Uncemented Bipolar Hemiarthroplasty for Femoral Neck Fracture: Not Recommended
For displaced intracapsular femoral neck fractures in elderly osteoporotic patients, you should use a cemented—not uncemented—bipolar hemiarthroplasty, as the American Academy of Orthopaedic Surgeons issues a strong recommendation for cemented femoral stems in this population. 1, 2, 3, 4
Why Cemented Fixation is Mandatory in Osteoporotic Bone
The 2022 AAOS guidelines provide the highest level of evidence (strong recommendation) specifically mandating cemented femoral stems for elderly patients undergoing arthroplasty for femoral neck fractures 1. This is not a preference—it is a directive that should be followed unless you have a clear and compelling rationale for an alternative approach 1.
Benefits of Cemented Fixation in Osteoporotic Patients:
- Improved hip function with higher functional scores postoperatively 3, 4
- Reduced residual postoperative pain compared to uncemented implants 3, 4
- Lower risk of periprosthetic fracture in osteoporotic bone, which is critical in this fragile population 3
- Immediate mechanical stability without requiring bone ingrowth 2, 4
Risks of Uncemented Fixation in This Population:
The case example in the 2022 AAOS guideline explicitly notes that using an uncemented implant "is not aligned with these updated guidelines which strongly support the use of cemented stems in hip fracture patients" 1. In osteoporotic bone, uncemented stems lack adequate initial fixation and carry higher periprosthetic fracture risk 3.
Bipolar vs. Unipolar Hemiarthroplasty: Either is Acceptable
Once you've committed to cemented fixation, the choice between bipolar and unipolar hemiarthroplasty is less critical, as both provide equivalent mortality, morbidity, and quality-of-life outcomes 3.
Evidence Supporting Either Choice:
- Moderate-strength recommendation from AAOS states unipolar and bipolar hemiarthroplasty are equally beneficial 3
- No difference in functional scores, revision rates, or mortality at medium-term follow-up 5, 6
- Bipolar implants have lower dislocation rates compared to unipolar (statistically significant in multiple studies) 5, 6
- Unipolar implants are substantially less expensive and may be appropriate for less-active elderly patients 6, 7
Given the lower dislocation risk with bipolar implants and equivalent functional outcomes, bipolar hemiarthroplasty is the safer default choice for most elderly patients with displaced femoral neck fractures 2, 5.
Complete Surgical Algorithm for This Patient
Preoperative Management:
- Administer tranexamic acid at the start of surgery to reduce blood loss 2, 3, 4
- Multimodal analgesia with preoperative femoral nerve block plus regular paracetamol 2, 3, 4
- Either spinal or general anesthesia is appropriate (strong recommendation) 1, 2, 3, 4
- Prophylactic antibiotics before incision 2
Surgical Technique:
- Posterior approach with meticulous capsular repair to minimize dislocation risk 2, 3
- Cemented bipolar hemiarthroplasty with the femoral stem inserted at 5-10 degrees of anteversion 2, 4
- Prepare bone cement per manufacturer specifications and insert stem during doughy phase 4
Postoperative Management:
- Fondaparinux or low-molecular-weight heparin for DVT prophylaxis 2, 3
- Weight-bearing as tolerated starting postoperative day 1 to reduce DVT risk and improve functional recovery 2, 3
- Interdisciplinary care programs (orthopedics, geriatrics, physical therapy, nursing) to decrease complications 1, 3, 4
- Outpatient DEXA scan and referral to bone health clinic for osteoporosis treatment to prevent future fractures 2, 3, 4
Common Pitfalls to Avoid
Do not use uncemented stems in elderly osteoporotic patients with femoral neck fractures—this directly contradicts strong guideline recommendations and increases periprosthetic fracture risk 1, 3, 4.
Do not skip capsular repair with posterior approach—meticulous repair significantly reduces dislocation risk 2, 3.
Do not delay surgery beyond 24-48 hours—early surgery improves outcomes 3.