What are the recommendations for an older adult with a recent hip fracture or severe osteoarthritis undergoing partial hip arthroplasty, considering their overall health status and potential comorbidities such as dementia?

Partial Hip Arthroplasty for Older Adults

For older adults with displaced femoral neck fractures, hemiarthroplasty with a cemented femoral stem is the definitive treatment of choice, particularly in patients with dementia or multiple comorbidities, and surgery should be performed within 24-48 hours of hospital admission. 1, 2

Patient Selection for Hemiarthroplasty vs Total Hip Arthroplasty

Hemiarthroplasty is specifically recommended for:

• Elderly patients with dementia due to high complication risks with total hip arthroplasty 2
• Frail patients with multiple comorbidities where shorter operative time and lower dislocation risk are priorities 1
• Patients with limited functional demands and life expectancy 1

Total hip arthroplasty may be considered for:

• Active, independent older adults without cognitive dysfunction 1
• Patients with pre-existing hip osteoarthritis 1
• Properly selected patients who may benefit functionally, accepting increased complication risk (moderate strength recommendation) 1

The 2022 AAOS guidelines upgraded the evidence supporting THA functional benefits to strong, but downgraded the recommendation strength to moderate due to increased complications, emphasizing careful patient selection 1

Critical Technical Requirements

Cemented femoral stems are strongly recommended (upgraded from moderate to strong recommendation in 2022) 1:

• Reduces periprosthetic fracture risk, particularly critical in osteoporotic elderly patients 2, 3
• All moderate-quality studies since 2014 support cemented stems 1
• Uncemented stems significantly elevate periprosthetic fracture risk in this population 2

Either unipolar or bipolar hemiarthroplasty is acceptable 2

No preferred surgical approach (moderate strength recommendation) 1:

• Current evidence shows no difference in outcomes between direct anterior, lateral, or posterior approaches 1
• This represents a change from 2014 guidelines that showed higher dislocation rates with posterior approach 1

Surgical Timing

Surgery within 24-48 hours of admission is recommended (moderate strength recommendation) 1, 4:

• Represents a change from the 2014 guideline recommendation of within 48 hours 1
• High-volume centers with dedicated hip fracture programs show improved outcomes with surgery within 24 hours 1
• Delaying surgery beyond 48 hours increases complications and mortality 2, 5
• The 24-48 hour window accommodates variation in facility resources while maintaining optimal outcomes 1

Perioperative Management

Anesthesia options (strong strength recommendation) 1:

• Either spinal or general anesthesia is appropriate 1, 5

Multimodal analgesia (strong strength recommendation) 1, 5:

• Incorporate preoperative peripheral nerve block (iliofascial block) to reduce pain and opioid requirements 5
• Continue regular acetaminophen throughout perioperative period 5

Tranexamic acid administration (strong strength recommendation) 1, 2, 4, 5:

• Administer at start of surgery to reduce blood loss and transfusion needs 2, 4, 5

VTE prophylaxis (strong strength recommendation) 1:

• Use in all hip fracture patients 1
• Continue for 4 weeks postoperatively with low molecular weight heparin or fondaparinux 4, 5
• For patients on anticoagulation for atrial fibrillation, restart on postoperative day 2 1

Antibiotic prophylaxis 5:

• Administer within one hour of skin incision, particularly against Staphylococcus aureus 5

Postoperative Mobilization

Immediate weight-bearing as tolerated is recommended (limited strength option) 4, 5:

• Prevents deconditioning and reduces complications 5
• Do not prescribe bed rest or restricted weight-bearing 5

Interdisciplinary Care Requirements

Interdisciplinary care programs should be used (strong strength recommendation, upgraded in 2022) 1:

• Decreases complications and improves outcomes for all hip fracture patients 1
• Represents expansion from 2014 guidelines that focused on patients with mild-to-moderate dementia 1
• Orthogeriatric comanagement is essential for frail elderly patients with multiple comorbidities and polypharmacy 1, 4

Special Considerations for Dementia Patients

Dementia significantly impacts outcomes:

• Dementia prevalence reaches 85% in elderly hip fracture patients 6
• Associated with higher mortality, more complications, and longer rehabilitation periods 7, 8
• Patients with dementia are less likely to be admitted to rehabilitation facilities 8
• Community-dwelling patients with dementia have 2.49 times higher risk of long-term care admission 8

Rehabilitation is critical despite dementia 9:

• Inpatient rehabilitation shows greatest mortality reduction compared to no rehabilitation 9
• Home-care based rehabilitation and inpatient rehabilitation both reduce long-term care placement risk 9
• Structured geriatric rehabilitation prevents poorer functional outcomes 2

In rare cases of severe dementia with poor prognosis, conservative treatment may be considered 7:

• Requires advance care planning and consideration of treatment proportionality 7
• Surgery remains standard for most patients with dementia 7

Bone Health and Secondary Prevention

Osteoporosis evaluation is strongly recommended 1, 5:

• Refer to Fracture Liaison Service or Bone Health Clinic 1, 4, 5
• Draw vitamin D, calcium, and parathyroid hormone levels during hospitalization 5
• Order outpatient DEXA scan 5
• Initiate bisphosphonate therapy to reduce future fracture risk 5

Critical Pitfalls to Avoid

Do not delay surgery for "medical optimization" beyond 24-48 hours 2, 5:

• Early surgery improves outcomes regardless of comorbidities 5

Do not choose total hip arthroplasty in dementia patients with multiple comorbidities 2:

• High complication rates make hemiarthroplasty the safer choice 2

Do not use uncemented stems 2:

• Significantly increases periprosthetic fracture risk in osteoporotic elderly patients 2

Do not neglect interdisciplinary care 2:

• Poor management of comorbidities leads to worse outcomes 2

Do not assume ability to walk excludes serious fracture 4:

• Minimally displaced femoral neck fractures can maintain weight-bearing ability initially 4