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Selected

Instructional
Course Lectures
The American Academy of Orthopaedic Surgeons
R OBERT A. H ART
EDITOR, VOL. 63

C OMMITTEE
R OBERT A. H ART
CHAIR

C RAIG J. D ELLA V ALLE

M ARK W. P AGNANO
T HOMAS W. T HROCKMORTON
P AUL T ORNETTA III
E X -O FFICIO
D EMPSEY S. S PRINGFIELD
DEPUTY EDITOR OF THE JOURNAL OF BONE AND JOINT SURGERY
FOR INSTRUCTIONAL COURSE LECTURES

Printed with permission of the American Academy of

Orthopaedic Surgeons. This article, as well as other lectures
presented at the Academys Annual Meeting, will be available
in March 2014 in Instructional Course Lectures, Volume 63.
The complete volume can be ordered online at www.aaos.org,
or by calling 800-626-6726 (8 A.M.-5 P.M., Central time).

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Geriatric Trauma: The Role of

Immediate Arthroplasty
Andrew H. Schmidt, MD, Jonathan P. Braman, MD, Paul J. Duwelius, MD, and Michael D. McKee, MD, FRCS(C)
An Instructional Course Lecture, American Academy of Orthopaedic Surgeons

Periarticular fractures in the elderly are

difficult to stabilize, and nonoperative
treatment is not well tolerated. Surgery
is usually indicated, but standard techniques of internal fixation often fail in this
age group because of osteopenic bone
and fracture comminution. These factors
often prevent sufficient fixation to allow
early weight-bearing, which is of critical
importance in the geriatric patient.
In contrast, immediate arthroplasty of periarticular fractures in the
elderly allows immediate mobilization
of the patient. The purpose of this
Instructional Course Lecture is to review
the role of immediate arthroplasty in
four common fractures that occur in the
elderly: the proximal and distal end of
the humerus, the acetabulum, and the
proximal part of the femur.
Shoulder Arthroplasty for Proximal
Humeral Fractures
Proximal humeral fractures are the third
most common fracture in the elderly
after wrist and hip fractures. They have a
substantial impact on quality of life even
when they are minimally displaced and

do not require surgery1. Factors consistently associated with poor outcomes

after either nonoperative management
or open reduction and internal fixation
(ORIF) are advanced patient age, fracture comminution, varus angulation of
the humeral head, and osteoporosis2-7.
Appropriate indications for shoulder
arthroplasty in patients with a complex
proximal humeral fracture are a dysvascular humeral head, a patient who
cannot tolerate the limitations that accompany nonsurgical treatment, and
a comminuted and/or varus displaced
fracture pattern, especially when associated with poor bone quality that
precludes ORIF.
Shoulder function following
hemiarthroplasty depends on anatomic
reduction and secure, stable tuberosity
fixation8. Reverse total shoulder arthroplasty is an attractive option for elderly
patients with displaced proximal humeral fractures since restoration of rotator cuff function is not as critical.
Expected patient activity level and longevity are the primary considerations for
choosing between reverse total shoulder

arthroplasty and shoulder hemiarthroplasty: reverse total shoulder arthroplasty is better for sedentary and elderly
patients, while shoulder hemiarthroplasty is better for patients with higher
activity levels (Figs. 1-A and 1-B)9,10.
Although short and intermediate-term
results of reverse total shoulder arthroplasty are reasonable, no long-term data
that estimate the longevity of these
devices in these patients are available,
and salvage options are limited.
Hemiarthroplasty of the Shoulder
Surgery is performed using a long
(15-cm) deltopectoral approach with the
patient in the beach-chair position. The
coracoacromial ligament is preserved
since this is an important secondary
restraint preventing anterosuperior escape of the humeral head if the greater
tuberosity does not heal. We tenodese the
biceps tendon. Large sutures are placed
at the bone-tendon interface of the
greater and lesser tuberosities to provide
control of the greater and lesser tuberosity fragments. External rotation of the
arm improves reduction of the greater

Disclosure: None of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of any
aspect of this work. One or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this
work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. Also, one or
more of the authors has had another relationship, or has engaged in another activity, that could be perceived to influence or have the potential to influence
what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of
the article.

J Bone Joint Surg Am. 2013;95:2231-9

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Fig. 1-A

Fig. 1-B

Figs. 1-A and 1-B A seventy-five-year-old woman who sustained a four-part fracture of the proximal part of the humerus, including comminution of the
humeral head and displacement of the tuberosities, in a fall from a standing height that involved her nondominant arm. Fig 1-A Preoperative
anteroposterior radiograph of the injured shoulder. Fig. 1-B Radiograph made after reverse total shoulder arthroplasty.

tuberosity. If there is a periosteal sleeve

that remains in place, we attempt to leave
it to facilitate reduction and stability.
However, in fractures that are more than
a few days old, contracture of the periosteum can preclude reduction of the
tuberosities and release may be needed. A
fracture-specific stem may improve the
outcome and should allow conversion to
a reverse total shoulder arthroplasty if
necessary11-13. Suture fixation must provide interfragmentary compression fixation between tuberosity fragments,
between the tuberosities and the humeral
shaft, and around the neck of the
implant14.
Proper positioning of the stem can
be difficult because the normal osseous
landmarks of the proximal part of the
humerus no longer exist. Achieving both
the correct retroversion and height of
the humeral head are critical for restoration of shoulder biomechanics and
function. Typically, the prosthetic humeral head should be placed in slightly
less than anatomic retroversion (20) to

reduce tension on the greater tuberosity

repair. Restoration of the height of the
humeral head is also challenging.
Krishnan et al. described the Gothic
arch to help to obtain the correct
hemiarthroplasty height15. Fortunately,
the pectoralis major tendon is
rarely torn in this injury, and both
Murachovsky et al.16 and Greiner et al.17
described its use as a landmark for the
assessment of humeral head height.
According to Murachovsky et al., the
mean distance (and 95% confidence
interval) between the top of the humeral
head and the top of the pectoralis major
tendon is 5.6 0.5 cm, which will help
in the accurate restoration of the humeral head position. Stems should be
cemented to obtain rotational control.
Total Shoulder Arthroplasty
Many surgeons perform reverse total
shoulder arthroplasty through the deltopectoral interval because of their comfort
with this approach. Additionally, ORIF
can be performed using the same

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approach, facilitating conversion from

one procedure to the other if intraoperative findings warrant. Other authors have
preferred the superolateral approach for
reverse total shoulder arthroplasty18. This
approach releases the anterior deltoid
muscle from the acromion and uses a split
in the anterolateral raphe of the deltoid
for access to the humeral shaft. The
humerus is exposed and reamed, and the
glenoid is addressed. Excellent en face
glenoid access is imperative for reverse
total shoulder arthroplasty. The height of
the implant is determined by assessing
tension in the deltoid and coracobrachialis muscles, which should be tight
enough so that the implants do not
dislocate, but are not difficult to reduce.
Tuberosity fixation is important in reverse
total shoulder arthroplasty following
fracture as it allows proper rotational
control of the arm after healing. Consequently, secure suture repair of the tuberosities to the humeral shaft, humeral
stem, and to each other is performed.
Humeral stems should be cemented in

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reverse total shoulder arthroplasty to

provide rotational stability of the
construct.
Overview
Reverse total shoulder arthroplasty and
shoulder hemiarthroplasty are both surgical options for comminuted fractures
of the proximal part of the humerus in
elderly patients with a dysvascular humeral
head and/or severe fracture comminution.
Younger patients should be treated with
ORIF whenever possible. Patients who are
more active or physiologically younger
should undergo shoulder hemiarthroplasty with a convertible implant. Reverse
total shoulder arthroplasty may be more
predictable for restoring the ability to
perform the activities of daily living for
elderly or sedentary patients with this
injury, especially those with an expected
life span of less than ten years.
Total Elbow Arthroplasty for
Fractures of the Distal End
of the Humerus
Improved surgical techniques, tricepssparing approaches, and anatomic pre-

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contoured plates have improved

outcomes following ORIF of intraarticular distal humeral fractures.
However, complications remain frequent in elderly patients with severe
fracture comminution and poor bone
quality. Suboptimal plate fixation in
osteopenic bone often leads to nonunion and more complications. Nonunion
or malunion of the distal end of the
humerus causes substantial impairment
in the functional ability and level of
independence of a patient19.
Total elbow arthroplasty is an
alternative to ORIF for comminuted,
intra-articular distal humeral fractures
in elderly patients (Figs. 2-A and 2-B).
Total elbow arthroplasty is reserved for
elderly patients only; it is not an option
for younger, higher-demand individuals. Primary total elbow arthroplasty
for elbow fracture was first reported, to
our knowledge, in 1997 by Cobb and
Morrey, who described twenty-one
elbows in twenty patients (mean age,
seventy-two years) with comminuted
distal humeral fractures that were
managed with a primary total elbow

Fig. 2-A

arthroplasty, resulting in a good or

excellent outcome in 95% of the twenty
elbows with complete data and only
one reoperation in the entire cohort20.
Other retrospective reviews from single
centers have confirmed similar, consistently reliable results21,22. In the first
comparative study, Frankle et al. performed a retrospective comparison of
ORIF and total elbow arthroplasty for
intra-articular distal humeral fractures
in twenty-four women older than sixtyfive years23. At the time of the shortterm follow-up, the patients who had
total elbow arthroplasty had excellent
or good results, with improved range
of motion and less need for physical
therapy than those who had ORIF, and
25% of patients treated with ORIF had
a mechanical failure that required revision to total elbow arthroplasty. Recently, in a randomized prospective
trial comparing ORIF and total elbow
arthroplasty for comminuted intraarticular distal humeral fractures in
elderly patients, McKee et al. reported
that total elbow arthroplasty improved
functional outcome compared with

Fig. 2-B

Figs. 2-A and 2-B A ninety-year-old man with an intra-articular distal humeral fracture. Fig. 2-A Preoperative axial computed tomographic image showing the
displaced distal humeral fragments. Fig. 2-B Lateral elbow radiograph made three months after total elbow reconstruction.

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ORIF on the basis of both objective

elbow performance scores and patientrated upper extremity disability and
symptoms24. They emphasized that the
mean age of the patients in their study
was close to eighty years of age, and that
this procedure is not suitable for
younger patients.

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Active infection or insufficient

soft-tissue coverage
Advanced dementia or noncompliance issues (e.g., substance abuse)
Extensor mechanism disruption (a
relative contraindication)
A type-2 or 3 open fracture
A young, active, high-demand
patient
Simple fracture pattern (i.e., two
articular fragments)

total elbow arthroplasty following a

distal humeral fracture. While some
promising preliminary results are
available for distal humeral hemiarthroplasty (typically with an anatomic
distal humeral replacement) that may
extend the indications for this procedure to younger patients, such an
approach should be considered experimental at present26.
The patient is placed in the lateral
decubitus position with the affected arm
free-draped over a bolster, with a tourniquet applied. A posterior approach is
used; the ulnar nerve is identified and
protected. The olecranon is not osteotomized; this compromises the insertion
and stability of the ulnar component.
When the fractured articular fragments
or condyles are excised, this creates a socalled working space allowing the humerus and ulna to be instrumented
and the components inserted without
detaching the triceps. Condylar resection does not appear to negatively
affect forearm or wrist strength, and
the condyles are not required for ligament attachment or stability when a
linked prosthesis is used27. If greater
exposure is required, the triceps can be
split or peeled from the olecranon28,29.
Following insertion of the prosthesis,
thorough irrigation and standard closure are performed: the ulnar nerve
remains in a tension-free position medially. A major benefit of the linked
total elbow arthroplasty in general
and the so-called triceps-on approach
in particular is the ability to allow
immediate full range of active motion
postoperatively. This enhances the
elbow-specific outcome, rapidly restores independent function to the
patient, and minimizes hospital and
rehabilitation time.

Technique
Total elbow arthroplasty for a fracture
requires the correct implant, equipment, and an experienced operatingroom staff and surgeon. The fracture is
splinted until conditions are optimized
for surgery; a wait of up to fourteen
days is rarely detrimental if required. A
cemented, linked, or semiconstrained
prosthesis is the treatment of choice for

Overview
Primary semiconstrained total elbow
arthroplasty has a role in the treatment of comminuted intra-articular
fractures of the distal end of the
humerus in selected elderly patients.
In this specific group, it results in
improved patient outcome compared
with ORIF, enhances the return
to independent function, and minimizes

Indications and Contraindications

While total elbow arthroplasty produces
reliably good results in the appropriate
patient, careful adherence to patient
selection and surgical technique are
critical.
Indications

A low-demand patient with an age

of more than sixty-five years
Preexisting, symptomatic arthritis
of the elbow
Articular comminution (typically
three or more articular fragments)
A closed or type-1 open fracture25
(if the arthroplasty is done within eight
to twelve hours of injury and satisfactory
debridement is obtained)
Delayed presentation with articular fragmentation rendering reconstruction unfeasible
Associated severe ligamentous damage and/or elbow instability
Contraindications

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hospital stay and rehabilitation

time.
ORIF and Immediate Total Hip
Replacement for the Management
of Selected Displaced Acetabular
Fractures in the Elderly
The recommended treatment for most
displaced acetabular fractures is ORIF30,31.
Acetabular fractures in the elderly are an
increasingly common injury pattern32-34.
In the elderly, these fractures are more
likely the result of a low-energy fall than
high-energy trauma34,35, yet they are often
comminuted with major displacement
and impaction of the articular surface32,33,36. Early mobilization of these
fragile patients is of primary importance
in restoring them to their preinjury level
of function, as well as preventing complications from prolonged recumbency37.
The difficulty of obtaining a satisfactory
result with internal fixation and the
common need for a delayed total hip
replacement to treat failed internal fixation in these patients makes initial prosthetic replacement attractive38-43. One
approach is to initially manage these
patients nonoperatively, performing delayed total hip replacement once the
fracture has healed in symptomatic patients36. However, delayed arthroplasty
following acetabular fracture in the elderly has inferior results compared with
primary arthroplasty for degenerative
disease41. Immediate total hip replacement with acetabular reconstruction allows early mobilization and lessens the
risk of subjecting the patient to two
major surgical procedures in a relatively
short time period (Figs. 3-A and 3-B).
The challenge of immediate total
hip replacement is to obtain stable acetabular component fixation, and to be
able to allow the patients early activity
without compromising fixation of the
implants or hip stability. In fact, reports of
this approach published several decades
ago noted problems with fixation of the
cemented acetabular component44. In
the last decade, there has been renewed
interest in treating selected acetabular
fractures with early total hip replacement33,42,45-48. Beaule et al. reported the
cases of ten patients managed with open
reduction and acute total hip replacement

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immobilization. The average Merle

dAubigne and Postel score was 16, indicating a good outcome. More recently,
Boraiah et al. described eighteen patients
who were treated by a protocol very
similar to ours and were followed for at
least one year; those authors also reported
one early acetabular failure requiring
revision surgery, while 81% of their
patients had good or excellent results
according to the Harris hip score48.
ORIF of the acetabulum and immediate total hip replacement is a
complex procedure that should be
performed by surgeons adept at both
surgical fixation of acetabular fractures
and total hip replacement. Published
results have indicated that functional
outcomes are similar to those after
primary total hip replacement for
osteoarthritis35,46.

Fig. 3-A

Fig. 3-B

Figs. 3-A and 3-B A seventy-six-year-old woman with osteoporosis who sustained a displaced acetabular fracture on the right side. Fig. 3-A Preoperative anteroposterior pelvic radiograph showing
the displaced acetabular fracture with the femoral head protruding into the fracture site. Fig. 3-B
Anteroposterior pelvic radiograph after internal fixation and immediate total hip replacement.

utilizing a direct anterior surgical approach for anterior wall or column

fractures in the elderly46. At an average
follow-up of three years, none of the

patients had nonunion or component

loosening or migration. One patient had
an anterior dislocation that was treated
successfully with closed reduction and

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Technique
Patients undergo surgery as soon as
possible after admission and thorough
evaluation by the orthopaedic, trauma,
and/or internal medicine services as
indicated by their injuries and medical
comorbidities (if any). Surgical procedures are usually done within two
to four days. Patients with fracturedislocations have their hip reduced immediately in the emergency department
with deep intravenous sedation. If the
hip is unstable following closed reduction, skeletal traction is placed, typically
through the distal end of the femur.
Subcutaneous heparin (5000 units
three times daily) and pneumatic
compression stockings are routinely
used for prophylaxis against venous
thromboembolism.
We initially repair the acetabular
fracture using standard techniques of
internal fixation as appropriate for the
fracture pattern. The goal of the internal
fixation is to reduce and stabilize the
anterior and/or posterior columns, not to
restore the articular surface. In patients
with major displacement of the anterior
column, an ilioinguinal approach or
Stoppa approach with the patient supine
is used to reduce and plate the pelvic brim
(Figs. 3-A and 3-B). Next, or for fractures
primarily involving the posterior wall
and/or column, a Kocher-Langenbeck

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approach is used with the patient in the

lateral decubitus position. Following exposure of the greater trochanter, the short
external rotators are released and tagged
with suture for later repair. A hip capsulotomy is performed, maintaining capsular flaps for later repair. The femoral
head is dislocated, the femoral neck cut,
and the femoral head removed in the
standard fashion. A cobra retractor is
placed over the anterior wall of the
acetabulum, and any posterior wall fragments are identified. The acetabular
labrum is excised. If there is a fracture of
the posterior column, the posterior column is carefully exposed and reduced
with clamps. If the posterior wall requires
reconstruction, an acetabular trial that is
similar in size to the resected femoral
head is selected and placed in the acetabulum for use as a template for reconstruction. The posterior wall fragment(s)
are repositioned against the acetabular
trial component, and the posterior wall
and column of the acetabulum are stabilized with a posterior buttress plate.
After the posterior wall and/or
column are stabilized, any residual bone
defects resulting from articular impaction or comminution are bone-grafted
using cancellous bone from the patients
femoral head. Following repair of the
acetabulum, total hip arthroplasty is
then performed through the same incision. The acetabulum is prepared with
standard reaming with medialization of
the cup to the floor of the cotyloid fossa.
For uncemented cups, once bleeding
subchondral bone is reached, a cup
1 mm larger than the outside diameter
of the last reamer is selected and
implanted with an interference fit. The
acetabular component is anchored
with additional screw fixation into the
ilium. Standard femoral canal preparation and femoral stem placement are
employed, using uncemented, proximally porous-coated implants in most
patients (Figs. 3-A and 3-B).
Postoperative Treatment
Patients receive prophylactic antibiotics
for twenty-four hours and are started on
warfarin or low-molecular-weight heparin postoperatively, which is continued
for four weeks following discharge.

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Prophylaxis against heterotopic ossification using low-dose radiation (a single

dose of 600 Gy) is recommended for
male patients who have a posterior
fracture-dislocation. Patients with displaced anterior or posterior column
fractures are mobilized with crutches or
a walker for six weeks. Patients with
isolated posterior wall fractures are
allowed full weight-bearing immediately. Patients are instructed to avoid hip
flexion beyond 90 and to sleep with a
pillow between their legs.
Displaced Femoral Neck Fractures:
The Case for Total Hip Replacement
Total hip replacement for the treatment
of displaced femoral neck fractures
(Fig. 4) in the elderly leads to improved
outcomes, fewer complications, and
decreased cost compared with other
treatment techniques of internal fixation or hemiarthroplasty. The incidence of hip fractures in the United
States in 1996 was approximately
250,000 cases, with projections that this

would increase to 500,000 fractures per

year by 204049. Thus, the management
of femoral neck fractures in a costeffective manner is of societal importance, not to mention the consequences
for the individual patient when complications of care occur.
This section reviews the role of
arthroplasty in the management of
fractures of the femoral neck: when
to replace the hip, which device to use,
and whether to cement or press-fit the
implant. Hemiarthroplasty has been the
preferred management for femoral neck
fractures that are not ideal for internal
fixation because of advanced patient age
and/or osteopenia. Advantages of hemiarthroplasty compared with total hip
arthroplasty are the quick and relatively
simple surgical technique and a documented low risk of dislocation50. The
main disadvantages of hemiarthroplasty
include the potential for rapid wear of
acetabular articular cartilage (requiring
conversion to total hip replacement) and
pain related to the metallic femoral head

Fig. 4

Preoperative (left) and postoperative (right) radiographs of a displaced femoral neck fracture in a
seventy-three-year-old woman who was treated with primary total hip arthroplasty.

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against the host acetabulum

(chondrolysis).
The justification for prosthetic
replacement in the treatment of femoral
neck fractures resides in the fact that
arthroplasty provides optimal functional recovery. The literature overwhelmingly supports arthroplasty for
the treatment of the displaced femoral
neck fracture in the elderly51-65. Complications and the need for multiple
procedures are decreased when total hip
replacement is utilized over other treatment options.
Schmidt et al. recently provided a
comprehensive review of the literature
regarding the optimal arthroplasty for
displaced femoral neck fractures63. Iorio
et al. conducted a survey in 2006 that
revealed that most surgeons preferred
treating geriatric patients with displaced
femoral neck fractures with bipolar arthroplasty66. However, at the time of their
survey, surgical practice was changing
because of the recent introduction of
highly cross-linked polyethylene and
larger femoral heads to decrease dislocation rates. Newer stem designs also were
proven to be successful in elderly patients
with femoral neck fractures67. The Displaced Femoral (neck fracture) Arthroplasty Consortium for Treatment and
Outcomes reported the results of their
prospective, multicenter randomized
clinical trial comparing hemiarthroplasty
and total hip arthroplasty in 2008, finding
that total hip replacement had superior
results58.
Treatment choices for displaced
femoral neck fractures might differ
depending on which outcome criteria we
consider. Possible criteria include complication rates, cost-effectiveness, and
short and long-term outcomes. Iorio
et al. presented a cost-effectiveness analysis of four surgical treatments for a
displaced femoral neck fracture68. This
series considered initial hospital costs,
rehabilitation costs, and costs of reoperations and complications. Those authors
determined that cemented total hip
replacement was the most cost-effective
treatment and that internal fixation was
the most expensive option68.
A highly compelling study is the
Scottish Trial of Arthroplasty or Reduc-

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tion (STARS) for subcapital femoral

neck fractures57. This multicenter randomized study showed that long-term
function was best after total hip replacement. The STARS study revealed
an incidence of osteonecrosis of 20%
and nonunion rates of 30% in the ORIF
group, consistent with prior studies. The
reoperation rate was much higher for
the internal fixation group, which had a
failure rate of 37%. Chondrolysis, which
generally manifested itself as pain, occurred in 20% of the bipolar-monopolar
treatment group, with a reoperation rate
of 5%. A systematic review of fixation
options indicated that cemented hip
replacement is associated with less pain
than uncemented hip replacement in
patients with a hip fracture69. This
finding was further substantiated in a
recent study supporting cemented stems
as being superior to bone ingrowth
stems70. In the STARS study, the total hip
replacement treatment group had the
best functional outcome and the least
pain, the lowest cost, and a reoperation
rate of 9%. Healy and Iorio also reported
better results and lower cost with total
hip replacement71. Several randomized
prospective series lend credence to the
fact that arthroplasty leads to better
results than internal fixation of displaced femoral neck fractures55-58,60,62,64.
Displaced femoral neck fractures
pose certain problems for the treating
surgeon. The randomized controlled
trial by Blomfeldt et al., which compared bipolar hemiarthroplasty with
total hip replacement for displaced intracapsular fractures of the femoral neck
in elderly patients, revealed superior
results in the total hip replacement
group in all outcomes parameters compared with the bipolar group, utilizing
the anterolateral approach in all cases to
reduce the risk of dislocation typically
associated with posterior approaches72.
However, capsular repair and use of a
large femoral head may mitigate the
dislocation risk when posterior approaches are done61,73. Berry et al. further described how the dislocation rate
can be decreased with careful attention
to detail, such as using larger femoral
heads, highly cross-linked polyethylene,
and capsular closure74. The surgeon may

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therefore use whatever surgical approach he or she is most comfortable

with. Surgical techniques are more difficult in displaced femoral neck fractures
compared with elective total hip replacement. Poor bone quality, intraoperative instability, and difficulties
with abnormal anatomy due to the
displaced fracture present unique problems. The surgeon can base his or her
preoperative plan on the nonfractured
side to best evaluate for stem size,
head center, limb length, and offset.
Technical pearls include the use of a
larger femoral head, careful reaming,
restoration of appropriate limb length
and offset, repair of the hip capsule, and
use of multiple acetabular screws with
compromised bone quality. Controversy
remains about whether to cement or
press-fit the femoral component53,70,72.
Treatment of these difficult fractures involves certain parameters that
are outside the surgeons control such as
the patients age, mental status, bone
quality, fracture pattern, time to diagnosis, and comorbidities. However, the
surgeon does have control over many
factors that are critical in the treatment
of these fractures. These include the
timing of surgery, choice of surgical
approach, restoration of hip center, use
of larger femoral heads to decrease the
prevalence of dislocation, capsular closure, and surgical experience. No single
approach works best for all fracture
types. However, for displaced femoral
neck fractures, the surgeon should give
strong consideration to the treatment of
these difficult fractures with a total hip
replacement to decrease cost, lower
complications, and restore the best
postoperative function.

Andrew H. Schmidt, MD
Department of Orthopedic Surgery,
Hennepin County Medical Center,
701 Park Avenue, Mailcode G2,
Minneapolis, MN 55415.
E-mail address: schmi115@umn.edu
Jonathan P. Braman, MD
Department of Orthopaedic Surgery,
University of Minnesota,
2450 Riverside Avenue South,

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#R200, Minneapolis, MN 55454.

E-mail address: brama011@umn.edu
Paul J. Duwelius, MD
Orthopedic and Fracture Specialists,
11782 SW Barnes Road, Suite 300,
Portland, OR 97225.
E-mail address: pduwelius@gmail.com

G E R I AT R I C T R AU M A : T H E R O L E

OF

I M M E D I AT E A R T H R O P L A S T Y

Michael D. McKee, MD, FRCS(C)

Division of Orthopaedic Surgery,
Department of Surgery,
University of Toronto,
St. Michaels Hospital,
55 Queen Street East, Suite 800,
Toronto, ON M5C 1R6, Canada.
E-mail address: mckeem@smh.ca

Printed with permission of the American Academy

of Orthopaedic Surgeons. This article, as well as
other lectures presented at the Academys Annual
Meeting, will be available in March 2014 in
Instructional Course Lectures, Volume 63. The
complete volume can be ordered online at
www.aaos.org, or by calling 800-626-6726
(8 a.m.-5 p.m., Central time).

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