What is the recommended management for an elderly patient with a femoral neck fracture and potential comorbidities such as osteoporosis?

Management of Femoral Neck Fractures in Elderly Patients

Immediate Surgical Decision

For elderly patients with femoral neck fractures, surgery should be performed within 24-48 hours of hospital admission, with arthroplasty (not internal fixation) as the definitive treatment for displaced fractures. 1, 2

Fracture Classification and Treatment Algorithm

Displaced (Unstable) Intracapsular Fractures

Arthroplasty is mandatory—internal fixation should not be used in elderly patients with displaced fractures. 1

The choice between total hip arthroplasty (THA) versus hemiarthroplasty depends on patient functional status:

• For healthy, active, independent elderly patients without cognitive dysfunction: Choose THA 1, 2

  • THA provides superior functional outcomes compared to hemiarthroplasty 1
  • The American Academy of Orthopaedic Surgeons acknowledges this comes with increased complication risk (higher dislocation rates, longer operative time, more blood loss), which is why the recommendation strength is moderate despite strong evidence for functional benefit 3, 1

• For frail patients, those with cognitive impairment, or limited life expectancy: Choose bipolar hemiarthroplasty 1, 2

  • Shorter operative time and lower dislocation risk while maintaining acceptable functional outcomes 2
  • Unipolar and bipolar designs are equally beneficial 1

Undisplaced Intracapsular Fractures

• Garden type 1 fractures can be managed conservatively with weight-bearing and physiotherapy in selected elderly patients with significant comorbidities 4
• Garden type 2 fractures should undergo surgical treatment to prevent displacement with weight-bearing 4

Extracapsular Fractures

• Stable intertrochanteric fractures: Either sliding hip screw or cephalomedullary device 1
• Unstable intertrochanteric fractures: Antegrade cephalomedullary nail 1
• Subtrochanteric/reverse obliquity fractures: Cephalomedullary device (strong recommendation) 1

Critical Technical Specifications for Arthroplasty

Femoral Stem Cementation

Always use cemented femoral stems—this is a strong recommendation. 3, 1, 2

• Cemented stems improve hip function, reduce residual pain, and critically decrease periprosthetic fracture risk 1, 2
• The American Academy of Orthopaedic Surgeons upgraded this from moderate to strong recommendation in 2021 based on accumulating evidence showing uncemented stems have unacceptable periprosthetic fracture rates in elderly hip fracture patients 3, 1
• While cemented stems increase surgical time and blood loss slightly, the overall benefit profile strongly favors cementation 3

Surgical Approach

• Current evidence shows no superiority of anterior, lateral, or posterior approaches in the general elderly population 3, 1, 2
• However, in high-risk patients with neurological or cognitive impairment, avoid the posterior approach due to increased dislocation risk—consider anterior or lateral approaches instead 2
• If using posterior approach, perform meticulous capsular repair to minimize dislocation 2

Anesthesia Selection

• Either spinal or general anesthesia is appropriate with no clear superiority 1, 2
• Spinal anesthesia may reduce postoperative confusion in elderly patients 1, 2

Perioperative Management Protocol

Preoperative

• Administer multimodal analgesia with preoperative nerve block (femoral nerve block) 1, 2
• Give prophylactic antibiotics before incision 2
• Correct reversible coagulopathy and optimize anticoagulation status 2
• Conduct DNAR discussions prior to surgery 2

Intraoperative

• Administer tranexamic acid at the start of surgery to reduce blood loss and transfusion requirements 1, 2
• Maintain active warming strategies to prevent hypothermia 2

Postoperative

• Implement interdisciplinary care programs—this decreases complications and improves outcomes 1, 2
• Administer fondaparinux or low molecular weight heparin for VTE prophylaxis (strong recommendation) 1, 2
• Continue multimodal analgesia with regular paracetamol 1, 2
• Use opioids cautiously; avoid codeine due to constipation, emesis, and association with postoperative cognitive dysfunction 2
• Avoid NSAIDs in patients with renal dysfunction 2

Mobilization

• Begin physical therapy on postoperative day one if medically stable with weight-bearing as tolerated 2
• Early mobilization reduces DVT risk and improves functional recovery 2

Transfusion Management

• Use a transfusion threshold no higher than 8 g/dL in asymptomatic patients 2
• Transfuse for symptomatic anemia 2

Critical Monitoring and Long-term Management

• Perform routine cognitive function assessment postoperatively 2
• Monitor for pressure sores, nutritional status, and renal function 2
• Arrange outpatient DEXA scan and referral to bone health clinic for osteoporosis evaluation and treatment 2

Common Pitfalls to Avoid

• Never use internal fixation for displaced femoral neck fractures in elderly patients—arthroplasty provides superior outcomes 1
• Never use uncemented stems in elderly hip fracture patients—the periprosthetic fracture risk is unacceptably high 1
• Do not delay surgery beyond 48 hours—outcomes worsen with delayed intervention 3, 1
• In patients with cognitive impairment, carefully consider surgical approach selection as posterior approach carries higher dislocation risk in this population 2