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Total Hip Arthroplasty and Hemiarthroplasty: US National Trends in the Treatment of Femoral Neck Fractures

The American Journal of Orthopedics. 2017 November;46(6):E474-E478
December 28, 2017 | The American Journal of Orthopedics
Colin Y. L. Woon, MD ; Vincent M. Moretti, MD ; Brian E. Schwartz, MD ; Benjamin A. Goldberg, MD
Author and Disclosure Information

Authors’ Disclosure Statement: The authors report no actual or potential conflict of interest in relation to this article. 

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.

Trends were evaluated by linear regression with the Pearson correlation coefficient (r). Statistical comparisons were made using the Student t test for continuous data, and both the Fisher exact test and the χ2 test for categorical variables. Significance level was set at P < .05. All analyses were performed with IBM SPSS Statistics 22. 

Results

Figure 1.
Of the 12,757 patients identified as having FNFs (Figure 1), 582 (4.6%) underwent THA, 6697 (52.5%) underwent HA, 3453 (27.1%) received internal fixation, and 1809 (14.2%) did not have their surgery documented. There were 164 men (28.2%) in the THA group and 1744 (26.0%) in the HA group (P = .27). Mean age was significantly (P < .01) higher for HA patients (81.1 years; range, 18-99 years) than for THA patients (76.9 years; range, 19-99 years), and there were significantly (P < .01) more medical comorbidities for HA patients (6.4 diagnoses; range, 1-7+ diagnoses) than for THA patients (6.1 diagnoses; range, 1-7 diagnoses).
Figure 2.
There was no clear trend in prevalence of FNFs between 2001 and 2010 (r = 0.25; Figure 2). During this period, fracture prevalence ranged from 406 to 477 per 100,000 admissions. However, there was increased frequency in use of both surgical techniques for FNFs over time: THA (r = 0.82; Figure 3) and HA (r = 0.80; Figure 4).
Figure 3.
Figure 4.
The rate of THAs for FNFs increased from 4.2% for 2001 to 2005 to 5.0% for 2006 to 2010 (P = .04); similarly, the rate of HAs for FNFs increased from 51.0% for 2001 to 2005 to 54.7% for 2006 to 2010 (P < .01).

Hospital stay was longer (P < .01) for THA patients (7.7 days; range, 1-312 days) than for HA patients (6.7 days; range, 1-118 days), and blood transfusion rate was higher (P = .02) for THA patients (30.4%) than for HA patients (25.7%), but the groups did not differ in their rates of DVT (THA, 1.2%; HA, 0.80%, P = .50), PE (THA, 0.52%; HA, 0.72%, P = .52), or mortality (THA, 1.8%; HA, 2.9%; P = .16). Discharge disposition varied with surgical status (P < .01): 23.2% of THA patients and 11.6% of HA patients were discharged directly home after their inpatient stay, and 76.8% of THA patients and 88.4% of HA patients were discharged or transferred to a short- or long-term care facility.

Table.
Figure 5.
Hospital size (number of beds) affected the number of HAs performed (P < .01) but not the number of THAs performed (P = .10; Table). Hospital location (Northeast, Midwest, South, West) affected THA frequency (P = .01), but not HA frequency (P = .07; Figure 5). In contrast, hospital type (proprietary, government, nonprofit/church) affected the HA rate (P < .01) but not the THA rate (P = .12; Table). 

Private medical insurance provided coverage for 14.3% of THAs and 9.1% of HAs, and Medicare provided coverage for 80.9% of THAs and 86.0% of HAs (P < .01).

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