What is the step-by-step procedure for treating a geriatric patient with a history of osteoporosis and comorbidities such as hypertension, diabetes, or cardiovascular disease, who has suffered a fracture of the intracapsular neck of the femur, using bipolar hemiarthroplasty?

Bipolar Hemiarthroplasty for Intracapsular Femoral Neck Fracture: Step-by-Step Procedure

For geriatric patients with displaced intracapsular femoral neck fractures and comorbidities, bipolar hemiarthroplasty with a cemented femoral stem is the definitive treatment, performed urgently within 24-48 hours to minimize mortality and morbidity. 1

Preoperative Preparation

Patient Optimization

• Perform surgery within 24-48 hours of admission, as delays beyond 48 hours significantly increase complications and mortality 1, 2
• Establish interdisciplinary care with an orthogeriatrics team to manage hypertension, diabetes, and cardiovascular disease 1, 2
• Conduct DNAR discussions prior to surgery, ensuring the anesthetist is aware of the outcome 3
• Correct reversible coagulopathy and optimize anticoagulation status 3

Anesthesia Selection

• Choose either spinal or general anesthesia—both are equally appropriate, though spinal anesthesia may reduce postoperative confusion in elderly patients 2
• Regional anesthesia requires blockade of the lateral cutaneous nerve of the thigh, femoral, obturator, sciatic, and lower subcostal nerves 3
• Administer a preoperative femoral nerve block for multimodal analgesia 2

Medication Administration

• Administer tranexamic acid at the start of the case to reduce blood loss and transfusion needs 1
• Give prophylactic antibiotics before incision 3
• Provide regular paracetamol throughout the perioperative period 2
• Avoid NSAIDs in patients with renal dysfunction 2

Surgical Technique

Patient Positioning and Approach

• Position the patient in lateral decubitus position
• Use a posterior approach with meticulous capsular repair to minimize dislocation risk 2
• Make a posterolateral incision over the hip joint

Femoral Head Removal

• Incise the hip capsule and expose the fracture site
• Perform femoral neck osteotomy at the base of the femoral neck using an oscillating saw 2
• Remove the femoral head and measure its size to select the appropriate bipolar head

Femoral Canal Preparation

• Use sequential reamers or broaches to prepare the femoral canal, starting with smaller sizes and progressively increasing 2
• Ensure adequate canal preparation for cemented fixation, as cemented arthroplasty improves hip function and is associated with lower residual pain postoperatively compared to uncemented 3

Prosthesis Insertion

• Insert the final cemented femoral stem with 5-10 degrees of anteversion 2
• Use cement pressurization techniques to ensure optimal fixation, which is particularly important in osteoporotic elderly patients 1
• Assemble the bipolar prosthesis by placing the appropriate-sized bipolar head onto the femoral stem 2
• The bipolar design allows motion at both the prosthetic head-acetabulum interface and the inner bearing, potentially reducing acetabular erosion 4, 5

Reduction and Stability Assessment

• Reduce the hip joint and assess stability through full range of motion
• Perform meticulous capsular repair to minimize dislocation risk 2
• Close the wound in layers with appropriate hemostasis

Postoperative Management

Immediate Postoperative Care

• Continue active warming strategies to prevent hypothermia 2
• Provide appropriate pain management with multimodal analgesia, using opioids cautiously in patients with renal dysfunction 2
• Avoid codeine due to constipation, emesis, and association with postoperative cognitive dysfunction 2

Thromboprophylaxis

• Administer fondaparinux or low molecular weight heparin for DVT prophylaxis 1, 2
• This is essential given the high thrombotic risk in elderly patients with hip fractures

Mobilization Protocol

• Begin physical therapy on postoperative day one if medically stable 2
• Implement early mobilization protocols with weight-bearing as tolerated, as this reduces DVT risk and improves functional recovery 1, 2
• Early mobilization is critical to prevent complications and improve outcomes 3

Monitoring and Complications

• Perform routine systems examinations and regular assessment of cognitive function 3
• Assess for pressure sores, nutritional status, and renal function 3
• Monitor wound healing and assess for signs of infection 3
• Consider transfusion for symptomatic anemia, using a transfusion threshold no higher than 8 g/dL in asymptomatic patients 2
• Correct postoperative anemia with appropriate transfusion protocols 3

Long-Term Follow-Up

• Arrange outpatient DEXA scan and referral to bone health clinic for osteoporosis evaluation and treatment 2
• Ensure adequate intake of calcium and vitamin D, smoking cessation, and limitation of alcohol intake 3
• Implement structured geriatric rehabilitation to prevent poorer functional outcomes 1

Critical Technical Considerations

Cemented vs. Uncemented Stems

Use cemented femoral stems exclusively in this population, as they are particularly important in elderly patients with osteoporosis 1. Using uncemented stems elevates periprosthetic fracture risk, which is particularly problematic in osteoporotic elderly patients 1.

Bipolar vs. Unipolar Choice

While both unipolar and bipolar prostheses provide acceptable outcomes 6, 7, bipolar hemiarthroplasty is preferred in frail patients because operative time is shorter and subsequent dislocation risk is lower while functional outcome is acceptable 3. Bipolar prostheses show better Harris hip scores and reduced acetabular erosion compared to unipolar designs 4, 5.

Common Pitfalls to Avoid

• Never delay surgery beyond 48 hours, as this increases complications and mortality 1
• Do not choose total hip arthroplasty in dementia patients with multiple comorbidities, as it is associated with high complication rates despite potentially better long-term function 1
• Avoid neglecting interdisciplinary care, as this leads to poor management of comorbidities 1
• Do not use uncemented stems in this elderly, osteoporotic population due to elevated periprosthetic fracture risk 1