at the Hospital Door

Surgery may take less than two hours. Recovery may take months.

Yet rehabilitation is often fragmented, delayed or reduced after discharge, precisely when the patient is trying to rebuild strength, balance and confidence.

The future model will connect hospital and home through:

• early mobilisation;
• daily goal-directed therapy;
• weekend rehabilitation;
• personalised exercise;
• community therapy;
• remote consultations;
• simple digital exercise programmes;
• wearable activity monitoring;
• support for carers;
• regular review of progress and barriers.

A 2025 meta-analysis of randomised trials found that telerehabilitation after hip fracture surgery may improve hip function, functional independence, treatment adherence and quality of life, although results were not equally strong for every outcome and the included interventions varied considerably. [7] (Springer)

Digital rehabilitation should therefore supplement—not automatically replace—skilled face-to-face assessment.

Technology may be especially valuable for patients who struggle to attend repeated appointments. However, services must avoid excluding people with cognitive impairment, sensory impairment, limited digital literacy or poor internet access.

The best future rehabilitation model will not be completely digital or completely hospital-based. It will be flexible, inclusive and continuous.

6. Preventing the Next Fracture Will Become Core Orthopaedic Practice

A fragility fracture is one of the strongest warnings that another fracture may occur.

The National Hip Fracture Database reports that approximately one-quarter of people who sustain a hip fracture will later experience another fragility fracture. Despite this, many patients still leave hospital without effective bone protection or a clearly coordinated prevention plan. [1] (nhfd.co.uk)

The National Osteoporosis Guideline Group recommends multidisciplinary, coordinator-based Fracture Liaison Services to identify people with fragility fractures, assess fracture and falls risk, investigate secondary causes and initiate appropriate pharmacological and non-pharmacological treatment. [8] (NOGG)

A 2024 systematic review and meta-analysis found moderate-certainty evidence that Fracture Liaison Service care was associated with a lower risk of secondary fragility fracture at follow-up of two years or longer. [9] (Springer)

The future fracture pathway should ensure that every eligible patient receives:

• osteoporosis risk assessment;
• appropriate blood investigations;
• vertebral fracture assessment where indicated;
• treatment according to fracture risk;
• calcium and vitamin D review where appropriate;
• falls and balance assessment;
• medication review;
• exercise and lifestyle advice;
• monitoring of treatment adherence;
• follow-up through a Fracture Liaison Service.

Orthopaedic care should not end when the wound heals.

A fracture episode should remain open until the system has addressed why the fracture occurred and what can be done to reduce the risk of another.

7. Orthogeriatrics Will Expand Beyond Hip Fracture

Hip fracture care has benefited enormously from national standards, registries, multidisciplinary pathways and regular audit.

However, an older person with a pelvic, proximal humeral, distal femoral, vertebral or periprosthetic fracture may have similar levels of frailty, pain, immobility and medical complexity without receiving the same coordinated care.

This is one of the most important inequalities within modern fracture services.

The National Hip Fracture Database has specifically highlighted differences in care according to fracture site and has begun expanding data collection to include pelvic fragility fractures. [1] (nhfd.co.uk)

Emerging research also supports extending orthogeriatric principles beyond the hip, because non-hip fragility fractures can be associated with substantial mortality, loss of function and failure to return home. (PMC)

The next stage of orthogeriatrics should therefore include:

• pelvic fragility fractures;
• distal femoral fractures;
• proximal humeral fractures;
• vertebral fractures;
• periprosthetic fractures;
• selected upper-limb fragility fractures;
• patients managed without surgery.

The patient should qualify for comprehensive care because of vulnerability and need—not merely because of the anatomical site of the fracture.

8. Data Will Become a Clinical Intervention

Registries such as the National Hip Fracture Database have shown that transparent measurement can transform practice.

The future will move beyond collecting retrospective data for annual reports. Clinical teams will use live information to identify pathway failures while the patient is still in hospital.

Future dashboards may alert teams when:

• a patient remains in the emergency department too long;
• surgery is delayed without a documented clinical reason;
• delirium screening has not been completed;
• mobilisation has not occurred;
• bone protection has not been considered;
• rehabilitation goals are missing;
• follow-up arrangements are incomplete.

However, data must not become a collection of targets disconnected from patient experience.

A service may achieve a timing target but still provide fragmented care. Another may record excellent mortality outcomes while patients struggle to regain mobility or return home.

The future of audit should therefore combine:

• clinical outcomes;
• process reliability;
• functional recovery;
• patient-reported outcomes;
• equity of access;
• long-term fracture prevention;
• patient and carer experience.

The best database is not the one with the most variables. It is the one that helps teams recognise problems and improve care.

9. The Human Conversation Will Remain Irreplaceable

Technology may predict risk. Surgery may restore stability. Rehabilitation may improve function.

But none of these can decide what outcome is acceptable to an individual patient.

Some patients will prioritise longevity. Others will prioritise comfort, avoiding institutional care or spending time with family. For patients with advanced frailty, terminal illness or very limited physiological reserve, operative treatment may not always provide the outcome that matters most to them.

Future orthogeriatric services must become better at:

• shared decision-making;
• assessing decision-making capacity;
• involving families and carers;
• understanding previously expressed wishes;
• discussing realistic outcomes;
• recognising when treatment is becoming burdensome;
• integrating palliative care where appropriate.

Orthogeriatrics should not be defined by doing more treatment.

It should be defined by providing the right treatment, to the right patient, for the right goal.

What Should the Ideal Fragility Fracture Service Look Like by 2035?

An excellent future service would provide:

1. Rapid transfer from the emergency department to an appropriate specialist ward.
2. Early joint orthopaedic, orthogeriatric and anaesthetic planning.
3. Surgery at the clinically appropriate time without avoidable delay.
4. A surgical strategy designed to support early mobilisation.
5. Daily assessment for delirium, pain, nutrition, hydration and medical complications.
6. Rehabilitation beginning by the day after surgery and available across the week.
7. Continuous rehabilitation between hospital, community and home.
8. Systematic osteoporosis and falls assessment after every fragility fracture.
9. Reliable Fracture Liaison Service follow-up.
10. Equal standards for hip and non-hip fragility fractures.
11. Live data used to identify and correct pathway failures.
12. Outcomes based on mobility, independence, quality of life and patient goals—not mortality alone.

The Future Is a Team, Not a Technology

Artificial intelligence, advanced implants and digital rehabilitation will all contribute to the future of fracture care.

But none of them will replace the need for coordinated human care.

The most powerful innovation may be a reliable pathway in which:

• the surgeon restores mechanical stability;
• the orthogeriatric clinician restores physiological stability;
• the multidisciplinary team restores function;
• the Fracture Liaison Service reduces the risk of another fracture;
• the patient defines what a successful recovery means.

Orthopaedic surgery saves the limb and stabilises the fracture.

Orthogeriatrics helps save the person behind the fracture.

The future belongs to services that understand they are inseparable.

Call to Action

If you work in fracture care, do not ask only whether your patients receive good surgery.

Ask whether they:

• reach the correct ward promptly;
• receive early multidisciplinary assessment;
• avoid preventable delirium and deconditioning;
• mobilise quickly;
• continue rehabilitation after discharge;
• receive effective bone protection;
• regain the best possible level of independence;
• experience the same standard of care regardless of fracture site.

If you or a family member has experienced a fragility fracture, ask the treating team:

Has bone health been assessed, has falls risk been addressed, and is there a clear rehabilitation and fracture-prevention plan?

A fragility fracture should never be treated as an isolated accident.

It is an opportunity to restore function, protect independence and prevent the next fracture.

Frequently Asked Questions

What is a fragility fracture?

A fragility fracture is a fracture that occurs following low-energy trauma, such as a fall from standing height or less. It may indicate reduced bone strength, osteoporosis or increased vulnerability to falls.

What does an orthogeriatric team do?

An orthogeriatric team combines orthopaedic and geriatric expertise. It manages the fracture while also addressing frailty, cognition, medical conditions, medications, nutrition, rehabilitation, falls risk and osteoporosis.

Will artificial intelligence replace orthopaedic surgeons or orthogeriatric clinicians?

No. AI may help detect fractures, identify risk and support clinical decisions. Diagnosis, treatment planning, communication, ethical judgement and shared decision-making must remain under appropriately trained healthcare professionals.

Can another fragility fracture be prevented?

Not every fracture can be prevented, but the risk may be reduced through osteoporosis assessment and treatment, falls prevention, strength and balance exercise, medication review, appropriate nutrition and coordinated follow-up through a Fracture Liaison Service.

Is orthogeriatric care only for hip fractures?

Hip fracture is currently the most established area of orthogeriatric practice. However, the same principles may benefit vulnerable older adults with pelvic, vertebral, distal femoral, proximal humeral, periprosthetic and other fragility fractures.

References

1. Royal College of Physicians, National Hip Fracture Database. Room for Improvement: Hip Fracture Care in 2024—The 2025 NHFD Annual Report. (nhfd.co.uk)
2. International Osteoporosis Foundation. Global projections and epidemiology of osteoporosis and fragility fractures. (International Osteoporosis Foundation)
3. National Institute for Health and Care Excellence. Hip Fracture: Management. NICE Clinical Guideline CG124, updated January 2023. (NICE)
4. Van Heghe A, Mordant G, Dupont J, et al. Effects of orthogeriatric care models on outcomes of hip fracture patients: a systematic review and meta-analysis. Calcified Tissue International. 2022;110:162–184.
5. Vleeshouwers K, et al. The effects of in-hospital orthogeriatric care on health-related quality of life in hip fracture patients: a systematic review and meta-analysis. Age and Ageing. 2025;54(4):afaf106. (OUP Academic)
6. National Institute for Health and Care Excellence. Artificial Intelligence Technologies to Aid Opportunistic Detection of Vertebral Fragility Fractures. NICE HealthTech Guidance HTG760, October 2025. (NICE)
7. Xiao H, Zeng W, Lu L, et al. Effectiveness of telerehabilitation in postoperative outcomes in patients following hip fracture surgery: a meta-analysis of randomised controlled trials. BMC Sports Science, Medicine and Rehabilitation. 2025;17:130. doi:10.1186/s13102-025-01169-4. (Springer)
8. National Osteoporosis Guideline Group. Clinical Guideline for the Prevention and Treatment of Osteoporosis. Updated December 2024. (NOGG)
9. Danazumi MS, Lightbody N, Dermody G. Effectiveness of fracture liaison services in reducing the risk of secondary fragility fractures in adults aged 50 and older: a systematic review and meta-analysis. Osteoporosis International. 2024. doi:10.1007/s00198-024-07052-1. (Springer)
10. Fragility Fracture Network. A Global Call to Action to Improve the Care of People with Fragility Fractures. (fragilityfracturenetwork.org)
11. National Institute for Health and Care Excellence. Falls: Assessment and Prevention in Older People and in People Aged 50 and Over at Higher Risk. NICE Guideline NG249, April 2025. (NICE)
12. International Osteoporosis Foundation. Capture the Fracture: Best Practice Framework and coordinated models of secondary fracture prevention. (International Osteoporosis Foundation)

Medical Disclaimer

This article is intended for general education and professional discussion. It does not replace an individual medical assessment, diagnosis or treatment plan. Decisions regarding fracture management, surgery, osteoporosis treatment and rehabilitation should be made with appropriately qualified healthcare professionals.