Total Hip Arthroplasty and Hemiarthroplasty: US National Trends in the Treatment of Femoral Neck Fractures
There is controversy regarding whether total hip arthroplasty (THA) or hemiarthroplasty (HA) is the treatment preferred for displaced intracapsular femoral neck fractures (FNFs). Using the US National Hospital Discharge Survey, we found that, of 12,757 patients admitted for FNF between 2001 and 2010, 4.6% underwent THA and 52.5% underwent HA. More of both procedures were performed over time. Mean age was higher for HA patients. Hospitalization duration and blood transfusion rates were higher for THA. There were region-based differences in frequency of THA and significant hospital-size-based differences in frequency of HA, possibly because of differences in regional training and subspecialist availability. In addition, a larger proportion of THA patients was covered by private insurance.
Take-Home Points
- An increasing number of THAs and HAs were performed over time for FNF.
- HA patients tended to be older.
- Hospitalization and blood transfusion rates were higher for THA.
- Hospital size affected the rate of HAs, while hospital location affected the rate of THAs.
- A larger proportion of THA patients had private insurance.
Femoral neck fractures (FNFs) are a common source of morbidity and mortality worldwide. The increasing number of FNFs in the United States is attributed to increases in number of US residents >65 years old, the average life span, and the incidence of osteoporosis.1 Three hundred forty thousand hip fractures occurred in the United States in 1996, and the number is expected to double by 2050.2 By that year, an estimated 6.3 million hip fractures will occur worldwide.3 Given the 1-year mortality rate of 14% to 36%, optimizing the management of these fractures is an important public health issue that must be addressed.4
Treatment is based on preoperative ambulatory status, cognitive function, comorbidities, fracture type and displacement, and other factors. In physiologically elderly patients with displaced fractures, surgical treatment usually involves either hemiarthroplasty (HA) or total hip arthroplasty (THA). There is controversy regarding which modality is the preferred treatment.
Proponents of HA point to a higher rate of dislocation for FNFs treated with THAs,5,6 attributed to increased range of motion.7 Proponents of THA point to superior short-term clinical results and fewer complications, especially in mobile, independent patients.8
We conducted a study to assess recent US national trends in performing THA and HA for FNFs and to evaluate perioperative outcomes for each treatment group.
Materials and Methods
Data for this study were obtained from the National Center for Health Statistics (NCHS) National Hospital Discharge Survey (NHDS) and were imported into Microsoft Office Excel 2010.9 The NHDS examines patient discharges from various hospitals across the US, including federal, military, and Veterans Administration hospitals.9 Only short-stay hospitals (mean stay, <30 days) and hospitals with a general specialty are included in the survey. Each year, about 1% of all hospital admissions from across the US are abstracted and weighted to provide nationwide estimates. The information collected from each hospital record includes age, sex, race, marital status, discharge month, discharge status, days of care, hospital location, hospital size (number of beds), hospital type (proprietary or for-profit, government, nonprofit/church), and up to 15 discharge diagnoses and 8 procedures performed during admission.9
International Classification of Diseases, Ninth Revision (ICD-9) procedure codes were used to search the NHDS for patients admitted after FNF for each year from 2001 through 2010. These codes were then used to identify patients within this group who underwent THA or HA. We also collected data on patient demographics, hospitalization duration, discharge disposition, in-hospital adverse events (deep vein thrombosis [DVT], pulmonary embolism [PE], blood transfusion, mortality), form of primary medical insurance, number of hospital beds (0-99, 100-199, 200-299, 300-499, ≥500), hospital type (proprietary, government, nonprofit/church), and hospital region (Northeast, Midwest, South, West).
