Perioperative Care Guided by Enhanced Recovery after Surgery in Older Adults with Intertrochanteric Femoral Fractures: A Prospective Comparative Study

Summary

This article describes the implementation of an enhanced recovery after surgery guided perioperative care pathway for older adults with intertrochanteric femoral fractures, outlining a structured multidisciplinary workflow designed to optimize perioperative management and support early functional recovery in routine clinical practice.

Abstract

Older adults with intertrochanteric femoral fractures represent a high–risk population in whom perioperative management remains challenging, often leading to delayed recovery and increased complication burden. Enhanced recovery after surgery (ERAS) offers a structured, multidisciplinary approach to optimize perioperative care; however, application of this approach in geriatric orthopedic trauma requires further clarification. This study evaluates a standardized ERAS–guided perioperative care pathway designed to improve clinical efficiency and early functional recovery in routine practice. Using institutional clinical data, 80 patients aged 70 years or older undergoing intramedullary fixation were analyzed under two perioperative care models: a conventional pathway and an ERAS–guided pathway. The pathway incorporated accelerated diagnostic assessment, targeted preoperative optimization, goal–directed anesthesia and fluid management, multimodal analgesia, early oral nutrition, and structured early mobilization. Perioperative efficiency, physiological stability, pain trajectories, functional recovery, and postoperative complications were systematically assessed. Implementation of the ERAS pathway was associated with a shorter admission–to–anesthesia interval (26.3 ± 9.1 vs. 47.8 ± 11.9 h, p < 0.001), reduced hemoglobin decline (16.1 ± 4.9 vs. 21.1 ± 6.1 g/L, p < 0.001), lower postoperative pain scores at 24 h (3.8 ± 0.9 vs. 4.6 ± 1.0, p < 0.001), and a reduced overall complication rate (10.0% vs. 32.5%, p = 0.014). In conclusion, a structured ERAS–guided perioperative pathway is feasible and clinically applicable in older adults with intertrochanteric femoral fractures, providing a reproducible framework that supports optimized perioperative management and facilitates early recovery in routine clinical practice.

Introduction

Intertrochanteric femoral fractures are common fragility injuries in older adults and represent a major challenge for orthopedic trauma systems because these injuries are frequently associated with frailty, multimorbidity, functional decline, and substantial perioperative risk^1,2. Although modern fixation strategies have improved fracture stabilization, older patients remain vulnerable to delayed recovery because surgical success depends not only on implant selection but also on timely perioperative optimization, blood conservation, pain control, prevention of complications, and early mobilization³. Intramedullary fixation is widely used for these fractures because this technique provides mechanical stability and supports early rehabilitation, and multiple studies have evaluated reduction techniques, nail design, screw configuration, and fixation–related complications in this population^4,5,6. However, even with technically successful fixation, perioperative hidden blood loss, delayed functional recovery, and variability in postoperative rehabilitation remain important barriers to early recovery^7,8.

The clinical complexity of intertrochanteric fractures in older adults makes this population particularly suitable for a structured enhanced recovery after surgery (ERAS)–guided pathway. Unlike elective orthopedic patients, these patients usually require urgent surgical coordination after an acute fracture event, often in the setting of acute pain, anemia, dehydration, limited cardiopulmonary reserve, and reduced tolerance to prolonged immobilization. Previous studies comparing different intramedullary devices and arthroplasty–based strategies have shown that implant selection and operative technique influence radiographic and clinical outcomes, but these factors alone do not fully address perioperative vulnerability or early functional recovery^9,10,11. Survival and recovery in very old patients are also affected by baseline physiological reserve and perioperative management, highlighting the importance of a coordinated pathway beyond the surgical procedure itself¹². Adjunctive strategies such as cerclage fixation, hydroxyapatite augmentation, or arthroplasty conversion may be relevant for selected fracture patterns or failed fixation, but such strategies do not replace the need for standardized perioperative care in routine geriatric fracture management^13,14,15,16.

A specific unresolved problem in this population is whether a complete and reproducible perioperative workflow can be implemented for urgent geriatric orthopedic trauma without delaying surgery or compromising safety. Conventional care for older adults with intertrochanteric fractures may involve fragmented preoperative evaluation, variable fasting and analgesic practices, non–standardized physiological optimization, inconsistent temperature and fluid management, delayed oral intake, and delayed mobilization. These workflow–level issues are clinically important because complex fracture patterns, lateral wall instability, rotational changes after fixation, contralateral refracture risk, and hidden blood loss can all complicate recovery and discharge planning^17,18,19,20. In addition, comparative evidence regarding fixation choices and biomechanical stability has expanded substantially, but less attention has been given to whether a standardized perioperative pathway can improve early recovery outcomes after intramedullary fixation in real–world older patients^21,22,23.

Therefore, the present study describes and evaluates a standardized ERAS–guided perioperative care pathway for older adults with intertrochanteric femoral fractures undergoing intramedullary fixation. The primary outcome was postoperative length of stay, selected as an indicator of integrated early recovery, including physiological stabilization, pain control, mobilization readiness, wound stability, oral intake, and discharge preparedness. Secondary outcomes included admission–to–anesthesia time, intraoperative blood loss, postoperative hemoglobin decline, pain scores, opioid consumption, early mobilization milestones, ambulation distance, postoperative complications, and adherence to core ERAS pathway components. Implementation of a structured ERAS–guided pathway was hypothesized to be associated with shorter postoperative hospitalization and improved early recovery without increasing perioperative safety risk.

Protocol

Ethical approval

All procedures involving human participants were conducted in accordance with the ethical standards of the institutional research committee and adhered to the Declaration of Helsinki. Ethical approval was obtained from the institutional review board of the 960th Hospital of the PLA Joint Logistic Support Force (Approval ID: 2023–110). Written informed consent was obtained from all participants or from legally authorized representatives prior to inclusion.

Study design

This study was conducted at a tertiary academic orthopedic trauma center capable of managing complex geriatric fractures. During the period from May 2023 to May 2024, all older adults presenting with suspected intertrochanteric femoral fractures were systematically evaluated through a unified workflow. Eligible patients were enrolled consecutively and managed according to one of two perioperative care pathways: the established conventional clinical pathway or the ERAS pathway, newly implemented in the department during this period. Both pathways used identical operative techniques and internal fixation methods, enabling a valid comparison of perioperative processes. Data collection was standardized and performed prospectively within the patient’s electronic medical record during clinical care; no retrospective chart reconstruction occurred. All surgical procedures in both pathways were performed by a fixed team of three senior orthopedic trauma surgeons, each with more than 200 independent intramedullary fixation procedures for intertrochanteric femoral fractures completed prior to the study period. No new surgeons, fellows, or trainees acted as primary operators during the study. The same operative team structure was maintained throughout May 2023 to May 2024, ensuring technical homogeneity and eliminating variability introduced by surgeon experience or personnel changes. Standardized operative indications, reduction principles, and fixation techniques were uniformly applied across all cases.

Clarification of group assignment and minimization of selection bias

Because this was not a randomized trial, group assignment was clarified as a predefined time–based departmental workflow allocation. Patients were not individually assigned to the conventional or ERAS pathway according to surgeon preference, patient preference, family preference, bed availability, or baseline clinical condition. Instead, the care pathway was determined by whether the patient was admitted before or after formal departmental activation of the ERAS pathway. This design minimized discretionary selection by clinicians but could not completely eliminate potential secular effects related to time. To reduce this risk, the study was conducted within a single institution over a limited 1–year period, with the same senior operative team, identical fixation strategy, unified perioperative staffing, consistent postoperative monitoring, and standardized prospective data collection. Baseline characteristics were compared between groups, and multivariable regression analyses were performed to further account for measured confounding. Because workflow–based allocation was not random, residual confounding could not be completely excluded. In particular, admission timing, weekday versus weekend admission, time from injury to admission, fracture severity, perioperative staffing conditions, and temporal changes in departmental practice may have influenced early recovery outcomes. These factors were therefore considered during bias assessment. Where available, time from injury to admission, fracture severity, age, sex, American Society of Anesthesiologists class, Charlson Comorbidity Index, baseline hemoglobin, and pre–injury mobility were included in adjusted analyses. However, unmeasured temporal and workflow–related confounders may remain and were acknowledged as limitations of the study.

Patient screening, enrollment, and eligibility

Upon arrival, all patients underwent immediate triage and clinical evaluation by orthopedic attending physicians. Screening involved clinical history, physical examination, standard radiography, and laboratory assessment. Eligible patients were aged 70 years or older at admission, had an intertrochanteric femoral fracture confirmed by standard anteroposterior and lateral hip radiographs, and underwent additional computed tomography when clarification of fracture morphology or lateral wall integrity was required. Eligibility also required suitability for operative treatment using a standardized intramedullary fixation approach, sufficient cognitive capacity to understand perioperative instructions and participate in rehabilitation, completion of eligibility confirmation before enrollment, and admission and management entirely within the defined study period. Patients were excluded in the presence of additional fractures involving major anatomical locations, including the pelvis, vertebrae, or contralateral hip, or severe polytrauma; pathological fractures secondary to tumors, metastasis, metabolic bone disease, or other nontraumatic causes; severe organ dysfunction, including decompensated heart failure classified as New York Heart Association class III–IV, advanced hepatic insufficiency, end-stage renal disease requiring dialysis, or severe chronic obstructive pulmonary disease requiring home oxygen; uncontrolled coagulopathy, hematologic disorders, systemic inflammatory disease, or severe immunosuppression; active psychiatric or neurocognitive disorders preventing reliable cooperation with perioperative care; refusal of operative management; or incomplete clinical records for key perioperative variables. A dual–pathway clinical management model was used during the study period. Patients were managed either under the conventional care pathway (pre–existing standard practice) or the newly implemented ERAS pathway.

Conventional care pathway

The conventional pathway reflected long–established local practice for managing intertrochanteric fractures and was characterized by non–standardized processes across the preoperative, intraoperative, and postoperative phases. In the preoperative phase, patients were admitted through routine triage and underwent laboratory testing, coagulation profiling, chest radiography, electrocardiography, and anesthesiology evaluation without predefined time targets. Fasting from solids and liquids began at midnight before surgery, and preoperative optimization was performed at the discretion of the treating clinician due to the absence of standardized readiness criteria. Pain control relied mainly on intermittent intravenous or intramuscular analgesics administered only when patients verbally reported moderate or severe pain. During the intraoperative phase, the anesthesiologist selected either regional or general anesthesia according to clinical judgment. Fluid management was based on conventional hemodynamic monitoring without the use of goal–directed strategies. Standard intramedullary fixation was performed, and temperature control measures were applied inconsistently. In the postoperative phase, oral intake was delayed until bowel motility returned, typically 24–48 h after surgery, and mobilization was postponed until pain became tolerable and the wound was deemed stable. Rehabilitation lacked structured progression criteria, and catheter or drainage removal followed routine local practice without standardized timelines. Complication monitoring was reactive rather than protocol–driven.

ERAS clinical pathway

The core elements of the ERAS pathway were adapted from published ERAS recommendations for orthopedic surgery and evidence–based hip–fracture care guidelines, including preoperative education, abbreviated fasting, multimodal opioid–sparing analgesia, goal–directed fluid management, early oral intake, thromboprophylaxis, device minimization, and early mobilization^21,22.

ERAS preoperative phase

In the ERAS pathway, patients underwent a streamlined and accelerated preoperative process beginning with a “green–channel” diagnostic workflow, in which radiographs, CT when indicated, full blood panels, coagulation tests, chest imaging, and electrocardiography were completed within 4 h of hospital arrival. Within the first 24 h, an interdisciplinary team comprising orthopedic surgeons, anesthesiologists, and internal medicine specialists reviewed comorbidities and finalized an individualized surgical plan. A dedicated ERAS nurse subsequently provided a structured 30–45 min education session within 24–72 h, addressing fracture characteristics, surgical goals, the importance of early mobilization, anticipated pain, and the multimodal analgesia strategy, breathing and limb–activation exercises, postoperative expectations, and psychological reassurance, supported by illustrated diagrams and simplified exercise guides, with family members participating and confirming completion of training. Preoperative physiological optimization was conducted by an internal medicine consultant who systematically evaluated and stabilized cardiovascular, respiratory, renal, and metabolic function, including blood pressure, glucose, and electrolyte control, smoking cessation counseling, incentive–spirometry–based pulmonary conditioning, anemia correction for hemoglobin <110 g/L, venous thromboembolism risk assessment, and nutritional screening to identify frailty. Nutritional preparation followed ERAS principles: normal meals were allowed until 6–12 h before surgery, clear fluids until 2 h before anesthesia, and prolonged fasting was avoided except when medically necessary; frail patients received high–protein oral supplements to reduce catabolic stress and postoperative insulin resistance^21,22.

ERAS intraoperative phase

During the intraoperative phase of the ERAS pathway, anesthesia was delivered according to standardized, goal–directed principles that prioritized regional anesthesia to reduce postoperative delirium risk, with carefully titrated sedation to prevent oversedation and active warming to maintain normothermia between 36–37 °C. Regional nerve blocks were incorporated whenever appropriate to support opioid–sparing analgesia. Fluid management followed a goal–directed strategy using dynamic hemodynamic monitoring, including stroke volume variation, mean arterial pressure, and urine output targets (≥ 0.5 mL/kg/h), ensuring avoidance of over–resuscitation and the consistent use of balanced crystalloid solutions^21,23. Surgical management relied on a minimally invasive, standardized intramedullary fixation technique characterized by small skin incisions, blunt soft–tissue dissection, fluoroscopy–guided fracture reduction, and precise nail insertion to protect the lateral femoral wall. Hemostasis was systematically secured before closure, and wound drains were avoided whenever feasible. Operative time and intraoperative blood loss were documented in real time to ensure procedural consistency and quality control.

ERAS postoperative phase

Postoperatively, multimodal analgesia formed the foundation of pain control. Unless contraindicated, patients received scheduled non–opioid baseline analgesia with acetaminophen 500 mg every 6–8 h and a cyclooxygenase–2 inhibitor according to renal function, gastrointestinal risk, and cardiovascular risk. Regional analgesia, including ultrasound–guided fascia iliaca compartment block or femoral nerve block with ropivacaine, was used when coagulation status and clinical condition allowed. Rescue opioid analgesia was administered only when the numeric rating scale (NRS) score remained ≥4 despite baseline therapy, using short–acting opioids titrated to clinical response. Excessive sedation and long–acting opioids were avoided to reduce delirium, respiratory depression, constipation, and fall risk. Pain assessments were performed at 12, 24, and 48 h, and opioid exposure was converted to morphine–equivalent dose for analysis. Mobilization began within hours of anesthesia recovery following a structured progression: on postoperative day 0, patients performed ankle pumps, quadriceps contractions, gluteal isometrics, and sat at the bedside; on day 1, patients stood with assistance and initiated walker–assisted ambulation; by days 2–3, patients advanced to longer walking distances and stair training when appropriate, with weight–bearing individualized according to fracture stability and physiotherapists documenting functional milestones daily. Early oral nutrition was introduced within 6 h after surgery, starting with clear liquids and advancing to soft and regular diets as tolerated, allowing for tapering of intravenous fluids once adequate oral intake was established. Pulmonary optimization included incentive spirometry every 2 h, assisted coughing, and upright positioning for at least 2 h per day. Thromboprophylaxis followed ERAS best practices, with pharmacologic agents initiated within 12 h unless contraindicated, continuous use of mechanical compression devices until independent ambulation, and daily limb assessments. Device management emphasized early removal, with urinary catheters withdrawn within 24–48 h and surgical drains avoided whenever possible. Discharge readiness was confirmed when patients exhibited stable vital signs, adequate oral intake, controlled pain managed with oral medications, independent ambulation using assistive devices, a clean and dry surgical wound, and completion of discharge education for both the patient and family^21,22,24.

To ensure reproducibility and strict adherence to ERAS principles, the pathway incorporated a standardized set of mandatory elements. An accelerated diagnostic workflow, referred to as the “green–channel”, was used to complete essential imaging and laboratory examinations within 4 h of admission, followed by interdisciplinary evaluation by the orthopedic, anesthesiology, and internal medicine teams within 24 h. A certified ERAS nurse delivered a structured 30–45-minute education session that included psychological counseling and mobility training. Comprehensive preoperative optimization included anemia correction, pulmonary conditioning, glycemic regulation, electrolyte stabilization, and frailty and nutritional screening. An abbreviated fasting regimen permitted clear fluids until 2 h before anesthesia induction. Regional anesthesia was prioritized and supplemented by nerve blocks to minimize opioid exposure, while goal–directed fluid management based on dynamic hemodynamic indices was used to maintain euvolemia. A standardized minimally invasive intramedullary fixation technique was applied, with particular attention to fracture reduction quality and preservation of the lateral femoral wall. The multimodal analgesia protocol incorporated scheduled pain assessments at 12, 24, and 48 h postoperatively. Early oral nutrition was initiated within 6 h after recovery from anesthesia, and structured mobilization began with bedside sitting on postoperative day 0. Early device removal included urinary catheter withdrawal within 24–48 h whenever feasible. Physiotherapy milestones were documented daily using standardized rehabilitation progress forms. Uniform application of these elements ensured delivery of an identical, protocolized intervention to all patients in the ERAS group.

Outcome measures

Outcome measures were evaluated systematically throughout hospitalization using predefined, standardized criteria to ensure reproducibility and minimize interobserver variability^11,25,26. All assessments were contemporaneously documented in the electronic medical record by trained clinical staff. The evaluated domains encompassed perioperative efficiency, postoperative physiological recovery, pain trajectories, hematologic stability, functional mobility, and surveillance for postoperative complications. Perioperative efficiency was assessed using three core indicators. The time from hospital admission to the initiation of anesthesia was automatically recorded in the hospital information system and used to reflect the efficiency of the diagnostic and preoperative optimization process. Operative duration was defined as the interval between skin incision and wound closure and was documented electronically in the operating room. Intraoperative blood loss was estimated by combining suction canister volume, after subtraction of irrigation fluid, with gravimetric assessment of surgical sponges using calibrated digital scales. Final values were recorded as the average of measurements independently reported by both the scrub nurse and the circulating nurse. Postoperative physiological recovery was monitored through serial hemoglobin measurements obtained within 6 h preoperatively and repeated 24–36 h after surgery using standardized automated hematology analyzers, allowing calculation of absolute hemoglobin decline as a marker of hemodynamic stability and perioperative blood conservation. Pain intensity was assessed using the 0–10 Numerical Rating Scale at fixed time points of 12, 24, and 48 h after recovery from anesthesia. Assessments were performed by trained nursing staff, and annual competency evaluations were conducted to ensure consistency. Length of postoperative hospital stay was defined as the number of days from surgery to discharge, with discharge determined by a multidisciplinary panel in accordance with standardized milestones for mobility, pain control, wound stability, and readiness for rehabilitation. Functional mobility outcomes were tracked using a structured physiotherapy log, recording time to first sitting, first assisted standing, and first ambulation with a walker, as well as measured ambulation distances during postoperative days 1–3 using a calibrated ward walkway to ensure precise and objective quantification. At discharge, patients were categorized into standardized levels of ambulation based on physiotherapist evaluation. These categories included independent ambulation with a walker, supervised ambulation, and assisted ambulation requiring full support. This classification enabled consistent comparison of functional outcomes across patients. Postoperative complications were monitored continuously in accordance with an institution–wide adverse event protocol. Cardiopulmonary events were defined as pneumonia, atelectasis, acute heart failure, arrhythmia, or pulmonary embolism. All diagnoses were made according to established guideline–based criteria and were confirmed by cardiology or pulmonology specialists. Venous thromboembolism was assessed using duplex ultrasonography performed upon clinical suspicion or in high–risk individuals. Delirium was screened daily using the confusion assessment method by trained nursing staff, with documentation of cognitive fluctuations and behavioral abnormalities. Wound complications, including infection, hematoma, and delayed healing, were evaluated daily by the orthopedic team, with additional imaging or laboratory testing obtained when indicated. Urinary retention was defined as failure to void after catheter removal requiring reinsertion, whereas gastrointestinal disturbances such as constipation or ileus were diagnosed based on absent bowel movements, intolerance to oral intake, or radiographic findings. All complications were graded using the Clavien–Dindo classification to ensure standardized severity reporting across the cohort. All outcomes in the present study were assessed during the index hospitalization. No systematic post–discharge follow–up was performed for medium–term complications, readmission, institutionalization, functional recovery, quality of life, or mortality after discharge. Therefore, the outcome assessment was limited to early in–hospital perioperative recovery.

Blinding and bias reduction in outcome assessment

Because of the nature of the perioperative care intervention, patients, surgeons, anesthesiologists, nurses, and physiotherapists could not be blinded to pathway allocation. This limitation was particularly relevant for subjective outcomes such as pain scores and functional mobility assessment. To reduce observer bias, pain was assessed using the standardized 0–10 Numerical Rating Scale at fixed postoperative time points by trained nursing staff, and functional milestones were recorded using predefined operational criteria rather than subjective global judgment. First sitting, first assisted standing, first walker–assisted ambulation, and ambulation distance were documented in structured physiotherapy logs, and walking distance was measured using a calibrated ward walkway. Objective outcomes, including admission–to–anesthesia time, operative duration, hemoglobin values, opioid consumption, length of stay, and mortality, were extracted from electronic medical records. Complications were defined using prespecified clinical criteria and verified through source–document review. Nevertheless, the lack of blinding may have introduced observer bias, and this was considered when interpreting subjective recovery outcomes.

Quality control and interobserver reliability

A multidimensional quality–control framework was implemented to ensure methodological rigor, procedural consistency, and reproducibility. All orthopedic surgeons performing intramedullary fixation had each completed more than 200 prior procedures, ensuring uniform technical proficiency across cases. ERAS nursing staff received structured training that encompassed psychological counseling, delivery of standardized patient education, and postoperative monitoring requirements. Physiotherapists adhered to unified rehabilitation protocols and documented patient progress using standardized daily assessment forms; protocol adherence was reviewed weekly by the rehabilitation supervisor. Data collection reliability was maintained through dual extraction of all variables by two independent researchers, with discrepancies resolved by re-examining original source documents; interobserver agreement for categorical outcomes exceeded 95%. To further ensure fidelity to the ERAS pathway, pathway adherence was assessed using the 13 predefined mandatory ERAS elements. Each element was recorded as completed, not completed, or not applicable because of a documented clinical contraindication. For each patient, the overall adherence rate was calculated as the number of completed applicable ERAS elements divided by the total number of applicable elements. High adherence was defined as completion of ≥90% of applicable elements, moderate adherence as 80–89%, and major protocol deviation as completion of <80% of applicable elements or omission of a safety–critical component without documented justification. Safety–critical components included perioperative risk assessment, venous thromboembolism prophylaxis, scheduled pain assessment, early mobilization assessment, and postoperative monitoring for complications. A monthly audit was conducted by a joint orthopedic–anesthesiology oversight committee to review adherence rates, identify deviations, document reasons for non–compliance, and provide feedback to clinical staff.

Statistical analysis

A priori sample size estimation was performed based on the primary perioperative outcome of postoperative length of stay. Historical institutional data suggested that ERAS implementation was associated with a reduction in postoperative hospitalization of approximately 1.5 days, with an estimated standard deviation of 2.0 days. Using a two–sided independent–samples t–test with an α level of 0.05 and statistical power (1 − β) of 0.80, the minimum required sample size was calculated to be 34 participants per group. The final cohort of 80 patients (40 per pathway) exceeded this requirement, providing adequate power to detect clinically meaningful differences across all primary and secondary outcomes²⁷.

Statistical analyses were conducted according to a prespecified analytical plan to compare all outcome domains between the ERAS and conventional care groups. All analyses were performed using validated statistical software. Data preprocessing included evaluation of distributional normality for all continuous variables using the Shapiro–Wilk test, along with outlier screening through boxplot inspection to identify potential entry errors or exceptional clinical scenarios. Missing data were infrequent owing to real–time electronic documentation; when present, complete–case analysis was applied to avoid the introduction of bias through imputation. Continuous variables were summarized as mean ± standard deviation when normally distributed, and between–group differences were examined using independent–samples t–tests. For variables deviating from normality, nonparametric Mann–Whitney U testing was used. Categorical variables were presented as frequencies and percentages, with between–group comparisons conducted using chi–square tests or Fisher’s exact test when expected cell counts were small. All tests were two–tailed, and a p value < 0.05 was interpreted as statistically significant. The outcome hierarchy was prespecified. Postoperative length of stay was the primary outcome. Secondary outcomes included admission–to–anesthesia time, intraoperative blood loss, postoperative hemoglobin decline, pain scores, opioid consumption, mobilization milestones, ambulation distance, postoperative complications, and ERAS adherence. Because multiple secondary outcomes were evaluated in this implementation–focused study, no formal multiplicity adjustment was applied to secondary endpoints. Therefore, secondary outcome findings were interpreted as exploratory and supportive, with emphasis placed on effect sizes, direction of estimates, and consistency across related recovery domains rather than isolated p values. Confidence intervals (CIs) were calculated at the 95% level where applicable to provide estimates of effect precision. To reduce overfitting in this modest cohort, adjusted analyses were restricted to the primary outcome and selected continuous secondary outcomes and were interpreted as exploratory sensitivity analyses. Adjusted linear regression models used a parsimonious covariate set selected a priori, including age, American Society of Anesthesiologists class, baseline hemoglobin, and fracture severity. Because the number of in–hospital complication events was limited, no full multivariable logistic regression model was fitted for overall complications.

Results

Results are presented according to the prespecified outcome hierarchy. The primary outcome was postoperative length of stay. Secondary outcomes are reported as exploratory outcomes and include perioperative workflow indicators, hematologic indicators, pain scores, opioid consumption, functional recovery measures, complications, and pathway adherence. Because multiple secondary endpoints were evaluated, these findings should be interpreted with attention to effect sizes and consistency across related domains rather than isolated p values.

Baseline clinical, functional, and fracture characteristics of the study cohort

A total of 80 older adults with intertrochanteric femoral fractures were enrolled, with 40 patients in the ERAS pathway and 40 receiving conventional care (Figure 1). As summarized in Table 1, no significant between–group differences were observed in demographic characteristics, comorbidity burden, nutritional and cognitive status, fracture morphology, or pre–injury mobility (all p > 0.05). These findings indicate that the two groups were broadly comparable at baseline, supporting the interpretability of subsequent comparisons of perioperative and early recovery outcomes.

Accelerated perioperative workflow and improved physiologic stability under ERAS management

As shown in Figure 2 and Table 2, the ERAS group had shorter perioperative time intervals than the conventional care group. As shown in Figure 2, patients managed under ERAS had shorter intervals from admission to anesthesia induction, started oral fluids and diet earlier, and reached key mobilization milestones earlier (first sitting, standing, and ambulation) than those receiving conventional care. The admission–to–anesthesia interval was shorter in the ERAS group than in the conventional care group (Table 2). The time from admission to anesthesia was nearly halved among ERAS patients compared with those in the conventional pathway (26.3 ± 9.1 h vs. 47.8 ± 11.9 h, p < 0.001), with a mean between–group difference of −21.5 h. Intraoperative characteristics differed significantly as well: ERAS patients demonstrated lower intraoperative blood loss, superior temperature maintenance, and reduced crystalloid infusion, while operative duration remained comparable between groups. Postoperative hemoglobin decline, expressed as change in hemoglobin (ΔHb), was significantly attenuated under ERAS management (16.1 ± 4.9 g/L vs. 21.1 ± 6.1 g/L, p < 0.001). Figure 3A further visualizes the association between intraoperative blood loss and hemoglobin drop, where the ERAS group exhibits a flatter regression slope. Figure 3B corroborates these patterns, showing significantly lower ΔHb values in the ERAS cohort. Consistent with these physiologic advantages, postoperative hospitalization duration was significantly shorter in the ERAS group.

Exploratory adjusted and effect–size analyses

Exploratory adjusted analyses were performed for the primary outcome and selected continuous secondary outcomes using a parsimonious covariate set. After adjustment for age, American Society of Anesthesiologists (ASA) class, baseline hemoglobin, and fracture severity, ERAS pathway allocation remained associated with shorter postoperative length of stay. For postoperative hemoglobin decline and 24 h NRS pain score, the direction of association was consistent with the unadjusted comparisons. Because the number of in–hospital complication events was limited, multivariable logistic regression was not performed for overall complications. Overall complications occurred in 4 of 40 patients in the ERAS group and 13 of 40 patients in the conventional care group, corresponding to an absolute risk difference of −22.5 percentage points and an unadjusted odds ratio of 0.23 (95% CI, 0.07–0.79; p = 0.014).

Attenuated postoperative pain trajectories and reduced opioid requirements

Although preoperative pain intensity was similar between groups, postoperative trajectories diverged markedly (Table 3). At 12, 24, and 48 h after surgery, patients in the ERAS group reported significantly lower NRS pain scores (all p < 0.001). As illustrated in Figure 4A, ERAS patients demonstrated a more rapid and pronounced decline in NRS pain scores at 12, 24, and 48 h postoperatively (all p < 0.001). Correspondingly, Figure 4B shows significantly lower morphine–equivalent opioid consumption on postoperative days 1 and 2 in the ERAS cohort, consistent with an opioid–sparing pattern under the ERAS pathway.

Postoperative safety profile and complication burden

The incidence of individual postoperative complications, including pulmonary infection, venous thromboembolism, urinary retention, wound complications, delirium, and cardiac events, did not differ significantly between groups (all p > 0.05). However, the overall complication rate was lower in the ERAS cohort (10.0% vs. 32.5%, p = 0.014; Table 4). Complication severity was further summarized according to the Clavien–Dindo classification. Most complications were mild to moderate and managed conservatively or pharmacologically. In the ERAS group, all recorded complications were classified as grade I–II, with no grade III–V events. In the conventional care group, most complications were grade I–II, while one in–hospital death was classified as grade V. No grade III–IV complications requiring surgical, endoscopic, radiologic, or intensive care intervention were recorded. Because of the small number of events, Clavien–Dindo severity categories were reported descriptively. In–hospital mortality was rare and comparable between groups, and no deaths occurred in the ERAS group. These findings support the feasibility and short–term safety of the ERAS pathway, showing accelerated early recovery without an observable increase in perioperative risk in this cohort.

Enhanced early functional recovery and mobility performance

Functional recovery indicators differed between groups, as shown in Table 5. Time to independent walker use was significantly shorter (4.6 ± 1.2 vs. 7.1 ± 1.8 days, p < 0.001), and ambulation distances on postoperative days 1–3 were consistently greater in the ERAS group (all p < 0.001). As shown in Figure 5A, walking distances recorded during postoperative days 1–3 were consistently greater among ERAS patients. Additionally, the time to independent walker use was significantly shorter, and a higher proportion of ERAS patients achieved independent mobility before discharge (Figure 5B; Table 5). Together, Table 5 and Figure 5 summarize early in–hospital functional recovery outcomes, showing that ERAS management was associated with earlier walker use, greater early ambulation distance, and higher independence before discharge.

Fidelity to ERAS protocol components across the perioperative continuum

Quantitative adherence to predefined pathway components is presented in Table 6 and Figure 6. In the ERAS group, adherence rates were high across core elements, including preoperative education, early oral intake, postoperative day 0 mobilization, multimodal analgesia, temperature maintenance, and venous thromboembolism prophylaxis. The overall ERAS adherence rate was calculated from the 13 predefined mandatory elements, and protocol deviations were reviewed during monthly audits. In the conventional care group, completion rates for ERAS–specific components were lower, as expected because these elements were not embedded as mandatory workflow requirements in routine care. These adherence data are reported to document implementation fidelity and protocol delivery. These adherence data should not be interpreted as evidence that adherence alone caused the observed clinical outcome differences.

In summary, the ERAS group had a shorter primary outcome of postoperative length of stay and showed shorter admission–to–anesthesia time, lower postoperative hemoglobin decline, lower early postoperative pain scores, lower opioid use, earlier mobilization, and fewer overall in–hospital complications than the conventional care group. Because this was a non–randomized study with multiple secondary outcomes, these findings should be interpreted as associations within an early in–hospital recovery framework. The adherence data document implementation fidelity but do not establish that individual ERAS components independently caused the observed outcome differences.

DATA AVAILABILITY:

The de–identified patient–level raw data used to generate Tables 1–6 and Figures 1–6 are provided as Supplementary Table 1. This file is designated for public release as part of the article’s supplementary materials. The dataset includes anonymized demographic, clinical, perioperative, postoperative recovery, complication, and protocol–adherence variables. No directly identifiable participant information is included.

Figure 1: Study flowchart and perioperative pathway allocation. This flowchart summarizes patient screening, eligibility assessment, exclusion, grouping, and in–hospital outcome assessment for older adults with suspected intertrochanteric femoral fractures admitted during a 1–year study period. ERAS, enhanced recovery after surgery. Please click here to view a larger version of this figure.

Figure 2: Perioperative efficiency and early recovery milestones in ERAS versus conventional pathways. This figure summarizes time–dependent perioperative milestones, including time from admission to anesthesia, first sitting, first standing, and first ambulation. Bars represent mean values, error bars represent standard deviation (SD), and individual points represent patient–level observations. Time variables are reported in h. Asterisks indicate between–group statistical significance as shown in the figure. ERAS, enhanced recovery after surgery. Please click here to view a larger version of this figure.

Figure 3: Hemoglobin stability in relation to intraoperative blood loss. (A) Panel A shows scatter plots with fitted regression lines demonstrating the association between intraoperative blood loss and postoperative hemoglobin decline. Postoperative hemoglobin decline is expressed as a change in hemoglobin (ΔHb, g/L), and R² indicates the coefficient of determination for each fitted line. (B) Panel B shows violin plots with embedded boxplots comparing ΔHb between groups. The center line indicates the median, boxes indicate the interquartile range, and whiskers indicate the observed data range. ERAS, enhanced recovery after surgery. Please click here to view a larger version of this figure.

Figure 4: Postoperative pain trajectories during the first 48 h after surgery. (A) Panel A shows Numeric Rating Scale (NRS) pain scores at preoperative baseline and at 12, 24, and 48 h postoperatively. The NRS ranges from 0 to 10, with higher scores indicating greater pain intensity. Connected markers represent group mean values, and individual points represent patient–level observations. (B) Panel B shows opioid consumption expressed as morphine–equivalent dose on postoperative days 1 and 2. Bars represent mean values, error bars represent SD, and individual points represent patient–level observations. Asterisks indicate between–group statistical significance as shown in the figure. ERAS, enhanced recovery after surgery. Please click here to view a larger version of this figure.

Figure 5: Early functional recovery and postoperative ambulation performance. (A) Panel A shows walking distance during postoperative days 1–3. Connected markers represent group mean values, error bars represent SD, and individual points represent patient–level observations. Walking distance is reported in meters. (B) Panel B shows discharge mobility status, classified as independent or assisted ambulation. Values above bars indicate the number of patients in each category. Asterisks indicate between–group statistical significance as shown in the figure. ERAS, enhanced recovery after surgery. Please click here to view a larger version of this figure.

Figure 6: Compliance with core components of the ERAS clinical pathway. The radar plot depicts adherence rates to core ERAS elements, including preoperative education, early oral fluids, early diet initiation, postoperative day 0 (POD0) mobilization, multimodal analgesia, temperature maintenance, and venous thromboembolism (VTE) prophylaxis. Values are presented as percentages of patients who completed each pathway component. The dashed circular line represents the mean overall ERAS adherence rate. ERAS, enhanced recovery after surgery. Please click here to view a larger version of this figure.

Variable	ERAS group (n = 40)	Conventional group (n = 40)	Test statistic	p value
Age, years	78.4 ± 4.2	79.1 ± 4.6	t = -0.579	0.565
Female, n (%)	26 (65.0)	25 (62.5)	χ2 = 0.054	0.816
BMI, kg/m2	23.1 ± 3.2	22.8 ± 3.0	t = 0.433	0.667
Living: independent/family/institution	18/19/3	17/20/3	χ2 = 0.054	0.973
Pre-injury mobility (indep./assist/non)	25/12/3	24/13/3	χ2 = 0.060	0.97
Time injury (admission, h)	10.8 ± 4.4	11.2 ± 4.1	t = -0.306	0.76
CCI	3.6 ± 1.2	3.7 ± 1.3	t = -0.351	0.727
ASA II/III/IV	14/22/4	13/21/6	χ2 = 0.460	0.794
Albumin, g/L	38.6 ± 4.1	38.2 ± 4.3	t = 0.428	0.67
NRS-2002 ≥3, n (%)	10 (25.0)	12 (30.0)	χ2 = 0.251	0.617
CRP, mg/L	18.7 ± 6.4	19.5 ± 7.1	t = -0.373	0.71
MMSE	23.1 ± 2.9	22.8 ± 3.2	t = 0.447	0.655
Evans II/III/IV	8/20/12	10/18/12	χ2 = 0.328	0.849
			χ2 = 0.050	0.823
Left fracture n (%)	22 (55.0)	21 (52.5)
Right fracture n (%)	18 (45.0)	19 (47.5)
Hypertension n (%)	24 (60.0)	23 (57.5)	χ2 = 0.052	0.82
Diabetes n (%)	14 (35.0)	15 (37.5)	χ2 = 0.054	0.816

Table 1: Baseline demographic, clinical, nutritional, cognitive, and fracture characteristics. This table compares baseline patient characteristics between the ERAS and conventional care groups, including demographic variables, comorbidity burden, nutritional status, cognitive status, fracture morphology, and pre–injury mobility. Continuous variables are presented as mean ± SD, and categorical variables are presented as n (%).

Outcome	ERAS group (n = 40)	Conventional group (n = 40)	Test statistic	p value
Admission-to-anesthesia, h	26.3 ± 9.1	47.8 ± 11.9	t = -9.077	<0.001
Operative duration, min	86.5 ± 15.4	89.7 ± 17.2	t = -0.877	0.384
Blood loss, mL	152.0 ± 58.7	181.5 ± 69.2	t = -2.056	0.043
Pre-op Hb, g/L	118.2 ± 11.6	117.5 ± 10.9	t = 0.278	0.782
Post-op Hb, g/L	102.1 ± 10.8	96.4 ± 11.7	t = 2.264	0.027
ΔHb, g/L	16.1 ± 4.9	21.1 ± 6.1	t = -4.042	<0.001
Regional anesthesia, n (%)	31 (77.5)	24 (60.0)	χ2 = 2.851	0.091
Nerve block used, n (%)	28 (70.0)	15 (37.5)	χ2 = 8.498	0.004
Lowest temperature, °C	36.2 ± 0.4	35.7 ± 0.6	t = 4.205	<0.001
Intraop fluids, mL	780 ± 210	1010 ± 260	t = -4.082	<0.001
First oral fluids, h	4.8 ± 1.2	15.6 ± 3.1	t = -20.171	<0.001
First oral diet, h	7.5 ± 2.4	27.8 ± 5.6	t = -20.995	<0.001
Catheter removal, h	28.5 ± 8.6	52.2 ± 12.4	t = -11.033	<0.001
First sitting, h	12.5 ± 4.2	21.7 ± 5.3	t = -8.059	<0.001
First standing, h	22.9 ± 6.5	37.4 ± 9.2	t = -7.817	<0.001
First ambulation, h	33.7 ± 8.1	56.5 ± 12.6	t = -10.011	<0.001
Post-op LOS, days	7.6 ± 2.1	10.3 ± 2.6	t = -5.109	<0.001
Total hospital stay, days	9.9 ± 2.5	14.7 ± 3.1	t = -7.481	<0.001

Table 2: Perioperative efficiency and hematologic indicators. This table compares admission–to–anesthesia time, operative duration, intraoperative blood loss, crystalloid infusion, temperature maintenance, hemoglobin decline, and postoperative length of stay between the ERAS and conventional care groups. Continuous variables are presented as mean ± SD.

Outcome	ERAS group (n = 40)	Conventional group (n = 40)	Test statistic	p value
Pre-op NRS	7.4 ± 1.0	7.5 ± 1.1	t = -0.425	0.672
NRS 12 h	5.0 ± 1.0	6.0 ± 1.1	t = -4.254	<0.001
NRS 24 h	3.8 ± 0.9	4.6 ± 1.0	t = -3.761	<0.001
NRS 48 h	2.5 ± 0.8	3.2 ± 0.9	t = -3.677	<0.001
Opioid use POD1 (mg ME)	16.8 ± 6.1	28.5 ± 8.2	t = -7.133	<0.001
Opioid use POD2 (mg ME)	10.3 ± 4.8	18.7 ± 6.5	t = -6.379	<0.001
Nerve block effectiveness, n (%)	30 (75.0)	14 (35.0)	χ2 = 12.929	<0.001

Table 3: Postoperative pain trajectories within 48 h after surgery. This table presents NRS pain scores at preoperative baseline and at 12, 24, and 48 h postoperatively, together with postoperative opioid consumption where applicable. The NRS ranges from 0 to 10, with higher scores indicating greater pain intensity. Continuous variables are presented as mean ± SD.

Complication	ERAS group (n = 40)	Conventional group (n = 40)	χ2 value	p value
Pulmonary infection	1 (2.5%)	4 (10.0%)	0.853	0.356
Deep vein thrombosis	1 (2.5%)	2 (5.0%)	0.346	0.556
Urinary retention	1 (2.5%)	3 (7.5%)	0.263	0.608
Wound complication	0 (0%)	1 (2.5%)	1.013	0.314
Delirium	1 (2.5%)	2 (5.0%)	0.346	0.556
Cardiac events	0 (0%)	1 (2.5%)	1.013	0.314
Overall complications	4 (10.0%)	13 (32.5%)	6.050	0.015
Clavien-Dindo grade I-II	4 (10.0%)	12 (30.0%)
Clavien-Dindo grade III-IV	0 (0.0%)	0 (0.0%)
Clavien-Dindo grade V	0 (0.0%)	1 (2.5%)
In-hospital mortality	0 (0%)	1 (2.5%)	1.013	0.314

Table 4: Postoperative complications, Clavien–Dindo severity grading, and in–hospital mortality. This table summarizes pulmonary infections, venous thromboembolism, urinary retention, wound complications, delirium, cardiac events, overall complications, Clavien–Dindo severity categories, and in–hospital mortality in the ERAS and conventional care groups. Categorical variables are presented as n (%). Clavien–Dindo severity categories are reported descriptively because of the small number of events.

Outcome	ERAS group (n = 40)	Conventional group (n = 40)	Test statistic	p value
Time to independent walker use (days)	4.6 ± 1.2	7.1 ± 1.8	t = -7.133	<0.001
POD1 ambulation distance (m)	18.5 ± 5.2	9.4 ± 2.6	t = 6.653	<0.001
POD2 ambulation distance (m)	38.2 ± 7.5	22.6 ± 5.3	t = 7.439	<0.001
POD3 ambulation distance (m)	67.4 ± 12.8	41.1 ± 9.2	t = 9.323	<0.001
Discharge mobility (indep./assist)	29/11	18/22	χ2 = 6.241	0.012

Table 5: Early functional recovery outcomes following ERAS–guided perioperative management. This table compares time to independent walker use, ambulation distance during postoperative days 1–3, and discharge mobility status between the ERAS and conventional care groups. Continuous variables are presented as mean ± SD, and categorical variables are presented as n (%).

ERAS Component	ERAS group (n = 40)	Conventional group (n = 40)	Test statistic	p value
Preoperative education	37 (92.5%)	11 (27.5%)	χ2 = 35.208	<0.001
Early oral fluids <6 h	33 (82.5%)	7 (17.5%)	χ2 = 33.800	<0.001
Early oral diet <12 h	31 (77.5%)	4 (10.0%)	χ2 = 37.029	<0.001
Early mobilization on POD0	28 (70.0%)	5 (12.5%)	χ2 = 27.286	<0.001
Multimodal analgesia adherence	34 (85.0%)	19 (47.5%)	χ2 = 12.579	<0.001
Temperature maintenance ≥36 °C	36 (90.0%)	26 (65.0%)	χ2 = 7.168	0.007
VTE prophylaxis adherence	39 (97.5%)	32 (80.0%)	χ2 = 4.507	0.034

Table 6: Compliance with key components of the ERAS pathway. This table summarizes adherence to prespecified ERAS components, including preoperative education, early oral intake, postoperative day 0 (POD0) mobilization, multimodal analgesia, temperature maintenance, and venous thromboembolism (VTE) prophylaxis. Compliance is presented as n (%) unless otherwise specified.

Supplementary Table 1: Raw data. All the de-identified patient data used for the study are listed in this table.Please click here to download this file.

Discussion

The present study evaluated a structured enhanced recovery after surgery (ERAS)–guided perioperative pathway for older adults undergoing intramedullary fixation for intertrochanteric femoral fractures. In this prospective comparative study, ERAS pathway allocation was associated with shorter postoperative length of stay, shorter admission–to–anesthesia time, lower postoperative hemoglobin decline, lower early postoperative pain scores, reduced opioid consumption, earlier mobilization, and fewer overall in–hospital complications. Because the study used a non–randomized, workflow–based allocation design, these findings should be interpreted as associations within an early in–hospital recovery framework rather than definitive causal effects. Previous studies of intertrochanteric fracture management have mainly emphasized fixation strategy, implant selection, mechanical stability, and postoperative complications^21,22. The present study extends this literature by focusing on how a structured perioperative workflow can be operationalized around urgent geriatric fracture care rather than by attributing recovery solely to surgical fixation or implant–related factors²³.

The main contribution of this study is not simply the observation that ERAS pathway allocation was associated with shorter hospitalization or earlier mobilization, as similar recovery–oriented goals have been widely discussed in orthopedic perioperative care. Instead, the specific value of the present work lies in the detailed implementation framework for urgent geriatric orthopedic trauma care. The pathway integrated accelerated diagnostic assessment, early multidisciplinary optimization, standardized anesthesia and fluid management, opioid–sparing analgesia, early oral intake, venous thromboembolism prophylaxis, device minimization, and structured mobilization into a single operational workflow. Prior studies have shown that technical factors such as rotational alignment and lag screw behavior may influence outcomes after intramedullary fixation^24,25. In contrast, the present study reports workflow metrics, predefined pathway components, protocol–fidelity assessment, and real–world delivery of a perioperative care model within routine clinical practice.

Several practical implementation points are worth emphasizing. First, pathway delivery required coordination among orthopedic surgeons, anesthesiologists, internal medicine physicians, nurses, physiotherapists, patients, and families. Second, common barriers included preoperative pain, dehydration, anemia, electrolyte disturbance, unstable chronic disease, concern about shortened fasting, fear of early mobilization, orthostatic intolerance, and inconsistent documentation of rehabilitation milestones. Third, implementation fidelity depended on trained ERAS nursing staff, structured patient and family education, written perioperative checklists, daily physiotherapy logs, predefined adherence criteria, and monthly multidisciplinary audits. These features are relevant because postoperative recovery after intertrochanteric fracture is influenced not only by fixation success but also by complications after fixation failure, rehabilitation readiness, and patient–level functional vulnerability^26,27. However, fidelity data should not be interpreted as proof that individual ERAS components caused the observed outcome differences. Rather, the fidelity data document whether the intended pathway was delivered as planned and provide context for interpreting the clinical associations.

This study has several important limitations. First, the non–randomized, time–based workflow allocation may have introduced residual confounding and secular effects, even though allocation was not based on clinician preference, patient preference, or perceived clinical risk. Factors such as admission timing, weekday versus weekend admission, staffing conditions, temporal changes in departmental practice, and unmeasured differences in baseline frailty may still have influenced outcomes. Second, the sample size was modest, and the number of complication events was limited; therefore, adjusted analyses were treated as exploratory and not as definitive causal evidence. Third, patients and outcome assessors could not be blinded to pathway allocation. Although standardized assessment tools, fixed time points, electronic medical record extraction, and predefined functional criteria were used to reduce bias, subjective outcomes such as pain scores and functional mobility remain vulnerable to observer and performance bias. Fourth, multiple secondary outcomes were assessed without formal multiplicity adjustment; therefore, secondary findings should be interpreted according to effect sizes and consistency across related recovery domains rather than isolated p values.

Additional limitations relate to generalizability and follow–up duration. This was a single–center study of 80 selected patients who were able to undergo intramedullary fixation and participate in perioperative instructions and rehabilitation. The exclusion of patients with severe organ dysfunction, severe psychiatric or neurocognitive disorders, pathological fractures, severe polytrauma, or incomplete key records may limit applicability to frailer hip–fracture populations commonly encountered in routine practice. This limitation is important because large observational and comparative studies have shown that geriatric intertrochanteric fracture outcomes may vary according to implant characteristics, revision risk, and fracture complexity^28,29,30. In addition, all outcomes were limited to the index hospitalization. The study did not assess post–discharge complications, readmission, institutionalization, medium–term functional recovery, quality of life, or mortality after discharge. Prior evidence suggests that treatment strategy and post–fracture recovery may influence longer–term prognosis and caregiver burden, but such outcomes were beyond the scope of the present study^31,32,33,34. Therefore, the findings should not be interpreted as evidence of sustained recovery, improved long–term resilience, or long–term functional benefit.

Future studies should validate this implementation framework in larger and more diverse cohorts of older adults with intertrochanteric femoral fractures. Randomized, cluster–randomized, or stepped–wedge designs would help reduce selection bias and better evaluate whether workflow–level ERAS implementation is independently associated with early recovery outcomes. Future work should also incorporate 30–day, 90–day, and 1–year follow–up to determine whether early in–hospital recovery associations translate into durable clinical benefit. Because technical factors such as localization methods, reduction quality, implant choice, and reducibility may also affect recovery after intertrochanteric fracture, future studies should integrate perioperative pathway assessment with fracture–specific surgical variables.

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Anesthesia workstation	Dräger	https://www.draeger.com/en_in/Products/Fabius-Plus	Anesthesia delivery; product URL provided because a public catalog number was not available
Automated hematology analyzer	Sysmex	https://www.sysmex.com/en-us/lab-solutions/hematology/xn-series/xn-1000	Hemoglobin testing; product URL provided because a public catalog number was not available
Biochemistry analyzer	Roche Diagnostics	04745914001	Biochemical screening; manufacturer catalog number for cobas c 501 module
Coagulation analyzer	Sysmex	https://www.sysmex.com/en-us/lab-solutions/hemostasis/sysmex-cs-5100	Coagulation profile; product URL provided because a public catalog number was not available
CT scanner	Siemens Healthineers	https://www.siemens-healthineers.com/en-us/computed-tomography/ecoline-refurbished-systems/somatomdefinitionas	Fracture morphology clarification; product URL provided because a public catalog number was not available
Digital radiography system	GE HealthCare	https://landing1.gehealthcare.com/rs/005-SHS-767/images/Discovery%20XR656HD%20Product%20Datasheet.pdf	Preoperative AP/lateral hip radiographs; product URL provided because a public catalog number was not available
Electrocardiography machine	Philips	860315	Preoperative cardiac evaluation; catalog number for PageWriter TC70 cardiograph
Electronic medical record system	Winning Health	https://www.winning.com.cn/	Prospective clinical data capture; product URL provided because a public catalog number was not available
Fluoroscopy C-arm	Ziehm Imaging	https://www.ziehm.com/en/cn/products/ziehm-vision-rfd/	Intraoperative imaging; product URL provided because a public catalog number was not available
Forced-air warming system	Solventum	https://assets.solventum.com/is/content/mmmspinco/Bair-Hugger-Therapy-775-Service-Manual-Englishpdf	Normothermia maintenance; product URL provided because a public catalog number was not available
Graphing software	GraphPad	https://www.graphpad.com/features	Figures and graphing; product URL provided because a catalog number is not applicable
Incentive spirometer	Teleflex	8884719009	Pulmonary optimization; manufacturer product identifier
Orthopedic power drill system	Stryker	https://www.stryker.com/us/en/orthopaedic-instruments/products/system-8.html	Drilling and screw insertion; product URL provided because a public catalog number was not available
PACS imaging system	Neusoft	https://www.neusoft.com/products/healthcare/intelligent-hospital-products/	Radiology storage and image retrieval; product URL provided because a public catalog number was not available
Patient monitoring system	Mindray	https://www.mindray.com/en/products/patient-monitoring/continuous-patient-monitoring/benevision-n22-n19	Vital signs monitoring; product URL provided because a public catalog number was not available
Portable pulse oximeter	Masimo	https://www.masimo.com/products/bedside-solutions/radical-7/	Continuous SpO2 monitoring; product URL provided because a public catalog number was not available
Proximal femoral nail antirotation system	DePuy Synthes	https://pdf.medicalexpo.com/pdf/depuy-synthes/pfna/79814-91907.html	Intramedullary fixation; product URL provided because the exact implant catalog number was not specified
SPSS statistical software	IBM	https://www.ibm.com/products/spss-statistics	Statistical analysis; product URL provided because a catalog number is not applicable
Surgical sutures	Ethicon	https://www.ethicon.com/na/epc/search/platform/wound%20closure?lang=en-default	Wound closure; product URL provided because the exact suture code depends on size and needle type
Ultrasound system for nerve block	FUJIFILM SonoSite	https://www.fujifilm.com/br/en/healthcare/ultrasound/devices/edge2	Nerve block guidance and ultrasonography when clinically indicated; product URL provided because a public catalog number was not available
Walking frame	Medline	MDS86410XWW	Postoperative ambulation; manufacturer catalog number