What is the appropriate orthopaedic management for an 85-year-old woman with a right subcapital femoral neck fracture, type 2 diabetes mellitus, and hypertension?

Orthopaedic Management of Subcapital Femoral Neck Fracture in an 85-Year-Old

This 85-year-old patient with a subcapital femoral neck fracture should undergo cemented hemiarthroplasty (either unipolar or bipolar) within 24-48 hours of admission. 1

Surgical Approach and Timing

Surgery must be performed within 24-48 hours of admission—delaying beyond 48 hours significantly increases mortality, pneumonia, pressure sores, and thromboembolic complications. 1, 2, 3 The American Academy of Orthopaedic Surgeons 2022 guidelines provide strong evidence for arthroplasty over internal fixation in displaced femoral neck fractures in elderly patients. 1

Why Hemiarthroplasty (Not Internal Fixation)

• Displaced subcapital fractures in elderly patients require arthroplasty, not internal fixation, as fixation carries unacceptably high rates of nonunion, avascular necrosis, and reoperation in this age group. 1, 4
• Internal fixation is reserved only for truly non-displaced femoral neck fractures, regardless of patient age. 4
• Dynamic hip screws are anatomically inappropriate for femoral neck fractures—they are used for intertrochanteric fractures only. 1

Hemiarthroplasty vs Total Hip Arthroplasty

For this 85-year-old patient, hemiarthroplasty is preferred over total hip arthroplasty (THA). 1 The American Academy of Orthopaedic Surgeons recommends hemiarthroplasty as definitive treatment for elderly patients with displaced femoral neck fractures, particularly those with dementia or multiple comorbidities, due to the high complication rates associated with THA in this population. 1 While THA may be considered in cognitively intact, highly functional elderly patients, the presence of diabetes and hypertension in this 85-year-old makes hemiarthroplasty the safer choice. 4, 5

Critical Technical Specifications

Cemented vs Uncemented Stems

Use a cemented femoral stem—this is particularly important in elderly patients with likely osteoporosis. 1 The American Academy of Orthopaedic Surgeons provides a strong recommendation for cemented femoral stems in this population. 1 Using uncemented stems elevates periprosthetic fracture risk, which is particularly problematic in osteoporotic elderly patients. 1

Unipolar vs Bipolar Hemiarthroplasty

Either unipolar or bipolar hemiarthroplasty is acceptable. 1 The choice between these two options does not significantly impact outcomes in elderly patients with limited functional demands.

Perioperative Adjuncts to Reduce Complications

Tranexamic Acid

Administer tranexamic acid at the start of the case to reduce blood loss and transfusion needs. 1 This is especially important given the patient's age and comorbidities.

VTE Prophylaxis

Provide VTE prophylaxis with fondaparinux or low molecular weight heparin starting postoperatively. 1 Early mobilization also reduces DVT risk and improves functional recovery. 1

Anesthetic Considerations

Regional anesthesia (spinal or epidural) is strongly preferred for this patient with diabetes and hypertension, as it reduces sympathetic hyperactivity, allows for early mobilization, improves postoperative pain control, and reduces DVT risk. 2 If general anesthesia is required, use invasive blood pressure monitoring and increase inspired oxygen concentration at the time of cementation. 2

Preoperative Optimization (Without Delaying Surgery)

Do NOT Delay Surgery for "Optimization"

Proceed to surgery within 36-48 hours without delay for "optimization" of chronic conditions like diabetes and hypertension. 2, 3 There is no evidence that delaying surgery to optimize chronic conditions improves outcomes—in fact, delay beyond 48 hours increases mortality. 3

Pain Management

• Administer regular paracetamol immediately unless contraindicated. 2, 3
• Strongly implement femoral nerve block or fascia iliaca block for superior pain control, which reduces anxiety and sympathetic hyperactivity. 2, 3
• Use opioids cautiously only after reviewing renal function, as 40% of hip fracture patients have renal dysfunction (GFR <60 mL/min). 2, 3
• Avoid NSAIDs entirely given likely renal dysfunction in elderly patients. 2

Medication Management

Continue her antihypertensive medications (including ACE inhibitors) on the morning of surgery with a sip of water—no evidence supports withholding ACE inhibitors in urgent hip fracture surgery. 2, 3

Diabetes Management

Follow hospital-specific perioperative diabetes protocols—hyperglycemia alone does not delay surgery unless the patient is ketotic or severely dehydrated. 3 Check current glucose control and assess for diabetic complications (nephropathy, neuropathy, retinopathy). 3

Postoperative Management

Interdisciplinary Care

Interdisciplinary care with an orthogeriatrics team is crucial to manage multiple comorbidities like diabetes and hypertension. 1 Surgery within 24-48 hours combined with structured geriatric rehabilitation prevents poorer functional outcomes and increased wheelchair/bedridden status at 1 year. 1

Early Mobilization

Early mobilization is critical—it improves oxygenation, respiratory function, reduces DVT risk, and improves functional recovery. 1, 2 Coordinate with physiotherapy and occupational therapy immediately postoperatively. 2

Monitoring and Supportive Care

• Provide supplemental oxygen for at least 24 hours (elderly patients are at risk of postoperative hypoxia). 2
• Continue regular paracetamol and add carefully prescribed opioids as needed. 2
• Monitor for postoperative cognitive dysfunction, which occurs in 25% of hip fracture patients. 2
• Remove urinary catheter as soon as possible to reduce UTI risk. 2

Common Pitfalls to Avoid

• Do NOT delay surgery beyond 48 hours for "optimization"—this increases complications and mortality. 1, 3
• Do NOT choose total hip arthroplasty in elderly patients with multiple comorbidities—hemiarthroplasty has lower complication rates. 1
• Do NOT use uncemented stems—this elevates periprosthetic fracture risk in osteoporotic elderly patients. 1
• Do NOT use internal fixation for displaced subcapital fractures in elderly patients—this leads to high rates of nonunion and reoperation. 1, 4
• Do NOT neglect interdisciplinary care—poor management of comorbidities like diabetes and hypertension leads to worse outcomes. 1

Risk Stratification and Communication

Calculate the Nottingham Hip Fracture Score to predict 30-day mortality and facilitate informed consent discussions with the patient and family. 2, 3 Document discussion of perioperative risks given multiple comorbidities—approximately 8.4% of patients die within 30 days, and up to 15-30% within one year. 2