With an aging population brought on by an increased life expectancy, there is predicted to be a corresponding increase in the number of fragility hip fractures that are treated.^1,2,3 The majority of these fractures are the result of a low-energy mechanism with osteoporotic bone. Although a nondisplaced, stable femoral neck fracture may be managed with internal fixation, unstable and/or displaced femoral neck fractures in this patient population have a low success rate of healing, and current recommendations are for management with arthroplasty.^4,5,6 Because these patients are prone to having an increased rate of complications due to age and multiple comorbidities, the primary goal in their management is generally to expedite medical optimization and thus minimize the time to surgical intervention.^4,7 An important secondary goal is for the surgeon to create a stable weight-bearing construct in order to minimize complications and maximize potential for early mobilization, which can help reduce the case mortality risk.⁸ The use of the DAA for hip HA has emerged as an important management strategy to expedite early postoperative recovery, reduce pain, and reduce the postoperative complication and revision rates associated with this procedure.

Although controversy exists on the choice of HA versus THA, the choice should be guided by the patient’s biological age, activity level, and health.⁹ For elderly patients with poor physiologic conditions, decreased functional demands, or cognitive limitations, the current literature suggests HA as the treatment of choice.^7,9 Although the vast majority of these geriatric hip fractures at this time are managed through an anterolateral or posterior surgical approach,¹⁰ a growing body of evidence suggests equal or improved results using the DAA to the hip.^11,12

Arthroplasty has clearly become the standard of care for displaced femoral neck fractures in the geriatric population.^13,14,15 However, absolute indications for HA versus THA continue to remain unclear. In a randomized controlled trial by Baker et al¹⁶ in 2006, patients who were mobile and dwelled in independent living settings before their injury were randomized to undergo either HA or THA for femoral neck fracture. Compared with their THA counterparts, patients in the HA arm tolerated significantly shorter walking distances and reported lower Oxford Hip Scores. Of the 32 HA patients with a 3-year follow-up, 20 showed radiographic evidence of acetabular erosion. When followed for 7 to 10 years, there was a significantly higher reoperation and mortality rate for HA compared with THA.^16,17 For these reasons, we generally prefer THA over HA in younger, higher-functioning, community ambulators who live independently. Preexisting osteoarthritis, rheumatoid arthritis, or other structural acetabular abnormality may also warrant consideration for THA because it offers superior pain scores and functional outcomes.¹⁸

It remains difficult to predict which surgery imparts the least risk for future reoperations in any given individual. A recent meta-analysis compared the risk of revision surgery after HA versus THA and demonstrated favorable results after HA for patients surviving less than 5 years after surgery. However, those surviving more than 5 years were more likely to undergo revision after initial HA.¹⁹ Consequently, patients with limited life expectancies are likely best served with HA, although it is not practical to ask surgeons to make such predictions in many circumstances.

The primary downfall of THA compared with HA is the increased risk of early postoperative instability, with one meta-analysis demonstrating a two-fold risk for dislocation.²⁰ Therefore, we tend to use HA for patients who cannot ambulate without assistance or live independently given these patients’ propensity for falls. Additionally, we use HA in patients with poor
physiologic reserve or with acute, life-threatening illness because the increased surgical exposure, procedural duration, and blood loss during THA are difficult to justify in the setting of such fragility. THA is typically used at our institution for patients with preexisting osteoarthrosis of the hip joint or for patients of any age with high functional demands who would be at greater risk for longer-term failure due to prosthetic arthropathy and then might need future conversion to THA if HA was used as the index procedure. Objective, quantifiable guidelines to help clinicians choose between THA and HA have yet to be determined, and the decision-making process at our institution is left to each individual attending surgeon based on the unique characteristics of each patient at injury presentation.

The decision about whether to use a cemented prosthesis remains controversial. The question has significant ramifications because the potential of an increased rate of pulmonary complications and death associated with the use of cement has been demonstrated in some studies,^21,22 whereas other studies have shown no additional complications and less pain and improved mobility^23,24,25 when cementing. Although no clear-cut recommendations can be made from the literature, our Yale hip fracture program does formally recommend that all patients 80 years and older have a cemented stem. For younger patients, the decision to cement the femoral stem remains at the surgeon’s discretion, but surgeons are still encouraged to have a low threshold to use a cemented stem, especially if the proximal femoral bone appears to be osteoporotic intraoperatively during femoral preparation.

The patient is placed in the supine position for the hip HA procedure. The surgeon may use a standard, radiolucent, or traction table. A gel bump under the ipsilateral hemisacrum and hemithorax can be helpful to facilitate surgical exposure on a standard or flat-top table. The patient is positioned on the table such that the hip joint falls right at the break of the table, which allows for intraoperative leg extension if needed. The contralateral arm and leg are secured and abducted onto a gel pad and arm board, and a sequential compression device is placed on the contralateral calf for thromboembolic prophylaxis. The ipsilateral arm is secured across the chest and adducted over a pillow with tape. Appropriate equipment includes identical tools used for DAA THA, including a rat tail rasp, a large bone hook, and single and dual offset broach handles. Perioperative antibiotics with both weight-based cefazolin and gentamicin (2 mg/kg, single dose) are administered within 30 minutes before incision. At Yale New Haven Hospital, all patients with hip fracture receive a staph screening nasal polymerase chain reaction swab upon admission. Vancomycin is added if the nasal polymerase chain reaction swab is positive for methicillin-resistant Staphylococcus aureus or if the patient has had an anaphylactic penicillin antibiotic allergy reaction in the past.

Because there is an increasing awareness of the importance of tranexamic acid (TXA) in the management of orthopaedic injuries,²⁶ our institution has recently worked to devise a protocol for TXA implementation for our hip fracture program (Figure 35.1). Currently, all of our patients with fragility hip fracture are screened on arrival in the emergency department by a physician assistant. If the patient has a known TXA allergy or current, acute
vascular event (clot), TXA is withheld. If the patient is less than 48 hours from their injury and has no “high-risk” red flags (creatine clearance <30 mL/min, vascular event <12 months ago, active malignancy, or on therapeutic anticoagulation), then the patient receives the full “4-dose protocol.” The first dose includes 1 g TXA infused intravenously over 10 minutes at admission. Second, 1 g TXA is infused intravenously over 8 hours while awaiting surgery. Third, 1 g TXA is infused intravenously over 10 minutes preoperatively in the operating room at the time of skin incision. The final dose of 1 g TXA is infused intravenously over 10 minutes in the postanesthesia care unit 3 hours after the incision dose. If the patient is found to be more than 48 hours out from injury at the time of arrival in the emergency department or has any of the high-risk red flags discussed earlier, then they receive a perioperative “2-dose protocol” that includes only the final two doses listed previously from the four-dose pathway (the immediate preoperative dose and the 3-hour postoperative dose only).