What is the most appropriate management for an elderly female with a femoral head fracture, dementia, hypertension (high blood pressure), ischemic heart disease, and chronic obstructive pulmonary disease (COPD) after a fall?

Hemiarthroplasty (Option 4)

For this elderly female with dementia and a femoral head (displaced femoral neck) fracture, hemiarthroplasty is the definitive treatment of choice. 1

Rationale for Hemiarthroplasty Over Other Options

Why Not Dynamic Hip Screw (Option 1)?

• Dynamic hip screws are indicated for intertrochanteric fractures, not femoral head/neck fractures 1
• This patient has a femoral head fracture, making this option anatomically inappropriate

Why Not Total Hip Replacement (Option 2)?

• While total hip arthroplasty (THA) may provide functional benefits over hemiarthroplasty in "properly selected patients," it comes at the risk of increased complications 1
• This patient has dementia, multiple comorbidities (COPD, ischemic heart disease, hypertension), and lives in a care facility - she is NOT a properly selected candidate for THA 1
• The AAOS guidelines specifically downgraded THA recommendation from strong to moderate due to complication risks, particularly relevant in high-risk patients 1
• Dementia patients already face higher rates of dislocation (OR 1.87), periprosthetic fractures (OR 1.29), and revision surgery (OR 1.23) with hemiarthroplasty alone 2

Why Not Non-Weight Bearing for 6 Weeks (Option 3)?

• Displaced femoral neck fractures require arthroplasty over fixation (strong AAOS recommendation) 1
• Non-operative management with prolonged immobilization in an elderly patient with dementia would lead to:
  • Catastrophic functional decline 1
  • Increased mortality risk 3, 4
  • Pressure ulcers, pneumonia, and thromboembolic complications 5
  • Loss of any remaining mobility 6

Evidence Supporting Hemiarthroplasty

Guideline-Based Recommendations

• AAOS 2022 guidelines provide strong evidence (strong recommendation) for arthroplasty over fixation in displaced femoral neck fractures 1
• The case example in the AAOS guideline describes an 88-year-old woman with cognitive decline and comorbidities who underwent hemiarthroplasty - nearly identical to this patient 1

Specific Advantages for This Patient Population

• Lower reoperation rates compared to internal fixation: 6% vs 20% in elderly patients 4
• In patients over 80 with dementia and/or institutionalized status, hemiarthroplasty shows acceptable 1-year outcomes with only 2% dislocation rate 3
• Allows immediate weight-bearing and early mobilization, critical for preventing complications in dementia patients 1, 6

Critical Technical Considerations

Surgical Approach

• Use cemented femoral stems (strong AAOS recommendation) - particularly important given her age and likely osteoporosis 1
• Either unipolar or bipolar hemiarthroplasty is acceptable (moderate recommendation) 1
• Spinal or general anesthesia are both appropriate 1

Perioperative Management

• Administer tranexamic acid at case start to reduce blood loss and transfusion needs (strong recommendation) 1
• Provide VTE prophylaxis with fondaparinux or low molecular weight heparin 5
• Surgery within 24-48 hours of admission improves outcomes 1, 7
• Interdisciplinary care with orthogeriatrics team is essential (strong recommendation) to manage her multiple comorbidities 1

Postoperative Rehabilitation

• Structured geriatric rehabilitation is crucial - lack of rehabilitation correlates with significantly poorer functional outcomes and increased wheelchair/bedridden status at 1 year 6
• Early mobilization reduces DVT risk and improves functional recovery 5

Common Pitfalls to Avoid

• Do not delay surgery beyond 48 hours - this increases complications and mortality 1
• Do not choose THA in dementia patients with multiple comorbidities - complication rates are unacceptably high 1, 2
• Do not use uncemented stems - periprosthetic fracture risk is elevated, particularly problematic in osteoporotic elderly patients 1
• Do not neglect interdisciplinary care - her COPD, ischemic heart disease, and hypertension require coordinated medical management 1

1, 3, 4, 6