Background: Since Mohamed et al. analyzed 2326 orthopedic cases in 2002 and believed that the POSSUM formula can be directly used to predict postoperative morbidity and mortality in orthopedic patients, applications of POSSUM and P-POSSUM scores in the hip fracture surgery have been mostly reported in the field of orthopedics, but there are still some inconsistencies in the related reports.

Methods: The electronic library was searched for all literature that met the purpose from its inception to 2021. Relative risk (RR) was selected to evaluate whether the model could be used to assess the risk of surgery in patients with elderly hip fractures. Finally, sensitivity analyses and subgroup analyses were performed.

Results: Thirteen studies were finally included, including 9 retrospective and 4 prospective studies.The morbidity analysis includes 11 studies, and the result was RR = 1.07 (95% CI 0.93-1.24), The mortality analysis includes 11 studies on POSSUM and 5 studies on P-POSSUM. The results of mortality by POSSUM and by P-POSSUM were RR = 1.93 (95% CI 1.21-3.08) and RR = 1.15 (95% CI 0.89-1.50), respectively. POSSUM had more accuracy to predict mortality for sample < 200 subgroup(RR = 2.45; 95% CI 0.71-8.42) than sample > 200 subgroup(RR = 1.59; 95% CI 1.06-2.40), and in the subgroup of hip fractures that did not distinguish between specific fracture types(RR = 1.69, 95% CI 0.87-3.32) than intertrochanteric neck fracture subgroup(RR = 5.04, 95% CI 1.07-23.75) and femoral femoral fracture subgroup(RR = 1.43,95% CI 1.10-1.84).

Conclusion: POSSUM can be used to predict morbidity in elderly hip fractures. The P-POSSUM was more accurate in predicting mortality in elderly hip fracture patients compared to the POSSUM, whose predictive value for mortality was influenced by the sample size and type of fracture studied. In addition, we believe that appropriate improvements to the POSSUM system are needed to address the characteristics of orthopedic surgery.