What is the treatment for an elderly patient with a fracture of the intracapsular neck of the femur, considering osteoporosis and the goal of early mobilization?

Treatment of Intracapsular Femoral Neck Fractures with Bipolar Hemiarthroplasty in Elderly Patients

For elderly patients with displaced intracapsular femoral neck fractures, particularly those with osteoporosis, frailty indicators, or cognitive impairment, bipolar hemiarthroplasty using a cemented femoral stem is the definitive treatment, allowing immediate full weight-bearing and early mobilization. 1

Patient Selection for Bipolar Hemiarthroplasty

Bipolar hemiarthroplasty is specifically indicated for frail elderly patients because it offers shorter operative time, lower dislocation risk, and acceptable functional outcomes compared to total hip arthroplasty, despite THA providing superior long-term function in healthier patients. 1, 2

Key patient characteristics favoring bipolar hemiarthroplasty include:

• Frailty indicators such as chronic kidney disease stage 3 or higher, previous cerebrovascular events, limited pre-injury mobility (requiring walker or cane), cognitive impairment, or multiple comorbidities 3
• Age over 80 years with displaced Garden III or IV femoral neck fractures 1, 4
• Low functional demand with limited community ambulation 5, 6

The American Academy of Orthopaedic Surgeons provides moderate-strength evidence that unipolar or bipolar hemiarthroplasty may be equally beneficial, though research suggests bipolar designs provide better range of motion and fewer complications like acetabular erosion. 1, 7

Surgical Technique and Perioperative Management

Timing and Approach

Surgery must be performed within 24-48 hours of admission to decrease complications and improve outcomes. 1, 2, 3

• The anterolateral or any standard hip arthroplasty approach is acceptable, as no specific approach demonstrates superiority 1
• Either spinal or general anesthesia is appropriate, with strong evidence supporting both options 1, 2

Implant Selection

A cemented femoral stem is mandatory (strong recommendation, strong evidence) because it improves hip function, reduces residual pain, and critically decreases periprosthetic fracture risk in osteoporotic bone. 1, 2, 3

Uncemented stems should never be used in elderly hip fracture patients due to unacceptably high periprosthetic fracture rates. 2

Blood Loss Management

Tranexamic acid must be administered at the start of the procedure (strong recommendation, strong evidence) to reduce blood loss and transfusion requirements. 1, 2, 3

This is particularly critical in patients on anticoagulation therapy, where 24.9% require blood transfusion, and the need correlates with anticoagulant use, cemented implants, and operative duration. 4

Postoperative Protocol

Immediate Postoperative Care

Interdisciplinary care involving orthogeriatrics is mandatory (strong recommendation, strong evidence) to decrease complications and improve outcomes. 1, 2, 3

Essential components include:

• Multimodal analgesia with preoperative nerve block for optimal pain control 2, 3
• Correction of postoperative anemia, particularly in patients on anticoagulants 3, 4
• Venous thromboembolism prophylaxis with agents like enoxaparin 1, 3
• Regular cognitive function assessment, pressure sore prevention, nutritional support, and wound care 1, 3

Mobilization

Immediate full weight-bearing as tolerated is permitted because the cemented hemiarthroplasty construct provides immediate stability. 1

Early mobilization with structured physical therapy, including muscle strengthening and balance training, is essential for optimal recovery and prevention of subsequent fractures. 3

Expected Functional Outcomes

Research demonstrates that bipolar hemiarthroplasty provides good functional outcomes in elderly patients:

• Harris Hip Score of 86-96 at 6-12 months postoperatively 5, 7
• 66.6% of patients achieve satisfactory hip function by standard outcome measures 6
• Better range of motion (mean 210° vs 181°) compared to unipolar designs 7

Complications and Mortality

The complication profile is favorable when proper technique is employed:

• Overall perioperative complication rate of 8.3-31.9%, with higher rates in patients with dementia or delayed surgical treatment 5, 4
• First-year mortality of 2.9-4.2%, with no deaths directly attributable to the surgical procedure 5, 6
• Specific complications include pressure sores (5.7%), surgical site infection (2.9%), and periprosthetic fracture (2.9%) 6

Critical pitfall to avoid: Delaying surgery beyond 48 hours due to anticoagulation management significantly increases complication rates. Early involvement of geriatric specialists facilitates rapid optimization and surgical clearance. 4

Management of Underlying Osteoporosis

Every patient requires systematic evaluation for osteoporosis after surgery, with Fracture Liaison Service providing the most effective organizational structure for risk evaluation and treatment initiation. 3

Address secondary hyperparathyroidism by correcting vitamin D deficiency and optimizing calcium intake before initiating anti-osteoporotic therapy. 3

Non-pharmacological measures include adequate calcium and vitamin D intake, smoking cessation, and alcohol limitation. 1