What is the management for a 35-year-old male with a fracture of the neck of the femur and impaired renal function on hemodialysis (HD)?

Management of Femoral Neck Fracture in a 35-Year-Old Male on Hemodialysis

Patients with femoral neck fractures who are on hemodialysis should undergo arthroplasty rather than internal fixation, regardless of fracture displacement, due to the high risk of complications with fixation in renal osteodystrophy. 1

Preoperative Management

Timing and Coordination

• Surgery should be performed within 24-48 hours of admission to reduce complications and improve outcomes 2
• Coordinate surgery around the patient's dialysis schedule 2
  • For urgent cases, arrange heparin-free dialysis if surgery cannot wait 2
• Optimize electrolyte balance and correct any abnormalities before surgery

Medication Management

• Discontinue antiplatelet medications if possible, except in cases of unstable angina 3
• For patients on anticoagulants:
  • Aim for INR <2 for surgery and <1.5 for neuraxial anesthesia 2
  • Small doses of vitamin K may be used to reverse warfarin effects 2

Pain Management

• Implement multimodal analgesia with preoperative nerve block 2
• Use caution with opioids due to high prevalence of renal dysfunction 4
  • Avoid oral opioids
  • Reduce both dose and frequency of IV opioids (typically by half) 2
  • Avoid codeine completely due to constipation and emetic effects 2
• Regular paracetamol administration is recommended 2
• NSAIDs are contraindicated in renal dysfunction 2
• Consider femoral nerve or fascia iliaca block for additional analgesia 2

Surgical Management

Surgical Approach

• Arthroplasty is strongly recommended over internal fixation 1
  • Studies show 83.3% of ESRF patients with internal fixation required conversion to arthroplasty due to non-union or avascular necrosis 1
  • Only 11% of those initially treated with hemiarthroplasty required revision 1
• For femoral neck fractures:
  • Uncemented modular bipolar hemiarthroplasty is appropriate for younger patients 5
  • Consider total hip arthroplasty in properly selected patients for better functional outcomes 2
• Use cemented femoral stems for better fixation 2

Intraoperative Considerations

• Either spinal or general anesthesia is appropriate 2
• Administer tranexamic acid to reduce blood loss and transfusion requirements 2
• Administer prophylactic antibiotics within one hour of skin incision 2
• Implement active warming strategies to prevent hypothermia 2
• Consider additional monitoring:
  • Invasive blood pressure monitoring 2
  • Cardiac output monitoring 2

Postoperative Management

Immediate Care

• Continue multimodal analgesia with caution regarding opioid dosing 2, 4
• Implement thromboprophylaxis with appropriate timing of anticoagulants 2
• Optimize fluid management with cardiac output-guided administration if available 2
• Monitor for electrolyte imbalances and coordinate with nephrology for dialysis resumption

Long-term Considerations

• Implement an interdisciplinary care program to improve outcomes 2
• Address underlying renal osteodystrophy to prevent future fractures 6, 5
• Arrange early mobilization and rehabilitation

Pitfalls and Caveats

• Renal osteodystrophy significantly increases fracture risk and complication rates 6, 5
• Internal fixation has a much higher failure rate in ESRF patients compared to the general population 1
• Patients with renal failure have a higher 30-day mortality (11.6% vs 7.1% in those with normal renal function) 4
• Be vigilant for opioid toxicity due to altered metabolism in renal failure 4
• Bone cement implantation syndrome risk may be higher; prepare for potential hypoxia and hypotension during cementation 2