Surgery is Absolutely Necessary for Femoral Neck Fractures in Elderly Women
Surgery should be performed within 24-48 hours of admission for all elderly women with femoral neck fractures, as this approach significantly reduces mortality, decreases complications, and improves functional outcomes compared to non-operative management. 1, 2, 3
Why Surgery is Essential
The evidence overwhelmingly supports surgical intervention for elderly patients with femoral neck fractures:
Mortality and morbidity reduction: Surgical treatment dramatically reduces the risk of death and complications associated with prolonged immobility, including pneumonia, pressure ulcers, venous thromboembolism, and urinary tract infections. 3, 4
Pain relief and function: Surgery provides superior pain control and enables early mobilization, which is critical for maintaining independence and preventing the devastating complications of bed rest in elderly patients. 5
Cost-effectiveness: Arthroplasty is the most cost-effective treatment when evaluating complication rates, mortality, reoperation rates, and functional outcomes over a 2-year period. 6
Surgical Approach Algorithm
The specific surgical procedure depends on fracture displacement and patient characteristics:
For Displaced (Unstable) Fractures:
Arthroplasty is strongly recommended over internal fixation for all displaced femoral neck fractures in elderly women. 1, 3
Active, healthy, independent elderly women without cognitive dysfunction should receive total hip arthroplasty (THA), which provides superior functional outcomes. 2, 3, 7
Frail elderly women with multiple comorbidities or cognitive impairment should receive hemiarthroplasty (either unipolar or bipolar designs are equally effective). 1, 2
For Non-Displaced (Stable) Fractures:
- Both internal fixation and hemiarthroplasty are feasible options, though hemiarthroplasty decreases reoperation rates while internal fixation reduces operative time, blood loss, and infection risk. 7
Critical Technical Requirements
When performing arthroplasty:
Cemented femoral stems are strongly recommended for all elderly patients, as they improve hip function, reduce residual pain, and significantly decrease periprosthetic fracture risk compared to uncemented stems. 1, 2, 3, 7, 8
Either spinal or general anesthesia is appropriate, with some evidence suggesting regional anesthesia may reduce postoperative confusion. 1, 2, 3
Tranexamic acid should be administered at the start of surgery to reduce blood loss and transfusion requirements. 1, 2, 3
Essential Perioperative Management
Interdisciplinary orthogeriatric care programs are mandatory and should begin immediately upon admission, as they decrease complications, reduce mortality, and improve functional outcomes. 1, 2, 3
Key components include:
Multimodal analgesia with preoperative nerve block for optimal pain control. 1, 2, 3
Venous thromboembolism prophylaxis for all patients postoperatively. 2, 3
Early mobilization and rehabilitation beginning immediately after surgery with physical training, muscle strengthening, and fall prevention strategies. 3
Critical Pitfalls to Avoid
Never delay surgery beyond 48 hours unless absolutely necessary for life-threatening medical optimization, as prolonged immobility significantly increases mortality and complications. 2, 3
Never use internal fixation for displaced fractures in elderly patients, as arthroplasty provides superior outcomes. 1, 3, 7
Never use uncemented stems in elderly osteoporotic patients, as they substantially increase periprosthetic fracture risk. 2, 3, 7
Never use preoperative traction, as it provides no benefit and may cause harm. 3
The Non-Operative Exception
Non-operative management should only be considered in the extremely rare circumstance where the patient is completely unfit for any anesthesia due to immediately life-threatening medical conditions. Even in these cases, mortality remains high and intensive medical input with close nursing care, physiotherapy, and aggressive pain management is necessary. 5 However, this represents a last resort when surgery is truly impossible, not a reasonable alternative to surgical management.