Choosing Between Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fractures: Patient Selection is the Key

Q: Is there a general consensus among orthopaedic surgeons about how best to choose between total hip arthroplasty (THA) versus hemiarthroplasty for their patients with femoral neck fractures?

Davis: No. There are conflicting opinions about which of these procedures is best suited to particular patients. Studies from individual centers tend to emphasize the improved functional outcomes in patients who have a THA, while national registry data tends to demonstrate the lower complication rate with hemiarthroplasty. The differences may relate to the patient populations in each study and the technical skills of the surgeons. Outcomes from each type of study are valuable. Surgeons and patients should balance the risks and benefits to determine the best approach for each individual patient.

Q: Based on your interpretation of the available registry data, what are the main advantages and disadvantages of THA?

Davis: Compared to hemiarthroplasty, THA yields better pain relief and patients are able to walk farther, on average. Disadvantages, however, include longer surgical time, increased dislocation risk, and potential for acetabular component loosening. Several countries have registry data that suggest rates of complications, including dislocation, are higher with THA versus hemiarthroplasty. Also in most hip fracture cases, the acetabular bone stock is softer and the acetabular fixation is less secure than in arthritic hips with denser bone. In my opinion, the literature supports THA as the procedure of choice for younger more active patients and those with pre-existing arthritis. (Figure 1)

Total Hip Arthroplasty (THA)

FIGURE 1A: Patient with femoral neck fracture for THA. FIGURE 1B: Patient X-ray after surgery. FIGURE 2: Appropriate candidate for hemiarthroplasty; 64-year-old man who fell on ice.

Q: Please detail the advantages and disadvantages of hemiarthroplasty.

Davis: With hemiarthroplasty, surgical time is shorter and the risk of complications, such as dislocation, is lower compared to THA. On the other hand, hemiarthroplasty tends to have more residual pain and shorter walking distance. I consider hemiarthroplasty a good choice for older, less active patients who have suffered a femoral neck fracture, but do not have extensive arthritis (Figure 2). In these types of patients, the acetabulum is often in good condition and there is sufficient healthy cartilage in the joint to support a hemiarthroplasty. Because they are less active, they may not be as bothered by limited walking distance or residual pain. Also, because these patients are often in poor health, minimizing the need for a secondary surgery due to complications may be a paramount concern, making hemiarthroplasty the better choice.

Q: In your opinion, why is it important for orthopaedic surgeons to understand the issues surrounding THA versus hemiarthroplasty?

Davis: As the baby boom population continues to age, problems like hip fracture, secondary to osteoporosis and falls, are becoming increasingly more common. The need for hip surgery and the subsequent potential for long-term loss of function will be a large-scale national health issue. I think by weighing better function against the risk of complications in the context of what each patient needs, we’ll achieve the best outcomes possible.


Charles Davis, III, M.D.Charles M. Davis, III, M.D., Ph.D.
Professor, Orthopaedics and Rehabilitation
Chief, Hip and Knee Joint Arthroplasty
PHONE: 717-531-5638
E-MAIL: cdavis2@hmc.psu.edu
FELLOWSHIP: Adult reconstruction, Mayo Clinic, Rochester, Minnesota
RESIDENCY: Orthopaedic surgery, Mayo Clinic, Rochester, Minnesota
MEDICAL SCHOOL: Vanderbilt University School of Medicine, Nashville, Tennessee


REFERENCES:

1. Kannan A, Kancherla R, McMahon S, Hawdon G, Soral A, Malhotra R. 2012. Arthroplasty options in femoral-neck fracture: answers from the national registries. Int Orthop. Jan;36(1):1-8.

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