Comparative Outcomes of Surgical Interventions for Femoral Neck Fractures: A Multicenter Analysis and Review of the Literature

Abstract

Background

Femoral neck fractures are a significant source of morbidity and mortality in older adults. This study compared demographics, outcomes and complications between the following treatment options: Open Reduction and Internal Fixation (ORIF), Total Hip Arthroplasty (THA) and Hemiarthroplasty (HA).

Methods

This was a population-based study using the Centers for Medicare & Medicaid Services dataset from 2017-2021. A total of 67,759 isolated hip fracture patients were analyzed. Multivariate regression analyses adjustmented for age, comorbidities and hospital volume. Outcomes were compared using odds ratios (OR) with 95% confidence intervals (CI).

Results

ORIF patients were the oldest (36.7% aged 85+), while THA patients were younger (18.6% aged 65-69). Females predominated for overall fracture incidence (66.9%–81.8%). HA patients had significantly higher risks of discharge mortality OR = 1.51 (95% CI 1.24, 1.83), deep venous thrombosis OR = 1.31 (95% CI 1.07, 1.60), cardiac arrest OR = 1.85 (95% CI 1.33, 2.57), pulmonary embolism OR = 1.76 (95% CI 1.38, 2.36), acute kidney injury OR = 1.32 (95% CI 1.24, 1.40) and overall infection compared to ORIF. THA and HA patients were associated with lower odds of rehab discharge (OR = 0.65 and OR = 0.90, respectively). THA was linked to shorter hospital stays (4.3 days) but an increased pulmonary embolism risk OR = 2.39 (95% CI 1.17, 4.88).

Conclusions

For femoral neck fractures, ORIF had the lowest complication rates. Hemiarthroplasty posed the highest complication risks, including mortality and thromboembolic events. THA appeared better suited for healthier individuals, with shorter hospital stays but higher rates of pulmonary embolism. Complication profiles vary significantly across fixation methods for femoral neck fractures. Individualized surgical planning is essential to balance risks and optimize outcomes for femoral neck fracture patients. There may be an opportunity to more carefully scrutinize surgical decision making for femoral neck fractures that would otherwise be treated with either ORIF or HA.

Keywords

hip fracture trauma orthopaedics ORIF arthroplasty level III retrospective cohort study

Introduction

The annual global incidence of hip fractures is projected to approach six million over the next 20-25 years. We can thus anticipate a correlated increase in the number of complications related to surgical treatment of these injuries.^1-4 Femoral neck fractures can present in many varieties, from non-to minimally-displaced usually fixed with open reduction and internal fixation (ORIF) to a higher-associated degree of displacement requiring hemi (HA) or total hip arthroplasty (THA). For non- or minimally displaced Garden I or II femoral neck fractures, ORIF is typically performed via one of three methods: three cannulated screws, a dynamic or sliding hip screw (DHS), or a femoral neck system (FNS) implant. ORIF may also be performed for displaced femoral neck fractures in younger patients to avoid early wear or revision associated with arthroplasty. In older patients, displaced femoral neck fractures are fittingly treated with either HA or THA the majority of the time.^5,6

However, ORIF of femoral neck fractures carries distinct risks. Bhandari et al demonstrated failure rates of up to 48% when displaced femoral neck fractures were treated with internal fixation.⁷ Factors such as inadequate fracture reduction, female sex, excessive alcohol consumption, medical comorbidities, smoking, age >50 and fixation with cannulated screws or pins compared to fixed angle devices have also been linked to failure after fixation of displaced femoral neck fractures.^8,9 In younger patients specifically (<50 years), fracture comminution, cannulated screws compared to fixed angle devices, poor fracture reduction and metabolic bone disease have been associated with failure after femoral neck fracture fixation.¹⁰

For non-displaced femoral neck fractures, there have been comparative outcome studies between ORIF and HA. In a systematic review and meta-analysis by Sattari et al, in a group of 400 elderly patients they demonstrated that HA was the preferred technique if early recovery, higher mobility and better quality of life are priorities.¹¹ However, in a study of 63 elderly non-displaced femoral neck fractures comparing ORIF and HA, Cintean et al demonstrated that ORIF led to faster recovery, shorter hospital stay and less complications.¹² In 2013, Fisher et al conducted a study comparing ORIF, HA and THA for 3423 displaced and non-displaced elderly femoral neck fractures. Using adjusted multivariate analysis, they found no differences in 30-day mortality rates among the three treatment options but did show that ORIF and HA led to a lower likelihood of developing respiratory complications compared to the THA group.¹³

Surgical management of femoral neck fractures influences perioperative care, complication risk, discharge disposition and healthcare resource utilization. ORIF is generally less invasive and may reduce operative time and physiologic stress in frail patients but carries risks of fixation failure and osteonecrosis, whereas HA and THA provide a more reliable “fixation” method in hip fractures at higher risk for osteonecrosis and failure after ORIF. This comes at the expense of arthroplasty-specific complications, including dislocation, infection and thromboembolic events.^14-16 Perioperative strategies such as timing to surgery, venous thromboembolism prophylaxis, early mobilization and multidisciplinary geriatric co-management further influence short-term outcomes after hip fracture surgery.^17,18 Given the substantial economic burden of hip fractures, which is in large part driven by length of stay, complications, post-acute care utilization and reoperation, understanding outcome differences across fixation strategies is increasingly important in the context of value-based care.^3,4

There is inconsistency in the available literature regarding the optimal surgical treatment for femoral neck fractures and the resultant outcomes after surgery. To our knowledge there has not been extensive, large-scale investigation into the outcomes of different surgical procedures for femoral neck fractures across all age groups based on fixation method. The purpose of this study was to retrospectively compare demographic, comorbidity, hospital stay and surgical factors related to hip fracture fixation method: ORIF vs THA vs HA. We also compared postoperative outcomes amongst the three surgical treatment options. These results have the potential to change the way we approach femoral neck fracture surgery. Not only should we be taking into account fracture morphology and displacement, individual patient factors should not be ignored but rather challenge us to use a holistic approach to this increasingly common injury.

Methods

Ethical Approval and Informed Consent

This study used de-identified administrative data and was deemed non-human subjects research and exempt from institutional review board review. Accordingly, written or verbal informed consent was not required.

Study Design and Population

This was a population-based study using the Centers for Medicare & Medicaid Services dataset. Following institutional review board screening, this study was deemed non-human subjects research and exempt from review. The study population was patients aged 18-89 years who underwent surgical intervention for isolated hip fractures from 2017-2021 at institutions participating in the Centers for Medicare & Medicaid Services (CMS) database (n = 67,759). Patients were excluded if they were younger than 18 years or older than 89 years, lacked a diagnosis code consistent with an isolated femoral neck fracture or did not undergo operative treatment. To focus on isolated injuries, patients with concurrent fracture codes involving other anatomic regions (including acetabulum, pelvis or femoral shaft) were excluded to minimize inclusion of polytrauma patients. Patients missing key demographic data required for multivariable analysis were also excluded.

For patient selection, ICD-10 codes for both displaced and non-displaced femoral neck fractures were used to generate our isolated femoral neck fracture cohort. Procedure codes were then used to stratify patients into three groups based on surgical treatment method: ORIF, THA or HA. Within the ORIF cohort, specific fixation constructs (eg, cannulated screws, DHS, FNS) could not be reliably distinguished using available CPT and ICD-10-PCS codes across institutions. Therefore, all ORIF techniques were analyzed as a single group. Within the THA and HA cohorts, specific surgical techniques including surgical approach, cement utilization or implant characteristics could not be reliably distinguished using available CPT and ICD-10-PCS codes. Therefore, all THA and HA procedures were analyzed collectively as a group.

Given the retrospective, claims-based nature of this study, patients were not prospectively screened or followed using standardized clinical protocols. Instead, cohort identification was performed using ICD-10 diagnosis codes for displaced and nondisplaced femoral neck fractures in combination with CPT and ICD-10-PCS procedure codes to classify surgical treatment as ORIF, HA or THA.

Postoperative outcomes were ascertained based on diagnosis and procedure codes recorded during the index hospitalization and, when applicable, during subsequent hospital readmissions captured within the database. The CMS dataset does not provide access to outpatient clinical visits, radiographic follow-up, functional outcome measures or patient-reported outcomes. Accordingly, follow-up in this study was limited to objectively coded in-hospital events and readmissions, consistent with prior population-based orthopaedic outcomes research using administrative data. This study was prepared in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

Cohorts and Outcomes

Various demographic, comorbidity, hospital stay and surgical factors were analyzed between the three groups: ORIF (n = 52,456) vs THA (n = 882) vs HA (n = 14,421) (Table 1). For ORIF patients specifically, we included postoperative incidences of common complications that lead to conversion arthroplasty (Table 2). Cohorts were then stratified by group, with THA and HA being compared to ORIF for a variety of postoperative outcomes using multivariate regression analysis (Table 3). Several steps were taken to minimize potential sources of bias inherent to retrospective administrative database studies. Selection bias was reduced by restricting the cohort to patients with isolated, operatively treated femoral neck fractures. Confounding was addressed using multivariable regression adjusting for relevant demographic, clinical and institutional factors including hospital volume.

Table 1.

Demographic, Comorbidity, Hospital Stay and Surgery Factor Group Comparison

	ORIFN = 52,456	THAN = 882	HAN = 14,421	P-value
Age
65∼69	11.2%	18.6%	16.8%	<0.0001
70∼74	14.5%	26.2%	19.3%	<0.0001
75∼79	17.6%	18.3%	19.9%	<0.0001
80∼85	20.0%	17.5%	18.2%	<0.0001
85+	36.7%	19.5%	25.9%	<0.0001
Gender
Male	29.8%	33.1%	32.0%	<0.0001
Female	70.2%	66.9%	68.0%	<0.0001
Race
White	91.9%	93.0%	92.3%	0.24
Black	4.1%	2.5%	3.4%	0.0002
Asian	1.0%	0.5%	1.1%	0.45
Other	3.0%	4.1%	3.2%	0.07
Comorbidity
Smoker	9.4%	7.6%	9.6%	0.05
Diabetes	22.4%	19.7%	20.3%	<0.0001
Alcohol use disorder	0.8%	1.0%	1.1%	0.04
History of irradiation	1.6%	1.8%	1.4%	0.34
Congestive heart failure	2.9%	1.9%	1.9%	<0.0001
Chronic renal insufficiency	4.0%	2.7%	3.4%	0.0048
History of cerebrovascular accident	11.8%	8.3%	8.9%	<0.0001
Disseminated cancer	0.01%	0.0%	0.0%	0.93
Limitation of activities due to disability	0.002%	0.0%	0.01%	0.91
Hypertension	49.7%	52.2%	51.7%	<0.0001
Chronic obstructive pulmonary disease	15.1%	11.2%	11.7%	<0.0001
Long-term steroid use	3.4%	3.2%	3.1%	0.08
Cirrhosis	0.6%	0.6%	0.5%	0.82
Dementia	17.6%	7.7%	10.5%	<0.0001
Anticoagulant therapy	13.6%	12.9%	12.6%	0.05
Angina pectoris	0.04%	0.11%	0.03%	0.75
Mental/personality disorder	0.02%	0.0%	0.03%	0.93
History of myocardial infarction	7.1%	4.5%	5.8%	<0.0001
History of peripheral arterial disease	4.0%	3.4%	3.3%	0.0027
ICU (Y/N)	13.0%	11.7%	13.2%	0.34
Length of hospital stay (days)	4.5 (±5.0)	4.3 (±3.2)	4.7 (±3.2)	<0.0001
Fixation within first 24 hours	80.9%	77.1%	75.9%	<0.0001

Use of italic is to indicate the p value met statistical significance.

Table 2.

ORIF-Specific Cohort Postoperative Outcomes

Postoperative outcome	Incidence (N = 52,456)
Femoral head osteonecrosis	0.05%
Post-traumatic arthritis	0.002%
Malunion	0.03%
Nonunion	0.17%

Table 3.

Group Comparison Postoperative Outcome Multivariate Regression Analysis

	ORIFN = 52,456	THAN = 882	HAN = 14,421
Rehab discharge	74.1%	58.6%	67.9%
		0.65 (0.57, 0.75)^a	0.90 (0.87, 0.94)^a
Discharge mortality	0.81%	0.68%	1.0%
		1.12 (0.50-2.52)^a	1.51 (1.24-1.83)^a
Hardware failure	0.34%	0.79%	0.62%
		2.22 (1.04, 4.75)^a	1.80 (1.39, 2.33)^a
Infection	0.06%	0.11%	0.13%
		1.67 (0.23, 12.36)^a	2.10 (1.17, 3.76)^a
Complication rate	27.3%	23.1%	26.9%
		0.97 (0.83, 1.14)^a	1.12 (1.07, 1.17)^a
Complications
Deep surgical site infection	0.01%	0.0%	0.0%
		0.002 (<0.001, >999)^a	0.001 (<0.001, >999)^a
Deep venous thrombosis	0.74%	0.57%	0.95%
		0.76 (0.32, 1.85)^a	1.31 (1.07, 1.60)^a
Pneumonia	3.16%	2.15%	2.79%
		0.76 (0.48, 1.20)^a	0.94 (0.84, 1.05)^a
UTI	12.7%	8.73%	11.38%
		0.80 (0.63, 1.01)^a	0.99 (0.94, 1.06)^a
ARDS	0.02%	0.0%	0.03%
		<0.001 (<0.001, >999)^a	1.94 (0.64, 5.90)^a
Sepsis	0.11%	0.0%	0.09%
		<0.001 (<0.001, >999)^a	0.82 (0.45, 1.51)^a
Wound infection	0.02%	0.0%	0.01%
		0.002 (<0.001, >999)^a	1.04 (0.22, 4.98)^a
Cardiac arrest	0.22%	0.23%	0.37%
		1.12 (0.28, 4.56)^a	1.85 (1.33, 2.57)^a
Pulmonary embolism	0.39%	0.91%	0.67%
		2.39 (1.17, 4.88)^a	1.76 (1.38, 2.26)^a
Acute myocardial infarction	1.35%	1.47%	1.19%
		1.40 (0.80, 2.44)^a	1.04 (0.88, 1.23)^a
Acute kidney injury	11.36%	10.88%	12.63%
		1.18 (0.95, 1.47)^a	1.32 (1.24, 1.40)^a
Stroke	1.36%	0.79%	1.4%
		0.66 (0.31, 1.39)^a	1.12 (0.95, 1.31)^a

^aAdjusted by age, race, smoker, diabetes, alcohol use disorder, history of irradiation, CHF, chronic renal failure, CVA, disseminated cancer, limitation of activities due to disability, hypertension, COPD, steroid use, cirrhosis, dementia, anticoagulant therapy, angina pectoris, mental/personality disorder, myocardial infarction, PAD, hospital volume.

Statistical Analysis

All data were analyzed by statistical support through our institution, using SAS version 9.4 (SAS Institute Inc., Cary, NC). A formal a priori power analysis was not performed, as this study was a retrospective analysis of a national administrative database. All patients meeting inclusion and exclusion criteria during the study period were included. The final sample size was determined by data availability rather than prospective sample size estimation. Descriptive variables were compared using chi-square tests for categorical variables and t-tests for continuous variables. A multivariable regression analysis, controlling for age, race, smoking status, multiple comorbidities, disability status, baseline anticoagulant therapy use and hospital volume (Table 3) was used to compare postoperative outcomes between groups.

Results

Demographics, Comorbidity, Hospital Stay and Surgery Factors

The age distribution among patients undergoing ORIF, HA and THA demonstrated significant variation (P < 0.0001). The largest proportion of ORIF patients were aged 85 years and older (36.7%), whereas THA patients were most commonly between 70-74 years (26.2%). In contrast, HA was more frequently performed in the 75-79 age group (19.9%), followed closely by those aged 85 and older (25.9%). Females patients predominated across across all surgical groups, with 70.2% of ORIF, 66.9% of THA and 68.0% of HA patients (P < 0.0001). Males accounted for a smaller proportion but were slightly more prevalent in the THA cohort (33.1%) compared to ORIF (29.8%) and HA (32.0%). The racial distribution revealed a predominantly White patient population, with 91.9% in the ORIF group, 93.0% in the THA group and 92.3% in the HA group. The differences in White patient representation were not statistically significant (P = 0.24). However, Black patients were significantly more likely to undergo ORIF (4.1%) compared to THA (2.5%) and HA (3.4%) (P = 0.0002). Asian patients constituted a small percentage across all groups (1.0% in ORIF, 0.5% in THA and 1.1% in HA), with no statistically significant difference (P = 0.45). Similarly, the “Other” racial category showed no significant variation among groups (3.0% ORIF, 4.1% THA and 3.2% HA; P = 0.07).

Smoking prevalence between the groups approached significance (P = 0.05), with 9.4% in ORIF patients, 7.6% in THA patients and 9.6% in HA patients. Diabetes was significantly more common in ORIF patients at 22.4%, compared to 19.7% in the THA and 20.3% in the HA groups (P < 0.0001). Alcohol use disorder showed a statistically significant difference across the groups (P = 0.04), with a prevalence of 0.8% in the ORIF, 1.0% in the THA and 1.1% in the HA groups. CHF was significantly more frequent in ORIF patients (2.9%) compared to 1.9% in both the THA and HA groups (P < 0.0001). Chronic renal insufficiency was found in 4.0% of ORIF patients, significantly higher than the 2.7% in THA and 3.4% in HA patients (P = 0.0048). COPD prevalence was also significantly higher in ORIF patients (15.1%) than in THA (11.2%) and HA (11.7%) patients (P < 0.0001). Similarly, a history of cerebrovascular accident (CVA) was significantly more prevalent in ORIF patients (11.8%) than in the THA (8.3%) and HA (8.9%) groups (P < 0.0001). Hypertension was common across all groups, affecting 49.7% of ORIF patients, 52.2% of THA patients and 51.7% of HA patients (P < 0.0001).

Dementia was significantly more prevalent in ORIF patients (17.6%) compared to 7.7% in the THA and 10.5% in the HA groups (P < 0.0001). Baseline anticoagulant therapy use between groups approached significance (P = 0.05), with 13.6% in the ORIF, 12.9% in the THA and 12.6% in the HA groups. History of MI was significantly more common in ORIF patients (7.1%) compared to 4.5% in THA and 5.8% in HA patients (P < 0.0001). The mean hospital stay was significantly different between groups (P < 0.0001), with ORIF patients averaging 4.5 ± 5.0 days, compared to 4.3 ± 3.2 days in THA and 4.7 ± 3.2 days in HA patients. Additionally, the ORIF group had a significantly higher proportion of patients fixed within 24 hours (80.9%), compared to 77.1% and 75.9% in the THA and HA groups, respectively (P < 0.0001).

ORIF-Specific Cohort Postoperative Outcomes

Among the 52,456 femoral neck fracture ORIF patients in this study, there was a 0.05% incidence of femoral head osteonecrosis, 0.002% incidence of post-traumatic arthritis, 0.03% incidence of malunion and a 0.17% incidence of nonunion.

Group Comparison Postoperative Outcomes Multivariate Regression Analysis

Patients who underwent ORIF had a rehab discharge rate of 74.1%, significantly higher than those who underwent THA (58.6%) (OR 0.65 (95% CI: 0.57-0.75)) and HA (67.9%) (OR 0.90 (95% CI: 0.87-0.94)). The discharge mortality rate was 0.81% for ORIF patients compared to a slightly lower mortality rate of 0.68% for THA patients, which was not statistically significant (OR 1.12 (95% CI: 0.50-2.52)). Conversely, compared to ORIF patients the HA group exhibited a significantly higher discharge mortality rate of 1.0% (OR 1.51 (95% CI: 1.24-1.83)). The overall complication rate was 27.3% for ORIF patients, compared to 23.1% for THA (OR 0.97 (95% CI: 0.83-1.14)) and 26.9% (OR 1.12 (95% CI: 1.07-1.17)) for HA patients.

Hardware failure occurred in 0.34% of ORIF cases, with higher incidences reported in both the THA (0.79%; OR 2.35 (95% CI: 1.10-5.02) and HA (0.62% OR 1.82 (95% CI: 1.41-2.35) groups. The incidence of overall infection in ORIF patients was 0.06%, compared to 0.11% in the THA group (OR 1.67 (95% CI: 0.23-12.36)) and 0.13% in the HA group (OR 2.10 (95% CI: 1.17-3.76)). Sepsis was reported in 0.11% of ORIF patients, compared to 0.09% of HA patients (OR 0.82 (95% CI: 0.45-1.51)) and 0% of THA patients (OR <0.001 (95% CI: <0.001– >999)).

Deep venous thrombosis (DVT) was observed in 0.74% of ORIF patients, compared to 0.95% of HA patients (OR 1.31 (95% CI: 1.07-1.60)) and 0.57% of THA patients (OR 0.76 (95% CI: 0.32-1.85)). Pulmonary embolism (PE) was more frequent in the arthroplasty groups than in ORIF patients, with rates of 0.91% for THA, 0.67% for HA and 0.39% for ORIF. The risk was significantly increased for both THA (OR 2.39 (95% CI: 1.17-4.88)) and HA (OR 1.76 (95% CI: 1.38-2.26)) compared to ORIF. Cardiac arrest was reported in 0.22% of ORIF patients, compared to 0.37% of HA patients (OR 1.85 (95% CI: 1.33-2.57)) and 0.23% in THA patients (OR 1.12 (95% CI: 0.28-4.56)). Finally, acute kidney injury (AKI) occurred in 11.36% of ORIF patients, compared to 12.63% of HA patients (OR 1.32 (95% CI: 1.24-1.40)) and 10.88% of THA patients (OR 1.18 (95% CI: 0.95-1.47)).

No difference in the incidence of stroke, pneumonia, acute respiratory distress syndrome (ARDS), acute myocardial infarction (AMI) or urinary tract infection (UTI) was observed between ORIF patients and HA/THA patients.

Discussion

Femoral neck fractures, particularly in elderly patients, are associated with substantial morbidity and mortality.^19,20 Prior studies have demonstrated that perioperative complications and mortality following hip fracture surgery are strongly influenced by patient age, comorbidity burden and perioperative management strategies.²¹ This underscores the need for individualized treatment selection in elderly patients. The predominance of female patients across all surgical groups in our study (66.9-70.2%) is consistent with epidemiological data indicating that hip fractures disproportionately affect postmenopausal women due to higher osteoporosis rates and longer life expectancy.²² The prolonged immobilization notoriously associated with femoral neck fractures leads to serious medical complications including pneumonia, urinary tract infections, pressure sores, surgical site infection and venous thromboembolism.^17,23,24 To date, most surgeons opt for internal fixation when femoral neck fractures are non- or minimally-displaced in the older population. The more common early postoperatives complications associated with this treatment method are nonunion and failure of fixation. The incidence of these complications has been reported to be as high as 30%.¹⁴ However, in our study the cumulative incidence of hardware failure and nonunion in the ORIF group was less than one percent, with higher rates of hardware failure being observe in both the HA and THA groups. Further, among over 52,000 ORIF patients in this study, the cumulative incidence of postoperative femoral head osteonecrosis, post-traumatic arthritis, malunion, nonunion and hardware failure was 0.59%.

In our cohort, the ORIF group was composed of mostly elderly patients with multiple comorbidities. This aligns with the historical tendency for more frail patients to undergo ORIF in order to decrease operative time and blood loss. In addition, the ORIF patients in our group were more likely to discharge to a rehab facility, which is also consistent with previous findings in hip fracture patients.¹⁸ Studies have suggested that, while ORIF has a higher failure rate in older adults, which contrasts with our findings, it is sometimes preferred to minimize operative burden. Particularly in patients with dementia, frailty or high medical complexity.¹⁵ Conversely, the predominance of THA in the 70-74-year group (26.2%) and hemiarthroplasty in those aged 75-79 years (19.9%) in our cohort follows the established practice of reserving THA for functionally independent, healthier elderly patients while utilizing hemiarthroplasty for those with more limited mobility or higher surgical risks.¹⁶ Notably, the literature supports that THA provides superior functional outcomes and lower reoperation rates compared to hemiarthroplasty in active elderly patients. Our study results reaffirm that surgical selection is highly influenced by patient age, functional status and perceived perioperative risk. Given that our analysis was adjusted for multiple confounders including race, smoking status, diabetes, chronic renal failure, cardiovascular disease and hospital volume, these observed differences in age-related surgical selection appear to be largely driven by intrinsic patient characteristics and surgeon preference rather than by disparities in comorbid burden or institutional factors.

Our study found significant differences in comorbidity prevalence among surgical groups. Compared to arthroplasty patients, ORIF patients had significantly higher rates of CHF, chronic renal insufficiency, and dementia. As stated previously, these findings align with the common practice that ORIF, a less invasive procedure with fewer postoperative precautions, is often chosen for more complex patients with high perioperative risk. As is common in THA and HA patients, the perceived risk of dislocation is a common postoperative concern. Studies have shown that dementia significantly increases the risk of postoperative delirium and functional decline, making arthroplasty less favorable for this population due to a higher incidence of falls and subsequent dislocations postoperatively.²⁵ Our adjusted analysis suggests that pre-existing medical conditions play a central role in surgical decision-making rather than hospital-level variation or institutional bias.

Our study’s racial distribution, with a predominantly White population (91.9-93.0%), mirrors national trends in hip fracture epidemiology.²⁶ However, the significantly lower rate of THA among Black patients suggests potential disparities in surgical decision-making, access to care, or underlying differences in bone health. Prior research has demonstrated that Black patients are less likely to undergo elective joint replacement and more likely to experience delays in hip fracture surgery, which can negatively impact outcomes.^27,28 Socioeconomic barriers, insurance status and healthcare access likely play a role in these differences, and further investigation is warranted to determine if these factors influence fracture management patterns in this cohort. Given that our analysis adjusted for multiple confounding variables, these findings suggest that disparities in THA utilization among Black patients persist even after accounting for known comorbid risk factors. This reinforces the need for systemic interventions to address potential inequities in access to advanced hip fracture care.

Our postoperative complication findings provide important insights into surgical risk profiles. These findings are consistent with contemporary large cohort studies demonstrating that perioperative complication profiles and short-term outcomes following femoral neck fracture surgery vary significantly by surgical strategy.^29,30 While overall complication rates were similar between ORIF (27.3%) and hemiarthroplasty (26.9%), THA had a slightly lower complication rate (23.1%), supporting prior studies and anecdotal evidence suggesting that THA may offer a more stable long-term outcome despite being a more extensive procedure.^30,31 THA patients also tend to be younger and healthier individuals in general, however it must be kept in mind that the THA performed in these patients was after a femoral neck fracture and not as an outpatient elective procedure. In the past, studies have shown that patients undergoing ORIF are at a greater risk of necessitating revision surgery, whether it’s due to nonunion, malunion, hardware failure, femoral head osteonecrosis, etc.^5-8,32,33 However, as previously stated, the aggregate incidence of the common postoperative ORIF complications necessitating revision surgery was less than one percent.

Additionally, the increased risk of thromboembolic events in the arthroplasty groups, particularly pulmonary embolism in THA (0.91%) and hemiarthroplasty (0.67%) compared to ORIF (0.39%), further challenges prior notions of the higher risk of perioperative complications in ORIF in comparison to arthroplasty hip fracture surgery.^34,35 Recent studies have similarly emphasized the importance of perioperative optimization and complication prevention strategies to reduce early adverse events and hospital readmissions following hip fracture surgery.^33,36 There is also recent evidence demonstrating persistently elevated mortality for several years following proximal femur fracture surgery in older adults, with cardiovascular disease, infection and thromboembolic events representing common causes of late death.³⁷ Although the present study was limited to perioperative outcomes, the observed differences in early postoperative complications—particularly thromboembolic events, infection, cardiac arrest, and acute kidney injury—may represent early contributors to the longer-term mortality patterns described in prior investigations.

These differences in postoperative complications persist, even after controlling for relevant comorbidities and anticoagulation status, suggesting that the intrinsic risk of the procedures themselves, rather than patient selection bias, may play a key role in these outcomes. The results from this study pose the question: for the Garden II/III hip fractures in the older population, are we better off resorting to ORIF instead of HA?

Limitations and Strengths

Our large study cohort included over 67,000 patients from a database spanning multiple trauma centers across the United States, which bolsters the generalizability and power of our findings. This cohort, which included isolated hip fractures, to our knowledge has not been extensively studied in the past when comparing the three treatment options for both displaced and nondisplaced femoral neck fractures. The absence of a formal a priori power analysis represents a limitation of this study. However, inclusion of a large national cohort provides substantial statistical power to detect clinically meaningful differences in common perioperative outcomes.

Several limitations should be acknowledged. First, the retrospective design and reliance on administrative claims data preclude prospective patient screening, standardized postoperative monitoring and long-term clinical follow-up. Outcome assessment was limited to events documented during the index hospitalization and subsequent hospital readmissions, and outpatient complications, radiographic findings, functional outcomes and patient-reported measures could not be captured. Cause-specific mortality and long-term survival beyond hospital discharge could not be evaluated, as the dataset does not provide access to death certificates or extended longitudinal follow-up.

Second, patient identification and outcome ascertainment depended on accurate ICD-10 and procedural coding, introducing potential misclassification bias. Although this limitation is inherent to large database studies, we mitigated its impact by using well-established coding strategies and focusing on objective, clinically relevant outcomes. Additionally, we were unable to perform subgroup analyses within the ORIF cohort based on specific fixation constructs. Implant-specific detail is not consistently captured in administrative claims data. Differences in outcomes among cannulated screw fixation, DHS and FNS implants therefore could not be evaluated.

Similarly, technique-specific factors for THA and HA including surgical approach and cement utilization could not be evaluated. These variables may influence perioperative complication risk and outcomes. Finally, the dataset did not allow stratification by fracture displacement classification or standardized treatment algorithms, which may influence procedure selection and outcomes. These findings should be interpreted within the context of claims-based follow-up, which captures inpatient events and readmissions but does not allow assessment of outpatient recovery or long-term functional outcomes.

Future Study

Future research should build upon these findings by refining surgical decision-making algorithms for femoral neck fractures through prospective and stratified analyses. Studies focusing on narrower age ranges and specific fracture characteristics, specifically Garden II and III femoral neck fractures, may help clarify which patients derive the greatest benefit from ORIF vs HA. Incorporation of standardized measures of frailty, functional status and bone quality may further enhance patient-specific treatment selection. Further, future studies incorporating implant-specific data should evaluate whether perioperative and longer-term outcomes differ among internal fixation constructs to further refine treatment selection.

Additionally, future investigations should aim to integrate longer-term follow-up, functional outcomes and patient-reported measures that are not captured in administrative datasets. From a clinical application standpoint, procedure-specific perioperative optimization strategies such as targeted venous thromboembolism prophylaxis, early mobilization protocols and multidisciplinary geriatric co-management represent potential therapeutic avenues to mitigate complication risk identified in this study. Ultimately, combining large-scale population data with prospective clinical studies may help develop evidence-based, value-conscious treatment pathways that improve outcomes for patients with femoral neck fractures.

Conclusion

Our large, population-based analysis demonstrates that perioperative outcomes following surgical treatment of isolated femoral neck fractures vary significantly based on surgical fixation method. After multivariable adjustment, HA was associated with higher rates of discharge mortality, thromboembolic events, AKI, cardiac arrest and overall complications compared to ORIF. THA was associated with shorter hospital stays but an increased risk of pulmonary embolism. Despite being performed more frequently in older patients with a higher burden of comorbidities, ORIF was associated with comparatively lower rates of several major perioperative complications.

Clinically, these findings suggest that surgical decision-making for femoral neck fractures should incorporate patient comorbidity burden and perioperative risk in addition to fracture morphology. In patients for whom either ORIF or HA may be reasonable, ORIF may be considered in carefully selected individuals to potentially reduce perioperative complications. These results also highlight the importance of targeted perioperative strategies, including thromboembolic prophylaxis and early multidisciplinary care planning, particularly in patients undergoing arthroplasty. While arthroplasty remains an essential treatment option for many patients, particularly those with significantly displaced fractures and higher functional demands, our results suggest that ORIF may represent a viable and potentially underutilitzed option in select patients where either ORIF or HA could be reasonably considered. Careful patient selection and risk stratification may therefore offer opportunities to reduce perioperative morbidity and optimize outcomes in femoral neck fracture care.

Footnotes

Acknowledgements

This research was supported in whole or in part by HCA Healthcare and/or an HCA Healthcare-affiliated entity. The views expressed in this publication represent those of the authors and do not necessarily represent the official views of HCA Healthcare or any of its affiliated entities.

ORCID iD

Daniel J. Lynch

Ethical Considerations

From our institution, our study was deemed as a non-human and IRB exempt study.

Author contributions

Daniel Lynch was responsible for the idea behind this project along with manuscript writing and editing. Arya Afzali assisted with table creation as well as manuscript editing. James McFadden assisted with project oversight and manuscript editing. Huazhi Liu was responsible for data acquisition and statistical analysis. Darwin Ang was responsible for project oversight and manuscript editing.

Funding

The authors received no financial support for the research or authorship of this article. Funding for open access publication of this article has been provided by HCA.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Data Availability Statement

Our data was obtained from the Centers for Medicare & Medicaid Services (CMS) database.*

References

Gullberg

Johnell

Kanis

. World-wide projections for hip fracture. Osteoporos Int. 1997;7(5):407-413. doi:10.1007/PL00004148

Cooper

Campion

Melton

. Hip fractures in the elderly: a world-wide projection. Osteoporos Int. 1992;2(6):285-289. doi:10.1007/BF01623184

Yan

Low

Vasanwala

Low

. Predictors of poor functional outcomes and mortality in patients with hip fracture: a systematic review. BMC Muscoskelet Disord. 2019;20(1):568. doi:10.1186/s12891-019-2950-0

Veronese

Maggi

. Epidemiology and social costs of hip fracture. Injury. 2018;49(8):1458-1460. doi:10.1016/j.injury.2018.04.015

Frihagen

Nordsletten

Madsen

. Hemiarthroplasty or internal fixation for intracapsular displaced femoral neck fractures: randomised controlled trial. BMJ. 2007;335(7632):1251-1254. doi:10.1136/bmj.39399.456551.25

Baker

Squires

Gargan

Bannister

. Total hip arthroplasty and hemiarthroplasty in Mobile, independent patients with a displaced intracapsular fracture of the femoral neck: a randomized, controlled trial. J Bone Jt Surg. 2006;88(12):2583-2589. doi:10.2106/JBJS.E.01373

Bhandari

Devereaux

Swiontkowski

, et al. Internal fixation compared with arthroplasty for displaced fractures of the femoral neck: a meta-analysis. J Bone Jt Surg-Am. 2003;85(9):1673-1681. doi:10.2106/00004623-200309000-00004

Kalsbeek

Van Donkelaar

Krijnen

Roerdink

De Groot

Schipper

. What makes fixation of femoral neck fractures fail? A systematic review and meta-analysis of risk factors. Injury. 2023;54(2):652-660. doi:10.1016/j.injury.2022.11.042

Duckworth

Bennet

Aderinto

Keating

. Fixation of intracapsular fractures of the femoral neck in young patients: risk factors for failure. J Bone Joint Surg Br. 2011;93-B(6):811-816. doi:10.1302/0301-620X.93B6.26432

10.

Collinge

Finlay

Rodriguez-Buitrago

, et al. Treatment failure in femoral neck fractures in adults less than 50 years of age: analysis of 492 patients repaired at 26 north American trauma centers. J Orthop Trauma. 2022;36(6):271-279. doi:10.1097/BOT.0000000000002355

11.

Sattari

Guilbault

MacMahon

Salem

Khanuja

. Internal fixation versus hemiarthroplasty for nondisplaced femoral neck fractures: a systematic review and meta-analysis. J Orthop Trauma. 2023;37(5):e219-e226. doi:10.1097/BOT.0000000000002558

12.

Cintean

Pankratz

Hofmann

Gebhard

Schütze

. Early results in non-displaced femoral neck fractures using the femoral neck system. Geriatr Orthop Surg Rehabil. 2021;12:21514593211050153. doi:10.1177/21514593211050153

13.

Fisher

Matthei

Obirieze

, et al. Open reduction internal fixation versus hemiarthroplasty versus total hip arthroplasty in the elderly: a review of the National surgical quality improvement program database. J Surg Res. 2013;181(2):193-198. doi:10.1016/j.jss.2012.07.004

14.

Lowe

Crist

Bhandari

Ferguson

. Optimal treatment of femoral neck fractures according to patient’s physiologic age: an evidence-based review. Orthop Clin N Am. 2010;41(2):157-166. doi:10.1016/j.ocl.2010.01.001

15.

Heetveld

Rogmark

Frihagen

Keating

. Internal fixation versus arthroplasty for displaced femoral neck fractures: what is the evidence? J Orthop Trauma. 2009;23(6):395-402. doi:10.1097/BOT.0b013e318176147d

16.

Healy

Iorio

. Total hip arthroplasty: optimal treatment for displaced femoral neck fractures in elderly patients. Clin Orthop. 2004;429:43-48.

17.

Lee

Choi

Lim

Koo

. Does venous thromboembolism affect rehabilitation after hip fracture surgery? Yonsei Med J. 2013;54(4):1015-1019. doi:10.3349/ymj.2013.54.4.1015

18.

Lynch

Romero

McFadden

Zeblisky

Liu

Ang

. Factors influencing postoperative inpatient rehabilitation requirement after surgical intervention for isolated hip fracture: a multicenter study. Orthop Surg. 2025;17(1):252-259. doi:10.1111/os.14290

19.

Kang

Lee

Won

Koo

. Mortality after hip fractures in Nonagenarians. J Bone Metab. 2012;19(2):83-86. doi:10.11005/jbm.2012.19.2.83

20.

De Jong

Klem

TMAL

Kuijper

Roukema

. Factors affecting the rate of surgical site infection in patients after hemiarthroplasty of the hip following a fracture of the neck of the femur. Bone Jt J. 2017;99-B(8):1088-1094. doi:10.1302/0301-620X.99B8.BJJ-2016-1119.R1

21.

Zhang

, et al. Prevalence, characteristics, and associated risk factors of the elderly with hip fractures: a cross-sectional analysis of NHANES 2005-2010. Clin Interv Aging. 2021;16:177-185. doi:10.2147/CIA.S291071

22.

Sing

Lin

Bartholomew

, et al. Global epidemiology of hip fractures: secular trends in incidence rate, post‐fracture treatment, and all‐cause mortality. J Bone Miner Res. 2023;38(8):1064-1075. doi:10.1002/jbmr.4821

23.

Park

Lee

Koo

. Lower urinary tract infection and periprosthetic joint infection after elective primary total hip arthroplasty. Hip Pelvis. 2017;29(1):30-34. doi:10.5371/hp.2017.29.1.30

24.

Tissingh

Sudlow

Jones

Nolan

. Orthopaedic surgical site infection surveillance in NHS England: national audit of current practice. Bone Jt J. 2017;99-B(2):171-174. doi:10.1302/0301-620X.99B2.BJJ-2016-0420.R1

25.

Zhao

Liang

Hong

, et al. Risk factors for postoperative delirium following total hip or knee arthroplasty: a meta-analysis. Front Psychol. 2022;13:993136. doi:10.3389/fpsyg.2022.993136

26.

Cooper

Mitchell

Lipsitz

, et al. Mortality and readmission after cervical fracture from a fall in older adults: Comparison with hip fracture using national medicare data. J Am Geriatr Soc. 2015;63(10):2036-2042. doi:10.1111/jgs.13670

27.

Amen

Varady

Shannon

Chopra

Rajaee

Chen

. Racial and ethnic disparities in hip fracture surgery care in the United States from 2006 to 2015: a nationwide trends study. J Am Acad Orthop Surg. 2022;30(2):e182-e190. doi:10.5435/JAAOS-D-21-00137

28.

Bethell

Taylor

Burke

, et al. Racial and ethnic disparities in providing guideline-concordant care after hip fracture surgery. JAMA Netw Open. 2024;7(8):e2429691. doi:10.1001/jamanetworkopen.2024.29691

29.

Cao

Chi

Zhang

, et al. The efficacy and safety of intravenous iron in geriatric hip fracture surgeries: a systematic review and meta-analysis. World J Surg. 2022;46(11):2595-2606. doi:10.1007/s00268-022-06690-y

30.

Parker

Gurusamy

. Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev. 2006;2011(11):CD001708. Cochrane bone, joint and muscle trauma group. doi:10.1002/14651858.CD001708.pub2

31.

Rogmark

Carlsson

Johnell

Sernbo

. A prospective randomised trial of internal fixation versus arthroplasty for displaced fractures of the neck of the femur: functional outcome for 450 patients at two years. J Bone Joint Surg Br. 2002;84-B(2):183-188. doi:10.1302/0301-620X.84B2.0840183

32.

Masson

Parker

Schoelzel

. Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. In: The Cochrane Collaboration , ed. Cochrane Database of Systematic Reviews. John Wiley & Sons, Ltd; 2003, CD001708. doi:10.1002/14651858.CD001708

33.

Rödén

Schön

Fredin

. Treatment of displaced femoral neck fractures: a randomized minimum 5-year follow-up study of screws and bipolar hemiprostheses in 100 patients. Acta Orthop Scand. 2003;74(1):42-44. doi:10.1080/00016470310013635

34.

Tidermark

Ponzer

Svensson

Söderqvist

Törnkvist

. Internal fixation compared with total hip replacement for displaced femoral neck fractures in the elderly: a randomised, controlled trial. J Bone Joint Surg Br. 2003;85-B(3):380-388. doi:10.1302/0301-620X.85B3.13609

35.

Blomfeldt

Törnkvist

Ponzer

Söderqvist

Tidermark

. Comparison of internal fixation with total hip replacement for displaced femoral neck fractures. Randomized, controlled trial performed at four years. J Bone Jt Surg Am. 2005;87(8):1680-1688. doi:10.2106/JBJS.D.02655

36.

Cao

Zhang

Sheng

, et al. General anesthesia versus regional anesthesia in the elderly patients undergoing hip fracture surgeries: a systematic review and meta-analysis of randomized clinical trials. World J Surg. 2023;47(6):1444-1456. doi:10.1007/s00268-023-06949-y

37.

Hashimoto

Shinyashiki

Ohtani

Kakinoki

Akagi

. How proximal femur fracture patients aged 65 and older fare in survival and cause of death 5+ years after surgery: a long-term follow-up. Medicine (Baltim). 2023;102(20):e33863. doi:10.1097/MD.0000000000033863