What is the treatment for a fracture of the intracapsular neck of the femur using bipolar hemiarthroplasty?

Treatment of Intracapsular Femoral Neck Fractures with Bipolar Hemiarthroplasty

For patients with unstable (displaced) intracapsular femoral neck fractures, bipolar hemiarthroplasty is an effective surgical treatment option that provides good functional outcomes with a low revision rate. 1

Patient Selection and Preoperative Considerations

• Indications:

  • Unstable (displaced) femoral neck fractures, particularly in elderly patients
  • Patients with limited functional demands or shorter life expectancy
  • Patients with higher surgical risk where a less extensive procedure is preferred

• Timing of Surgery:

  • Surgery should be performed within 24-48 hours of admission for better outcomes (moderate recommendation) 1
  • Delay beyond 48 hours increases risk of complications and mortality

• Preoperative Assessment:

  • Evaluate cognitive status, pre-fracture mobility, and comorbidities
  • Avoid preoperative traction (strong recommendation against) 1
  • Obtain standard radiographs (AP pelvis and lateral hip views)
  • Consider MRI for suspected occult fractures (nearly 100% sensitivity) 2

Surgical Procedure

Anesthesia and Perioperative Care

• Either spinal or general anesthesia is appropriate (strong recommendation) 1
• Administer tranexamic acid to reduce blood loss and transfusion needs (strong recommendation) 1
• Implement multimodal analgesia incorporating preoperative nerve block (strong recommendation) 1

Surgical Technique

1. Approach:

   • Anterolateral or posterior approach can be used (no preferred approach per guidelines) 1
   • Modified posterior approach with preservation of short external rotators may reduce dislocation risk, particularly in patients with neurological disorders 3

2. Femoral Component:

   • Use cemented femoral stems (strong recommendation) 1
   • Cemented fixation provides excellent long-term survivorship with 20-year cumulative revision rate of only 3.5% 4

3. Prosthesis Selection:

   • Bipolar prosthesis consists of:
     • Femoral stem
     • Bipolar head (outer shell articulates with acetabulum, inner bearing articulates with femoral head)
   • Either unipolar or bipolar hemiarthroplasty can be equally beneficial (moderate recommendation) 1
   • Bipolar design may provide better range of motion (210.63° vs 181.58° for unipolar) 5

Postoperative Management

• Immediate Postoperative Care:

  • Implement interdisciplinary care programs to decrease complications and improve outcomes (strong recommendation) 1
  • Early mobilization with weight-bearing as tolerated
  • DVT prophylaxis according to institutional protocols

• Rehabilitation Protocol:

  • Begin physical therapy on postoperative day 1
  • Progress from assisted to independent ambulation based on patient ability
  • Focus on hip abductor strengthening and gait training

• Follow-up Schedule:

  • First follow-up at 2-4 weeks
  • Subsequent follow-ups at 3 months, 6 months, and annually thereafter
  • Radiographic evaluation to assess component position and potential complications

Outcomes and Complications

• Functional Outcomes:

  • Mean Harris Hip Score with bipolar hemiarthroplasty ranges from 79-86 5
  • Functional activities are generally better with bipolar compared to unipolar designs 5

• Complications:

  • Dislocation: Lower rates with bipolar (0%) compared to unipolar (7.7%) in patients with neurological disorders 3
  • Acetabular erosion: Less common with bipolar compared to unipolar designs 5
  • Other complications: Infection, periprosthetic fracture, aseptic loosening
  • Long-term survivorship is excellent with 20-year cumulative incidence of revision of only 3.5% 4

Special Considerations

• Total Hip Arthroplasty vs. Hemiarthroplasty:

  • In properly selected patients, total hip arthroplasty may provide better function but with potentially increased complications (moderate recommendation) 1
  • Consider total hip arthroplasty for younger, more active patients with longer life expectancy 6

• Unipolar vs. Bipolar:

  • Both provide elderly patients with equal ambulatory ability and low revision rates at medium-term follow-up 7
  • Bipolar designs may have lower dislocation rates and better range of motion 5, 3

Conclusion

Bipolar hemiarthroplasty represents an effective treatment for displaced intracapsular femoral neck fractures, particularly in elderly patients. The procedure should be performed within 24-48 hours of admission, using cemented femoral stems and appropriate surgical technique. Interdisciplinary care and early mobilization are essential for optimal outcomes.