How soon should an elderly patient with a femoral neck fracture undergo surgery?

Timing of Surgery for Elderly Patients with Femoral Neck Fracture

Elderly patients with femoral neck fractures should undergo surgery within 24 to 48 hours of hospital admission to reduce mortality and morbidity. 1

Optimal Surgical Timing Window

The most recent American Academy of Orthopaedic Surgeons (AAOS) 2022 guidelines provide a moderate-strength recommendation for surgery within 24-48 hours of admission, representing an update from the previous 48-hour target. 1 This recommendation reflects:

• High-volume centers with dedicated hip fracture programs have demonstrated improved outcomes with surgery within 24 hours 1
• The 24-48 hour window acknowledges resource variation across different facilities while maintaining evidence-based standards 1
• The ideal approach is surgery as soon as safely possible at your specific facility with your available surgical team 1

Evidence Supporting Early Surgery

Delaying surgery beyond 48 hours from admission is associated with:

• Increased mortality (particularly if delay is prolonged) 1
• Increased morbidity including pressure sores, pneumonia, and thromboembolic complications 1
• Prolonged inpatient hospital stay 1

Critical Caveat: Medical Optimization vs. Delay

There is no evidence that delaying surgery to allow pre-operative physiological stabilization improves outcomes. 1 However, certain medical conditions warrant brief delay:

Acceptable Reasons to Delay Surgery:

• Hemoglobin <8 g/dL 1
• Severe electrolyte abnormalities (sodium <120 or >150 mmol/L; potassium <2.8 or >6.0 mmol/L) 1
• Uncontrolled diabetes 1
• Uncontrolled or acute onset left ventricular failure 1
• Correctable cardiac arrhythmia with ventricular rate >120/min 1
• Chest infection with sepsis 1
• Reversible coagulopathy 1

Unacceptable Reasons to Delay Surgery:

• Lack of facilities or theatre space 1
• Awaiting echocardiography 1
• Unavailable surgical expertise 1
• Minor electrolyte abnormalities 1

Special Consideration: Anticoagulation and Antiplatelet Therapy

Patients on antiplatelet therapy (aspirin, clopidogrel) do not require discontinuation prior to surgery. 2 Recent evidence supports:

• Acetylsalicylic acid (ASA) and clopidogrel in monotherapy or combination can continue without delay 2
• Warfarin patients should receive early vitamin K administration to allow surgery within 24 hours; prothrombin complex concentrate (PCC) is reserved for extreme cases only 2
• Direct oral anticoagulants (DOACs) must be discontinued 24-48 hours prior to surgery depending on drug type, timing of last dose, and renal function 2
• Early surgery with antiplatelet agents (within 72 hours) is safe and results in better postoperative outcomes without increased perioperative blood loss or mortality 3

Practical Implementation Algorithm

1. Upon admission: Initiate resuscitation protocol with monitoring, IV fluids, analgesia, thermoregulation, and pressure care 1

2. Within 4 hours: Admit to appropriate ward with orthogeriatric and surgical expertise 1

3. Immediate assessment: Identify and treat reversible medical conditions without unnecessary delay 1

4. Target surgery: 24-48 hours from admission unless clear reversible medical contraindications exist 1

5. Multidisciplinary coordination: Involve orthogeriatricians, anesthetists, surgeons, nursing staff, and physiotherapists in pre-operative optimization 1

Common Pitfall to Avoid

Do not delay surgery for "medical clearance" or routine pre-operative testing that does not change immediate management. 1 The mortality benefit of early surgery outweighs theoretical risks of operating on medically complex patients, provided life-threatening conditions are addressed. 1, 2