What is the best treatment approach for a femoral head fracture in an elderly patient?

Treatment of Femoral Head Fracture in Elderly Patients

For elderly patients with femoral head fractures, arthroplasty with a cemented femoral stem is the definitive treatment, and surgery should be performed within 24-48 hours of hospital admission under interdisciplinary orthogeriatric care. 1, 2, 3

Immediate Management and Preoperative Optimization

Establish interdisciplinary orthogeriatric care immediately upon admission to decrease complications, reduce mortality, and improve functional outcomes. 1, 3 The joint care model between geriatrician and orthopedic surgeon demonstrates the shortest time to surgery, lowest length of hospital stay, and lowest mortality rates. 3

Essential Preoperative Steps:

• Perform surgery within 24-48 hours of admission (moderate strength recommendation from AAOS 2022 guidelines). 1, 2 Data from high-volume centers show improved outcomes with surgery within 24 hours, though 24-48 hours is more realistic given resource variations. 1
• Obtain preoperative workup: chest X-ray, ECG, complete blood count, coagulation studies, blood type, renal function, and cognitive baseline assessment. 3
• Provide multimodal analgesia with preoperative nerve block (strong recommendation). 1, 2, 3
• Ensure adequate fluid resuscitation during the preoperative period. 3
• Do NOT use preoperative traction as it provides no benefit and may cause harm. 3

Surgical Decision Algorithm

For Displaced/Unstable Femoral Head Fractures:

Arthroplasty is strongly recommended over internal fixation for all elderly patients with displaced femoral head fractures. 2, 3, 4 Internal fixation should be avoided in this population as arthroplasty provides superior outcomes. 2, 3

Choosing Between THA and Hemiarthroplasty:

• Total Hip Arthroplasty (THA): Preferred for healthy, active, independent elderly patients without cognitive dysfunction who have good functional status and life expectancy. 1, 2, 3 THA provides superior functional outcomes compared to hemiarthroplasty, though with increased complication risk. 1, 2
• Hemiarthroplasty: Preferred for frail patients with cognitive impairment or limited life expectancy. 2 Either unipolar or bipolar designs are equally beneficial. 1, 2, 3

Surgical Technique Specifications

Anesthesia:

Either spinal or general anesthesia is appropriate for elderly hip fracture patients. 1, 2, 3 Some evidence suggests regional anesthesia may reduce postoperative confusion. 2

Surgical Approach:

No single surgical approach (anterior, lateral, or posterior) demonstrates superiority over others for arthroplasty in hip fractures. 1 The 2022 AAOS guidelines updated this recommendation from the 2014 version, which had favored avoiding posterior approaches due to dislocation concerns—current evidence does not support this distinction. 1

Implant Selection:

Cemented femoral stems are strongly recommended (upgraded from moderate to strong recommendation in 2021 AAOS guidelines). 1, 2, 3 Cemented stems improve hip function, reduce residual pain, and decrease periprosthetic fracture risk compared to uncemented stems. 1, 2, 3 The AAOS acknowledges increased surgical time and blood loss with cemented stems but considers the overall benefit to outweigh these risks. 1

Intraoperative Adjuncts:

Administer tranexamic acid (TXA) at the start of surgery (strong recommendation) to reduce blood loss and transfusion requirements. 1, 2, 3

Postoperative Management

Essential Components:

• Provide venous thromboembolism (VTE) prophylaxis (strong recommendation upgraded from moderate in 2021 AAOS guidelines). 1, 3
• Continue multimodal analgesia for pain control. 2, 3
• Implement early mobilization with weight-bearing as tolerated. 1
• Begin rehabilitation program with physical training, muscle strengthening, followed by long-term balance training and fall prevention. 3
• Evaluate for osteoporosis in all patients aged 50 years and older with fragility fractures. 3

Critical Pitfalls to Avoid

• Do not delay surgery beyond 48 hours unless absolutely necessary for life-threatening medical conditions (acceptable delays include hemoglobin <8 g/dL, severe electrolyte abnormalities, uncontrolled heart failure, or acute chest infection with sepsis). 1, 3 Prolonged delay increases mortality, pressure sores, pneumonia, and thromboembolic complications. 1
• Do not use internal fixation for displaced femoral head fractures in elderly patients—arthroplasty is superior. 2, 3
• Do not use uncemented stems in elderly osteoporotic patients due to increased periprosthetic fracture risk. 2, 3
• Do not manage these patients with orthopedic surgery alone—interdisciplinary care is essential for optimal outcomes. 1, 3

Special Consideration for Severe Impaction:

In elderly patients with severe femoral head impaction or comminution, total hip replacement is preferable to attempted fixation. 4