The Octogenarian With a Displaced Femoral Neck Fracture

Recommendation: total hip arthroplasty (THA) or hemiarthroplasty via a direct lateral or posterior approach - not internal fixation.

Reasoning by option:

• Internal fixation (cannulated screws/DHS): In Garden IV fractures in patients >80, the reoperation rate for nonunion/avascular necrosis approaches 30–40%. She is cognitively intact and ambulatory, so she is not a 'non-operative' candidate. Fixation is the wrong choice for a displaced intracapsular fracture in this age group.
• Hemiarthroplasty vs THA: For an independently mobile, cognitively intact patient with a Garden IV fracture, THA offers better function and lower revision rates than hemiarthroplasty, especially if acetabular cartilage is preserved. THA is reasonable here despite age; age alone is not a contraindication. If the anaesthetic risk is prohibitive, a cemented hemiarthroplasty is the fallback.
• Cemented vs uncemented: Cemented stems reduce periprosthetic fracture and early pain; use modern cementing technique with a cement restrictor, but be aware of bone cement implantation syndrome risk in a patient with aortic stenosis - communicate with anaesthesia, optimize volume status, and avoid oversedation.
• Timing: operate within 24–48 hours once anticoagulation is reversed/assessed. Apixaban 18 hours ago with normal renal function may allow neuraxial anaesthesia after checking anti-Xa or per local protocol; do not delay surgery for days.

Discuss goals with the family: the aim is early mobilization and return to her walker, not 'just a pin.'

Preoperative optimization (within 24–48 h):

• Glycaemic control: target glucose 6–10 mmol/L. HbA1c 8.9% predicts poor healing and infection; involve medicine to adjust insulin. Do not cancel surgery solely for HbA1c - delay increases mortality.
• Aortic stenosis: obtain cardiology/anaesthesia review. Avoid spinal hypotension; use careful fluid management and vasopressors. Consider invasive monitoring. Bone cement implantation syndrome is the specific hazard - warn the anaesthetist, ventilate with 100% O2 during cementing, and maintain volume.
• Anticoagulation: check anti-Xa or follow local reversal protocol; apixaban can be resumed 24–48 h post-op depending on haemostasis.
• Renal function: avoid nephrotoxic drugs; adjust antibiotic dosing (cefazolin dose by weight and renal function).
• VTE prophylaxis with mechanical + pharmacological agents once haemostasis is secure.
• Delirium prevention: screen for cognitive impairment, correct electrolytes, avoid benzodiazepines, early mobilization, and involve family.
• Nutrition and pressure areas: pressure-relief mattress, early dietitian review.

Key exam point: do not let medical optimization become a reason for indefinite delay - mortality rises with each day of delay beyond 48 hours in frail hip fracture patients.

Differential: delirium (multifactorial) plus possible DVT.

1. Delirium work-up: screen for infection (urine, chest, wound), electrolyte disturbance, hypoglycaemia, opioid toxicity, urinary retention, constipation, and myocardial ischaemia (ECG, troponin given aortic stenosis). Review medications - stop anticholinergics and benzodiazepines. Non-pharmacological measures first (orientation, sleep hygiene, family presence, glasses/hearing aids).
2. Calf swelling: with a swollen calf post-arthroplasty, exclude DVT with duplex ultrasound. Do not massage the leg. Check whether she is on prophylaxis. If DVT confirmed, start therapeutic anticoagulation (LMWH or DOAC, renal dosing) and continue for 3 months.
3. Exclude compartment syndrome if pain is out of proportion - though less likely here.
4. Wound check for haematoma or infection.

Exam trap: attributing confusion to 'old age' or the anaesthetic without a structured search for reversible causes. Document a delirium screen and act on it.