What is the recommended treatment for a displaced femoral neck fracture?

Treatment of Displaced Femoral Neck Fractures

For displaced femoral neck fractures in older adults, arthroplasty is strongly recommended over internal fixation. 1

Surgical Treatment Algorithm

Primary Treatment Choice: Arthroplasty Over Fixation

• Arthroplasty is the definitive treatment for all displaced (unstable) femoral neck fractures in elderly patients, as it provides superior outcomes compared to internal fixation in terms of mortality, morbidity, and quality of life 1, 2
• Internal fixation carries unacceptably high rates of non-union and avascular necrosis in displaced fractures, making arthroplasty the clear choice 3

Selecting Between Total Hip Arthroplasty vs Hemiarthroplasty

For properly selected active elderly patients with:

• Good functional status and mobility
• Reasonable life expectancy (typically >2-3 years)
• Absence of significant cognitive impairment

Total hip arthroplasty (THA) provides superior functional outcomes compared to hemiarthroplasty, though at the cost of slightly increased complications 1, 2

For patients with:

• Limited mobility or functional status
• Significant cognitive impairment or dementia
• Multiple comorbidities limiting life expectancy
• Lower functional demands

Hemiarthroplasty (either unipolar or bipolar) is appropriate, as both designs provide equivalent outcomes 1, 2

Critical Technical Specifications

Cement Use

• Cemented femoral stems are strongly recommended for all elderly patients with osteoporosis undergoing arthroplasty for femoral neck fractures 1, 2
• This recommendation was upgraded from moderate to strong strength based on accumulated evidence showing reduced periprosthetic fracture risk with cemented stems 1
• While cemented stems may increase surgical time and blood loss slightly, the overall benefit in stability and reduced fracture risk outweighs these concerns 1

Surgical Approach

• Either direct anterior, lateral, or posterior approach is appropriate, as current evidence does not support superiority of one approach over another 1
• The posterior approach no longer shows higher dislocation rates when proper capsular repair is performed 1

Anesthesia

• Either spinal or general anesthesia is appropriate for hip fracture surgery 1, 2

Timing and Perioperative Management

Surgical Timing

• Surgery should be performed within 24-48 hours of hospital admission to optimize outcomes 1, 2
• High-volume centers with dedicated hip fracture programs demonstrate best outcomes with surgery within 24 hours, though 24-48 hours is more realistic given resource variation 1
• The goal is surgery as soon as safely possible at your facility 1

Preoperative Management

• Do NOT use preoperative traction - it provides no benefit and may cause harm 1, 2
• Implement multimodal analgesia with preoperative nerve block 2
• Ensure adequate fluid management 2
• Obtain chest X-ray, ECG, complete blood count, coagulation studies, renal function, and baseline cognitive assessment 2

Intraoperative Adjuncts

• Administer tranexamic acid at the start of surgery to reduce blood loss and transfusion requirements 2, 4

Interdisciplinary Care Model

• All hip fracture patients should receive interdisciplinary orthogeriatric comanagement starting immediately upon admission 2
• The joint care model between geriatrician and orthopedic surgeon on a dedicated orthogeriatric ward demonstrates shortest time to surgery, shortest hospital stay, and lowest mortality rates 2
• This approach decreases complications, reduces mortality, and improves functional outcomes 2

Postoperative Management

• Administer appropriate VTE prophylaxis to all elderly hip fracture patients postoperatively 1, 2
• Begin early rehabilitation with physical training and muscle strengthening, followed by long-term balance training and fall prevention 2
• Every patient aged 50 years and older with a fragility fracture must be systematically evaluated for osteoporosis and risk of subsequent fractures 2

Critical Pitfalls to Avoid

• Do NOT use internal fixation for displaced femoral neck fractures in elderly patients - arthroplasty provides definitively superior outcomes 1, 2
• Do NOT use uncemented stems in elderly osteoporotic patients - cemented fixation reduces periprosthetic fracture risk 1, 2
• Do NOT delay surgery beyond 48 hours unless absolutely necessary for life-threatening medical optimization, as prolonged immobility significantly increases mortality and complications 1, 2
• Do NOT manage these patients with orthopedic surgery alone - comprehensive geriatric assessment and comanagement is essential for optimal outcomes 2