Hemiarthroplasty for Femoral Neck Fracture

Indication. A displaced intracapsular femoral neck fracture (Garden III or IV) in an elderly, low-demand patient in whom the native femoral head cannot be reliably saved and the acetabulum is healthy. The operation replaces the femoral head and neck with a stem that articulates directly with the native acetabulum, restoring a stable, painless hip for immediate weight-bearing. Absolute indications:

• Displaced intracapsular femoral neck fracture in an elderly patient (typically over 70 years)
• Low functional demand — walks with aids, limited community ambulation
• Cognitive impairment (dementia), making compliance with hip precautions unreliable
• Limited life expectancy (under 5-10 years)
• Significant medical comorbidities favouring a shorter operative time
• No pre-existing acetabular arthritis on imaging Relative indications:
• Undisplaced fractures (Garden I or II) in the very elderly with severe osteoporosis, where fixation is likely to fail
• Pathological fractures from metastatic disease (palliative hemiarthroplasty)
• Failed internal fixation of a femoral neck fracture (salvage)
• An elderly patient with rheumatoid arthritis and poor bone quality The one decision that matters — hemi, THA, or fixation. Every displaced fracture in an older patient must be matched to the patient, not the X-ray:

Total hip arthroplasty is preferred over hemiarthroplasty when the patient is active with independent community ambulation, is cognitively intact with a life expectancy over 10 years, is younger (around 60-70) with a displaced fracture, or has pre-existing acetabular arthritis or an inflammatory arthropathy.

Contraindications. Absolute: active sepsis or local infection, medical instability precluding surgery, or a palliative patient with very limited life expectancy (comfort measures only). Relative: severe osteoporosis with concern for periprosthetic fracture (usually still proceed), anticoagulation that cannot be reversed (delay if possible), and significant cardiac disease raising BCIS risk (consider uncemented). Pre-operative optimisation and timing. The target is surgery on the day of, or the day after, admission, and within 36-48 hours (NICE NG124). Registry data across the UK NHFD, Norwegian, Swedish and Australian or New Zealand audits consistently associate surgery beyond 48 hours with increased mortality. Delay only for a clear reversible problem — anaemia requiring transfusion, fluid or electrolyte derangement, reversible coagulopathy, uncontrolled diabetes or arrhythmia — and do NOT delay for non-correctable comorbidities or minor abnormalities. Every patient gets early orthogeriatric review, a comprehensive geriatric assessment, and delirium prevention. Anticoagulation and transfusion. For warfarin, target an INR under 1.5 (vitamin K with or without prothrombin complex). Withhold DOACs for 24-48 hours depending on renal function. Continue aspirin (no increased bleeding risk in hip fracture) and balance clopidogrel against delay (often proceed). Transfuse to a haemoglobin over 80 g/L for most patients, or over 100 g/L with significant cardiac disease — the FOCUS trial showed no benefit to a liberal transfusion strategy.

Implant selection. A CEMENTED stem is the recommended standard for elderly hip-fracture patients (NICE NG124, Cochrane, multiple national registries): WHiTE 5 showed better quality of life at 4 months and far fewer periprosthetic fractures (0.5 percent vs 2.1 percent) with cement, and the Norwegian Hip Fracture Register (n=30,178) showed uncemented fixation carried 1.5 times the reoperation risk and 5.1 times the periprosthetic-fracture risk with no mortality difference. Consider UNCEMENTED only for significant cardiopulmonary disease or pulmonary hypertension (BCIS risk), previous BCIS, or a very narrow or sclerotic canal where cementing is impractical. Bipolar versus unipolar head choice shows no difference in acetabular erosion, pain or function (Cochrane) — most surgeons use bipolar but unipolar is equally acceptable. Stem options include a collared stem (prevents subsidence, loads the calcar), a polished tapered stem such as the Exeter (subsides into the mantle), or a composite-beam stem designed for cement fixation. Consent. Counsel the family honestly: this is a major operation with 5-8 percent 30-day mortality and 20-30 percent 1-year mortality that reflects the frailty of the population. Discuss dislocation (1-5 percent), bone cement implantation syndrome, periprosthetic fracture, infection (1-2 percent), DVT or PE, and the need for extended VTE prophylaxis. For patients with dementia, acknowledge that hip precautions will be difficult to maintain. Around 60-70 percent return to their pre-fracture mobility level.

The goal: through the posterior (Moore or Southern) approach, expose the hip through a true internervous plane, remove the fractured head and neck, prepare and cement the femoral canal with third-generation technique, insert a well-sized stem and head articulating with a healthy acetabulum, and then perform an enhanced posterior soft-tissue repair that protects against dislocation. The exposure — laid out in steps 1 to 5 below — is the heart of the operation and is described in depth on the posterior approach to the hip page.

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Immediate post-operative care and mobilisation | Phase | Timing | Weight-bearing and precautions | Therapy | |-------|--------|-------------------------------|---------| | 1 | Day 0-1 | Full weight-bearing as tolerated; sit out of bed | Stand and walk with a frame | | 2 | Weeks 1-6 | Hip precautions (posterior): avoid flexion over 90 degrees, adduction past midline, internal rotation | Gait training, transfers, stairs | | 3 | Weeks 6-12 | Precautions continue (difficult in dementia) | Progressive independence | | 4 | Beyond 12 weeks | Return to function | Discharge to physiotherapy only if needed | - Full weight-bearing from Day 1 — there are no restrictions on loading a cemented hemiarthroplasty.

• VTE prophylaxis: LMWH or a DOAC for an extended duration of around 28-35 days (NICE NG89, AAOS), plus mechanical prophylaxis until mobile. Tranexamic acid intra-operatively if not contraindicated.
• Orthogeriatric co-management continues for medical optimisation, delirium prevention and discharge planning.
• Follow-up: radiograph before discharge, wound check at 2 weeks, review at 6 weeks with radiographs, then only if symptomatic. Red flags: increasing pain after initial improvement (infection or dislocation), wound discharge or erythema, fever, or new inability to weight-bear. Complications

Medical complications are common and reflect frailty: cardiac events (MI, arrhythmia) and respiratory complications (pneumonia, ARDS) each around 5-10 percent, delirium in 15-40 percent (especially with pre-existing cognitive impairment), pressure injuries 5-10 percent (reduced by early surgery), and urinary retention or UTI in 20-30 percent. 1-year mortality of 20-30 percent reflects the population, not the procedure.

Epidemiology. Femoral neck fractures are classic fragility fractures of the elderly. Around 60-70 percent of patients return to their pre-fracture mobility level after hemiarthroplasty, but most never regain full pre-fracture independence. 30-day mortality is 5-8 percent and 1-year mortality 20-30 percent across international hip-fracture registries — figures that reflect the frailty of the population rather than the operation itself. Long term, acetabular erosion develops in 10-20 percent at 10 years and around 5-10 percent require conversion to THA, although many patients do not survive long enough for this to matter. Garden classification of femoral neck fractures. This is the standard system used to grade displacement and guide management — undisplaced (Garden I or II) fractures are generally fixed, while displaced (Garden III or IV) fractures in the elderly are arthroplasty candidates.

Key randomised evidence. The HEALTH trial (NEJM 2019, 1,495 independently ambulating patients, 80 centres in 10 countries) found no significant difference in secondary hip procedures at 24 months (7.9 percent THA vs 8.3 percent hemi, HR 0.95, p=0.79) and only a clinically unimportant functional gain for THA, while dislocation or instability was higher with THA (4.7 percent vs 2.4 percent) and mortality similar (14.3 percent vs 13.1 percent). The WHiTE 5 trial (NEJM 2022, 1,225 patients aged 60 or over) found cemented hemiarthroplasty gave better EQ-5D quality of life at 4 months (0.371 vs 0.315, adjusted difference 0.055, p=0.02) and far fewer periprosthetic fractures (0.5 percent vs 2.1 percent, odds ratio 4.37 for uncemented). The FAITH trial (Lancet 2017) compared sliding hip screw with cancellous screws for fixation — a fixation question, not arthroplasty — and found no overall difference in reoperation, though the sliding hip screw was favoured in displaced or basicervical fractures and in smokers; the high failure rate of fixation in displaced elderly fractures (around 20-40 percent) underpins the move to arthroplasty. The Cochrane review (Parker 2010, 23 RCTs, 2,861 patients) found cemented prostheses gave less residual pain and better mobility than uncemented, no difference between unipolar and bipolar designs, and only a trend to better function with THA at the cost of higher dislocation. Registry evidence. The Norwegian Hip Fracture Register (30,178 bipolar hemiarthroplasties) showed uncemented fixation carried 1.5 times the overall reoperation risk and 5.1 times the periprosthetic-fracture risk, with no difference in 1-year mortality, pain or quality of life. Swedish, UK (NHFD) and Australian (AOANJRR) data are broadly concordant — higher early revision and periprosthetic fracture with uncemented hemiarthroplasty in the frail elderly. Approach-specific evidence. The posterior approach is faster with less blood loss and better abductor preservation than the lateral (Hardinge) approach, which has a lower dislocation rate but damages the abductors. Enhanced posterior repair — capsular repair plus short external rotator reattachment — reduces dislocation from 5-10 percent to 1-2 percent and should be standard for the posterior approach. Process-of-care benchmarks (UK NHFD, ANZHFR, Fragility Fracture Network): surgery within 36-48 hours of admission, orthogeriatric assessment for every patient, mobilisation on the first postoperative day, and bone-health assessment with falls prevention before discharge. NICE NG124 recommends operating on the day of or the day after admission, using cemented implants, offering THA only to patients who walked independently outdoors with no more than a stick and are cognitively intact, and using an anterolateral or posterior approach with capsular repair.