Perioperative Anemia and Transfusion Management in Older Adults with Osteoporotic Hip Fractures: A Narrative Review of Current Evidence and Emerging Strategies.

Osteoporotic hip fractures represent a major and escalating public health burden in aging populations, carrying substantial morbidity, mortality, and healthcare costs. Perioperative anemia is exceedingly common in this frail cohort, with reported preoperative prevalence ranging from 40% to over 50%, and is an established independent predictor of adverse short- and long-term outcomes including mortality, impaired functional recovery, postoperative delirium, and prolonged hospitalization. The management of anemia and the judicious use of allogeneic blood transfusion are central to the multidisciplinary care of these patients. This narrative review provides a comprehensive and critical appraisal of the contemporary evidence governing perioperative anemia management in elderly osteoporotic hip fracture patients, drawing on randomized controlled trials, meta-analyses, and large observational studies identified through searches of major bibliographic databases. We critically examine the epidemiology and multifactorial etiology of perioperative anemia; the evolution of transfusion-risk prediction from traditional clinical indices to machine learning; pharmacological blood conservation, with robust evidence for tranexamic acid and intravenous iron; the debate between restrictive and liberal transfusion thresholds and the need for individualized, physiologically guided decision-making; the perioperative management of patients on antithrombotic therapy; and the influence of surgical technique, fracture type, and nutritional and frailty status. Several practical messages emerge: a restrictive transfusion strategy (hemoglobin 7-8 g/dL) is appropriate for most patients but should be individualized, favoring a more liberal approach in frail, cardiovascularly vulnerable, or delirium-prone patients and nursing-home residents; early and intraoperative tranexamic acid and intravenous iron meaningfully reduce transfusion requirements; surgery should generally not be delayed solely because of antithrombotic medication; and care is best delivered through a multimodal, stepwise Patient Blood Management approach embedded within integrated orthogeriatric care pathways. Priorities for future research include the prospective validation of individualized, physiologically guided transfusion algorithms, the adoption of patient-centered outcome measures, and the rigorous evaluation of emerging technologies.