What is the recommended definitive treatment and peri‑operative management for a patient over 60 years old with disabling hip osteoarthritis or a femoral neck fracture that has failed conservative therapy?

Hip Surgery: Definitive Treatment and Perioperative Management

Definitive Surgical Treatment

For patients over 60 with disabling hip osteoarthritis or displaced femoral neck fractures who have failed conservative management, total hip arthroplasty (THA) is the definitive treatment for active, independent patients without cognitive dysfunction, while hemiarthroplasty is preferred for frail patients with limited mobility. 1, 2

Surgical Decision Algorithm

For Displaced Femoral Neck Fractures:

• Active, independent patients without cognitive impairment: THA provides superior functional outcomes despite increased complication risk (moderate strength recommendation with strong evidence) 3, 1
• Frail patients with limited mobility or cognitive dysfunction: Bipolar or unipolar hemiarthroplasty (both equally beneficial) 2, 4
• Patients with pre-existing hip osteoarthritis: THA is strongly indicated 3

Critical Caveat: THA for femoral neck fractures carries higher mortality (1.8% vs 0.3%), major morbidity (24.2% vs 19%), reoperation rates (3.7% vs 2.7%), and readmission rates (7.3% vs 5.5%) compared to elective THA for osteoarthritis 5. This increased risk must be weighed against the functional benefits in patient selection.

For Hip Osteoarthritis:

• THA is indicated when conservative management (exercise, weight loss, NSAIDs) has failed and patients have advanced symptoms with structural damage 6

---

Perioperative Management Protocol

Timing

Surgery must be performed within 24-48 hours of admission for optimal outcomes 1, 4

Anesthesia

Either spinal or general anesthesia is appropriate (strong recommendation) 3, 1, 2, 4. Regional anesthesia may reduce postoperative confusion 1

Implant Selection

Cemented femoral stems are strongly recommended for all elderly hip fracture patients 3, 1, 2, 4. This is a critical recommendation because:

• Cemented stems improve hip function 1, 4
• Reduce residual postoperative pain 1, 4
• Decrease periprosthetic fracture risk in osteoporotic bone 1, 4, 7

Common Pitfall: The guidelines explicitly note that uncemented stems should NOT be used in elderly hip fracture patients due to increased periprosthetic fracture risk 3, 1

Surgical Approach

No single approach is superior (moderate recommendation), though posterior approach is commonly used 3. However, avoid posterior approach in patients with neurological or cognitive impairment due to higher dislocation risk 4

---

Pharmacologic Perioperative Measures

Tranexamic Acid

Administer tranexamic acid at the start of surgery to reduce blood loss and transfusion requirements 1, 2, 4

Pain Management

Implement multimodal analgesia incorporating preoperative femoral nerve block (strong recommendation) 1, 2, 4. Continue regular paracetamol throughout the perioperative period 2, 4

VTE Prophylaxis

Venous thromboembolism prophylaxis is strongly recommended 3, 1. Options include fondaparinux or low-molecular-weight heparin 4. For patients on anticoagulation (e.g., apixaban for atrial fibrillation), restart on postoperative day 2 3

---

Postoperative Management

Mobilization

Weight-bearing as tolerated beginning on postoperative day 1 reduces DVT risk and promotes functional recovery 4

Interdisciplinary Care

Utilize interdisciplinary care programs involving orthopedics, geriatrics, physical therapy, and nursing to decrease complications and improve outcomes (strong recommendation) 1, 2, 4

Osteoporosis Management

Arrange outpatient DEXA scan and referral to bone health clinic for osteoporosis evaluation and treatment 3, 2, 4. Initiate anti-osteoporotic medication to prevent subsequent fractures 2. This is critical given that osteoporosis is underdiagnosed in up to 73% of patients undergoing hip arthroplasty 7

---

Key Clinical Considerations

For Hemiarthroplasty Specifically:

• Unipolar and bipolar designs provide equivalent mortality, morbidity, and quality-of-life outcomes (moderate strength recommendation) 4
• Patient or family preference may guide choice between unipolar and bipolar after shared decision-making 4

Surgical Technique for Cemented Stems:

• Prepare bone cement according to manufacturer specifications 2
• Insert final femoral stem with 5-10 degrees of anteversion while cement is in doughy phase 2

Important Distinction: While THA provides superior functional outcomes for active patients with femoral neck fractures, it comes with increased surgical time, blood loss, and complication rates compared to hemiarthroplasty 1, 5. This is why the AAOS downgraded the recommendation from strong to moderate despite strong evidence for functional benefit 1.