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Hemiarthroplasty for hip fracture

80 citationsUpdated Sep 2026

Overview

Hemiarthroplasty is a definitive treatment strategy for displaced intracapsular femoral neck fractures in elderly patients, offering high long-term survivorship and very low rates of conversion to total hip arthroplasty [18, 68]. National registry data support the continued use of bipolar hemiarthroplasty in this population, with age, method of fixation, and surgical approach serving as key prognostic variables for implant survival [31]. For patients with neurological disease who are not eligible for total hip arthroplasty, hemiarthoseplasty is the indicated procedure [13]. Surgeons should consider restoring capsular integrity to minimize post-operative dislocation rates [112].

Contemporary cemented hemiarthroplasty provides better results than uncemented fixation for displaced intracapsular fractures [4]. Level 1 evidence indicates that cemented stems offer improved 1-year mortality rates and result in less periprosthetic fracture compared with noncemented alternatives [8]. Uncemented hemiarthroplasties carry a higher risk of later femoral fractures and increased reoperation risk in elderly patients [3, 21]. All routinely used noncemented stem design types are associated with a higher risk of aseptic revision compared with cemented fixation [43]. The AAOS Clinical Practice Guideline strongly supports the use of cemented stems for hemiarthroplasty in femoral neck fractures [27]. Cemented fixation is recommended because it does not increase cardiopulmonary complications [15], and intraoperative fractures during cemented procedures do not contribute to increased secondary surgery, morbidity, or mortality [26]. Patients preferred the outcome after cemented Thompson hemiarthroplasty over uncemented Austin-Moore hemiarthroplasty [22].

While contemporary total hip arthroplasty provides a benefit regarding revision outcomes for women aged 60 to 74 years compared with hemiarthroplasty [29], it carries an increased risk of revision in women aged 80 to 85 years and men aged 75 to 85 years [29]. The outcome of hemiarthroplasty revised to total hip arthroplasty is influenced by patient age rather than the articulation used [7]. The standard of care for surgical management of failed hemiarthroplasty is conversion to a total hip arthroplasty [11]. Patients with neurological disease who are eligible for total hip arthroplasty could benefit from a dual-mobility component [13].

Anatomy & Pathophysiology

Bony Anatomy and Vascular Supply

The trochanteric region of the proximal femur is a well-vascularized area dependent on the structural integrity of a laminated cancellous bone arcade extending from the femoral head and epiphyseal scar, around Ward's triangle, to the lesser trochanter [72]. The calcar femorale, also known as Adam's arch, is a strong plate of bone located posteriorly and medially that is most affected by posteromedial fracture comminution [72]. Tensile trabeculae are located between Ward's triangle and the greater trochanter [72]. The best quality bone in the proximal femur is found beneath the articular surface [72]. With aging, the morphology of the hip changes through thinning of the cortex, expansion of the bone diameter, and loss of tension and compression trabeculae [72].

The major blood supply to the proximal femur originates from two branches of the profunda femoris artery: the medial circumflex artery and the lateral circumflex artery [74]. The medial circumflex artery travels posterior to the iliopsoas tendon and to the medial side of the proximal femur between the insertion of the inferomedial capsule and the lesser trochanter [74]. The lateral circumflex artery travels posterior to the femoral neck [74]. The transverse branch of the lateral circumflex artery divides at the anterolateral border of the intertrochanteric line and gives off branches that penetrate the lateral and anterolateral portions of the greater trochanter [74]. By age 3 years, the contribution of the lateral circumflex vessel to the blood supply of the proximal femur diminishes, and the entire blood supply of the proximal femoral epiphysis and physis comes from lateral epiphyseal vessels derived from the medial circumflex artery [74]. The artery of the ligamentum teres provides approximately 20% of the blood supply to the femoral head beginning at approximately 8 years of age and is maintained into adulthood [74]. Very few vessels supplying the femoral head travel within the capsule, meaning a capsulotomy incision should not compromise the vascularity of the femoral head [74].

Soft Tissue Anatomy and Biomechanics

The main structural attachments to the proximal femur include the hip capsule and the musculotendinous junctions of the gluteus medius and minimus at the greater trochanter, iliopsoas at the lesser trochanter, piriformis and short external rotators posteriorly, oblique head of the rectus femoris at the anterior capsule, and vastus lateralis on the lateral femur distal to the greater trochanter [72]. The hip capsule is especially important in the reduction of pertrochanteric fractures, as its continuity with the distal fragment provides the soft tissue attachment necessary for a stable reduction [72]. With capsular disruption, the greater trochanter is abducted and externally rotated by the gluteus medius and short external rotators, while the shaft is displaced posteriorly and medially by the adductors and hamstrings [72]. This muscular displacement pattern accounts for the usual shortening and coxa vara deformity of displaced fractures [72]. The femoral nerve is located anteriorly and the sciatic nerve posteriorly relative to the trochanteric region, though they are rarely encountered or injured in surgical approaches for repair of trochanteric fractures [72]. The hip abductor moment arm varies substantially throughout the hip's range of motion in the coronal plane [73].

Fracture Classification and Pathophysiology

Intertrochanteric fractures are extracapsular fractures of the proximal femur, whereas femoral neck fractures are intracapsular [50]. Because the blood supply to the intertrochanteric region is rich and extracapsular fractures offer minimal risk of disrupting blood supply to the femoral head, the rate of healing complications such as nonunion and osteonecrosis is much lower with intertrochanteric fractures than with intracapsular fractures [50]. The AO/Orthopaedic Trauma Association (OTA) classification of intertrochanteric fractures, types 31-A1 through 31-A3, has been advocated as the most comprehensive and useful classification system to date [50]. The AO/OTA classification system for trochanteric hip fractures defines three broad groups: 31.A1 (two-part/stable), 31.A2 (comminuted/unstable), and 31.A3 (reverse/transverse) [80]. Assessments of the AO/OTA classification system have shown it to have an acceptable degree of intra- and interobserver variation and to be useful in determining treatment and outcome [80]. The additional subdivisions used in the AO system, in which the three groups are each subdivided into three further groups, have not been demonstrated to be of any relevance in determining treatment and have an unacceptable degree of intra- and interobserver variation [80].

For two-part trochanteric fractures (A1), the fracture line runs through the trochanters and the fracture may be displaced or undisplaced [80]. For comminuted trochanteric fractures (A2), the main fracture line runs through the trochanters, and the fracture may have three or four main parts with the lesser and greater trochanters forming the third and fourth part [80]. For reversed/transverse fractures (A3), the fracture line is at the level of the lesser trochanter, with possible comminution or extension of the fracture line distally or proximally [80]. Lateral wall integrity is just as important to the stability of intertrochanteric fractures as posteromedial cortex apposition [50]. Compromise to the lateral wall can lead to significant revision surgery rates if fixed with sliding hip screws [50]. The thickness of the lateral wall can be measured to predict which fractures are at risk for subsequent failure using a sliding hip screw implant design, with a thickness of less than 20.5 mm indicating risk [50]. Basal cervical fractures represent only 2% to 3% of all hip fractures [87]. The location of the intracapsular fracture has not been shown to influence management or outcome [87]. The degree of displacement is the more important consideration for intracapsular fractures and is the basis of commonly used classification systems [87].

Epidemiology and Patient Factors

A proximal femur or hip fracture remains the most common reason for an elderly person to be admitted to an acute orthopedic ward [75]. An estimated 1.3 million hip fractures occurred worldwide in 1990, with predictions of 2.6 million by 2025 and 4.5 million by 2050 assuming no age-specific increase [75]. Estimations that include an age-specific increase give predicted values of between 7.3 and 21.3 million hip fractures by 2050 [75]. Almost half of hip fractures are extracapsular, confined to the area of bone between the hip joint capsular attachments to a level of 5 cm distal to the lower border of the lesser trochanter [75]. Patients with an extracapsular fracture tend to be slightly older and frailer than those with an intracapsular fracture [75]. The average age of patients with hip fractures is progressively increasing to a mean of about 80 years in developed countries [75].

The overall incidence of hip fractures in 1990 was between 1.25 and 1.66 million worldwide [78]. By 2050, the number of hip fractures could increase to between 4.5 and 6.5 million per year around the world [78]. In the United States, the total number of hip fractures per year in persons older than 50 years was projected to increase from 238,000 in 1990 to 512,000 by the year 2040 [78]. There is a 3:1 female-to-male ratio of both femoral neck and intertrochanteric hip fractures [78]. The lifetime risk of having a hip fracture is significantly higher in women (14% to 16%) than in men of the same age (6%) [78]. More than 315,000 hospitalizations in the United States for hip fractures accounted for 38% of all injury-related hospital stays in elderly patients [78]. The mean cost for a hospital stay after hip fracture was $15,400 per patient, and the average length of stay was 6.3 days [78]. Approximately 1 in 6 patients live at least 10 years following a hip fracture [2]. A hip fracture has a dramatic impact on the patients' health-related quality of life, and the deterioration in health-related quality of life is sustained one year after the fracture [16]. The Nottingham Hip Fracture Score (NHFS) was able to discriminate survival at all timepoints with similar accuracy to the validating studies in the hip fracture cohort [46].

Pathophysiology of Implant-Related Complications

Bone cement implantation syndrome (BCIS) is a clinical spectrum characterized by transient hypoxia, hypotension, and cardiac arrhythmias or arrest in the postcementation period [44]. BCIS is estimated to occur in 25% to 46% of cemented arthroplasty cases, though this is likely an underestimation because milder presentations may go unrecognized [44]. The etiology of BCIS is presumably multifactorial, involving bone marrow, fat, and cement embolization; histamine release; and complement activation [44]. Factors that may predispose patients to the development of BCIS include older age, impaired baseline cardiopulmonary function, osteoporosis, and concomitant hip fracture [44]. Intraoperative variables such as the use of long-stem prostheses, cementing technique, and anesthetic regimen have been associated with BCIS [44]. Two potential periods for haemodynamic instability were observed during hip hemiarthroplasty surgery: within five minutes of cementing the femoral canal and after final reduction of the prosthesis [129].

The higher fracture risk associated with uncemented stems is biomechanically plausible because achieving initial stability requires press-fit fixation, which can generate increased hoop stresses within the femoral cortex during insertion [39]. In elderly patients with osteoporotic bone, press-fit fixation may predispose to intraoperative or early postoperative periprosthetic fractures [39]. Cemented stems provide immediate and more uniform load distribution along the femoral canal, reducing stress concentration [39]. The reduction in periprosthetic fracture risk represented the most pronounced and consistent effect observed across trials comparing cemented and uncemented fixation [39]. Intraoperative femoral fractures were observed exclusively in the uncemented group in a randomized study by Inngul et al., highlighting the challenges of press-fit fixation in osteoporotic bone [39].

Hip hemiarthroplasty is associated with acetabular erosion and protrusion [135]. Extensive cartilage damage, grossly and histologically, occurs in the presence of hip hemiarthroplasty in the absence of alterations in subchondral bone plate thickness and trabecular architecture [135]. There is an increase in subchondral bone plate porosity following hip hemiarthroplasty [135]. The lower frictional coefficients of ceramic compared to metal against fresh cadaveric acetabula may have a clinical impact on the process of the protrusion of the corresponding femoral head through the acetabulum [94]. Concern regarding excessive acetabular wear resulting in conversion to total hip arthroplasty after hemiarthroplasty in patients with tumors is not supported by the data [34].

Periprosthetic fractures around hip hemiarthroplasty implants occurred in 79 patients, with 62 fractures around uncemented prostheses and 17 around cemented prostheses [61]. The mean time from hip fracture surgery to periprosthetic fracture was 35 months, with a median of only 5 months [61]. 36 fractures (46%) occurred within 3 months of primary hip fracture surgery, with all but one of these cases occurring around Austin Moore prostheses [61]. At the time of periprosthetic fracture, 38% of patients had a mini-mental score of 5 or less, indicating significant cognitive impairment [61]. Only 22% of patients with periprosthetic fracture around hemiarthroplasty had no significant medical co-morbidities [61]. 42% of patients with periprosthetic fracture lived in residential or institutional care, and 15% were hospital in-patients at the time of fracture [61].

Classification

Patient Selection and Prognostic Factors

Age, method of fixation, and surgical approach are critical prognostic variables determining implant survival for femoral-neck fractures in the elderly [31]. Hip fracture exerts a dramatic impact on health-related quality of life, with deterioration sustained one year post-fracture [16]. The Nottingham Hip Fracture Score (NHFS) discriminates survival at all timepoints with accuracy comparable to validating studies in hip fracture cohorts [46]. A general consensus exists for femoral head-conserving surgery in young patients and replacement arthroplasty in elderly patients with subcapital fractures [62].

Cemented versus Uncemented Fixation

The AAOS Clinical Practice Guideline upgrades its recommendation from “moderate” to “strong” support for cemented stems in hemiarthroplasty for femoral neck fracture [27]. Current level 1 evidence demonstrates that cemented hemiarthroplasty offers improved 1-year mortality rates and less periprosthetic fracture compared with noncemented hemiarthroplasty [8]. Contemporary cemented hemiarthroplasty yields better results than uncemented hemiarthroplasty for displaced intracapsular hip fractures [4]. In current generation stems, cemented fixation results in fewer implant-related complications and similar mortality compared with cementless stems [69]. Cemented hemiarthroplasty is associated with lower rates of periprosthetic fracture and loosening, though it involves longer surgical time and higher perioperative mortality compared with noncemented implants [44]. Conversely, cementless hemiarthroplasty carries an 11-fold increased risk of periprosthetic fracture relative to cemented hemiarthroplasty [28]. All routinely used noncemented stem design types in elderly hip fracture patients are associated with a higher risk of aseptic revision compared with cemented fixation [43]. While uncemented hemiarthroplasty may result in higher hip scores, it carries an unacceptably high risk of later femoral fractures [3]. Management of displaced femoral neck fractures in elderly patients with cemented and cementless hemiarthroplasty provides comparable morbidity and mortality; however, functional outcome tends to be lower in patients treated with cementless hemiarthroplasty [19]. At each follow-up examination, the Harris hip score was significantly higher in patients with cemented hemiarthroplasty [10]. The reduction in periprosthetic fracture risk represents the most pronounced and consistent effect observed across trials comparing cemented and uncemented fixation [39]. Intraoperative femoral fractures were observed exclusively in the uncemented group in the randomized study by Inngul et al. [39]. Achieving initial stability with uncemented stems requires press-fit fixation, which generates increased hoop stresses within the femoral cortex during insertion, predisposing elderly patients with osteoporotic bone to intraoperative or early postoperative periprosthetic fractures [39]. Authors recommend cemented arthroplasty for hip fractures and propose the Metaphyseal-Diaphyseal index (MDI) score to identify candidates suitable for uncemented arthroplasty, though prospective validation is needed [126].

Mortality and Perioperative Safety

There are no differences in the risk of mortality when comparing contemporary cemented with uncemented hemiarthroplasty in the management of intracapsular hip fractures [9]. These findings support recommendations to use cemented femoral fixation in total hip arthroplasty and hemiarthroplasty for hip fracture patients, as cemented fixation does not increase cardiopulmonary complications [15]. Bone cement implantation syndrome (BCIS) is estimated to occur in 25% to 46% of cemented arthroplasty cases [44]. BCIS is a clinical spectrum characterized by transient hypoxia, hypotension, and cardiac arrhythmias or arrest in the postcementation period, associated with prolonged intubation and increased 30-day mortality rates [44]. ASA classification influences the cardiovascular system during cemented hemiarthroplasty, and bone cement influences intraoperative blood pressure in patients rated ≥ASA III [110].

Implant Design and Articulation

The long-term survivorship of bipolar hemiarthroplasty prostheses used to treat displaced femoral neck fractures in the elderly is high, and the procedure can be considered definitive for the majority of elderly patients with a femoral neck fracture [18]. National registry data supports the continued use of bipolar hemiarthroplasty in femoral-neck fracture in the elderly [31]. In a study of hip fractures in older patients, total hip arthroplasty was associated with a lower risk of all-cause revision compared with unipolar and bipolar hemiarthroplasty among patients aged 60 to 79 years and those with an ASA classification of I or II [60]. The cumulative incidence of revision at 1 year was 1.7% for unipolar hemiarthroplasty and 2.0% for bipolar hemiarthroplasty [115]. The cumulative incidence of revision at 5 years was 2.9% for unipolar hemiarthroplasty and 2.7% for bipolar hemiarthroplasty [115]. The cumulative incidence of revision at 10 years was 3.2% for unipolar hemiarthroplasty and 3.0% for bipolar hemiarthroplasty [115]. Modular hip hemiarthroplasty patients may be susceptible to metallosis and adverse reaction to metal debris despite being less active individuals than those who receive a total hip arthroplasty [63]. Hip hemiarthroplasty head sizes can be reliably predicted from non-standardised pre-operative radiographs using a simple, adoptable model [17].

Complications and Revision

Although there have been changes in operation methods for hip fractures and management has developed, a 25-year study does not show any effect on functional outcome [6]. The lag time between the index hemiarthroplasty operation and periprosthetic fracture varied from 11 days to 5 years, with a mean of 2 years [98]. Of 15 patients who sustained periprosthetic fractures after hemiarthroplasty, 13 represented Vancouver Type B2 fractures [98]. The choice of locking or conventional plates for the treatment of Vancouver type B1 periprosthetic fractures, and cemented or cementless femoral components fixation for B2 and B3 fractures, had no significant influence on risk for reoperation [121].

Clinical Presentation

A hip fracture exerts a dramatic impact on health-related quality of life, with deterioration sustained one year after the injury [16]. In the elderly patient, the primary treatment goal is to regain function as soon as possible while minimizing pain and complications [37]. Patients with femoral neck fractures are heterogeneous regarding age, activity level, underlying health, and other factors influencing surgical benefits and risks [89]. Post-operatively, patients frequently demonstrate a decline in function and a high rate of complications, including an increased risk of mortality [37]. In the event of treatment failure, many elderly patients lack the capacity to withstand a secondary procedure [37].

Prognostic Factors and Surgical Selection

Preoperative dementia: The presence of preoperative dementia is an independent predictor of increased postoperative mortality in patients undergoing hip fracture repair [58].

Neurological disease: Most patients with a neurological disease are not eligible for total hip arthroplasty and should thus undergo hemiarthroplasty [13].

Age and sex-specific outcomes: When contemporary surgical options for femoral neck fracture are used, there is a benefit with respect to revision outcomes for total hip arthroplasty in women who are 60 to 74 years old [29]. Conversely, there is an increased risk of revision in women 80 to 85 years old and men 75 to 85 years old compared with hemiarthroplasty [29].

Implant fixation: Functional outcome of patients treated with cementless hemiarthroplasty tends to be lower than those treated with cemented hemiarthroplasty [19].

Investigations

Clinical Presentation: The diagnosis of hip fracture is initially established from clinical presentation, where patients describe a history of a fall from standing height and demonstrate a shortened and externally rotated limb on examination [50].

Plain radiography: Plain radiographs of the pelvis and the hip constitute the next diagnostic step [50]. A traction-internal rotation view of the affected hip may help elucidate the true fracture pattern [50]. In one study assessing 47 complete sets of hip fracture radiographs before and after traction-internal rotation views, this view led to better agreement among surgeons in classifying the type of fracture and its stability [50]. In some cases, the traction-internal rotation view led to a change in the choice of the implant used to fix the fracture [50].

CT: In rare instances, when radiographs are nondiagnostic and suspicion remains high, CT scan may be used to diagnose occult intertrochanteric hip fractures [50].

MRI: In rare instances, when radiographs are nondiagnostic and suspicion remains high, magnetic resonance imaging may be used to diagnose occult intertrochanteric hip fractures [50].

Laboratory: Because 92.5% of laboratory tests did not influence postoperative management, routine laboratory tests after hip hemiarthroplasty for femoral neck fractures are less instructive for the majority of elderly patients [12].

Postoperative Imaging: Hip radiographs obtained in clinic within 6 months of surgery rarely lead to a change in treatment course and thereby are a source of excess cost and radiation exposure to the patient [70].

Treatment

Operative

Indications: Cemented hemiarthroplasty is supported for the routine management of elderly patients with displaced intracapsular fractures of the hip [1]. While most patients with neurological disease are not eligible for total hip arthroplasty and should undergo hemiarthroplasty, those eligible for total hip arthroplasty could benefit from a dual-mobility component [13]. For severe osteoporotic elderly patients with unstable intertrochanteric fractures, bipolar hemiarthroplasty is an effective method of treatment [105].

Surgical Approach / Technique: The two most commonly used approaches for hemiarthroplasty to the hip are the lateral and the posterior approach [52]. The posterior approach is claimed to result in better regain of function due to less damage to hip muscles, while anterior and lateral approaches have a lower risk of dislocation [52]. The SuperPath approach for artificial femoral head replacement in elderly patients with femoral neck fractures involves smaller incision length, less intraoperative bleeding, a lower transfusion rate, and a shorter starting time of weight-bearing activity [102]. A study aimed to provide evidence-based support for the rational and effective application of posterolateral mini-incision hip hemiarthroplasty in elderly patients with hip fractures to improve postoperative pain and hip joint function [49].

Implant Selection: Contemporary cemented hemiarthroplasty provides better results than uncemented hemiarthroplasty for patients with displaced intracapsular fractures of the hip [4]. Level 1 evidence indicates that cemented hemiarthroplasty for femoral neck fractures offers improved 1-year mortality rates and less periprosthetic fracture compared with noncemented hemiarthroplasty [8]. The AAOS Clinical Practice Guideline upgraded its recommendation from “moderate” to “strong” support for the use of cemented stems for hemiarthroplasty in the setting of a femoral neck fracture [27]. Cemented femoral fixation in hemiarthroplasty for hip fractures does not increase cardiopulmonary complications [15].

Uncemented hemiarthroplasty carries an unacceptably high risk of later femoral fractures compared to cemented fixation [3]. Uncemented hemiarthroplasties should not be used when treating elderly patients with hip fractures due to an increased reoperation risk [21]. All routinely used noncemented stem design types in hemiarthroplasty for elderly hip fracture patients are associated with a higher risk of aseptic revision compared with cemented fixation [43]. Press-fit hemiarthroplasties are more likely to result in repeat procedures on the same hip, while cemented hemiarthroplasties are associated with a trend toward longer survival without repeat surgery [59]. In hemiarthroplasty using current generation stems, cemented stems result in fewer implant-related complications and similar mortality compared with cementless stems [69].

There are no differences in the risk of mortality when comparing contemporary cemented with uncemented hemiarthroplasty for intracapsular hip fractures [9]. Management of displaced femoral neck fractures in elderly patients with cemented and cementless hemiarthroplasty provides comparable outcomes regarding morbidity and mortality, but functional outcome tends to be lower in patients treated with cementless hemiarthroplasty [19]. The Harris hip score was significantly higher in patients with cemented hemiarthroplasty at each follow-up examination [10]. Cemented hemiarthroplasty is expected to increase health-related quality of life compared with modern uncemented hemiarthroplasty for all subgroups of patients aged > 60 years with a displaced intracapsular fracture of the hip [5]. Uncemented hemiarthroplasties may have a role in elderly patients with significant co-morbid disease [38]. A modern uncemented hip hemiarthroplasty for intracapsular hip fracture using a proven stem design results in a satisfactory return to pre-injury mobility status and place of residence, and an acceptable mortality rate [99].

Thompson hip hemiarthroplasties are associated with higher dislocation rates compared to a contemporaneous cohort of other implant choices [14]. Larger effective femoral heads used during conversion of hemiarthroplasties to total hip arthroplasties resulted in high survivorship free of revision, minimal complications, and excellent clinical outcomes at short-term follow-up [40].

Outcomes, Complications, and Revision: Hip hemiarthroplasty is a safe surgery with a low mortality rate during the early postoperative stage [45]. Uncemented hemiarthroplasty was associated with no perioperative deaths and a 30-day mortality rate of 5% in a single-center series of 857 patients [20]. Although there have been changes in operation methods for hip fractures and management has developed, a 25-year study did not show any effect on functional outcome [6].

Total hip arthroplasty is at significantly higher risk of dislocation but lower risk of revision within 12 months compared to hemiarthroplasty for independently mobile older adults with intracapsular hip fractures [23]. When contemporary surgical options for femoral neck fracture are used, total hip arthroplasty offers a benefit with respect to revision outcomes for women aged 60 to 74 years, but carries an increased risk of revision compared with hemiarthroplasty in women aged 80 to 85 years and men aged 75 to 85 years [29].

The mean time from hip fracture surgery to periprosthetic fracture around a hemiarthroplasty was 35 months, with a median of 5 months [61]. 46% of periprosthetic fractures around hemiarthroplasty occurred within 3 months of primary hip fracture surgery, with all but one case occurring around Austin Moore prostheses [61].

Perioperative Management: Routine laboratory tests after hip hemiarthroplasty for femoral neck fractures are less instructive for the majority of elderly patients because 92.5% of tests did not influence postoperative management [12]. The use of high-dose antibiotic impregnated cement in hip hemiarthroplasty for fractured neck of femur is the subject of a trial intended to inform evidence-based recommendations for its management [47]. Treatment of osteoporosis should be initiated in eligible patients who sustain a femoral neck fracture, especially those who undergo hip arthroplasty [104].

Complications

Periprosthetic fracture: Uncemented hemiarthroplasty carries an unacceptably high risk of later femoral fractures compared to cemented hemiarthroplasty [3]. Cemented hemiarthroplasty offers less periprosthetic fracture compared with noncemented hemiarthroplasty [8]. Specifically, cementless hemiarthroplasty is associated with an 11-fold increased risk of periprosthetic fracture relative to cemented hemiarthroplasty [28]. Intraoperative periprosthetic femur fractures during bipolar hemiarthroplasty for displaced neck of femur fractures occurred in 10.3% of cases [107]. The incidence of intraoperative periprosthetic femur fractures was significantly higher for uncemented prostheses (14.7%) than for cemented prostheses [107]. Noncemented total hip arthroplasty also carries an increased risk of periprosthetic fracture, a serious complication with notable morbidity [67].

Dislocation: Thompson hip hemiarthroplasties are associated with higher dislocation rates compared to a contemporaneous cohort of implant choices [14]. Total hip arthroplasty is at significantly higher risk of dislocation compared to hemiarthroplasty within 12 months [23]. Short- and medium-term dislocation rates following total hip replacement were significantly higher than following cemented hemiarthroplasty [66]. Dementia was associated with increased periprosthetic dislocation rates after hemiarthroplasty for femoral neck fracture [101].

Mortality: Cemented hemiarthroplasty for femoral neck fractures offers improved 1-year mortality rates compared with noncemented hemiarthroplasty [8]. Uncemented hemiarthroplasty was associated with a 30-day mortality rate of 5% in a single-center series of 857 patients [20]. Dementia was associated with higher 1-year mortality after hemiarthroplasty for femoral neck fracture [101]. Longer operation times in hip hemiarthroplasty for femoral neck fractures are associated with increased risk of mortality [41].

Revision and Reoperation: Cemented hemiarthroplasty is associated with a lower risk of reoperation up to five years postoperatively compared with uncemented hemiarthroplasty [48]. Total hip arthroplasty is associated with a lower risk of all-cause revision compared with unipolar and bipolar hemiarthroplasty among patients aged 60 to 79 years with an ASA classification of I or II [60]. When contemporary surgical options are used, total hip arthroplasty provides a benefit regarding revision outcomes for women aged 60 to 74 years compared with hemiarthroplasty [29]. Conversely, total hip arthroplasty carries an increased risk of revision compared with hemiarthroplasty in women aged 80 to 85 years and men aged 75 to 85 years [29]. Total hip arthroplasty is associated with a lower risk of revision within 12 months compared to hemiarthroplasty [23]. Larger effective femoral heads used during conversion of hemiarthroplasties to total hip arthroplasties resulted in high survivorship free of revision and minimal complications at short-term follow-up [40].

Functional Outcomes and Quality of Life: At each follow-up examination, the Harris hip score was significantly higher in patients with cemented hemiarthroplasty compared to cementless [10]. Although there have been changes in operation methods for hip fractures over a 25-year period, the study does not show any effect on functional outcome [6].

Other Considerations: Dementia was associated with increased major complications after hemiarthroplasty for femoral neck fracture [101]. Dementia was associated with higher 30- and 90-day readmission after hemiarthroplasty for femoral neck fracture [101]. Surgeon volume and experience did not influence early outcome and complication rates in hip hemiarthroplasty [30]. Routine laboratory tests after hip hemiarthroplasty for femoral neck fractures are less instructive for the majority of elderly patients, as 92.5% of tests did not influence postoperative management [12].

Recovery

Mortality and Survival: A meta-analysis of 11 studies enrolling 1899 hips found no significant difference in mortality within three months after operation between cemented hemiarthroplasty (12.8%) and uncemented hemiarthroplasty (13.1%) [64]. The same meta-analysis found no significant difference in mortality at last follow-up between cemented hemiarthroplasty (38.3%) and uncemented hemiarthroplasty (40.7%) [64]. Longer operation times in hip hemiarthroplasty for femoral neck fractures are associated with an increased risk of complications and mortality [41].

Functional Outcomes and Quality of Life: Although there have been changes in operation methods for hip fractures and management has developed, a 25-year study does not show any effect on functional outcome [6].

Complications and Reoperation: Uncemented hemiarthroplasty may result in higher hip scores but appears to carry an unacceptably high risk of later femoral fractures [3]. Current level 1 evidence shows that cemented hemiarthroplasty for femoral neck fractures offers less periprosthetic fracture compared with noncemented hemiarthroplasty [8]. Cemented hemiarthroplasty was associated with a lower risk of reoperation up to five years postoperatively compared with uncemented hemiarthroplasty [48]. Uncemented hemiarthroplasties should not be used when treating elderly patients with hip fractures because there is an increased reoperation risk [21]. Thompson hip hemiarthroplasties are associated with higher dislocation rates when compared to a contemporaneous cohort of implant choices [14]. Short- and medium-term dislocation rates following total hip replacement were significantly higher than following cemented hemiarthroplasty, with no difference in medium-term revision rates [66].

Long-Term Survivorship and Definitive Treatment: These results further support the use of a cemented hemiarthroplasty for the routine management of elderly patients with a displaced intracapsular fracture of the hip [1]. Contemporary cemented hemiarthroplasty gives better results than an uncemented hemiarthroplasty for patients with a displaced intracapsular fracture of the hip [4]. Concern regarding excessive acetabular wear resulting in conversion to total hip arthroplasty is not supported by the data [34].

Postoperative Management and Costs: Routine laboratory tests after hip hemiarthroplasty for femoral neck fractures are less instructive for the majority of elderly patients because 92.5% of laboratory tests did not influence postoperative management [12]. Despite documented higher upfront costs for cemented hemiarthroplasty, the averaged total costs over a 10-year time horizon were $2,534 less for cemented hemiarthroplasty than for uncemented hemiarthroplasty [139].

Key Evidence

• [L1] These results further support the use of a cemented hemiarthroplasty for the routine management of elderly patients with a displaced intracapsular fracture of the hip. [1] (10.1302/0301-620x.105b11.bjj-2023-0534.r1)
• [L3] Approximately 1 in 6 patients live at least 10 years following a hip fracture. [2] (10.2106/jbjs.24.00379)
• [L1] The uncemented hemiarthroplasty may result in higher hip scores but appears to carry an unacceptably high risk of later femoral fractures. [3] (10.1007/s11999-013-3308-9)
• [L1] These results indicate that a contemporary cemented hemiarthroplasty gives better results than an uncemented hemiarthroplasty for patients with a displaced intracapsular fracture of the hip. [4] (10.1302/0301-620x.102b1.bjj-2019-1041.r1)
• [L1] The use of a cemented hemiarthroplasty is expected to increase health-related quality of life compared with modern uncemented hemiarthroplasty for all subgroups of patients aged > 60 years with a displaced intracapsular fracture of the hip. [5] (10.1302/0301-620x.106b7.bjj-2024-0267)
• [L3] Although there have been changes in operation methods for hip fractures and the management has developed, the study does not show any effect on functional outcome over a 25-year period. [6] (10.1016/j.injury.2018.10.010)
• [L3] The outcome of hemiarthroplasty performed for fractured neck of femur revised to THA is influenced by patient age, not by the articulation used. [7] (10.1016/j.arth.2021.04.001)
• [L1] The current level 1 evidence shows that cemented hemiarthroplasty for femoral neck fractures offers improved 1-year mortality rates and less periprosthetic fracture compared with noncemented hemiarthroplasty. [8] (10.5435/jaaos-d-23-00564)
• [L1] There are no differences in the risk of mortality when comparing the use of contemporary cemented with uncemented hemiarthroplasty in the management of intracapsular hip fractures. [9] (10.1302/0301-620x.102b9.bjj-2020-0282.r1)
• [L1] At each follow-up examination the Harris hip score was significantly higher in patients with cemented HA. [10] (10.1016/s0020-1383(13)70201-8)
• [L5] The standard of care for surgical management of failed hemiarthroplasty is conversion to a total hip arthroplasty. [11] (10.5435/jaaos-d-16-00723)
• [L3] Because 92.5% of laboratory tests did not influence postoperative management, routine laboratory tests after hip hemiarthroplasty for femoral neck fractures are less instructive for the majority of elderly patients. [12] (10.1186/s12891-021-04698-4)
• [L3] Most patients with a neurological disease are not eligible for total hip arthroplasty and should thus undergo hemiarthroplasty, whereas those eligible for total hip arthroplasty could benefit from a dual-mobility component. [13] (10.1302/0301-620x.104b1.bjj-2021-0855.r1)
• [L3] Thompson hip hemiarthroplasties are associated with higher dislocation rates when compared to a contemporaneous cohort of implant choices and considerations for their use should be made in conjunction with this major risk factor for the need for subsequent operations. [14] (10.1016/j.arth.2020.01.061)
• [L2] These findings further support the recommendations to use cemented femoral fixation in THA and hemiarthroplasty for patients with hip fractures. [15] (10.1097/corr.0000000000003645)
• [L3] A hip fracture has a dramatic impact on the patients' HRQoL, and the deterioration in HRQoL sustained also one year after the fracture. [16] (10.1186/s12891-016-1111-y)
• [Paper] Hip hemiarthroplasty head sizes can be reliably predicted from non-standardised pre-operative radiographs using a simple, adoptable model. [17] (10.1016/j.injury.2019.08.025)
• [L4] The long-term survivorship of bipolar hemiarthroplasty prostheses used to treat displaced femoral neck fractures in the elderly was high, and the procedure can be considered definitive for the majority of elderly patients with a femoral neck fracture. [18] (10.1007/s11999-015-4462-z)
• [L1] Management of displaced femoral neck fractures in elderly patients with cemented and cementless hemiarthroplasty provides a comparable outcome with regard to morbidity and mortality; however, functional outcome of patients treated with cementless HA tends to be lower. [19] (10.1016/j.injury.2015.10.069)
• [L3] Uncemented hemiarthroplasty was associated with no perioperative deaths and a 30-day mortality rate of 5% in this series. [20] (10.1016/j.arth.2021.01.055)
• [L3] Uncemented hemiarthroplasties should not be used when treating elderly patients with hip fractures because there is an increased reoperation risk. [21] (10.1097/corr.0000000000000826)
• [L3] Patients preferred the outcome after cemented Thompson hemiarthroplasty over uncemented Austin-Moore hemiarthroplasty. [22] (10.1016/j.injury.2005.09.016)
• [L1] These data suggest that THA is at significantly higher risk of dislocation but lower risk of revision within 12 months. [23] (10.1186/s12891-019-2590-4)
• [L3] Intraoperative fractures during cemented hemiarthroplasty do not contribute to an increased risk of secondary surgery, morbidity, or mortality after surgery. [26] (10.1016/j.arth.2024.08.006)
• [Paper] The AAOS published a Clinical Practice Guideline upgrading its recommendation from “moderate” to “strong” support for the use of cemented stems for hemiarthroplasty in the setting of a femoral neck fracture. [27] (10.5435/jaaosglobal-d-24-00183)
• [L3] Cementless hemiarthroplasty is associated with increased surgical complications relative to cemented hemiarthroplasty, with an 11-fold increased risk of periprosthetic fracture. [28] (10.1016/j.arth.2025.03.067)
• [L3] When contemporary surgical options for femoral neck fracture are used, there is a benefit with respect to revision outcomes for total hip arthroplasty in women who are 60 to 74 years old, but an increased risk of revision in women 80 to 85 years old and men 75 to 85 years old compared with hemiarthroplasty. [29] (10.2106/jbjs.21.01256)
• [L3] Surgeon volume and experience did not influence early outcome and complication rates in hip hemiarthroplasty. [30] (10.1007/s00402-018-3076-9)
• [Paper] Our review of data from national registries supports the continued use of bipolar hemiarthroplasty in femoral-neck fracture in the elderly and identifies age, method of fixation and surgical approach as important prognostic variables in determining implant survival. [31] (10.1007/s00264-011-1354-z)
• [L4] Concern regarding excessive acetabular wear resulting in conversion to total hip arthroplasty is not supported by the data. [34] (10.1097/blo.0b013e31802dc4e7)
• [L2] [37] (10.1302/0301-620x.98b3.36515)
• [L3] Our results suggest that uncemented hemiarthroplasties may have a role to play in elderly patients with significant co-morbid disease. [38] (10.1302/0301-620x.96b9.33935)
• [L1] [39] (10.1016/j.injury.2026.113428)
• [L3] Larger effective femoral heads used during conversion of hemiarthroplasties to THAs resulted in high survivorship free of revision, minimal complications, and excellent clinical outcomes at short-term follow-up. [40] (10.1016/j.arth.2017.04.061)
• [L5] The letter highlights the importance of minimizing operative time in hip hemiarthroplasty for femoral neck fractures, noting that longer operation times are associated with increased risk of complications and mortality, while emphasizing the need for future prospective studies to explore causality. [41] (10.1186/s13018-024-04882-x)
• [L3] In the hemiarthroplasty treatment of elderly patients with hip fracture, all routinely used noncemented stem design types were associated with a higher risk of aseptic revision as compared with cemented fixation. [43] (10.5435/jaaos-d-20-01312)
• [L3] [44] (10.5435/jaaos-d-24-00239)
• [L3] Hip hemiarthroplasty is a safe surgery with a low mortality rate during the early postoperative stage. [45] (10.1186/s42836-024-00247-1)
• [L3] NHFS was able to discriminate survival at all timepoints with similar accuracy to the validating studies in the hip fracture cohort. [46] (10.1302/0301-620x.107b11.bjj-2024-1635.r2)
• [L2] The results from this trial will inform evidence-based recommendations for antibiotic impregnated cement in the management of patients with a fractured neck of femur undergoing a hip hemiarthroplasty. [47] (10.1186/1471-2474-14-356)
• [L3] In contrast, cemented hemiarthroplasty was associated with a lower risk of reoperation up to five years postoperatively compared with uncemented hemiarthroplasty. [48] (10.1302/0301-620x.104b1.bjj-2021-0523.r1)
• [L1] The study aimed to provide evidence-based support for the rational and effective application of this surgical technique in elderly patients with hip fractures to improve postoperative pain and hip joint function. [49] (10.5435/jaaosglobal-d-25-00206)
• [L1] [52] (10.1016/j.injury.2015.02.020)
• [L3] The presence of preoperative dementia is an independent predictor of increased postoperative mortality in patients undergoing hip fracture repair. [58] (10.5435/jaaosglobal-d-26-00177)
• [L3] Press-fit hemiarthroplasties were more likely to result in repeat procedures on the same hip, while cemented hemiarthroplasties were associated with a trend toward longer survival without repeat surgery. [59] (10.5435/jaaos-d-21-01178)
• [L3] In this study of hip fractures in older patients, THA was associated with a lower risk of all-cause revision compared with unipolar and bipolar hemiarthroplasty among patients who were 60 to 79 years old and those who had an ASA classification of I or II. [60] (10.2106/jbjs.23.00486)
• [L4] [61] (10.1016/j.injury.2012.09.015)
• [L4] There is a general consensus for femoral head-conserving surgery in young patients and replacement arthroplasty in elderly patients with subcapital fractures. [62] (10.1016/j.injury.2015.10.066)
• [L3] Modular hip hemiarthroplasty patients may be susceptible to metallosis and adverse reaction to metal debris despite being less active individuals than those who receive a total hip arthroplasty. [63] (10.1302/0301-620x.107b4.bjj-2024-0576.r1)
• [L1] [64] (10.1007/s00402-020-03737-4)
• [L3] Short- and medium-term dislocation rates following THR were significantly higher than following cemented hemiarthroplasty, with no difference in medium-term revision rates. [66] (10.1016/j.injury.2013.03.021)
• [L4] Although noncemented THA remains generally safe for elderly patients, it does carry an increased risk of periprosthetic fracture, a serious complication with notable morbidity. [67] (10.5435/jaaosglobal-d-25-00288)
• [L4] Hemiarthroplasty remains an important treatment strategy for displaced femoral neck fractures in the elderly with very low rates of conversion to THA. [68] (10.1016/j.arth.2016.06.048)
• [L1] In hemiarthroplasty of the hip using current generation stems, cemented stems result in fewer implant-related complications and similar mortality compared with cementless stems. [69] (10.1302/0301-620x.99b4.bjj-2016-0758.r1)
• [L4] Hip radiographs obtained in clinic within 6 months of surgery rarely lead to a change in treatment course and thereby are a source of excess cost and radiation exposure to the patient. [70] (10.1016/j.injury.2019.07.005)
• [L5] Hip abductor moment arm varies substantially throughout the hip's range of motion in the coronal plane. [73] (10.1186/1749-799x-6-6)
• [Paper] [89] (10.1016/j.arth.2024.05.064)
• [L5] The lower frictional coefficients of ceramic compared to metal against fresh cadaveric acetabula may have a clinical impact on the process of the protrusion of the corresponding femoral head through the acetabulum. [94] (10.1007/s00402-004-0734-x)
• [Paper] [98] (10.1016/j.injury.2013.07.023)
• [L4] A modern uncemented hip hemi-arthroplasty for intracapsular hip fracture using a proven stem design results in a satisfactory return to pre-injury mobility status and place of residence, and an acceptable mortality rate. [99] (10.1302/0301-620x.95b11.31609)
• [L3] Dementia was associated with increased major complications, increased periprosthetic dislocation rates, higher 30- and 90-day readmission, and 1-year mortality after hemiarthroplasty for femoral neck fracture. [101] (10.5435/jaaos-d-25-01507)
• [L1] [102] (10.1016/j.injury.2019.06.006)
• [L3] Treatment of osteoporosis should be initiated in eligible patients who sustain a femoral neck fracture, especially those who undergo hip arthroplasty. [104] (10.1016/j.arth.2022.10.042)
• [Paper] For the severe osteoporotic elderly with unstable fractures, bipolar hemiarthroplasty is an effective method to treat the unstable intertrochanteric fractures. [105] (10.1016/j.injury.2020.01.010)
• [L3] [107] (10.1007/s00402-018-2952-7)
• [L3] ASA classification influences the cardiovascular system during cemented hemiarthroplasty, and bone cement influences intraoperative blood pressure in patients rated ≥ASA III. [110] (10.1016/j.otsr.2018.03.014)
• [L5] The authors recommend that surgeons performing hip hemiarthroplasty should consider restoring capsular integrity to minimize rates of post-operative dislocation. [112] (10.1302/0301-620x.97b1.34038)
• [L2] [115] (10.1016/j.arth.2023.07.006)
• [L3] [121] (10.1302/0301-620x.101b11.bjj-2019-0480.r2)
• [L2] The authors recommend cemented arthroplasty for hip fractures and propose the MDI score to identify candidates suitable for uncemented arthroplasty, though prospective validation is needed. [126] (10.1186/1749-799x-6-59)
• [L2] Two potential periods for haemodynamic instability were observed during hip hemiarthroplasty surgery: within five minutes of cementing the femoral canal and after final reduction of the prosthesis. [129] (10.1302/0301-620x.107b1.bjj-2024-0548.r1)
• [L5] [135] (10.1097/01.blo.0000164029.91632.15)
• [L4] Despite documented higher upfront costs for cemented hemiarthroplasty, the averaged total costs over a 10-year time horizon were $2,534 less for cemented hemiarthroplasty than for uncemented hemiarthroplasty. [139] (10.1016/j.arth.2024.10.098)

See Also

• Adverse reaction to metal debris
• Total hip replacement

References

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