Femoral head fractures: hemiarthroplasty or total hip arthroplasty?

Most femoral neck fractures are osteoporotic fractures in the elderly. The one-year mortality after neck fracture in this group is 24%. For hemiarthroplasty (HA) the bipolar heads have a risk reduction for reoperation due to acetabular erosion compared with monoblock heads. Surprisingly, the bipolar head had an increased reoperation risk for dislocation, infection and for periprosthetic fracture. Total hip arthroplasty (THA) after fracture has a four-fold raised risk for dislocation compared with THA after osteoarthritis. A larger head on the same neck (head to neck ratio) results in a theoretically larger range of movement and hence less risk for dislocation. The dual mobility bearing has, theoretically, the largest range of movement and good clinical results. Functional results are better for THA compared with HA. Arthroplasty for fracture has much better results compared with arthroplasty after a failed internal fixation; the risk for reoperation is more than doubled for the latter. A Swedish hip arthroplasty register study found a 20-fold higher risk for periprosthetic fracture when comparing uncemented HA with matt cemented HA. Also a polished cemented stem had 131/2-fold higher risks compared with a matt. The mortality during the first day after surgery is higher for cemented compared with uncemented arthroplasties, but lower after one week, one month and one year. Analysing the time points together resulted in no difference. A matt cemented THA with a maximum head size, maybe dual mobility, has the best results, and is also for the low-demanding elderly.