Comparing Complications and Costs of Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fractures
Authors: Ravi Bheeshma , Pincus Daniel , Khan Hayat , Wasserstein David , Jenkinson Richard , Kreder Hans J. 
Published: April 2019

Background:
Although the prevalence of displaced femoral neck fractures in the elderly population is increasing worldwide, there remains controversy as to whether these injuries should be managed with hemiarthroplasty or total hip arthroplasty. Although total hip arthroplasties result in better function, they are more expensive and may have higher complication rates. Our objective was to compare the complication rates and health-care costs between hemiarthroplasty and total hip arthroplasty for displaced femoral neck fractures in the elderly population.

Methods:
A population-based, retrospective cohort study was performed on adults (≥60 years of age) undergoing either hemiarthroplasty or total hip arthroplasty for hip fracture between April 1, 2004, and March 31, 2014. We excluded patients who resided in long-term care facilities prior to the injury and those who were discharged to these facilities after the surgical procedure. Patients who underwent a hemiarthroplasty and those who underwent a total hip arthroplasty were matched using a propensity score encompassing patient demographic characteristics, patient comorbidities, and provider factors. After matching, we compared the rates of medical and surgical complications, as well as the perioperative and postoperative health-care costs in the year following the surgical procedure. The primary outcome was the occurrence of a medical complication (acute myocardial infarction, deep venous thrombosis, pulmonary embolism, ileus, pneumonia, renal failure) within 90 days or a surgical complication (dislocation, infection, revision surgical procedure) within 1 year. Additionally, we examined the change in health-care costs in the year following the surgical procedure, including costs associated with the index admission, relative to the year before the surgical procedure.

Results:
Among 29,121 eligible patients, 2,713 (9.3%) underwent a total hip arthroplasty. After successfully matching 2,689 patients who underwent a total hip arthroplasty with those who underwent a hemiarthroplasty, the patients who underwent a total hip arthroplasty were at an increased risk for dislocation (1.7% compared with 1.0%; p = 0.02), but were at a decreased risk for revision (0.2% compared with 1.8%; p < 0.0001), relative to patients who underwent a hemiarthroplasty. Furthermore, the overall increase in the annual health-care expenditure in the year following the surgical procedure was approximately $2,700 in Canadian dollars lower in patients who underwent a total hip arthroplasty (p < 0.001).

Conclusions:
Among elderly patients with displaced femoral neck fractures, total hip arthroplasty was associated with lower rates of revision surgical procedures and reduced health-care costs during the index admission and in the year following the surgical procedure, relative to hemiarthroplasty.

Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.