What is the management protocol for an elderly patient with a fracture of the neck of femur, considering potential underlying medical conditions such as cardiovascular disease or diabetes?

Management Protocol for Fracture of Neck of Femur

Immediate Assessment and Preoperative Optimization

Elderly patients with neck of femur fractures require immediate interdisciplinary orthogeriatric care with surgery performed within 24-48 hours of admission to reduce mortality and complications. 1, 2

Initial Evaluation and Stabilization

• Implement interdisciplinary orthogeriatric comanagement immediately upon admission, utilizing a joint care model between geriatrician and orthopedic surgeon on a dedicated orthogeriatric ward, which demonstrates the shortest time to surgery, shortest hospital stay, and lowest mortality rates 2
• Obtain chest X-ray, ECG, full blood count, clotting studies, blood group, renal function tests, and baseline cognitive function assessment 2
• Provide multimodal analgesia incorporating a preoperative nerve block to treat pain effectively 2
• Ensure adequate fluid management during the preoperative period to optimize hemodynamic status 2
• Do NOT use preoperative traction as it provides no benefit and may cause harm 2

Management of Anticoagulation and Antiplatelet Therapy

• Continue acetylsalicylic acid (ASA) and clopidogrel without discontinuation prior to surgery 3
• For patients on warfarin, administer vitamin K early to allow surgery within 24 hours; reserve prothrombin complex concentrate (PCC) only for extreme cases 3
• Discontinue direct oral anticoagulants 24-48 hours prior to surgery based on drug type, timing of last dose, and renal function 3
• Resume anticoagulation therapy 24-48 hours postoperatively 3

Surgical Decision-Making Algorithm

For Displaced Femoral Neck Fractures (Garden III-IV)

Arthroplasty is strongly recommended over internal fixation for all displaced femoral neck fractures in elderly patients. 2, 4

Patient Selection for Type of Arthroplasty:

• Active, independent elderly patients without cognitive dysfunction: Total hip arthroplasty (THA) provides superior functional outcomes compared to hemiarthroplasty, though with increased complication risk 1, 2
• Frail patients, those with dementia, or multiple comorbidities: Hemiarthroplasty is the definitive treatment of choice due to shorter operative time, lower dislocation risk, and acceptable functional outcomes 1, 4
• Either unipolar or bipolar hemiarthroplasty designs are equally beneficial with no clear superiority of one over the other 2

For Non-Displaced Femoral Neck Fractures (Garden I-II)

• Internal fixation with cannulated screws in a percutaneous manner is appropriate for stable non-displaced fractures in biologically young patients 1
• Hemiarthroplasty may be considered in elderly patients to decrease re-operation rate, though internal fixation reduces operative time, blood loss, and infection risk 5

For Intertrochanteric Fractures

• Use sliding hip screw for stable intertrochanteric fractures 1
• Use antegrade cephalomedullary nail for unstable intertrochanteric, subtrochanteric, or reverse oblique fractures 1

Surgical Technique Specifications

Anesthesia and Approach

• Either spinal or general anesthesia is appropriate for hip fracture surgery in elderly patients 2
• No surgical approach (direct anterior, lateral, or posterior) demonstrates superiority over another for arthroplasty 1
• Neuraxial anesthesia is possible when ASA is taken by the patient and in cases of effective warfarin reversal 3

Critical Technical Requirements

Use cemented femoral stems for all elderly patients with osteoporosis undergoing arthroplasty for femoral neck fractures. 1, 2, 4 This represents a strong recommendation based on reduced periprosthetic fracture risk, despite slightly increased surgical time and blood loss 1

• Administer tranexamic acid at the start of surgery to reduce blood loss and transfusion requirements 2, 4
• Follow hospital antibiotic protocols with administration within one hour of skin incision 1

Intraoperative Monitoring and Management

• Consider invasive blood pressure monitoring for patients with limited left ventricular function or valvular heart disease 1
• Employ active warming strategies throughout the procedure and continue postoperatively to prevent hypothermia 1
• Use thromboembolism stockings or intermittent compression devices intra-operatively 1
• Optimize fluid management using cardiac output-guided administration to reduce hospital stay and improve outcomes 1

Postoperative Management

Immediate Postoperative Care

• Administer appropriate VTE prophylaxis (fondaparinux or low molecular weight heparin) to all elderly hip fracture patients postoperatively 1, 2, 4
• Continue regular paracetamol administration throughout the peri-operative period 1
• Use non-steroidal anti-inflammatory drugs with extreme caution and avoid in patients with renal dysfunction 1
• Reduce dose and frequency of intravenous opioids in patients with renal dysfunction; avoid codeine due to constipation, emesis, and cognitive dysfunction 1

Rehabilitation and Mobilization

• Begin early mobilization and physical training immediately postoperatively to reduce DVT risk and improve functional recovery 2, 4
• Implement structured geriatric rehabilitation with muscle strengthening followed by long-term balance training and multidimensional fall prevention 2

Secondary Fracture Prevention

• Systematically evaluate every patient aged 50 years and older with a fragility fracture for osteoporosis and risk of subsequent fractures 1, 2
• Initiate appropriate osteoporosis treatment with regular monitoring for tolerance and adherence 1

Critical Pitfalls to Avoid

• Do not delay surgery beyond 48 hours unless absolutely necessary for life-threatening medical optimization, as prolonged immobility significantly increases mortality and complications 2, 4
• Do not use internal fixation for displaced femoral neck fractures in elderly osteoporotic patients, as arthroplasty provides superior outcomes 2
• Do not use uncemented stems in elderly patients with osteoporosis, as cemented fixation provides superior stability and reduces periprosthetic fracture risk 1, 2, 4
• Do not choose total hip arthroplasty in dementia patients with multiple comorbidities due to high complication rates 4
• Do not overlook interdisciplinary care, as orthopedic surgery alone without comprehensive geriatric comanagement results in worse outcomes 2, 4

Special Considerations for Patients with Cardiovascular Disease or Diabetes

• Perform comprehensive cardiovascular assessment with ECG and consider invasive monitoring for patients with limited left ventricular function 1
• Optimize glycemic control perioperatively while avoiding hypoglycemia 1
• Ensure adequate renal function assessment and adjust medication dosing accordingly 1, 2
• Monitor for bone cement implantation syndrome (hypoxia, hypotension, loss of consciousness) during cemented arthroplasty 1