Surgical Management of Displaced Intracapsular Femoral Neck Fractures

Preoperative Considerations

The American Academy of Orthopaedic Surgeons recommends bipolar hemiarthroplasty with a cemented femoral stem for displaced intracapsular femoral neck fractures in elderly patients, performed through a posterior approach with meticulous capsular repair to minimize dislocation risk 1, 2, 3
Either spinal or general anesthesia is appropriate for this procedure, with no superiority of one over the other, though spinal anesthesia may reduce postoperative confusion in elderly patients 1, 2, 4

Administer multimodal analgesia incorporating a preoperative nerve block (femoral nerve block) to optimize pain control 1, 5
Administer regular paracetamol throughout the perioperative period to reduce pain and inflammation 5
Use opioids cautiously, especially in patients with renal dysfunction; avoid codeine due to constipation, emesis, and association with postoperative cognitive dysfunction 5

Perform femoral neck osteotomy at the base of the femoral neck using an oscillating saw 6
Use sequential reamers or broaches to prepare the femoral canal, starting with smaller sizes and progressively increasing 6
Insert the final femoral stem with 5-10 degrees of anteversion 6
Assemble the bipolar prosthesis by placing the appropriate-sized bipolar head onto the femoral stem 6

Administer fondaparinux or low molecular weight heparin for DVT prophylaxis 1, 5, 6
Implement early mobilization protocols with weight-bearing as tolerated to reduce complications and improve outcomes 5
Begin physical therapy on postoperative day one if medically stable 5

Arrange outpatient DEXA scan and referral to bone health clinic for osteoporosis evaluation and treatment 5
Utilize interdisciplinary care programs to decrease complications and improve outcomes 1, 2

The American Society of Anesthesiologists recommends conducting DNAR discussions prior to surgery, ensuring the anesthetist is aware of the outcome, and correcting reversible coagulopathy and optimizing anticoagulation status in patients undergoing bipolar hemiarthroplasty 7
Regional anesthesia requires blockade of the lateral cutaneous nerve of the thigh, femoral, obturator, sciatic, and lower subcostal nerves in patients undergoing bipolar hemiarthroplasty 7
Prophylactic antibiotics should be given before incision in patients undergoing bipolar hemiarthroplasty, as recommended by the American Academy of Orthopaedic Surgeons 8

The patient should be positioned in lateral decubitus position during bipolar hemiarthroplasty surgery 8
Incise the hip capsule and expose the fracture site during bipolar hemiarthroplasty, with cemented arthroplasty improving hip function and associated with lower residual pain postoperatively 7

Early mobilization protocols with weight-bearing as tolerated should be implemented, as this reduces DVT risk and improves functional recovery, according to the American College of Rheumatology 8
Routine systems examinations and regular assessment of cognitive function should be performed postoperatively, with monitoring for pressure sores, nutritional status, and renal function 8
Correct postoperative anemia with appropriate transfusion protocols, using a transfusion threshold no higher than 8 g/dL in asymptomatic patients, as recommended by the American Society of Hematology 8

Bipolar hemiarthroplasty is preferred in frail patients because operative time is shorter and subsequent dislocation risk is lower while functional outcome is acceptable, according to the American Academy of Orthopaedic Surgeons 8, 9

The American Academy of Orthopaedic Surgeons states that current evidence does not show outcome differences between surgical approaches (anterior, lateral, or posterior) in the general population 10, 11, 12
In high-risk patients, such as those with neurological or cognitive impairment, the posterior approach may be associated with an increased dislocation risk, and surgeons should consider alternative approaches 10, 11, 12