What are the official guidelines for managing neck of femur fractures in elderly patients with osteoporosis?

Management of Neck of Femur Fractures in Elderly Patients with Osteoporosis

Elderly patients with neck of femur fractures should receive immediate interdisciplinary orthogeriatric care with surgery performed within 24-48 hours of admission, and for displaced fractures, arthroplasty with a cemented femoral stem is the treatment of choice over internal fixation. 1

Immediate Assessment and Preoperative Management

Multidisciplinary Care Model

• Interdisciplinary orthogeriatric comanagement should be implemented immediately upon admission to decrease complications, reduce mortality, and improve functional outcomes. 1
• The joint care model between geriatrician and orthopedic surgeon on a dedicated orthogeriatric ward demonstrates the shortest time to surgery, shortest length of hospital stay, and lowest inpatient and 1-year mortality rates. 1
• Preoperative assessment must include chest X-ray, ECG, full blood count, clotting studies, blood group, renal function, and cognitive baseline function assessment. 1

Pain Management and Preparation

• Multimodal analgesia incorporating a preoperative nerve block is strongly recommended to treat pain after hip fracture. 1
• Adequate fluid management should be ensured during the preoperative period. 1
• Preoperative traction should NOT be used as it provides no benefit and may cause harm. 1

Surgical Timing

• Surgery should be performed within 24-48 hours of admission to significantly reduce short-term and mid-term mortality rates and decrease medical complications from immobility (pneumonia, pressure ulcers, increased length of stay). 1, 2
• While this is a moderate strength recommendation, the evidence consistently shows improved outcomes with early surgery, and delays should only occur for optimization of acute life-threatening medical conditions. 1

Surgical Decision-Making Algorithm

For Displaced (Unstable) Femoral Neck Fractures

Arthroplasty is strongly recommended over internal fixation for all displaced femoral neck fractures in elderly patients with osteoporosis. 1

Choice Between Hemiarthroplasty and Total Hip Arthroplasty:

• In properly selected active elderly patients with good functional status and life expectancy, total hip arthroplasty (THA) provides superior functional outcomes compared to hemiarthroplasty, though with a slightly increased complication risk. 1
• For patients with limited life expectancy, significant comorbidities, or low functional demands, hemiarthroplasty is appropriate. 3, 4
• When performing hemiarthroplasty, either unipolar or bipolar designs are equally beneficial with no clear superiority of one over the other. 1

For Stable (Non-displaced) Femoral Neck Fractures

• Treatment options include hemiarthroplasty, internal fixation, or in rare cases nonsurgical care, though the evidence is limited. 1
• In active elderly patients, closed reduction with percutaneous cannulated screw fixation should be performed as soon as possible to minimize healing problems from vascular disruption. 3

For Intertrochanteric Fractures

• For stable intertrochanteric fractures, either a sliding hip screw or cephalomedullary device is recommended with equal efficacy. 1
• For subtrochanteric or reverse obliquity fractures, a cephalomedullary device is strongly recommended. 1

Surgical Technique Specifications

Anesthesia

• Either spinal or general anesthesia is appropriate for hip fracture surgery in elderly patients. 1
• Both have equivalent safety profiles, though spinal anesthesia may reduce postoperative confusion in some elderly patients. 2

Implant Selection for Arthroplasty

• Cemented femoral stems are strongly recommended for elderly patients with osteoporosis undergoing arthroplasty for femoral neck fractures. 1, 2
• The femoral canal should be thoroughly cleaned and dried before cement application, with the stem inserted at 5-10° of anteversion. 2
• In high-risk patients with conditions like Parkinson's disease or dementia, dual mobility cups should be considered to reduce dislocation risk. 5

Intraoperative Adjuncts

• Tranexamic acid should be administered at the start of surgery to reduce blood loss and transfusion requirements. 1, 2
• The posterior capsule and short external rotators should be repaired when using a posterior approach to reduce dislocation risk. 2

Postoperative Management

Venous Thromboembolism Prophylaxis

• Appropriate VTE prophylaxis should be administered to all elderly hip fracture patients postoperatively. 1, 2

Rehabilitation

• An appropriate rehabilitation program should begin early postoperatively with physical training and muscle strengthening, followed by long-term balance training and multidimensional fall prevention. 1

Secondary Fracture Prevention

• Every patient aged 50 years and older with a fragility fracture should be systematically evaluated for osteoporosis and risk of subsequent fractures. 1
• Evaluation should include clinical risk factors, DXA of spine and hip, vertebral fracture assessment, falls risk evaluation, and screening for secondary osteoporosis. 1
• A designated coordinator should oversee secondary fracture prevention, liaising between surgeons, rheumatologists/endocrinologists, geriatricians, and general practitioners. 1

Critical Pitfalls to Avoid

• Do not delay surgery beyond 48 hours unless absolutely necessary for life-threatening medical optimization, as prolonged immobility significantly increases mortality and complications. 1
• Do not use internal fixation for displaced femoral neck fractures in elderly osteoporotic patients, as arthroplasty provides superior outcomes. 1
• Do not use uncemented stems in elderly patients with osteoporosis, as cemented fixation provides superior stability and reduces periprosthetic fracture risk. 1, 2
• Do not overlook the need for comprehensive geriatric assessment and comanagement, as orthopedic surgery alone without interdisciplinary care results in worse outcomes. 1