Decision-making Between Arthroplasty and Osteosynthesis in Geriatric Hip Fragility Fractures: Insights into Clinical Outcomes

Decision-making Between Arthroplasty and Osteosynthesis in Geriatric Hip Fragility Fractures: Insights into Clinical Outcomes | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Decision-making Between Arthroplasty and Osteosynthesis in Geriatric Hip Fragility Fractures: Insights into Clinical Outcomes Cumhur Deniz Davulcu, Muhammed Yusuf Afacan This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8253825/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 14 Apr, 2026 Read the published version in Orthopedic Surgery and Trauma Journal → Version 1 posted You are reading this latest preprint version Abstract Aim Geriatric hip fragility fractures represent a significant challenge in orthopedic practice due to high morbidity and functional impairment. The choice between arthroplasty and osteosynthesis remains a critical decision influenced by patient factors, fracture characteristics, and expected outcomes. This study aimed to compare the clinical outcomes of arthroplasty and osteosynthesis in elderly patients with hip fragility fractures, identifying the most effective treatment approach. Methods A retrospective cohort study was conducted, including 130 patients treated at a tertiary center between 2016 and 2023. Patients were divided into two groups: 65 underwent arthroplasty (55 hemiarthroplasty, 10 total hip arthroplasty) and 65 osteosynthesis with proximal femoral nails. Intraoperative metrics (surgical duration, blood loss), postoperative parameters (mobilization time, hospital stay, complications), functional outcomes (Harris Hip Score [HHS], Visual Analog Scale [VAS]), and radiological outcomes were evaluated. Results The arthroplasty group demonstrated significantly shorter surgical duration (78.3 ± 12.4 vs. 92.7 ± 15.8 minutes; p < 0.001), earlier mobilization (1.1 ± 0.8 vs. 2.4 ± 1.2 days; p < 0.001), and reduced hospital stays (4.8 ± 1.4 vs. 6.2 ± 1.7 days; p < 0.001). Postoperative complications were lower in the arthroplasty group (9%) compared to osteosynthesis (15%; p = 0.03). Functional recovery at 12 months favored arthroplasty, with higher HHS (89.3 ± 4.6 vs. 83.7 ± 6.3; p < 0.001) and lower VAS pain scores (1.8 ± 0.5 vs. 2.9 ± 0.8; p < 0.001). Radiological assessments confirmed satisfactory fracture healing in 91% of osteosynthesis cases and implant stability in 97% of arthroplasty cases. Multivariate analysis identified arthroplasty as an independent predictor of shorter hospital stay (p = 0.02) and lower complication rates (p = 0.01). Conclusion Arthroplasty offers superior clinical outcomes in terms of faster recovery, fewer complications, and better functional scores compared to osteosynthesis for geriatric hip fragility fractures. These findings support arthroplasty as the preferred treatment in suitable elderly hip fracture patients, with further prospective studies recommended to strengthen the evidence base. Geriatric hip fractures Fragility fractures Femoral neck fractures Intertrochanteric femur fractures Proximal femoral nail Total hip arthroplasty Hip bipolar hemiarthroplasty Figures Figure 1 INTRODUCTION Geriatric hip fractures, with significant annual incidence and high morbidity, pose a considerable challenge to healthcare systems and increase the risk of contralateral fractures due to factors like falls, poor bone quality, and deconditioning 1 . Osteoporosis, marked by reduced bone mineral density (BMD) and increased fracture risk, becomes increasingly prevalent with aging, contributing to a significant rise in osteoporotic fractures globally as the population ages 2 . Vitamin D deficiency, prevalent in many populations, particularly among the elderly, increases the risk of fragility fractures by contributing to low bone mass, muscle weakness, and falls 3 . Fragility fractures are defined as low-energy fractures 4 , and are common in older adults, with a substantial lifetime risk, particularly among women, and are associated with increased mortality in men, impaired mobility, extended hospital stays, and diminished life expectancy due to underlying osteoporosis 5 , 6 . Hip fractures can be extracapsular as intertrochanteric femur fractures (ITF) or intracapsular as femoral neck fractures in its nature 7 . The proximal femoral nail (PFN) aligns well with the femoral anatomy and offers superior stability, making it a common choice for treating unstable ITFs 7 , 8 . However, osteoporosis in elderly patients can increase surgical failure rates and complications, prompting consideration of hip arthroplasty as a favorable alternative in selected cases 7 , 9 . On the other hand, femoral neck fractures are optimally managed with arthroplasty, with hemiarthroplasty (HA) being standard for most elderly patients and total hip arthroplasty (THA) offering better functional outcomes in select active individuals, while cemented arthroplasty reduces periprosthetic fracture risk, though skilled surgeons can achieve similar outcomes with cementless techniques 10 . This study hypothesizes that arthroplasty provides shorter hospital stays, fewer postoperative complications, and superior functional recovery compared to osteosynthesis, while osteosynthesis is associated with increased complications and prolonged hospitalization. The aim of this study is to compare the clinical outcomes of arthroplasty and osteosynthesis in the treatment of geriatric hip fragility fractures, thereby identifying the most effective treatment approach for the elderly population. MATERIALS AND METHODS This study was designed as a retrospective cohort analysis to compare the clinical outcomes of arthroplasty and osteosynthesis in the management of geriatric hip fragility fractures. The data were collected from patient records at a tertiary healthcare center over an eight-year period, from January 2016 to December 2023. All patients were treated by experienced orthopedic surgeons, and surgical approaches were standardized across the study period to ensure consistency. Ethical approval was obtained from the Clinical Research Ethics Committee and the study adhered to the principles of the Declaration of Helsinki. The study population included patients aged 65 years and older who presented with low-energy trauma resulting in hip fragility fractures. A total of 130 patients met the inclusion criteria, with 65 treated with arthroplasty either HA or THA and 65 with osteosynthesis with PFN. Patient records were reviewed to extract demographic information, fracture characteristics, surgical details, and postoperative outcomes. Patients were included in the study if they were aged 65 years or older, sustained a hip fracture due to low-energy trauma, and underwent treatment with either arthroplasty or osteosynthesis. Complete medical records documenting preoperative, intraoperative, and postoperative data were required for inclusion. Patients with fractures resulting from high-energy trauma, pathological fractures, or multiple fractures at different anatomical sites were excluded. Additionally, those with incomplete medical records or a history of prior surgery on the affected hip were not considered for analysis. The choice of surgical technique was based on the type of fracture and the patient’s clinical condition. All intertrochanteric femoral fractures were treated using PFNs, a technique that provides anatomical alignment and stability, particularly in unstable fracture patterns. For femoral neck fractures, usually cementless HA was the standard approach, with bipolar implants used in the majority of cases to improve joint stability and reduce wear. Cementless THA was performed in the minority of femoral neck fractures, primarily in patients with higher activity levels and better pre-fracture functional status. An example of each fracture type and used implants were depicted in Fig. 1 . A comprehensive set of clinical and functional parameters was evaluated to assess outcomes. Intraoperative metrics included the duration of surgery and estimated blood loss. Postoperative evaluations focused on wound healing, the occurrence of complications such as infections, thromboembolism, and implant failure, as well as time to mobilization and the total length of hospital stay. Functional outcomes were measured using the Harris Hip Score (HHS) and Visual Analog Scale (VAS) for pain at six and twelve months postoperatively. Radiographic assessments were conducted to monitor fracture healing and implant stability during follow-up visits. Follow-up assessments were performed at predetermined intervals, with clinical and radiological evaluations conducted at one, three, six, and twelve months postoperatively. Data collection was carried out through a detailed review of electronic health records and archived medical files. Preoperative demographic and clinical data, such as age, sex, comorbidities, and fracture type, were meticulously documented. Postoperative outcomes, including complications, functional recovery were systematically recorded and verified. Statistical Analysis To ensure the study was adequately powered, a sample size calculation was performed before data collection with G*Power (Version 3.1.9.6). Assuming a medium effect size of 0.5, a significance level of 0.05, and a statistical power of 80%, a minimum of 128 patients was required, with 64 patients in each treatment group. The final sample size of 130 patients exceeded this requirement, providing additional reliability to the analysis. This calculation was critical for minimizing the risk of type II errors and ensuring the study’s conclusions were robust. Statistical analyses were conducted using IBM SPSS Statistics 24.0 software. Continuous variables were expressed as means with standard deviations or medians with interquartile ranges, depending on the normality of the data distribution. Normality was assessed using the Kolmogorov-Smirnov test. Independent t-tests were used for normally distributed continuous variables, while the Mann-Whitney U test was applied for non-normally distributed data. Categorical variables were analyzed using the chi-square test or Fisher’s exact test, as appropriate. Multivariate logistic regression models were employed to identify independent predictors of adverse outcomes, including prolonged hospital stays and postoperative complications. Potential confounders, such as age, sex, and comorbidities, were adjusted for in the analysis. A p-value of less than 0.05 was considered statistically significant. The study was carried out with the permission of the Istanbul University-Cerrahpasa Hospital Scientific Research Evaluation and Ethics Committee (Date: 10.12.2024, Decision No: 1178481). We obtained an informed consent form from all patients for the procedure. All procedures were carried out in accordance with the ethical rules and the principles of the Declaration of Helsinki. Retrospective analysis was performed on patients who were hospitalized between January 2016 to December 2023. RESULTS A total of 130 patients, comprising 65 treated with arthroplasty and 65 with osteosynthesis, were included in the study. Among 65 patients of arthroplasty 55 were treated with HA and 10 with THA. The mean age of the patients was 76.8 ± 6.4 years, with females accounting for 58% of the total cohort. The two groups were comparable in age (arthroplasty: 77.2 ± 6.1 years; osteosynthesis: 78.4 ± 6.7 years; p = 0.45) and gender distribution (arthroplasty: 60% female; osteosynthesis: 56% female; p = 0.68). Comorbidities such as hypertension (arthroplasty: 51%; osteosynthesis: 48%; p = 0.74), diabetes (arthroplasty: 30%; osteosynthesis: 33%; p = 0.72), and cardiovascular diseases (arthroplasty: 28%; osteosynthesis: 31%; p = 0.71) were equally distributed between groups. The mean duration of surgery was significantly shorter in the arthroplasty group (78.3 ± 12.4 minutes) compared to the osteosynthesis group (92.7 ± 15.8 minutes; p < 0.001). There was no significant difference regarding the estimated intraoperative blood loss in both groups (p = 0.6). Patients in the arthroplasty group had significantly faster mobilization times, with a mean of 1.1 ± 0.8 days compared to 2.4 ± 1.2 days in the osteosynthesis group (p < 0.001). The length of hospital stay was also shorter for the arthroplasty group (4.8 ± 1.4 days) compared to the osteosynthesis group (6.2 ± 1.7 days; p < 0.001). Among the arthroplasty group 60 patients were mobilized with full weight bearing and 5 with partial while in the osteosynthesis group all patients were mobilized firstly with partial weight bearing. Postoperative complications were observed in 10 patients in the osteosynthesis group, significantly higher than the 6 patients reported in the arthroplasty group (p = 0.03). Implant failure was the most common complication in the osteosynthesis group seen in 6 patients, followed by infections in 4 patients. 15 patients had prolonged serous discharge in the wound dressing which ceased maximally at the 10. day. The arthroplasty group’s complications primarily included prosthetic dislocations in 2 patients posteriorly, wound-related issues in 2 patients and femoral fracture in 2 patients associated with intraoperative femoral stem hammering. The arthroplasty group demonstrated better functional recovery as assessed by the Harris Hip Score (HHS). At one year, the mean HHS was 89.3 ± 4.6 for arthroplasty and 83.7 ± 6.3 for osteosynthesis (p < 0.001). Pain levels, measured using the Visual Analog Scale (VAS), were lower in the arthroplasty group at 12 months (1.8 ± 0.5 vs. 2.9 ± 0.8; p < 0.001). Radiological evaluations demonstrated satisfactory fracture healing in 91% of patients in the osteosynthesis group by 12 months. Implants were stable in 97% of arthroplasty cases. Revision surgery was required in 9% of osteosynthesis patients, primarily due to nonunion or implant failure, compared to 3% in the arthroplasty group, a difference that approached but did not reach statistical significance (p = 0.12). Postoperative complications were analyzed by subgroup. Patients with diabetes had a higher overall complication rate compared to non-diabetic patients (p = 0.02). Advanced age (≥ 80 years) was also associated with prolonged hospitalization (p = 0.01). Multivariate logistic regression identified arthroplasty as an independent predictor of shorter hospital stay (odds ratio [OR]: 0.45; 95% confidence interval [CI]: 0.31–0.73; p = 0.02) and lower postoperative complication rates (OR: 0.52; 95% CI: 0.34–0.79; p = 0.01). Diabetes and advanced age were significant predictors of adverse outcomes, including increased complications and prolonged hospitalization. DISCUSSION The findings of this study highlight significant differences in outcomes between arthroplasty and osteosynthesis in the management of geriatric hip fragility fractures. Arthroplasty demonstrated superior performance with shorter surgical duration, faster mobilization, reduced hospital stays, and lower complication rates compared to osteosynthesis. Patients treated with arthroplasty also achieved better functional outcomes, as evidenced by higher HHS and lower VAS for pain scores at one year. While radiological evaluations showed satisfactory fracture healing in both groups, implant stability was notably higher in the arthroplasty group. Subgroup analyses revealed that advanced age and comorbidities like diabetes were predictors of prolonged hospitalization and increased complications. Multivariate analysis confirmed arthroplasty as an independent predictor of shorter hospital stays and fewer complications, underscoring its advantages in this patient population. PFN demonstrated superior long-term functional outcomes and lower mortality rates, consistent with Kumar et al., who emphasized the advantages of PFN in reducing operative times, blood loss, and overall mortality 9 . Gölge et al. supported this, noting a significantly higher mortality risk in patients treated with HA, suggesting careful patient selection for HA and favoring PFN when possible 11 . Furthermore, Jolly et al. highlighted that while HA offers superior short-term functional outcomes, PFN surpasses it in long-term results, with better HHS observed at the 12-month follow-up 12 . Despite PFN's long-term benefits, HA allows for earlier mobilization and full weight-bearing, which is critical in elderly patients at high risk of complications from prolonged immobilization. This aligns with Rathod et al., who emphasized the reduction of immobilization-related complications with HA, and Uçpunar et al., who highlighted decreased dependency and early mobilization as key benefits of HA 13,14 . Lu et al. further supported HA's medium-term survival advantages in nonagenarians, though acknowledging its association with increased intraoperative blood loss and transfusion requirements 15 . The complication profiles of both techniques varied. Zhou et al. noted higher risks of superficial infections with HA and a greater incidence of screw cutouts with PFN 16 . Chen et al. observed that while HA enables earlier weight-bearing, it does not achieve better clinical outcomes than PFN in unstable ITF fractures 7 . Surucu et al. reported less postoperative cognitive impairment with PFN, underscoring its systemic advantages in frail populations 17 . PFN's biomechanical stability in unstable fracture patterns was highlighted by Zhang et al., who found it superior to dynamic hip screws (DHS) for ITF fractures 18 . Taşkın et al. found no significant differences in balance and postural stability between HA and PFN 19 . Long intramedullary nails (LIN) demonstrated no significant advantage over short intramedullary nails (SIN), according to Zhang et al., though LIN caused greater trauma 20 . This underscores the need for personalized surgical approaches based on fracture characteristics and patient factors. Furthermore, Ariachakaran et al. noted that PFN has the least intraoperative blood loss and shortest hospital stay, which are pivotal in optimizing perioperative care 21 . Müller et al. identified infection prevention as a critical determinant of outcomes in proximal femoral fractures, emphasizing its importance alongside intrinsic patient variables 22 . Dong et al. further observed that hip replacement provides superior short-term recovery but does not reduce overall complications compared to internal fixation 23 . This study has several strengths that enhance its relevance and reliability. It provides a comprehensive analysis of clinical, functional, and radiological outcomes, enabling a holistic comparison between arthroplasty and osteosynthesis in the treatment of geriatric hip fragility fractures. The inclusion of standardized surgical protocols minimizes variability, ensuring consistency in treatment approaches. However, the study is not without limitations. Its retrospective design inherently limits causal inferences and may introduce selection bias. Being a single-center study, the generalizability of the findings to other healthcare settings is limited. Although the sample size was sufficient for detecting medium effect sizes, it may not have been large enough to detect smaller, clinically significant differences, particularly in subgroup analyses. The inclusion of both hemiarthroplasty and total hip arthroplasty within the arthroplasty group introduces heterogeneity, which could obscure the nuanced differences between these approaches. The first year clinical score, while capturing short term outcomes, does not provide insight into long-term complications or implant survivorship. Cheng et al. and Zhang et al. also called for high-quality, large-scale randomized controlled trials to address the limitations of current evidence and provide more robust guidance underscoring the need for further prospective research to validate these findings. CONCLUSION Arthroplasty provides significant advantages over osteosynthesis in the treatment of geriatric hip fragility fractures, particularly in terms of faster mobilization, shorter hospital stays, and superior functional recovery. While both techniques demonstrated acceptable radiological outcomes, the lower complication rates and higher implant stability associated with arthroplasty underscore its role as a preferred treatment modality for this population. Notably, arthroplasty should be strongly considered for managing intertrochanteric femur fractures, especially in elderly patients with limited functional reserves or comorbid conditions that predispose them to complications. These findings advocate for a paradigm shift in favor of arthroplasty in appropriate clinical scenarios, with further prospective studies warranted to validate these recommendations. Declarations Declaration of conflict of interest: The authors do NOT have any potential conflicts of interest for this manuscript. Declaration of funding: The authors received NO financial support for the preparation, research, authorship, and publication of this manuscript. Declaration of ethical approval for study: The study was approved by the local ethics committee. Declaration of informed consent: There is no information (names, initials, hospital identification numbers, or photographs) in the submitted manuscript that can be used to identify patients. Informed consent was obtained from all individual participants included in the study. Consent to publish: Participants provided consent for publication of anonymized data. Clinical trial number : not applicable. Disclosure : The authors report no conflicts of interest in this work. Author Contribution Authors who Conceived and designed the analysis: C.D.D, M.Y.AAuthors who Collected the data: C.D.D, M.Y.A Authors who Contributed data or analysis tools: C.D.D, M.Y.AAuthors who Performed the analysis: C.D.D, M.Y.AAuthors who Wrote the paper: C.D.D, M.Y.A Acknowledgments : None. References Ratnasamy PP, Rudisill KE, Oghenesume OP, Riedel MD, Grauer JN (2023) Risk of Contralateral Hip Fracture Following Initial Hip Fracture Among Geriatric Fragility Fracture Patients. JAAOS Glob Res Rev 7(7). 10.5435/JAAOSGlobal-D-23-00001 Li G, Thabane L, Papaioannou A, Ioannidis G, Levine MAH, Adachi JD (2017) An overview of osteoporosis and frailty in the elderly. BMC Musculoskelet Disord 18(1):46. 10.1186/s12891-017-1403-x Dadra A, Aggarwal S, Kumar P, Kumar V, Dibar DP, Bhadada SK (2019) High prevalence of vitamin D deficiency and osteoporosis in patients with fragility fractures of hip: A pilot study. 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Unfallchirurg 121(7):550–559. 10.1007/s00113-017-0386-2 Dong JB, Wang ZY, Lu H, Tian Y, Wang XR, Zhang ZQ (2015) Meta-analysis of internal fixation versus hip replacement in the treatment of trochanteric fractures. Zhongguo Gu Shang 28(3):245–251. http://www.ncbi.nlm.nih.gov/pubmed/25936195 Additional Declarations No competing interests reported. Cite Share Download PDF Status: Published Journal Publication published 14 Apr, 2026 Read the published version in Orthopedic Surgery and Trauma Journal → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. 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16:49:40","extension":"png","order_by":6,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":629603,"visible":true,"origin":"","legend":"","description":"","filename":"OnlineFigure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8253825/v1/01dd256c841ed9eecac0afa0.png"},{"id":98193883,"identity":"ce659117-dd4b-408a-bb36-22ecf6ea0d74","added_by":"auto","created_at":"2025-12-15 06:22:39","extension":"xml","order_by":7,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":68554,"visible":true,"origin":"","legend":"","description":"","filename":"bbad9d562ea94c798604bc5ab39806681structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-8253825/v1/8be60cb99aaa63cd1f6a586d.xml"},{"id":98431740,"identity":"0fa7536d-9d3f-4ee6-9ed8-770686ea4398","added_by":"auto","created_at":"2025-12-17 16:48:17","extension":"html","order_by":8,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":76779,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-8253825/v1/63bd7cd5f5282fa3a33f9b46.html"},{"id":98430484,"identity":"3d63b83f-e774-46e6-8b7d-edcd3a0c6eb6","added_by":"auto","created_at":"2025-12-17 16:45:34","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":3839877,"visible":true,"origin":"","legend":"\u003cp\u003eRadiographic representations of intertrochanteric (A) and femoral neck (C and E) fractures treated with various surgical methods. These images highlight the fracture patterns (A, C, E), and the corresponding surgical implants (B, D, F) utilized for stabilization and restoration of hip function.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1A: \u003c/strong\u003eRadiograph showing a right intertrochanteric femur fracture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1B:\u003c/strong\u003e Postoperative radiograph of an intertrochanteric femur fracture treated with a proximal femoral nail (PFN), demonstrating anatomical alignment and stable fixation with intramedullary instrumentation.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1C:\u003c/strong\u003e Radiograph showing a right femoral neck fracture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1D:\u003c/strong\u003e Postoperative radiograph depicting a bipolar hemiarthroplasty used for the management of a femoral neck fracture, with proper alignment of the prosthetic components.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1E:\u003c/strong\u003e Radiograph of another right femoral neck fracture.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFigure 1F:\u003c/strong\u003e Postoperative radiograph of a total hip arthroplasty performed for a femoral neck fracture, demonstrating the placement of the acetabular and femoral components.\u003c/p\u003e","description":"","filename":"Figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-8253825/v1/7b5c9aafa0beb2d385133d94.png"},{"id":108435162,"identity":"255a81b9-a3a7-48d5-9d6c-14e80284c6ce","added_by":"auto","created_at":"2026-05-04 15:37:36","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":5118746,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8253825/v1/1b65c9f2-6150-4147-b104-eecf0d79797f.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Decision-making Between Arthroplasty and Osteosynthesis in Geriatric Hip Fragility Fractures: Insights into Clinical Outcomes","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eGeriatric hip fractures, with significant annual incidence and high morbidity, pose a considerable challenge to healthcare systems and increase the risk of contralateral fractures due to factors like falls, poor bone quality, and deconditioning \u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e. Osteoporosis, marked by reduced bone mineral density (BMD) and increased fracture risk, becomes increasingly prevalent with aging, contributing to a significant rise in osteoporotic fractures globally as the population ages \u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e. Vitamin D deficiency, prevalent in many populations, particularly among the elderly, increases the risk of fragility fractures by contributing to low bone mass, muscle weakness, and falls \u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e. Fragility fractures are defined as low-energy fractures \u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e, and are common in older adults, with a substantial lifetime risk, particularly among women, and are associated with increased mortality in men, impaired mobility, extended hospital stays, and diminished life expectancy due to underlying osteoporosis \u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e,\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eHip fractures can be extracapsular as intertrochanteric femur fractures (ITF) or intracapsular as femoral neck fractures in its nature \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. The proximal femoral nail (PFN) aligns well with the femoral anatomy and offers superior stability, making it a common choice for treating unstable ITFs \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e. However, osteoporosis in elderly patients can increase surgical failure rates and complications, prompting consideration of hip arthroplasty as a favorable alternative in selected cases \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e,\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. On the other hand, femoral neck fractures are optimally managed with arthroplasty, with hemiarthroplasty (HA) being standard for most elderly patients and total hip arthroplasty (THA) offering better functional outcomes in select active individuals, while cemented arthroplasty reduces periprosthetic fracture risk, though skilled surgeons can achieve similar outcomes with cementless techniques \u003csup\u003e\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis study hypothesizes that arthroplasty provides shorter hospital stays, fewer postoperative complications, and superior functional recovery compared to osteosynthesis, while osteosynthesis is associated with increased complications and prolonged hospitalization. The aim of this study is to compare the clinical outcomes of arthroplasty and osteosynthesis in the treatment of geriatric hip fragility fractures, thereby identifying the most effective treatment approach for the elderly population.\u003c/p\u003e"},{"header":"MATERIALS AND METHODS","content":"\u003cp\u003eThis study was designed as a retrospective cohort analysis to compare the clinical outcomes of arthroplasty and osteosynthesis in the management of geriatric hip fragility fractures. The data were collected from patient records at a tertiary healthcare center over an eight-year period, from January 2016 to December 2023. All patients were treated by experienced orthopedic surgeons, and surgical approaches were standardized across the study period to ensure consistency. Ethical approval was obtained from the Clinical Research Ethics Committee and the study adhered to the principles of the Declaration of Helsinki.\u003c/p\u003e\u003cp\u003eThe study population included patients aged 65 years and older who presented with low-energy trauma resulting in hip fragility fractures. A total of 130 patients met the inclusion criteria, with 65 treated with arthroplasty either HA or THA and 65 with osteosynthesis with PFN. Patient records were reviewed to extract demographic information, fracture characteristics, surgical details, and postoperative outcomes.\u003c/p\u003e\u003cp\u003ePatients were included in the study if they were aged 65 years or older, sustained a hip fracture due to low-energy trauma, and underwent treatment with either arthroplasty or osteosynthesis. Complete medical records documenting preoperative, intraoperative, and postoperative data were required for inclusion. Patients with fractures resulting from high-energy trauma, pathological fractures, or multiple fractures at different anatomical sites were excluded. Additionally, those with incomplete medical records or a history of prior surgery on the affected hip were not considered for analysis.\u003c/p\u003e\u003cp\u003eThe choice of surgical technique was based on the type of fracture and the patient\u0026rsquo;s clinical condition. All intertrochanteric femoral fractures were treated using PFNs, a technique that provides anatomical alignment and stability, particularly in unstable fracture patterns. For femoral neck fractures, usually cementless HA was the standard approach, with bipolar implants used in the majority of cases to improve joint stability and reduce wear. Cementless THA was performed in the minority of femoral neck fractures, primarily in patients with higher activity levels and better pre-fracture functional status. An example of each fracture type and used implants were depicted in Fig.\u0026nbsp;\u003cspan refid=\"Fig7\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e\u003cp\u003eA comprehensive set of clinical and functional parameters was evaluated to assess outcomes. Intraoperative metrics included the duration of surgery and estimated blood loss. Postoperative evaluations focused on wound healing, the occurrence of complications such as infections, thromboembolism, and implant failure, as well as time to mobilization and the total length of hospital stay. Functional outcomes were measured using the Harris Hip Score (HHS) and Visual Analog Scale (VAS) for pain at six and twelve months postoperatively. Radiographic assessments were conducted to monitor fracture healing and implant stability during follow-up visits. Follow-up assessments were performed at predetermined intervals, with clinical and radiological evaluations conducted at one, three, six, and twelve months postoperatively. Data collection was carried out through a detailed review of electronic health records and archived medical files. Preoperative demographic and clinical data, such as age, sex, comorbidities, and fracture type, were meticulously documented. Postoperative outcomes, including complications, functional recovery were systematically recorded and verified.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStatistical Analysis\u003c/h2\u003e\u003cp\u003eTo ensure the study was adequately powered, a sample size calculation was performed before data collection with G*Power (Version 3.1.9.6). Assuming a medium effect size of 0.5, a significance level of 0.05, and a statistical power of 80%, a minimum of 128 patients was required, with 64 patients in each treatment group. The final sample size of 130 patients exceeded this requirement, providing additional reliability to the analysis. This calculation was critical for minimizing the risk of type II errors and ensuring the study\u0026rsquo;s conclusions were robust.\u003c/p\u003e\u003cp\u003eStatistical analyses were conducted using IBM SPSS Statistics 24.0 software. Continuous variables were expressed as means with standard deviations or medians with interquartile ranges, depending on the normality of the data distribution. Normality was assessed using the Kolmogorov-Smirnov test. Independent t-tests were used for normally distributed continuous variables, while the Mann-Whitney U test was applied for non-normally distributed data. Categorical variables were analyzed using the chi-square test or Fisher\u0026rsquo;s exact test, as appropriate. Multivariate logistic regression models were employed to identify independent predictors of adverse outcomes, including prolonged hospital stays and postoperative complications. Potential confounders, such as age, sex, and comorbidities, were adjusted for in the analysis. A p-value of less than 0.05 was considered statistically significant.\u003c/p\u003e\u003cp\u003e The study was carried out with the permission of the Istanbul University-Cerrahpasa Hospital Scientific Research Evaluation and Ethics Committee (Date: 10.12.2024, Decision No: 1178481). We obtained an informed consent form from all patients for the procedure. All procedures were carried out in accordance with the ethical rules and the principles of the Declaration of Helsinki. Retrospective analysis was performed on patients who were hospitalized between January 2016 to December 2023.\u003c/p\u003e\u003c/div\u003e"},{"header":"RESULTS","content":"\u003cp\u003eA total of 130 patients, comprising 65 treated with arthroplasty and 65 with osteosynthesis, were included in the study. Among 65 patients of arthroplasty 55 were treated with HA and 10 with THA. The mean age of the patients was 76.8\u0026thinsp;\u0026plusmn;\u0026thinsp;6.4 years, with females accounting for 58% of the total cohort. The two groups were comparable in age (arthroplasty: 77.2\u0026thinsp;\u0026plusmn;\u0026thinsp;6.1 years; osteosynthesis: 78.4\u0026thinsp;\u0026plusmn;\u0026thinsp;6.7 years; p\u0026thinsp;=\u0026thinsp;0.45) and gender distribution (arthroplasty: 60% female; osteosynthesis: 56% female; p\u0026thinsp;=\u0026thinsp;0.68). Comorbidities such as hypertension (arthroplasty: 51%; osteosynthesis: 48%; p\u0026thinsp;=\u0026thinsp;0.74), diabetes (arthroplasty: 30%; osteosynthesis: 33%; p\u0026thinsp;=\u0026thinsp;0.72), and cardiovascular diseases (arthroplasty: 28%; osteosynthesis: 31%; p\u0026thinsp;=\u0026thinsp;0.71) were equally distributed between groups.\u003c/p\u003e\u003cp\u003eThe mean duration of surgery was significantly shorter in the arthroplasty group (78.3\u0026thinsp;\u0026plusmn;\u0026thinsp;12.4 minutes) compared to the osteosynthesis group (92.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.8 minutes; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). There was no significant difference regarding the estimated intraoperative blood loss in both groups (p\u0026thinsp;=\u0026thinsp;0.6). Patients in the arthroplasty group had significantly faster mobilization times, with a mean of 1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 days compared to 2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 days in the osteosynthesis group (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). The length of hospital stay was also shorter for the arthroplasty group (4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 days) compared to the osteosynthesis group (6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 days; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Among the arthroplasty group 60 patients were mobilized with full weight bearing and 5 with partial while in the osteosynthesis group all patients were mobilized firstly with partial weight bearing. Postoperative complications were observed in 10 patients in the osteosynthesis group, significantly higher than the 6 patients reported in the arthroplasty group (p\u0026thinsp;=\u0026thinsp;0.03). Implant failure was the most common complication in the osteosynthesis group seen in 6 patients, followed by infections in 4 patients. 15 patients had prolonged serous discharge in the wound dressing which ceased maximally at the 10. day. The arthroplasty group\u0026rsquo;s complications primarily included prosthetic dislocations in 2 patients posteriorly, wound-related issues in 2 patients and femoral fracture in 2 patients associated with intraoperative femoral stem hammering. The arthroplasty group demonstrated better functional recovery as assessed by the Harris Hip Score (HHS). At one year, the mean HHS was 89.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 for arthroplasty and 83.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3 for osteosynthesis (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Pain levels, measured using the Visual Analog Scale (VAS), were lower in the arthroplasty group at 12 months (1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 vs. 2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Radiological evaluations demonstrated satisfactory fracture healing in 91% of patients in the osteosynthesis group by 12 months. Implants were stable in 97% of arthroplasty cases. Revision surgery was required in 9% of osteosynthesis patients, primarily due to nonunion or implant failure, compared to 3% in the arthroplasty group, a difference that approached but did not reach statistical significance (p\u0026thinsp;=\u0026thinsp;0.12). Postoperative complications were analyzed by subgroup. Patients with diabetes had a higher overall complication rate compared to non-diabetic patients (p\u0026thinsp;=\u0026thinsp;0.02). Advanced age (\u0026ge;\u0026thinsp;80 years) was also associated with prolonged hospitalization (p\u0026thinsp;=\u0026thinsp;0.01). Multivariate logistic regression identified arthroplasty as an independent predictor of shorter hospital stay (odds ratio [OR]: 0.45; 95% confidence interval [CI]: 0.31\u0026ndash;0.73; p\u0026thinsp;=\u0026thinsp;0.02) and lower postoperative complication rates (OR: 0.52; 95% CI: 0.34\u0026ndash;0.79; p\u0026thinsp;=\u0026thinsp;0.01). Diabetes and advanced age were significant predictors of adverse outcomes, including increased complications and prolonged hospitalization.\u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eThe findings of this study highlight significant differences in outcomes between arthroplasty and osteosynthesis in the management of geriatric hip fragility fractures. Arthroplasty demonstrated superior performance with shorter surgical duration, faster mobilization, reduced hospital stays, and lower complication rates compared to osteosynthesis. Patients treated with arthroplasty also achieved better functional outcomes, as evidenced by higher HHS and lower VAS for pain scores at one year. While radiological evaluations showed satisfactory fracture healing in both groups, implant stability was notably higher in the arthroplasty group. Subgroup analyses revealed that advanced age and comorbidities like diabetes were predictors of prolonged hospitalization and increased complications. Multivariate analysis confirmed arthroplasty as an independent predictor of shorter hospital stays and fewer complications, underscoring its advantages in this patient population.\u003c/p\u003e\u003cp\u003ePFN demonstrated superior long-term functional outcomes and lower mortality rates, consistent with Kumar et al., who emphasized the advantages of PFN in reducing operative times, blood loss, and overall mortality \u003csup\u003e\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u003c/sup\u003e. G\u0026ouml;lge et al. supported this, noting a significantly higher mortality risk in patients treated with HA, suggesting careful patient selection for HA and favoring PFN when possible \u003csup\u003e\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e\u003c/sup\u003e. Furthermore, Jolly et al. highlighted that while HA offers superior short-term functional outcomes, PFN surpasses it in long-term results, with better HHS observed at the 12-month follow-up \u003csup\u003e12\u003c/sup\u003e. Despite PFN's long-term benefits, HA allows for earlier mobilization and full weight-bearing, which is critical in elderly patients at high risk of complications from prolonged immobilization. This aligns with Rathod et al., who emphasized the reduction of immobilization-related complications with HA, and U\u0026ccedil;punar et al., who highlighted decreased dependency and early mobilization as key benefits of HA \u003csup\u003e13,14\u003c/sup\u003e. Lu et al. further supported HA's medium-term survival advantages in nonagenarians, though acknowledging its association with increased intraoperative blood loss and transfusion requirements \u003csup\u003e\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e\u003c/sup\u003e. The complication profiles of both techniques varied. Zhou et al. noted higher risks of superficial infections with HA and a greater incidence of screw cutouts with PFN \u003csup\u003e\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e\u003c/sup\u003e. Chen et al. observed that while HA enables earlier weight-bearing, it does not achieve better clinical outcomes than PFN in unstable ITF fractures \u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e. Surucu et al. reported less postoperative cognitive impairment with PFN, underscoring its systemic advantages in frail populations \u003csup\u003e\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003ePFN's biomechanical stability in unstable fracture patterns was highlighted by Zhang et al., who found it superior to dynamic hip screws (DHS) for ITF fractures \u003csup\u003e\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e\u003c/sup\u003e. Taşkın et al. found no significant differences in balance and postural stability between HA and PFN \u003csup\u003e\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e\u003c/sup\u003e. Long intramedullary nails (LIN) demonstrated no significant advantage over short intramedullary nails (SIN), according to Zhang et al., though LIN caused greater trauma \u003csup\u003e\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e\u003c/sup\u003e. This underscores the need for personalized surgical approaches based on fracture characteristics and patient factors. Furthermore, Ariachakaran et al. noted that PFN has the least intraoperative blood loss and shortest hospital stay, which are pivotal in optimizing perioperative care \u003csup\u003e\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e\u003c/sup\u003e. M\u0026uuml;ller et al. identified infection prevention as a critical determinant of outcomes in proximal femoral fractures, emphasizing its importance alongside intrinsic patient variables \u003csup\u003e\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e\u003c/sup\u003e. Dong et al. further observed that hip replacement provides superior short-term recovery but does not reduce overall complications compared to internal fixation \u003csup\u003e\u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u003c/sup\u003e.\u003c/p\u003e\u003cp\u003eThis study has several strengths that enhance its relevance and reliability. It provides a comprehensive analysis of clinical, functional, and radiological outcomes, enabling a holistic comparison between arthroplasty and osteosynthesis in the treatment of geriatric hip fragility fractures. The inclusion of standardized surgical protocols minimizes variability, ensuring consistency in treatment approaches. However, the study is not without limitations. Its retrospective design inherently limits causal inferences and may introduce selection bias. Being a single-center study, the generalizability of the findings to other healthcare settings is limited. Although the sample size was sufficient for detecting medium effect sizes, it may not have been large enough to detect smaller, clinically significant differences, particularly in subgroup analyses. The inclusion of both hemiarthroplasty and total hip arthroplasty within the arthroplasty group introduces heterogeneity, which could obscure the nuanced differences between these approaches. The first year clinical score, while capturing short term outcomes, does not provide insight into long-term complications or implant survivorship. Cheng et al. and Zhang et al. also called for high-quality, large-scale randomized controlled trials to address the limitations of current evidence and provide more robust guidance underscoring the need for further prospective research to validate these findings.\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eArthroplasty provides significant advantages over osteosynthesis in the treatment of geriatric hip fragility fractures, particularly in terms of faster mobilization, shorter hospital stays, and superior functional recovery. While both techniques demonstrated acceptable radiological outcomes, the lower complication rates and higher implant stability associated with arthroplasty underscore its role as a preferred treatment modality for this population. Notably, arthroplasty should be strongly considered for managing intertrochanteric femur fractures, especially in elderly patients with limited functional reserves or comorbid conditions that predispose them to complications. These findings advocate for a paradigm shift in favor of arthroplasty in appropriate clinical scenarios, with further prospective studies warranted to validate these recommendations.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eDeclaration of conflict of interest:\u0026nbsp;\u003c/strong\u003eThe authors do NOT have any potential conflicts of interest for this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of funding:\u003c/strong\u003e The authors received NO financial support for the preparation, research, authorship, and publication of this manuscript.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of ethical approval for study:\u003c/strong\u003e The study was approved by the local ethics committee.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDeclaration of informed consent:\u003c/strong\u003e There is no information (names, initials, hospital identification numbers, or photographs) in the submitted manuscript that can be used to identify patients. Informed consent was obtained from all individual participants included in the study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to publish:\u0026nbsp;\u003c/strong\u003eParticipants provided consent for publication of anonymized data.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e: not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eDisclosure\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eThe authors report no conflicts of interest in this work.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAuthors who Conceived and designed the analysis: C.D.D, M.Y.AAuthors who Collected the data: C.D.D, M.Y.A Authors who Contributed data or analysis tools: C.D.D, M.Y.AAuthors who Performed the analysis: C.D.D, M.Y.AAuthors who Wrote the paper: C.D.D, M.Y.A\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAcknowledgments\u003c/strong\u003e:\u003c/p\u003e\n\u003cp\u003eNone.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eRatnasamy PP, Rudisill KE, Oghenesume OP, Riedel MD, Grauer JN (2023) Risk of Contralateral Hip Fracture Following Initial Hip Fracture Among Geriatric Fragility Fracture Patients. 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Zhongguo Gu Shang 28(3):245\u0026ndash;251. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttp://www.ncbi.nlm.nih.gov/pubmed/25936195\u003c/span\u003e\u003cspan address=\"http://www.ncbi.nlm.nih.gov/pubmed/25936195\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Geriatric hip fractures, Fragility fractures, Femoral neck fractures, Intertrochanteric femur fractures, Proximal femoral nail, Total hip arthroplasty, Hip bipolar hemiarthroplasty","lastPublishedDoi":"10.21203/rs.3.rs-8253825/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8253825/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eAim\u003c/h2\u003e\u003cp\u003eGeriatric hip fragility fractures represent a significant challenge in orthopedic practice due to high morbidity and functional impairment. The choice between arthroplasty and osteosynthesis remains a critical decision influenced by patient factors, fracture characteristics, and expected outcomes. This study aimed to compare the clinical outcomes of arthroplasty and osteosynthesis in elderly patients with hip fragility fractures, identifying the most effective treatment approach.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e\u003cp\u003eA retrospective cohort study was conducted, including 130 patients treated at a tertiary center between 2016 and 2023. Patients were divided into two groups: 65 underwent arthroplasty (55 hemiarthroplasty, 10 total hip arthroplasty) and 65 osteosynthesis with proximal femoral nails. Intraoperative metrics (surgical duration, blood loss), postoperative parameters (mobilization time, hospital stay, complications), functional outcomes (Harris Hip Score [HHS], Visual Analog Scale [VAS]), and radiological outcomes were evaluated.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e\u003cp\u003eThe arthroplasty group demonstrated significantly shorter surgical duration (78.3\u0026thinsp;\u0026plusmn;\u0026thinsp;12.4 vs. 92.7\u0026thinsp;\u0026plusmn;\u0026thinsp;15.8 minutes; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), earlier mobilization (1.1\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8 vs. 2.4\u0026thinsp;\u0026plusmn;\u0026thinsp;1.2 days; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and reduced hospital stays (4.8\u0026thinsp;\u0026plusmn;\u0026thinsp;1.4 vs. 6.2\u0026thinsp;\u0026plusmn;\u0026thinsp;1.7 days; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Postoperative complications were lower in the arthroplasty group (9%) compared to osteosynthesis (15%; p\u0026thinsp;=\u0026thinsp;0.03). Functional recovery at 12 months favored arthroplasty, with higher HHS (89.3\u0026thinsp;\u0026plusmn;\u0026thinsp;4.6 vs. 83.7\u0026thinsp;\u0026plusmn;\u0026thinsp;6.3; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001) and lower VAS pain scores (1.8\u0026thinsp;\u0026plusmn;\u0026thinsp;0.5 vs. 2.9\u0026thinsp;\u0026plusmn;\u0026thinsp;0.8; p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Radiological assessments confirmed satisfactory fracture healing in 91% of osteosynthesis cases and implant stability in 97% of arthroplasty cases. Multivariate analysis identified arthroplasty as an independent predictor of shorter hospital stay (p\u0026thinsp;=\u0026thinsp;0.02) and lower complication rates (p\u0026thinsp;=\u0026thinsp;0.01).\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e\u003cp\u003eArthroplasty offers superior clinical outcomes in terms of faster recovery, fewer complications, and better functional scores compared to osteosynthesis for geriatric hip fragility fractures. These findings support arthroplasty as the preferred treatment in suitable elderly hip fracture patients, with further prospective studies recommended to strengthen the evidence base.\u003c/p\u003e","manuscriptTitle":"Decision-making Between Arthroplasty and Osteosynthesis in Geriatric Hip Fragility Fractures: Insights into Clinical Outcomes","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-12-15 06:22:33","doi":"10.21203/rs.3.rs-8253825/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f86005cc-ab2a-474a-a834-bcff816f4b82","owner":[],"postedDate":"December 15th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-05-04T15:37:25+00:00","versionOfRecord":{"articleIdentity":"rs-8253825","link":"https://doi.org/10.14744/ortst.2026.89952","journal":{"identity":"orthopedic-surgery-and-trauma-journal","isVorOnly":true,"title":"Orthopedic Surgery and Trauma Journal"},"publishedOn":"2026-04-15 00:00:00","publishedOnDateReadable":"April 15th, 2026"},"versionCreatedAt":"2025-12-15 06:22:33","video":"","vorDoi":"10.14744/ortst.2026.89952","vorDoiUrl":"https://doi.org/10.14744/ortst.2026.89952","workflowStages":[]},"version":"v1","identity":"rs-8253825","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8253825","identity":"rs-8253825","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}