How to manage an elderly patient with a partial femoral neck fracture, CKD, and metabolic bone disease?

Management of Elderly Patient with Partial Femoral Neck Fracture, CKD, and Metabolic Bone Disease

This patient requires urgent surgical intervention with arthroplasty (hemiarthroplasty preferred given frailty indicators) within 24-48 hours, followed by aggressive treatment of the underlying metabolic bone disease with calcium, vitamin D, and consideration of anti-osteoporotic therapy after addressing the secondary hyperparathyroidism. 1

Immediate Surgical Management

Fracture Classification and Surgical Approach

• This partial femoral neck fracture with cortical bone loss represents an unstable intracapsular fracture that requires arthroplasty rather than internal fixation 2, 1
• Hemiarthroplasty is strongly preferred over total hip arthroplasty in this patient given multiple frailty indicators: CKD stage 3, previous TIA, smoking history, and alcohol abuse 2, 1
• The rationale for hemiarthroplasty is shorter operative time, lower dislocation risk, and acceptable functional outcomes in frail patients, despite THA offering superior long-term function in healthier individuals 2, 1

Critical Consideration for CKD Patients

• Patients with CKD and metabolic bone disease have dramatically higher failure rates with internal fixation - one study showed 83.3% of intracapsular fractures treated with internal fixation required conversion to arthroplasty due to non-union or avascular necrosis, compared to only 11% revision rate with primary hemiarthroplasty 3
• This makes arthroplasty the definitive choice regardless of fracture displacement in CKD patients 3

Surgical Timing and Technique

• Surgery must be performed within 24-48 hours of admission for optimal outcomes 1
• Cemented femoral stems are strongly recommended to improve hip function, reduce residual pain, and decrease periprosthetic fracture risk, particularly important given this patient's osteopenic bone quality 1
• Either spinal or general anesthesia is appropriate, though regional anesthesia may reduce postoperative confusion 1

Perioperative Management

Pain Control and Blood Conservation

• Multimodal analgesia incorporating preoperative nerve block should be used for optimal pain control 1
• Tranexamic acid administration is recommended to reduce blood loss and transfusion requirements 1
• Correction of postoperative anemia is essential 2

Comprehensive Postoperative Care

• Antibiotic prophylaxis 2, 1
• Regular cognitive function assessment (given previous TIA) 2, 1
• Pressure sore prevention 2, 1
• Nutritional support 2, 1
• Early mobilization is critical - patients treated with hemiarthroplasty typically start walking sooner and achieve better functional outcomes 4
• Venous thromboembolism prophylaxis 1

Management of Metabolic Bone Disease

Laboratory Interpretation

• The combination of low calcium (2.10 mmol/L), low phosphate (0.6 mmol/L), elevated alkaline phosphatase (175 U/L), and elevated PTH (6.1 pmol/L) indicates secondary hyperparathyroidism with metabolic bone disease, likely related to CKD stage 3 and nutritional deficiencies 2

Immediate Metabolic Interventions

• All patients require at least 1000 mg calcium and 800 IU vitamin D supplementation daily 5
• Address the secondary hyperparathyroidism by correcting vitamin D deficiency and optimizing calcium intake before considering anti-osteoporotic therapy 2

Secondary Fracture Prevention

• Every patient aged 50 years and over with a fragility fracture requires systematic evaluation for osteoporosis risk 2, 6
• Fracture Liaison Service (FLS) is the most effective organizational structure for risk evaluation and treatment initiation 2
• DXA scanning of spine and hip should be performed once metabolic abnormalities are corrected 6
• Smoking cessation and alcohol limitation are essential given this patient's risk factors 6

Anti-Osteoporotic Therapy Considerations

• Once secondary hyperparathyroidism is addressed and calcium/vitamin D status optimized, consider pharmacological osteoporosis treatment 6
• Denosumab has demonstrated efficacy in patients with CKD and can increase BMD significantly (4.8% at lumbar spine at 1 year) 5
• However, caution is warranted as denosumab causes marked suppression of bone remodeling (35-38% of patients had no tetracycline label indicating suppressed bone formation), and long-term consequences in CKD patients are unknown 5

Common Pitfalls to Avoid

• Do not attempt internal fixation even if the fracture appears partially stable - the metabolic bone disease and CKD dramatically increase failure rates 3
• Do not use uncemented stems in elderly patients with osteoporotic bone due to increased periprosthetic fracture risk 1
• Do not delay surgery beyond 48 hours - outcomes worsen significantly with delayed intervention 1
• Do not start anti-osteoporotic therapy before correcting the underlying secondary hyperparathyroidism and vitamin D deficiency 2
• Ensure adequate posterior capsule and soft tissue repair during surgery to minimize dislocation risk, which is the main complication of hemiarthroplasty 7

Rehabilitation Protocol

• Early mobilization with structured physical therapy including muscle strengthening and balance training 6
• Multidimensional fall prevention strategies are crucial in this high-risk patient 6
• Long-term continuation of balance training to prevent subsequent fractures 6