A second JBJS review takes the global view. Fragility fracture care remains suboptimal worldwide even though the evidence is not contested: timely surgery, orthogeriatric care, early mobilisation, unrestricted weight-bearing and secondary fracture prevention all have strong support. International quality standards and registry-based audit have turned that evidence into measurable indicators, and in many high-income systems the indicators have moved care.
In low- and middle-income countries, the authors are explicit that implementation is limited by health-system constraints — workforce shortages, delayed presentation, limited infrastructure, fragmented pathways — rather than by any gap in evidence. They also report that quality standards have been successfully adapted to local contexts while keeping their clinical core, which is the more useful finding: the standard does not have to be imported whole to work.
For Indian practice the specific items are unrestricted weight-bearing and early mobilisation, both of which are still commonly restricted after fixation, and secondary prevention, which frequently has no owner. A unit does not need a registry to start: a monthly count of how many hip fractures reached theatre within 48 hours, how many were weight-bearing on day one, and how many left on bone protection is an audit any department can run, and those three numbers are where the gap shows.
- Allow unrestricted weight-bearing after fixation unless there is a specific reason not to
- Mobilise on day one and record when it happened
- Assign secondary fracture prevention to a named role, not to the discharge summary
- Start a three-indicator audit — time to theatre, day-one weight-bearing, bone protection at discharge
- Adapt an international quality standard to your unit rather than waiting for a national one
Why it matters
It relocates the problem from what we do not know to what we are not doing, which is the part a department can change this month.
Don't overread it
This is a narrative review and position piece — it does not report new outcome data for any intervention.
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