import { OnePagerSummary, ExamWarning, InfoCardGrid, InfoCard, MnemonicCard, EvidenceCard, VivaScenarioSection, VivaScenario, ExamCheatSheet, ContentSection, ExamPearl, SafetyAlert, NumberHighlightRow, NumberHighlight, Tabs, Tab, ComparisonTable } from '@/components/mdx' **Major danger in posterior approach**. Location: 2-3cm posterior to posterior acetabular wall, emerges below piriformis. Risk: 0.5-2% transient injury. Protection: Hip flexed, knee flexed to relax nerve, avoid excessive retraction posteriorly. **Emerge below piriformis with sciatic nerve**. Location: Inferior to piriformis, course to gluteus maximus. Protection: Stay within safe zone above piriformis or clearly below with visualisation. **Motor to gluteus medius/minimus**. Location: Exits greater sciatic notch 3-5cm above GT tip. Protection: Never extend incision or dissection more than 5cm proximal to GT tip. **Anteromedial to hip joint**. Location: Femoral triangle, 4-5cm anterior to capsule. Protection: Anterior retractor on bone only, never slide medially into soft tissue. **Absolute Indications (Garden III/IV Femoral Neck Fracture):** - Displaced intracapsular femoral neck fracture in elderly (typically >70 years) - Low functional demand (walks with aids, limited community ambulation) - Cognitive impairment (dementia - compliance with hip precautions unreliable) - Limited life expectancy (<5-10 years) - Significant medical comorbidities favouring shorter operative time - No pre-existing acetabular arthritis on imaging **Relative Indications:** - Undisplaced fractures (Garden I/II) in very elderly with severe osteoporosis where fixation likely to fail - Pathological fractures from metastatic disease (palliative hemiarthroplasty) - Failed internal fixation of femoral neck fracture (salvage procedure) - Elderly patient with rheumatoid arthritis (bone quality concerns) **Exam Key**: "The classic hemiarthroplasty patient is elderly (>75), has dementia or limited mobility, and presents with a displaced intracapsular fracture. The HEALTH trial showed no functional difference vs THA, but hemiarthroplasty is faster, simpler, and appropriate for patients unlikely to survive long enough to develop acetabular erosion." - Active patient with independent community ambulation (walking without aids) - Cognitively intact with good life expectancy (>10 years) - Pre-existing acetabular arthritis or inflammatory arthropathy - Younger patient (age 60-70) with displaced fracture - Pre-existing hip symptoms suggesting osteoarthritis - Inflammatory arthritis (RA, seronegative arthropathy) **HEALTH Trial Key Finding**: No difference in hip function at 24 months, but THA had lower reoperation rate (5.3% vs 8.3%). Use shared decision-making with patient/family considering pre-injury function, cognitive status, life expectancy, and patient preferences. **Absolute Contraindications:** - Active sepsis or local infection - Medical instability precluding surgery - Palliative patient with very limited life expectancy (comfort measures only) **Relative Contraindications:** - Severe osteoporosis with concern for periprosthetic fracture (still usually proceed) - Anticoagulation that cannot be reversed (delay if possible) - Significant cardiac disease increasing BCIS risk (consider uncemented) **Internervous Plane:** - Between gluteus maximus (inferior gluteal nerve) and gluteus medius (superior gluteal nerve) - Gluteus maximus is split in line with its fibres, not detached - This is a TRUE internervous plane - no muscle denervation occurs **Superficial Anatomy:** - Greater trochanter - key palpable landmark - Posterior superior iliac spine - incision curves toward this - Gluteal fold - marks inferior extent of gluteus maximus - Femoral shaft axis - incision follows this distally **Exam Key**: "The posterior approach uses a true internervous plane through gluteus maximus between superior and inferior gluteal nerves. I must stay below the safe zone for the superior gluteal nerve - no more than 5cm proximal to the tip of the greater trochanter." **Sciatic Nerve (CRITICAL):** - Location: 2-3cm posterior to posterior acetabular wall - Emerges below piriformis (90%) or through piriformis (10%) - At risk during posterior retractor placement and capsulotomy - Protection: Hip flexed, knee flexed to relax nerve; retractor on ischium not soft tissue **Short External Rotators (Superior to Inferior):** 1. Piriformis - attaches to superior greater trochanter 2. Superior gemellus 3. Obturator internus 4. Inferior gemellus 5. Quadratus femoris - most inferior, lies on lesser trochanter **Vascular Structures:** - Inferior gluteal vessels - emerge below piriformis with sciatic nerve - Superior gluteal vessels - exit above piriformis (protected if stay below) - Medial circumflex femoral artery - deep to quadratus femoris (supplies femoral head - already compromised by fracture) The superior gluteal nerve exits the greater sciatic notch above piriformis and runs on the deep surface of gluteus medius. It is at risk if dissection extends MORE than 5cm proximal to the tip of the greater trochanter. This is the "SAFE ZONE" limit - never violate it. **Hip Joint Capsule:** - Thick anteriorly (iliofemoral ligament - strongest ligament in body) - Thinner posteriorly (ischiofemoral ligament) - Posterior capsule attaches along posterior femoral neck - Zona orbicularis - circular fibres create collar around femoral neck **Capsulotomy Technique:** - T-capsulotomy or posterior longitudinal capsulotomy - TAG the capsule for later repair (reduces dislocation) - Capsule is an important posterior stabiliser **Exam Key**: "Enhanced posterior repair including capsule AND short external rotator reattachment reduces dislocation from 5-10% to 1-2%. I always tag my capsule and rotators before cutting to ensure anatomical repair." **Essential Radiographs:** - AP pelvis - both hips visible for templating comparison - Lateral hip (cross-table or shoot-through) - assess displacement - Traction views may help assess reducibility (rarely needed) **Garden Classification:** - **Grade I**: Incomplete/impacted valgus fracture (stable) - **Grade II**: Complete but undisplaced (stable) - **Grade III**: Complete, partially displaced (varus position) - **Grade IV**: Complete, fully displaced (no trabecular contact) **Templating (Contralateral Hip):** - Femoral head size (determines prosthetic head) - Stem size and offset - Neck cut level relative to lesser trochanter - Leg length assessment **Exam Key**: "I template using the contralateral hip. I measure the femoral head diameter which directly determines my prosthetic head size. I assess neck length from tip of trochanter to head centre and compare post-operatively to confirm leg length restoration." **Target: Surgery Within 36 Hours** - ANZHFR data shows surgery >48 hours associated with increased mortality - Delay for medical optimisation only if clear reversible issue - Do NOT delay for minor abnormalities (mild hyponatraemia, mild anaemia) **Orthogeriatric Co-Management:** - Early geriatrician review (within 24 hours) - Comprehensive geriatric assessment - Delirium prevention strategies (orientation, hydration, mobilisation) - Medication review (anticholinergics, sedatives) **Anticoagulation Management:** - Warfarin: Target INR <1.5 (Vitamin K +/- Prothrombin complex) - DOACs: Withhold for 24-48 hours depending on renal function - Aspirin: Continue (no increased bleeding risk in hip fracture) - Clopidogrel: Balance bleeding vs delay - often proceed **Transfusion Threshold:** - Hb >80 g/L for most patients - Hb >100 g/L if significant cardiac disease - FOCUS trial: Liberal transfusion showed no benefit ANZHFR 2023 data: Only 68% of Australian hip fracture patients receive surgery within 48 hours. Delayed surgery is associated with increased 30-day mortality, pressure injuries, and pneumonia. Advocate strongly for timely surgery. **Cemented vs Uncemented:** - **Cemented** is STANDARD for elderly hip fracture patients - AOANJRR: Cemented 5.9% revision at 10 years vs uncemented 8.1% - Cochrane review: Cemented associated with less pain, better mobility, fewer reoperations - Consider **uncemented** only if: significant cardiac disease (BCIS risk), previous BCIS, patient request **Bipolar vs Unipolar:** - No evidence of difference in acetabular erosion, pain, or function - Bipolar theoretically reduces acetabular wear (inner bearing moves first) - In practice, inner bearing often seizes over time - Most surgeons use bipolar but unipolar equally acceptable **Stem Design:** - Collared stem: Prevents subsidence, transfers load to calcar - Polished tapered (e.g., Exeter): Subsides into cement mantle - Composite beam (e.g., CPT): Designed for cement fixation **Dislocation (1-5%):** - Posterior approach higher risk than anterior (mitigated by enhanced repair) - Enhanced posterior repair reduces to 1-2% - Higher in cognitively impaired (cannot follow precautions) - Management: Closed reduction, hip precautions, revision if recurrent **BCIS (1-2% significant, 0.1% fatal):** - Bone Cement Implantation Syndrome - emboli during cementing - Manifests as hypotension, hypoxia, cardiovascular collapse - Prevention: Third-generation cementing, anaesthetic communication - Higher risk in: cardiac disease, long-stem revision, pathological fracture **Periprosthetic Fracture (1-3%):** - Intraoperative: During preparation or insertion (more common with uncemented) - Postoperative: Falls, usually Vancouver B or C pattern - Risk factors: Osteoporosis, uncemented stems, female sex **Infection (1-2%):** - Deep infection requires DAIR (early) or staged revision (late) - Superficial wound infection managed with antibiotics - Risk factors: Diabetes, immunosuppression, prolonged surgery **Mortality:** - 30-day mortality: 5-8% (Australian data) - 1-year mortality: 20-30% (reflects frailty, not procedure) - This is higher than elective arthroplasty - must counsel family **Medical Complications:** - Cardiac events (MI, arrhythmia): 5-10% - Respiratory (pneumonia, ARDS): 5-10% - Delirium: 15-40% (especially with pre-existing cognitive impairment) - Pressure injuries: 5-10% (reduced with early surgery) - Urinary retention/UTI: 20-30% **DVT/PE (1-3% with prophylaxis):** - Chemical prophylaxis reduces risk significantly - Australian standard: LMWH or DOAC for 35 days - Mechanical prophylaxis intraoperatively **Expected Outcomes:** - 60-70% return to pre-fracture mobility level - Full weight-bearing from Day 1 - Most patients never regain full pre-fracture independence **Hip Precautions (Posterior Approach):** - Avoid hip flexion >90 degrees - Avoid adduction past midline - Avoid internal rotation - Duration: 6-12 weeks (difficult in dementia) **Long-term Considerations:** - Acetabular erosion 10-20% at 10 years (groin pain, limp) - May require conversion to THA (5-10% at 10 years) - Many patients do not survive long enough for this to matter **Exam Key**: "When consenting, I explain this is a major operation with 5-8% 30-day mortality. The goal is to return them to their pre-fracture mobility level which 60-70% achieve. I discuss BCIS risk and the need for DVT prophylaxis for 35 days. For patients with dementia, I acknowledge hip precautions will be difficult to maintain." **HEALTH Trial (NEJM 2019):** - 1,495 patients, displaced femoral neck fractures, age >50 - THA vs hemiarthroplasty - **Primary outcome**: No difference in hip function at 24 months - **Secondary outcome**: THA lower reoperation rate (5.3% vs 8.3%) - **Conclusion**: Both acceptable; patient selection matters **FAITH Trial (JAMA 2017):** - Sliding hip screw vs cancellous screws for femoral neck fractures - No difference in reoperation or complications - Internal fixation high failure rate in elderly (20-40%) **Cochrane Review (2010, updated):** - Cemented hemiarthroplasty: Less pain, better mobility, fewer reoperations - Bipolar vs unipolar: No significant difference in outcomes **Exam Key**: "The HEALTH trial is the key evidence. It showed no difference in function between THA and hemiarthroplasty at 2 years, but THA had lower reoperation (5.3% vs 8.3%). This supports hemiarthroplasty in low-demand elderly where shorter surgery and simpler procedure are beneficial." **AOANJRR Annual Report 2023 - Hemiarthroplasty:** - Cemented hemiarthroplasty: 5.9% cumulative revision at 10 years - Uncemented hemiarthroplasty: 8.1% cumulative revision at 10 years - **Conclusion**: Cemented is SUPERIOR in elderly patients **ANZHFR Annual Report 2023:** - 20,300+ hip fractures in Australia annually - Median time to surgery: 25 hours (target <36 hours) - 68% receive surgery within 48 hours (target >80%) - 30-day mortality: 7.1% (unchanged despite improvements in care) - 120-day mortality: 11.2% **Key Quality Indicators:** - Orthogeriatric assessment: 62% (target 100%) - Surgery within 48 hours: 68% (target >80%) - Mobilisation Day 1: 82% - Return to pre-fracture residence: 64% ANZHFR data drives quality improvement. Best practice includes: surgery within 36 hours, orthogeriatric co-management, fragility fracture identification, and falls prevention. Ensure your unit participates in the registry. **Cemented vs Uncemented Meta-Analysis:** - Parker 2020: 25 RCTs, 3,077 patients - Cemented: Less residual pain, better mobility scores - Uncemented: Higher revision rate, more periprosthetic fractures - BCIS: No significant difference in mortality (BCIS is real but rare) **Third-Generation Cementing:** - Restrictor, lavage, retrograde gun, pressurisation - Achieves 2-4mm cement interdigitation into cancellous bone - Reduces radiolucent lines and aseptic loosening - Standard of care in modern cemented arthroplasty **Posterior vs Lateral Approach:** - Posterior: Faster, less blood loss, better abductor preservation - Lateral (Hardinge): Lower dislocation rate, but abductor damage - Enhanced posterior repair: Reduces dislocation to match lateral rates (1-2%) **Enhanced Posterior Repair Evidence:** - Multiple studies show dislocation reduced from 5-10% to 1-2% - Includes capsular repair AND short external rotator reattachment - Should be STANDARD for posterior approach hemiarthroplasty **Patient Positioning:** - Lateral decubitus position (posterior approach) - Beanbag or dedicated hip positioner - Affected side up - Axillary roll for brachial plexus protection - Lower leg flexed, upper leg supported **Equipment:** - Hemiarthroplasty system (modular or monoblock) - Cemented stem (polished tapered e.g., Exeter, or composite beam) - Bipolar or unipolar heads (sizes 38-58mm typically) - Head sizing gauge - Third-generation cementing equipment: restrictor, cement gun, pressuriser - Pulsatile lavage system - Long-handled retractors (Hohmann, Charnley) **Cement Preparation:** - High-viscosity cement (Simplex P, Palacos) - Vacuum mixing system (reduces porosity) - Cement gun with long nozzle - Restrictor (polyethylene or bone plug) - Proximal pressuriser ### Step 1: Positioning and Preparation Position patient in lateral decubitus with beanbag. Affected hip uppermost. Prep from iliac crest to below knee. Drape to allow limb manipulation. Ensure adequate padding of bony prominences. Confirm antibiotic prophylaxis administered (Cefazolin 2g IV within 60 minutes of incision). **Exam Key**: "I position the patient lateral decubitus with the affected hip up. The beanbag secures the pelvis. I ensure an axillary roll is placed to protect the brachial plexus. The whole limb is prepped and draped free to allow manipulation during the procedure." Check: Axillary roll (brachial plexus), head position (facial pressure), fibular head (common peroneal nerve), medial/lateral malleoli, genitalia (males). Document all padding before draping. Elderly patients with thin skin are particularly vulnerable. ### Step 2: Incision and Superficial Dissection Curvilinear incision centred on greater trochanter, extending 8-10cm distally along femoral shaft and curving 6-8cm proximally toward PSIS. Incise skin and subcutaneous tissue. Identify and incise fascia lata in line with incision. Split gluteus maximus along its fibres (internervous plane - superior gluteal nerve above, inferior gluteal nerve below). **Exam Key**: "I make a curvilinear incision centred on the greater trochanter. After incising fascia lata, I split gluteus maximus in line with its fibres. This is a true internervous plane with superior gluteal nerve above and inferior gluteal nerve below." Never extend proximal dissection more than 5cm above greater trochanter tip. The superior gluteal nerve runs on deep surface of gluteus medius - damage causes abductor weakness and Trendelenburg gait. ### Step 3: Identification of Short External Rotators Retract gluteus maximus to expose short external rotators. From superior to inferior: piriformis, gemelli (superior and inferior with obturator internus between), quadratus femoris. The sciatic nerve lies posterior to these structures. Place posterior retractor carefully on ischium, NOT in soft tissues. **Exam Key**: "After retracting gluteus maximus, I identify the short external rotators from superior to inferior: piriformis, superior gemellus, obturator internus, inferior gemellus, and quadratus femoris. I palpate for the sciatic nerve which lies posterior to these muscles before placing any retractors." - Visualise or palpate sciatic nerve before placing retractors - Keep hip flexed and knee flexed to relax nerve - Posterior retractor on BONE (ischium) not soft tissue - Limit retraction time to reduce neuropraxia risk ### Step 4: Capsulotomy and Dislocation Tag and detach short external rotators (piriformis and conjoint tendon) from their femoral insertion - preserve for later repair. Perform T-capsulotomy or posterior capsulotomy. Internally rotate and flex hip to dislocate. May need to lever femoral head out with bone hook. The fractured head typically remains in acetabulum attached to ligamentum teres. **Exam Key**: "I tag and detach piriformis and conjoint tendon from their femoral insertion, preserving them for repair. I perform a T-shaped capsulotomy, then internally rotate and flex the hip to dislocate. The femoral head is usually in the acetabulum still attached to the ligamentum teres." ALWAYS tag the capsule and short external rotators with stay sutures before detaching. Without tags, accurate anatomical repair is impossible. Enhanced repair reduces dislocation from 5-10% to 1-2% - worth the extra minute. ### Step 5: Femoral Head Removal and Sizing Extract femoral head using corkscrew or bone hook. Measure head diameter with sizing gauge - typically 38-58mm (most commonly 46-50mm). This determines prosthetic head size. Examine acetabulum for pre-existing arthritis, cartilage damage, or acetabular protrusion. **Exam Key**: "I remove the femoral head and measure it with the sizing gauge. This directly determines my prosthetic head size. I inspect the acetabulum - if there is significant pre-existing arthritis, I would consider converting to total hip arthroplasty." Carefully inspect acetabulum for: 1) Pre-existing OA (exposed bone, osteophytes) - consider THA conversion. 2) Rheumatoid protrusion - may need THA. 3) Normal cartilage - proceed with hemiarthroplasty. This decision point should be discussed with patient/family pre-operatively. ### Step 6: Femoral Neck Osteotomy Cut femoral neck at appropriate level for implant system. Typically 1-1.5cm above lesser trochanter (or as per templating). Preserve calcar femorale for collar seating. Use oscillating saw with care to protect soft tissues. Remove remaining neck bone with rongeurs if needed. **Exam Key**: "I use the templated neck cut level, typically 1-1.5cm above the lesser trochanter. I protect soft tissues with retractors and use the oscillating saw with copious irrigation. The cut should be perpendicular to the femoral neck axis and preserve the calcar for collar support." - Too high: Insufficient calcar support for collar, stem subsidence risk - Too low: Risk of calcar fracture, inadequate stem insertion, intraoperative fracture - Always template pre-operatively and confirm level matches plan ### Step 7: Femoral Canal Preparation Insert box chisel or starter awl to open medullary canal - aim laterally to avoid varus. Use T-handle reamer to enter canal in correct alignment. Progressively ream or broach to appropriate size. Maintain 10-15 degrees of anteversion matching native femoral version. Avoid varus positioning of stem. Check rotational alignment frequently. **Exam Key**: "I open the canal with the box chisel, aiming lateral to avoid varus. I broach sequentially to the templated size, maintaining 10-15 degrees of anteversion matching native femoral version. The broach should be stable with no toggle." - Start lateral to avoid varus - varus positioning increases fracture risk and leads to poor outcomes - Ream/broach sequentially - never skip sizes - If resistance encountered, check alignment before forcing - Any crack heard = STOP and assess for fracture (may need cables/cerclage) ### Step 8: Trial Reduction Insert trial stem with trial head matching measured size. Reduce hip and assess: - Stability in flexion-internal rotation (posterior approach prone) - Stability in extension-external rotation (anterior approach prone) - Leg length (compare to contralateral with knees together, heels level) - Soft tissue tension and impingement (should require moderate force to dislocate) Adjust head/neck offset if modular system allows. Document trial stability for operative note. **Exam Key**: "During trial reduction I assess: 1) Stability - particularly in flexion/internal rotation for posterior approach (should require at least 90° flexion, 45° IR to dislocate), 2) Leg length - knees together, heels level comparing to contralateral, 3) Soft tissue tension - moderate shuck test, 4) Range of motion without impingement." If unstable during trial: Consider larger head (increases jump distance), different offset (increases tension), or accept that patient needs strict hip precautions. Do NOT proceed to final implantation without addressing instability. Document findings. ### Step 9: Third-Generation Cementing Technique **For cemented hemiarthroplasty (standard in elderly):** 1. **Restrictor Placement**: Insert cement restrictor 2cm distal to planned stem tip 2. **Pulsatile Lavage**: Thoroughly wash canal with jet lavage to remove debris and fat 3. **Dry Canal**: Pack with swabs, use suction to achieve dry canal 4. **Mix Cement**: Vacuum-mix high-viscosity cement to doughy phase 5. **Retrograde Filling**: Apply cement with gun from restrictor proximally 6. **Pressurisation**: Maintain digital or mechanical pressure during filling 7. **Stem Insertion**: Insert stem slowly with controlled pressure 8. **Maintain Pressure**: Continue pressurising around stem until cement cured **Exam Key**: "I use third-generation cementing technique. First, I place a restrictor 2cm distal to the stem tip. I lavage the canal with pulsatile irrigation and dry it thoroughly. I mix high-viscosity cement in a vacuum system and apply it retrograde with a cement gun. I maintain pressurisation during insertion and until the cement fully cures. This achieves optimal cement interdigitation of 2-4mm." - Communicate with anaesthetist before cementing - Pulsatile lavage removes fat and debris reducing emboli - Slow, controlled stem insertion reduces intramedullary pressure - Have vasopressors and resuscitation ready - Consider uncemented in patients with severe cardiac disease ### Step 10: Final Implantation Insert definitive stem and head. For bipolar: assemble inner head to stem, then outer shell (confirm locking mechanism engaged). For unipolar: single head component. Reduce hip and confirm stability with same tests as trial. Check leg length. Document final implant sizes including stem, head diameter, and neck length. **Exam Key**: "After cementing, I insert the definitive stem maintaining position until cement fully cured. I assemble the head (inner head to stem, then outer bipolar shell if used). I confirm the locking mechanism is engaged, reduce the hip, and repeat my stability assessment. I document all component sizes." Before closing: 1) Confirm head is fully seated on taper (visual and tactile check), 2) Bipolar shell locked to inner head (audible/visual click), 3) Stability confirmed same as trial, 4) All swabs and instruments counted correct. Never close without confirming head assembly. ### Step 11: Posterior Capsular Repair Repair posterior capsule with strong absorbable or non-absorbable suture (e.g., No. 2 Ethibond or FiberWire). Reattach short external rotators (piriformis, conjoint tendon) to their femoral insertion through drill holes or trans-osseous technique. This enhanced soft tissue repair reduces dislocation rate from 5-10% to 1-2%. **Exam Key**: "I perform enhanced posterior repair which is ESSENTIAL for reducing dislocation. I repair the capsule first, then reattach the short external rotators through drill holes in the greater trochanter using strong non-absorbable suture. This reduces dislocation from 5-10% to 1-2%." Enhanced posterior repair should be STANDARD OF CARE for posterior approach hemiarthroplasty. Evidence strongly supports reduced dislocation (from 5-10% to 1-2%). This includes: 1) Capsular repair, 2) Short external rotator reattachment through bone. Never skip this step. ### Step 12: Closure Copious irrigation (at least 1-2L saline). Meticulous haemostasis. Optional drain (controversial - I use based on bleeding/anticoagulation). Close fascia lata over gluteus maximus with strong absorbable suture (e.g., 0 Vicryl). Subcutaneous layer with absorbable suture. Skin with staples or subcuticular suture. Sterile, waterproof dressing. Post-operative radiograph in recovery. **Exam Key**: "I perform copious irrigation (1-2 litres) and meticulous haemostasis. I close fascia lata first as this is the strength layer (0 Vicryl). I may use a drain depending on bleeding. Subcutaneous closure reduces dead space. I use either staples or subcuticular suture for skin and apply a waterproof dressing." 1) Final swab and instrument count CORRECT, 2) Post-operative X-ray ordered, 3) Implant details documented (sticker in notes), 4) VTE prophylaxis prescribed, 5) Antibiotics discontinued (single dose unless specific indication), 6) Weight-bearing status documented. Never leave theatre without X-ray arranged. **Immediate Post-operative:** - Full weight-bearing as tolerated from Day 1 - DVT prophylaxis: LMWH or DOAC for 35 days (Australian standard) - Tranexamic acid if not contraindicated - Orthogeriatric co-management for medical issues **Mobilisation:** - Sit out of bed Day 0-1 - Stand and walk with frame Day 1 - Physiotherapy for gait training, stairs, transfers - Hip precautions for 6-12 weeks (posterior approach): avoid flexion >90 degrees, adduction beyond midline, internal rotation **Follow-up:** - Radiograph before discharge - Wound check at 2 weeks - Review at 6 weeks with radiographs - Further follow-up only if symptomatic **Red Flags:** - Increasing pain after initial improvement (infection, dislocation) - Wound discharge or erythema - Fever - Inability to weight-bear 1. HEALTH Investigators. Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture. *N Engl J Med*. 2019;381(23):2199-2208. 2. Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR). Hip, Knee & Shoulder Arthroplasty: 2023 Annual Report. Adelaide: AOA. 3. Donaldson AJ, Thomson HE, Harper NJ, Kenny NW. Bone cement implantation syndrome. *Br J Anaesth*. 2009;102(1):12-22. 4. Parker MJ, Gurusamy KS, Azegami S. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. *Cochrane Database Syst Rev*. 2010;(6):CD001706. 5. Rogmark C, Leonardsson O. Hip arthroplasty for the treatment of displaced fractures of the femoral neck in elderly patients. *Bone Joint J*. 2016;98-B(3):291-297. 6. NICE Guideline NG124. Hip fracture: management. National Institute for Health and Care Excellence. 2017 (updated 2023). 7. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. *J Bone Joint Surg Am*. 2006;88(2):249-260. 8. Bhandari M, Devereaux PJ, Swiontkowski MF, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck. *J Bone Joint Surg Am*. 2003;85(9):1673-1681. 9. Australian and New Zealand Hip Fracture Registry (ANZHFR). Annual Report 2023. Hip fracture care in Australia and New Zealand. 10. Kristensen TB, Dybvik E, Kristoffersen M, et al. Cemented or Uncemented Hemiarthroplasty for Femoral Neck Fracture? Data from the Norwegian Hip Fracture Register. *Clin Orthop Relat Res*. 2020;478(1):90-100.