What is the best course of treatment for an elderly patient with a subcapital fracture of the left femur neck, potentially with osteoporosis or a history of falls?

Treatment of Subcapital Fracture of the Left Femur Neck in Elderly Patients

For elderly patients with displaced subcapital femoral neck fractures, proceed with arthroplasty rather than internal fixation, selecting between total hip arthroplasty (THA) for cognitively intact, active patients or bipolar hemiarthroplasty for frail patients, using a cemented femoral stem in both cases. 1

Initial Assessment and Surgical Decision Algorithm

Determine fracture displacement status first:

• Non-displaced fractures: Treat with closed reduction and percutaneous cannulated screw fixation regardless of patient age 1, 2
• Displaced fractures: Proceed to patient-specific assessment below 1

Patient Selection for Surgical Approach (Displaced Fractures)

Assess three key patient factors to guide arthroplasty selection:

For Total Hip Arthroplasty (THA):

• Cognitively intact (no dementia or significant cognitive dysfunction) 1, 2
• Active and independent (able to walk several blocks, drives, employed or highly functional) 1
• Pre-existing hip osteoarthritis (provides additional indication) 1

THA offers superior long-term functional outcomes and quality of life but carries higher complication and dislocation risk. 1

For Bipolar Hemiarthroplasty:

• Frail patients with limited functional demands 1, 3
• Cognitively impaired or dementia present 2
• Shorter operative time needed (reduces anesthetic exposure) 1, 3

Hemiarthroplasty provides acceptable functional outcomes with lower dislocation risk and shorter operative time. 1, 3

Critical Technical Requirements

Cemented vs. Non-Cemented Stems:

Use cemented femoral stems in all elderly hip fracture patients—this is a strong recommendation from the AAOS 2022 guidelines. 1, 3 The guidelines explicitly note that non-cemented stems are not aligned with current evidence-based practice for this population.

Surgical Approach:

• No single approach (anterior, lateral, posterior) demonstrates superiority in general populations 1, 3
• In high-risk patients with neurological or cognitive impairment, avoid posterior approach due to increased dislocation risk; consider anterior or lateral approaches instead 3
• If using posterior approach, perform meticulous capsular repair to minimize dislocation 3

Anesthesia Selection:

Either spinal or general anesthesia is appropriate—no outcome difference between the two. 1, 3 Consider spinal anesthesia in elderly patients as it may reduce postoperative confusion.

Perioperative Management Protocol

Preoperative Optimization:

• Involve orthogeriatric team or hospitalist for medical optimization before surgery 1
• Correct reversible coagulopathy and optimize anticoagulation status 3
• Administer prophylactic antibiotics before incision 3

Pain Management:

• Multimodal analgesia with preoperative femoral nerve block 3
• Regular paracetamol throughout perioperative period 3
• Minimize opioids, especially in renal dysfunction; avoid codeine (causes constipation, emesis, and postoperative cognitive dysfunction) 3

Thromboembolism Prophylaxis:

Administer VTE prophylaxis for minimum 1 month postoperatively—this is a strong AAOS recommendation. 1 Options include:

• Low molecular weight heparin (e.g., Lovenox) 1, 3
• Fondaparinux 3
• Resume home anticoagulation (e.g., apixaban) on postoperative day 2 if applicable 1

Transfusion Protocol:

Use transfusion threshold no higher than 8 g/dL in asymptomatic postoperative patients. 1, 3 Transfuse for symptomatic anemia regardless of hemoglobin level.

Postoperative Care and Mobilization

Early Mobilization:

Begin weight-bearing as tolerated immediately postoperatively with physical therapy starting on postoperative day 1. 1, 3 Early mobilization reduces DVT risk and improves functional recovery. 3

Monitoring Requirements:

• Regular cognitive function assessment 1, 3
• Pressure sore surveillance 1, 3
• Nutritional status and renal function monitoring 1, 3
• Bowel and bladder function assessment 1

Secondary Fracture Prevention (Critical for Long-term Outcomes)

Every patient ≥50 years with a fragility fracture requires systematic osteoporosis evaluation—this directly impacts future morbidity and mortality. 1

Mandatory Follow-up:

• Arrange outpatient DEXA scan 3
• Refer to bone health/osteoporosis clinic within 1 month 1, 3
• Implement Fracture Liaison Service (FLS) if available—most effective organizational structure for preventing subsequent fractures 1

Non-Pharmacological Treatment:

• Adequate calcium and vitamin D intake 1
• Smoking cessation and alcohol limitation 1
• Long-term balance training and multidimensional fall prevention 1

Pharmacological Treatment:

Initiate drugs demonstrated to reduce vertebral, non-vertebral, and hip fracture risk (bisphosphonates, denosumab, or anabolic agents depending on fracture risk profile). 1

Common Pitfalls to Avoid

• Do not use non-cemented stems in elderly hip fracture patients—explicitly contradicts current guidelines 1
• Do not delay surgery in active elderly patients with displaced fractures—urgent reduction preserves blood supply 4
• Do not overlook cognitive assessment—this fundamentally changes surgical approach selection 1, 2
• Do not discharge without osteoporosis evaluation plan—secondary fracture prevention is as important as treating the index fracture 1