What is the optimal ward course (pre‑, peri‑ and post‑operative management) for an elderly male with a closed complete right femoral‑neck fracture scheduled for cemented bipolar hemiarthroplasty, who has hypertension, benign prostatic hyperplasia, chronic osteopenia on teriparatide, chronic kidney disease with hyponatremia and hypokalemia, anemia, and coronary artery disease with prior myocardial infarction, right bundle‑branch block and inducible ischemia?

Ward Course for Elderly Male with Closed Complete Right Femoral Neck Fracture Undergoing Cemented Bipolar Hemiarthroplasty

This high-risk patient with coronary artery disease, inducible ischemia, and multiple comorbidities requires urgent cemented bipolar hemiarthroplasty within 24-48 hours of admission, with meticulous attention to bone cement implantation syndrome (BCIS) prevention, aggressive pre-operative optimization of cardiac status and electrolyte abnormalities, and early post-operative mobilization to reduce mortality and improve functional outcomes. 1, 2, 3

Pre-Operative Management (Days 1-2)

Immediate Priorities

• Correct hyponatremia (129 mmol/L) and hypokalemia (3.30 mmol/L) before surgery to reduce cardiac arrhythmia risk during cement insertion 4
• Ensure adequate hydration with IV fluids (currently at 60 cc/hr, may need adjustment based on sodium correction rate) to optimize hemodynamic stability during anesthesia 4
• Transfuse packed red blood cells if hemoglobin drops below 8 g/dL or patient becomes symptomatic (current Hgb 9.3 g/dL) 2
• Continue traction to the right leg for pain control (currently effective with pain 2-3/10) 1, 2

Cardiac Risk Stratification and Optimization

• This patient is at extremely high risk for BCIS due to age, male sex, significant cardiopulmonary disease (prior MI, RBBB, inducible ischemia on stress test), and diuretic use 4
• Arrange invasive arterial blood pressure monitoring for surgery given high-risk cardiac status 4
• Prepare vasopressors (metaraminol/adrenaline) in advance for immediate use during cement insertion 4
• Continue nifedipine and spironolactone to maintain blood pressure control, but monitor closely for intra-operative hypotension 4

Anesthesia Planning

• Either spinal or general anesthesia is appropriate with strong evidence supporting both modalities 1, 2
• Spinal anesthesia may reduce post-operative confusion in this elderly patient 2
• Regional anesthesia requires blockade of lateral cutaneous nerve of thigh, femoral, obturator, sciatic, and lower subcostal nerves 2

Pharmacologic Preparation

• Administer tranexamic acid at the start of surgery to reduce intra-operative blood loss 1, 2, 3
• Provide pre-operative femoral nerve block as part of multimodal analgesia regimen 1, 2
• Give prophylactic antibiotics before incision per AAOS guidelines 2
• Initiate thromboprophylaxis with fondaparinux or low-molecular-weight heparin 1, 2, 3
• Continue regular paracetamol throughout peri-operative period 1, 2

Pre-Operative Checklist and Team Briefing

• Conduct pre-list briefing identifying this patient's high BCIS risk to entire theatre team 4
• Perform WHO Safe Surgery checklist "time-out" immediately before surgery, emphasizing cement-related risks 4
• Ensure all theatre staff understand their defined roles in resuscitating the patient if severe BCIS occurs 4
• Discuss DNAR status with patient/family and ensure anesthetist is aware of outcome 2

Intra-Operative Management

Critical BCIS Prevention Protocol

• Surgeon must verbally announce to anesthetist before preparing femoral canal for cement insertion 4
• Anesthetist must verbally confirm awareness that surgeon is about to prepare/apply cement 4
• Set blood pressure monitoring to "stat" mode during and shortly after cement application 4
• Maintain systolic blood pressure within 20% of pre-induction values using vasopressors and/or fluids 4

Surgical Technique to Minimize BCIS

• Thoroughly wash and dry the femoral canal using pressurized lavage system to clean endosteal bone of fat and marrow 4
• Use distal suction catheter on top of intramedullary plug in femoral shaft 4
• Insert cement from gun in retrograde fashion on top of plug, pulling catheter out as soon as blocked with cement 4
• Avoid vigorous manual pressurization or pressurization devices in this high-risk patient 4

Surgical Approach and Technique

• Use posterior approach with meticulous capsular repair to minimize dislocation risk 1, 2
• Position patient in lateral decubitus 2
• Perform femoral neck osteotomy at base using oscillating saw 2
• Use sequential reamers/broaches starting with smaller sizes and progressively increasing 2
• Insert final femoral stem with 5-10 degrees of anteversion 2

Monitoring for BCIS During Critical Phases

• Grade 1 BCIS (SaO₂ <94% or >20% fall in SBP) occurs in ~20% of cases 4
• Grade 2 BCIS (SaO₂ <88% or >40% fall in SBP or loss of consciousness) occurs in ~3% 4
• Grade 3 BCIS (cardiopulmonary resuscitation required) occurs in ~1% 4
• Watch for sudden drop in end-tidal pCO₂ during general anesthesia, indicating right heart failure/catastrophic reduction in cardiac output 4
• Cardiovascular compromise can occur during femoral canal preparation, cement/prosthesis insertion, and hip reduction 4

Post-Operative Management (Days 1-7)

Immediate Post-Operative Care (Day 0-1)

• Continue active warming strategies to prevent hypothermia 2
• Monitor for cardiovascular complications given high BCIS risk during surgery 4
• Perform routine systems examinations and regular cognitive function assessment 2
• Monitor for pressure sores, nutritional status, and renal function 2
• Correct post-operative anemia with transfusion threshold no higher than 8 g/dL in asymptomatic patients 2

Pain Management

• Continue multimodal analgesia with regular paracetamol 1, 2
• Use opioids cautiously given renal dysfunction (increased renal parenchymal echogenicity on ultrasound) 2
• Avoid codeine due to constipation, emesis, and association with post-operative cognitive dysfunction 2
• Avoid NSAIDs given renal dysfunction 2

Early Mobilization Protocol

• Begin weight-bearing as tolerated on post-operative day 1 if medically stable 1, 2, 3
• Early mobilization reduces DVT risk and improves functional recovery 1, 2, 3
• Physical therapy should start immediately once patient is stable 2

Thromboprophylaxis

• Continue fondaparinux or low-molecular-weight heparin for DVT prophylaxis 1, 2, 3
• Early mobilization provides additional DVT protection 1, 2

Electrolyte and Fluid Management

• Continue monitoring and correcting hyponatremia (was 129 mmol/L pre-operatively) 4
• Repeat serum sodium with next blood gas as planned [@patient notes@]
• Monitor potassium levels (was 3.30 mmol/L pre-operatively) and replace as needed 4

Hematuria Management

• Monitor for resolution of hematuria (present pre-operatively, likely related to BPH) [@patient notes@]
• Continue Duodart (dutasteride/tamsulosin combination) for BPH management [@patient notes@]
• Ultrasound showed enlarged prostate (~52g) with no bladder abnormalities [@patient notes@]

Cardiovascular Monitoring

• Close monitoring given prior MI, RBBB, and inducible ischemia on dobutamine stress test [@patient notes@]
• Continue nifedipine and spironolactone for hypertension control [@patient notes@]
• Watch for arrhythmias given RBBB and electrolyte abnormalities [@patient notes@]

Discharge Planning and Long-Term Management

Bone Health

• Arrange outpatient DEXA scan and referral to bone health clinic for osteoporosis evaluation and treatment 1, 2, 3
• Continue teriparatide for osteoporosis management [@patient notes@]
• This patient already had T11 compression fracture requiring kyphoplasty, indicating severe osteoporosis [@patient notes@]

Interdisciplinary Care

• Implement interdisciplinary care programs (orthopedics, geriatrics, physical therapy, nursing) to lower complication rates 1, 3
• Structured geriatric rehabilitation is crucial to prevent poorer functional outcomes 3
• Coordinate with cardiology for ongoing management of coronary artery disease [@patient notes@]

Follow-Up

• Monitor for late complications including dislocation, infection, and prosthetic loosening 5, 6
• Cemented bipolar hemiarthroplasty has 10-year survivorship free of reoperation of 93.6% 5
• Functional outcomes are excellent with 96.2% of patients having no or slight pain at long-term follow-up 5, 6

Common Pitfalls to Avoid

• Delaying surgery beyond 48 hours increases complications and mortality 3
• Inadequate pre-operative hydration increases BCIS risk 4
• Failure to correct electrolyte abnormalities pre-operatively increases cardiac complications 4
• Vigorous cement pressurization in high-risk patients dramatically increases BCIS risk 4
• Lack of communication between surgeon and anesthetist during cement insertion is dangerous 4
• Delayed mobilization increases DVT risk and worsens functional outcomes 1, 2, 3
• Neglecting interdisciplinary care leads to poor management of multiple comorbidities 3