Determinants of Total Hip Arthroplasty Versus Hemiarthroplasty for Femoral Neck Fracture in Older Adults: A Nationwide Analysis of 99,084 Cases

Determinants of Total Hip Arthroplasty Versus Hemiarthroplasty for Femoral Neck Fracture in Older Adults: A Nationwide Analysis of 99,084 Cases | 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 Determinants of Total Hip Arthroplasty Versus Hemiarthroplasty for Femoral Neck Fracture in Older Adults: A Nationwide Analysis of 99,084 Cases David Maman, Yaniv Steinfield, Yaron Berkovich This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8609988/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background Surgical management of displaced femoral neck fractures in older adults typically involves hemiarthroplasty or total hip arthroplasty (THA). Although guidelines recommend THA for healthier, cognitively intact, community-dwelling adults, real-world procedure selection varies widely. This study evaluated nationwide determinantsfe of receiving THA versus hemiarthroplasty using a contemporary U.S. dataset. Methods A retrospective cohort study was conducted using the 2022 Nationwide Readmissions Database (NRD). Patients ≥ 65 years hospitalized with femoral neck fracture were identified using ICD-10-CM codes. Those treated with internal fixation or non-arthroplasty procedures were excluded. Weighted analyses characterized demographics, comorbidities, and hospital utilization between THA and hemiarthroplasty groups. A multivariable logistic regression model identified independent predictors of receiving THA. All analyses accounted for NRD survey design. Results Among 142,013 operative cases, 99,084 met inclusion criteria (81.8% hemiarthroplasty; 18.2% THA). Patients receiving THA were younger (76.6 vs 81.9 years), had shorter length of stay (6.06 vs 7.24 days), and were more frequently discharged home (17.5% vs 6.2%). Metabolic conditions were associated with increased odds of THA: obesity (OR 1.17), sleep apnea (OR 1.12), Frailty-related conditions were associated with markedly reduced THA likelihood, including Alzheimer’s disease (OR 0.48), Parkinson disease (OR 0.55), chronic kidney disease (OR 0.78), chronic lung disease (OR 0.73), and congestive heart failure (OR 0.69). Each additional year of age decreased the odds of THA by ~ 9%. Conclusion In this nationwide cohort, THA selection was strongly guided by patient age, frailty, and cognitive impairment, while metabolic comorbidities were associated with slightly higher THA utilization. These findings highlight real-world adherence to guideline-based patient selection and underscore the central role of functional reserve in treatment planning. Level of Evidence: Level III Femoral neck fracture total hip arthroplasty Hemiarthroplasty Patient selection Figures Figure 1 Introduction Femoral neck fractures are among the most consequential fragility injuries in older adults, frequently resulting in substantial pain, loss of mobility, and long-term functional decline, with major downstream effects on independence and health-system utilization.( 1 ) As populations age globally, the burden of hip fractures is expected to remain high and continue rising in many settings, amplifying clinical and economic pressures on healthcare systems.( 1 ) For displaced intracapsular femoral neck fractures in older adults, arthroplasty is the dominant surgical strategy, with hemiarthroplasty and total hip arthroplasty (THA) representing the two principal options. Contemporary guidelines generally support consideration of THA in carefully selected patients who are community ambulators, cognitively intact, and medically fit, while hemiarthroplasty is typically preferred for frailer patients with limited functional reserve or substantial comorbidity.( 2 , 3 ) Despite these recommendations, multiple population-based studies have demonstrated meaningful variation in THA utilization across institutions and patient subgroups, suggesting that real-world procedure selection is influenced by factors beyond guideline criteria alone.( 4 , 5 ) Prior comparative literature on THA versus hemiarthroplasty has largely emphasized clinical outcomes (e.g., function, dislocation, reoperation, mortality) and resource utilization. In the landmark HEALTH randomized trial, THA provided modest functional advantages but was associated with a higher risk of certain serious adverse events, reinforcing the importance of patient selection.( 6 ) However, comparatively fewer investigations have focused on how surgeons choose between THA and hemiarthroplasty in routine practice at a national level, and existing work has often relied on regional cohorts or administrative datasets from earlier eras.( 4 , 5 ) At the same time, utilization trends suggest that THA is increasingly used for fracture indications in selected older adults, heightening the relevance of characterizing contemporary selection patterns. Understanding nationwide determinants of procedure selection is clinically important for several reasons. First, quantifying patient-level predictors of THA versus hemiarthroplasty can help evaluate real-world alignment with evidence-based recommendations.( 2 , 3 ) Second, identifying determinants associated with differential use may highlight potential disparities or unwarranted practice variation.( 4 , 5 ) Finally, delineating the comorbidity and frailty profiles that influence procedure choice can refine shared decision-making and risk stratification in a setting where functional reserve is central to expected benefit from THA.( 6 ) Using the 2022 Nationwide Readmissions Database (NRD) a large, nationally representative all-payer U.S. inpatient dataset designed for weighted analyses we sought to ( 1 ) describe the distribution of operative procedures performed for femoral neck fracture in older adults; ( 2 ) compare demographic, clinical, and hospital characteristics between patients undergoing THA and those receiving hemiarthroplasty; and ( 3 ) identify independent predictors of receiving THA rather than hemiarthroplasty using a survey-weighted multivariable logistic regression model.( 7 ) By analyzing 99,084 arthroplasty cases, this study provides a contemporary national assessment of patient-level factors associated with arthroplasty selection for femoral neck fracture. Materials and Methods Data Source This retrospective cohort study used data from the 2022 Nationwide Readmissions Database (NRD), part of the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality. The NRD contains all-payer inpatient discharge records from 30 participating U.S. states and is designed to allow nationally weighted estimation of hospitalizations and readmissions. Each record includes patient demographics, diagnoses and procedures coded using ICD-10-CM/PCS, hospital characteristics, discharge disposition, charges, length of stay, and a unique visit linkage number. Study Population We identified all patients aged 65 years or older who were hospitalized with femoral neck fracture in 2022. Femoral neck fractures were defined using ICD-10-CM diagnosis codes for intracapsular proximal femur fractures (S72.00-S72.09). Patients younger than 65 years and those with missing key demographic or procedural data were excluded. Surgical procedure categorization Patients were grouped according to the primary procedure performed during the index hospitalization: Internal fixation (cannulated screws, dynamic hip screw, cephalomedullary nail) Hemiarthroplasty Total hip arthroplasty (THA) Other procedure or no procedure Procedure categories were defined using ICD-10-PCS codes. Because the study objective was to compare hemiarthroplasty with THA, patients undergoing internal fixation or other procedures were excluded from the final analytic cohort. Primary outcome The primary outcome was the type of arthroplasty performed: total hip arthroplasty (THA) vs hemiarthroplasty. Secondary outcomes Secondary clinical and utilization outcomes compared descriptively between groups included: In-hospital mortality Length of stay (days) Total hospital charges (USD) Discharge disposition (home, home health care, skilled nursing facility/rehabilitation/long-term care, short-term hospital transfer, against medical advice, in-hospital death) These outcomes were analyzed for descriptive context but were not included as predictors in the multivariable model to avoid introducing post-exposure variables. Covariates Demographic covariates included age (continuous) and sex. Clinical covariates included comorbidities identified using ICD-10-CM codes Hypertension, dyslipidemia, sleep apnea, chronic anemia, smoking, alcohol abuse, osteoporosis, mental disorders, Parkinson disease, Alzheimer’s disease, chronic kidney disease, congestive heart failure (CHF), chronic lung disease, thyroid disorders, liver disease, diabetes mellitus, history of myocardial infarction (MI), peripheral vascular disease, history of cerebrovascular accident (CVA), dementia, peptic ulcer disease, hemiplegia, neoplasms, and obesity. Statistical Analysis Continuous variables were summarized as means with standard deviations and compared using independent-samples t-tests. Categorical variables were summarized as frequencies with percentages and compared using χ² tests. All analyses accounted for NRD sampling weights, strata, and clusters according to HCUP recommendations to produce nationally representative estimates. A multivariable logistic regression model was constructed to identify independent predictors of receiving THA rather than hemiarthroplasty. The dependent variable was (1 = THA, 0 = hemiarthroplasty). All demographic and clinical covariates were entered simultaneously. Odds ratios (ORs) with 95% confidence intervals (CIs) and p-values were reported. Model diagnostics included: Hosmer-Lemeshow goodness-of-fit test Examination of variance inflation factors for multicollinearity Evaluation of model convergence and stability of estimates A two-sided p-value < 0.05 was considered statistically significant. Statistical analyses were performed using IBM SPSS. Missing Data Variables with missingness < 1% were analyzed using complete-case methods. No variable exceeded HCUP thresholds requiring imputation, and patterns of missing data were determined to be random at the dataset level. Ethical Considerations The NRD is a publicly available, fully deidentified dataset; therefore, the study did not require institutional review board approval or informed consent according to federal guidelines. Results In the 2022 Nationwide Readmissions Database, 142,013 patients aged 65 years or older underwent operative treatment for femoral neck fracture. Hemiarthroplasty was the most common procedure, performed in 81,003 patients (57.0%), followed by internal fixation in 30,483 patients (21.5%), total hip arthroplasty (THA) in 18,081 patients (12.7%), and other or unspecified procedures in 12,445 patients (8.8%) (Table 1 ). Table 1 Distribution of Surgical Procedure Types in NRD 2022 Procedure type Frequency Percent Internal Fixation 30,483 21.5 Hemiarthroplasty 81,003 57.0 Total Hip Arthroplasty 18,081 12.7 Other procedure / No procedure 12,445 8.8 Total 142,013 100.0 Because the objective of this study was to compare outcomes between hemiarthroplasty and THA, patients treated with internal fixation or other procedures were excluded. The final analytic cohort consisted of 99,084 arthroplasty patients, of whom 81,003 (81.8%) underwent hemiarthroplasty and 18,081 (18.2%) underwent THA (Table 2 ). Table 2 Analytic Cohort: Hemiarthroplasty vs Total Hip Arthroplasty Procedure type Frequency Percent Hemiarthroplasty 81,003 81.8 Total Hip Arthroplasty 18,081 18.2 Total 99,084 100.0 Baseline characteristics and hospitalization metrics for the analytic cohort are presented in Table 3 . Patients undergoing total hip arthroplasty were younger (76.6 vs 81.9 years) and slightly less often female (65.6% vs 67.6%). Medicare was the primary payer for 89.4% of THA patients and 93.2% of hemiarthroplasty patients. Length of stay was shorter after THA (6.06 vs 7.24 days), while total hospital charges were slightly higher (108,847 USD vs 103,617 USD). In-hospital mortality remained low overall but differed substantially between groups, occurring in 0.7% of THA cases compared with 1.9% among hemiarthroplasty patients. Table 3 Demographics and Hospital Utilization Outcomes by Procedure Type Variable Hemiarthroplasty (n = 81,003) Total Hip Arthroplasty (n = 18,081) p-value Age, mean ± SD (years) 81.93 ± 6.97 76.55 ± 7.27 < 0.001 Female (%) 67.6 65.6 < 0.001 Primary payer: Medicare (%) 93.2 89.4 < 0.001 Length of stay, mean ± SD (days) 7.24 ± 6.21 6.06 ± 5.54 < 0.001 Total hospital charges, mean ± SD (USD) 103,617 ± 78,141 108,847 ± 79,055 < 0.001 In-hospital mortality (%) 1.9 0.7 < 0.001 Discharge disposition differed substantially between groups and is presented in Table 4 . Patients undergoing hemiarthroplasty were most commonly discharged to skilled nursing facilities, rehabilitation centers, or long-term care (73.6%), whereas this occurred in only 49.1% of total hip arthroplasty patients. Conversely, discharge home occurred nearly three times more frequently after total hip arthroplasty (17.5%) compared with hemiarthroplasty (6.2%). Use of home health services was also higher in the total hip arthroplasty group (32.2% vs 17.7%). In-hospital mortality, consistent with earlier results, was significantly more common among hemiarthroplasty patients (1.9% vs 0.7%). These differences were statistically significant (p < 0.001). Table 4 Discharge Disposition by Procedure Type Disposition category Hemiarthroplasty (%) Total Hip Arthroplasty (%) Home 6.2 17.5 Short-term hospital transfer 0.5 0.4 SNF / Rehab / Long-term care 73.6 49.1 Home health care 17.7 32.2 Against medical advice 0.1 0.1 Died in hospital 1.9 0.7 In the multivariable logistic regression model evaluating factors associated with receiving total hip arthroplasty (THA) rather than hemiarthroplasty, several patient characteristics demonstrated significant associations (Fig. 1 ). Obesity (OR 1.17, 95% CI 1.10–1.25, p < 0.001), sleep apnea (OR 1.12, 95% CI 1.04–1.21, p = 0.004), thyroid disorders (OR 1.08, 95% CI 1.04–1.13, p < 0.001), and dyslipidemia (OR 1.06, 95% CI 1.02–1.09, p = 0.003) were associated with increased odds of receiving THA. These findings indicate that patients with metabolic or endocrine comorbidities were modestly more likely to undergo THA. By contrast, a wide range of clinical conditions were associated with significantly lower likelihood of receiving THA. These included Alzheimer’s disease (OR 0.48, 95% CI 0.43–0.53), peptic ulcer disease (OR 0.55, 95% CI 0.52–0.59), Parkinson disease (OR 0.55, 95% CI 0.50–0.60), history of myocardial infarction (OR 0.60, 95% CI 0.46–0.78), and chronic kidney disease (OR 0.78, 95% CI 0.74–0.82), all with p < 0.001. Several additional comorbidities showed similar associations, including congestive heart failure, chronic lung disease, liver disease, dementia, alcohol abuse, and mental disorders, with odds ratios generally ranging from 0.69 to 0.77 and all p < 0.001. This pattern reflects a broad tendency to avoid THA in patients with systemic frailty or cognitive impairment. Age demonstrated a strong independent effect, with each additional year lowering the odds of receiving THA by approximately 9 percent (OR 0.91, 95% CI 0.905–0.909, p < 0.001). Female sex was also associated with lower use of THA (OR 0.92, 95% CI 0.887–0.958, p < 0.001). Overall, the selection of THA was strongly influenced by patient frailty markers, chronic cardiopulmonary disease, cognitive disorders, and metabolic profiles. Figure 1 presents the complete set of adjusted odds ratios and confidence intervals for all predictors. Discussion In this nationally representative cohort of 99,084 older adults undergoing arthroplasty for femoral neck fracture, several important findings emerged regarding real-world determinants of procedure selection. First, THA accounted for 18.2% of arthroplasty procedures, consistent with prior reports demonstrating increasing utilization of THA for fracture indications over the past decade ( 8 , 9 ). Second, substantial differences were observed in baseline characteristics between patients receiving THA and those undergoing hemiarthroplasty, underscoring the importance of patient-level factors in surgical decision-making ( 10 , 11 ). Third, multivariable analysis revealed a consistent pattern in which metabolic and endocrine comorbidities were associated with slightly increased odds of THA, whereas frailty-associated, cognitive, and systemic disease factors were strongly associated with decreased THA utilization ( 12 , 13 ). Conditions such as Alzheimer’s disease, dementia, Parkinson disease, chronic kidney disease, chronic lung disease, congestive heart failure, and liver disease were all associated with significantly lower odds of THA. These findings closely align with guideline recommendations and expert consensus statements that favor hemiarthroplasty for frail, medically complex, or cognitively impaired individuals who are less likely to benefit from the functional advantages of THA ( 14 – 16 ). The magnitude of the observed associations, with odds ratios frequently ranging between 0.45 and 0.75, highlights the strong and consistent influence of frailty markers on real-world procedure selection ( 12 , 17 ). Age demonstrated a particularly pronounced effect, with each additional year associated with an approximately 9% reduction in the likelihood of receiving THA. Similar age-dependent patterns have been reported in prior national and regional analyses and likely reflect the combined influence of increasing frailty, comorbidity burden, and reduced postoperative functional expectations among the oldest patients ( 8 , 10 , 18 ). Although age alone is an imperfect surrogate for functional status, it remains a central consideration in arthroplasty decision-making for hip fracture patients ( 14 , 16 ). In contrast, obesity, dyslipidemia, sleep apnea, and thyroid disorders were associated with modest increases in THA utilization. These conditions may serve as markers of a distinct health phenotype characterized by preserved ambulation and community dwelling despite chronic disease, rather than classic frailty ( 11 , 19 ). Alternatively, these findings may reflect residual confounding related to unmeasured functional status or social support factors that influence surgeon perception of a patient’s capacity to benefit from THA ( 12 , 17 ). Importantly, effect sizes were small, and these associations should be interpreted as correlates of selection rather than causal drivers of procedure choice ( 13 , 18 ). Female sex was associated with slightly lower THA utilization, consistent with prior population-based studies ( 10 , 11 ). Potential explanations include sex-related differences in bone density, baseline mobility, living arrangements, or surgeon preference, although unmeasured functional variables likely contribute to this association ( 18 ). Marked differences in discharge disposition further support the role of baseline functional status in procedure selection. Patients undergoing THA were substantially more likely to be discharged home or with home health services, whereas those treated with hemiarthroplasty more frequently required skilled nursing or long-term care ( 9 , 12 ). Although discharge disposition represents a post-treatment variable and cannot be interpreted as a determinant of procedure choice, these findings are consistent with prior literature linking THA selection to higher pre fracture independence and anticipated rehabilitation potential ( 14 , 15 , 17 ). Previous comparative studies of THA versus hemiarthroplasty have largely focused on postoperative outcomes, demonstrating modest functional advantages of THA in selected patients alongside higher risks of instability and revision ( 16 , 18 ). The present study extends this body of work by focusing on real-world determinants of arthroplasty selection rather than outcomes, providing a contemporary nationwide assessment of how demographic and comorbidity profiles shape surgical decision-making ( 8 , 10 , 12 ). The findings support the conclusion that surgeons preferentially offer THA to younger, healthier, cognitively intact patients while appropriately avoiding THA in those with substantial frailty or systemic disease ( 14 – 16 ). From a clinical perspective, these results suggest substantial concordance between real-world practice and guideline-based recommendations ( 14 , 15 ). Quantifying determinants of procedure choice may help identify areas of unwarranted variation and support efforts to standardize patient selection across institutions ( 10 , 11 ). In addition, these data can inform preoperative counselling and shared decision-making by clarifying which patient characteristics are most strongly associated with THA utilization in routine practice ( 12 , 17 , 19 , 20 ). Strengths of this study include the large, nationally representative cohort, standardized coding, and rigorous survey-weighted analytic approach ( 13 ). Limitations include the use of administrative data, which lack granular clinical details such as fracture displacement, pre fracture ambulatory capacity, cognitive testing, radiographic findings, and surgeon-specific factors ( 12 , 18 ). Residual confounding is therefore possible, and causal inferences cannot be drawn. Nevertheless, the consistency and magnitude of observed associations across multiple frailty and cognitive domains support the clinical plausibility and relevance of the findings ( 14 – 16 ). Conclusion patient selection for THA versus hemiarthroplasty in femoral neck fracture is strongly influenced by age, frailty, cognitive impairment, and systemic comorbidity burden, while metabolic and endocrine conditions are associated with slightly higher THA utilization. These findings emphasize the central role of functional reserve in arthroplasty decision-making and support continued refinement of patient selection frameworks as THA use in fracture care continues to evolve. Declarations Ethics approval and consent to participate: The NRD is de-identified public data; the study was exempt from IRB review and informed consent under 45 CFR 46.101(b). Consent for publication: Not applicable. Funding: No external funding. Consent to Publish declaration: not applicable Ethics and Consent to Participate declarations: not applicable Author Contribution Concept/design: DM, YB; Data curation/analysis: DM; Interpretation: all authors; Drafting: DM; Critical revision: all authors; Final approval: all authors Data Availability NRD data are available from HCUP by data use agreement; ICD-10 code lists and balance diagnostics can be provided as supplementary materials on request. References Ebeling PR (2023) Hip fractures and aging: a global problem requiring coordinated global solutions. J Bone Min Res 38(8):1062–1063. https://doi.org/10.1002/jbmr.4881 National Institute for Health and Care Excellence (NICE) (2011) updated 2023) Hip fracture: management (CG124). Recommendations: total hip replacement versus hemiarthroplasty criteria. NICE guideline O’Connor MI, Switzer JA (2022) AAOS clinical practice guideline summary: management of hip fractures in older adults. 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Nationwide Readmissions Database (NRD) documentation Tohidi M, Mann SM, McIsaac MA, Groome PA (2023) Comparative Effectiveness of Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fracture: A Propensity-Score-Matched Cohort Study. J Bone Joint Surg Am 105(8):591–599. 10.2106/JBJS.22.01193 Tohidi M, Mann SM, Groome PA (2023) Total hip arthroplasty versus hemiarthroplasty for treatment of femoral neck fractures: a population-based analysis of practice variation in Ontario, Canada. Bone Joint J 105–B(2):180–189. 10.1302/0301-620X.105B2.BJJ-2022-0878.R1 Edelstein AI, Otero JE, Joseph H et al (2023) Hemiarthroplasty Versus Total Hip Arthroplasty for Femoral Neck Fractures: An Analysis of the American Joint Replacement Registry. J Bone Joint Surg Am 105(21):1695–1702. 10.2106/JBJS.23.00247 Pangaud C, Pioger C, Pauly V et al (2023) Total hip arthroplasty reduces the risk of dislocation after femoral neck fracture. 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Hip Int 32(1):131–139. 10.1177/1120700020920814 Falotico GG, Leal LF, Yamaguchi AM et al (2025) Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fracture: an overview of systematic reviews. J Orthop Surg Res 20:614. 10.1186/s13018-025-06144-w Tian P, Yang Y, He T, Wang L, Zhang Q, Cai Y (2025) Impact of frailty on postoperative complications in older adults after hip fracture: a systematic review of observational studies. Front Med (Lausanne) 12:1667462. 10.3389/fmed.2025.1667462 PMID: 41368319; PMCID: PMC12682881 Levi Y, Rapp K, Herrmann S et al (2020) Intensive Inpatient vs. Home-Based Rehabilitation After Hip Fracture: A Longitudinal Observational Study. Front Med (Lausanne) 7:592693. 10.3389/fmed.2020.592693 Morioka N, Tamiya N, Jin X et al (2021) Dementia and patient outcomes after hip surgery in older patients: A retrospective observational study using nationwide claims data in Japan. PLoS ONE 16(4):e0249364. 10.1371/journal.pone.0249364 Georgiadis GM (2023) Total Hip Arthroplasty or Hemiarthroplasty for Displaced Femoral Neck Fractures? Commentary on an article by Mina Tohidi, MD, FRCS(C), PhD. et al J Bone Joint Surg Am 105(8):e23. 10.2106/JBJS.23.00007 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8609988","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":589356886,"identity":"1050078e-39f1-430b-b9e9-4a3afb4b75f5","order_by":0,"name":"David Maman","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAABAElEQVRIiWNgGAWjYPACZhAyfABkJYDYYMDGTliLscEBFC3M+HRAlJlJgLWgCmIC3fbTiZ8LGKzlDY4zb6v+UGGXZ87OfOwBQ40dAx8OLWZncjdLz2BIN9xwmK3sxoEzycWWzWzpBgzHknE6zOxA7gZpHobDjDObecxuHGw7kLjhMI+ZBAPbAdxazr/d/BuoxR6kpeDgP5iWf3i03MjdBrIlsZ+Zx4zhYANUC2MbPi1vt1nzGKQn9zOzFUucOZYM1MKWJpHYl8yD22G5m2/zVFjbtvEf3vihosYuccP5w8ckPnyzk5Nvb8CuBwwM0AUSGBh48KgfBaNgFIyCUUAAAADewVWsgFz7+QAAAABJRU5ErkJggg==","orcid":"","institution":"Carmel Medical Center","correspondingAuthor":true,"prefix":"","firstName":"David","middleName":"","lastName":"Maman","suffix":""},{"id":589356887,"identity":"77f1a66a-f87a-48c2-85b4-11b384625d34","order_by":1,"name":"Yaniv Steinfield","email":"","orcid":"","institution":"Carmel Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Yaniv","middleName":"","lastName":"Steinfield","suffix":""},{"id":589356888,"identity":"d65aaee7-9491-4c34-a7f0-261d8147d491","order_by":2,"name":"Yaron Berkovich","email":"","orcid":"","institution":"Carmel Medical Center","correspondingAuthor":false,"prefix":"","firstName":"Yaron","middleName":"","lastName":"Berkovich","suffix":""}],"badges":[],"createdAt":"2026-01-15 11:38:14","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8609988/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8609988/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":102747948,"identity":"42db6bf5-8a50-42ea-8788-b071c4c1a884","added_by":"auto","created_at":"2026-02-16 09:05:38","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":251247,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003ePredictors of Receiving Total Hip Arthroplasty vs Hemiarthroplasty\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-8609988/v1/af7cfa829648a1ce02bbafb7.png"},{"id":102750849,"identity":"550a4f4e-7f5e-42f4-a7b5-ae23e8c2568b","added_by":"auto","created_at":"2026-02-16 09:22:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":904644,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8609988/v1/1cdb307f-a0a3-4f85-88f8-41dc63809edf.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Determinants of Total Hip Arthroplasty Versus Hemiarthroplasty for Femoral Neck Fracture in Older Adults: A Nationwide Analysis of 99,084 Cases","fulltext":[{"header":"Introduction","content":"\u003cp\u003eFemoral neck fractures are among the most consequential fragility injuries in older adults, frequently resulting in substantial pain, loss of mobility, and long-term functional decline, with major downstream effects on independence and health-system utilization.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) As populations age globally, the burden of hip fractures is expected to remain high and continue rising in many settings, amplifying clinical and economic pressures on healthcare systems.(\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eFor displaced intracapsular femoral neck fractures in older adults, arthroplasty is the dominant surgical strategy, with hemiarthroplasty and total hip arthroplasty (THA) representing the two principal options. Contemporary guidelines generally support consideration of THA in carefully selected patients who are community ambulators, cognitively intact, and medically fit, while hemiarthroplasty is typically preferred for frailer patients with limited functional reserve or substantial comorbidity.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Despite these recommendations, multiple population-based studies have demonstrated meaningful variation in THA utilization across institutions and patient subgroups, suggesting that real-world procedure selection is influenced by factors beyond guideline criteria alone.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e \u003cp\u003ePrior comparative literature on THA versus hemiarthroplasty has largely emphasized clinical outcomes (e.g., function, dislocation, reoperation, mortality) and resource utilization. In the landmark HEALTH randomized trial, THA provided modest functional advantages but was associated with a higher risk of certain serious adverse events, reinforcing the importance of patient selection.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e) However, comparatively fewer investigations have focused on how surgeons choose between THA and hemiarthroplasty in routine practice at a national level, and existing work has often relied on regional cohorts or administrative datasets from earlier eras.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) At the same time, utilization trends suggest that THA is increasingly used for fracture indications in selected older adults, heightening the relevance of characterizing contemporary selection patterns.\u003c/p\u003e \u003cp\u003eUnderstanding nationwide determinants of procedure selection is clinically important for several reasons. First, quantifying patient-level predictors of THA versus hemiarthroplasty can help evaluate real-world alignment with evidence-based recommendations.(\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) Second, identifying determinants associated with differential use may highlight potential disparities or unwarranted practice variation.(\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) Finally, delineating the comorbidity and frailty profiles that influence procedure choice can refine shared decision-making and risk stratification in a setting where functional reserve is central to expected benefit from THA.(\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e \u003cp\u003eUsing the 2022 Nationwide Readmissions Database (NRD) a large, nationally representative all-payer U.S. inpatient dataset designed for weighted analyses we sought to (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) describe the distribution of operative procedures performed for femoral neck fracture in older adults; (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) compare demographic, clinical, and hospital characteristics between patients undergoing THA and those receiving hemiarthroplasty; and (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) identify independent predictors of receiving THA rather than hemiarthroplasty using a survey-weighted multivariable logistic regression model.(\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e) By analyzing 99,084 arthroplasty cases, this study provides a contemporary national assessment of patient-level factors associated with arthroplasty selection for femoral neck fracture.\u003c/p\u003e"},{"header":"Materials and Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eData Source\u003c/h2\u003e \u003cp\u003eThis retrospective cohort study used data from the 2022 Nationwide Readmissions Database (NRD), part of the Healthcare Cost and Utilization Project (HCUP) of the Agency for Healthcare Research and Quality. The NRD contains all-payer inpatient discharge records from 30 participating U.S. states and is designed to allow nationally weighted estimation of hospitalizations and readmissions. Each record includes patient demographics, diagnoses and procedures coded using ICD-10-CM/PCS, hospital characteristics, discharge disposition, charges, length of stay, and a unique visit linkage number.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eStudy Population\u003c/h3\u003e\n\u003cp\u003eWe identified all patients aged 65 years or older who were hospitalized with femoral neck fracture in 2022. Femoral neck fractures were defined using ICD-10-CM diagnosis codes for intracapsular proximal femur fractures (S72.00-S72.09). Patients younger than 65 years and those with missing key demographic or procedural data were excluded.\u003c/p\u003e\n\u003ch3\u003eSurgical procedure categorization\u003c/h3\u003e\n\u003cp\u003ePatients were grouped according to the primary procedure performed during the index hospitalization:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eInternal fixation (cannulated screws, dynamic hip screw, cephalomedullary nail)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eHemiarthroplasty\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTotal hip arthroplasty (THA)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eOther procedure or no procedure\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eProcedure categories were defined using ICD-10-PCS codes. Because the study objective was to compare hemiarthroplasty with THA, patients undergoing internal fixation or other procedures were excluded from the final analytic cohort.\u003c/p\u003e \u003cp\u003ePrimary outcome\u003c/p\u003e \u003cp\u003eThe primary outcome was the type of arthroplasty performed: total hip arthroplasty (THA) vs hemiarthroplasty.\u003c/p\u003e \u003cp\u003eSecondary outcomes\u003c/p\u003e \u003cp\u003eSecondary clinical and utilization outcomes compared descriptively between groups included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eIn-hospital mortality\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eLength of stay (days)\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eTotal hospital charges (USD)\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eDischarge disposition (home, home health care, skilled nursing facility/rehabilitation/long-term care, short-term hospital transfer, against medical advice, in-hospital death)\u003c/p\u003e \u003cp\u003eThese outcomes were analyzed for descriptive context but were not included as predictors in the multivariable model to avoid introducing post-exposure variables.\u003c/p\u003e\n\u003ch3\u003eCovariates\u003c/h3\u003e\n\u003cp\u003eDemographic covariates included age (continuous) and sex.\u003c/p\u003e \u003cp\u003eClinical covariates included comorbidities identified using ICD-10-CM codes\u003c/p\u003e \u003cp\u003eHypertension, dyslipidemia, sleep apnea, chronic anemia, smoking, alcohol abuse, osteoporosis, mental disorders, Parkinson disease, Alzheimer\u0026rsquo;s disease, chronic kidney disease, congestive heart failure (CHF), chronic lung disease, thyroid disorders, liver disease, diabetes mellitus, history of myocardial infarction (MI), peripheral vascular disease, history of cerebrovascular accident (CVA), dementia, peptic ulcer disease, hemiplegia, neoplasms, and obesity.\u003c/p\u003e \u003cdiv id=\"Sec7\" class=\"Section2\"\u003e \u003ch2\u003eStatistical Analysis\u003c/h2\u003e \u003cp\u003eContinuous variables were summarized as means with standard deviations and compared using independent-samples t-tests. Categorical variables were summarized as frequencies with percentages and compared using χ\u0026sup2; tests. All analyses accounted for NRD sampling weights, strata, and clusters according to HCUP recommendations to produce nationally representative estimates.\u003c/p\u003e \u003cp\u003eA multivariable logistic regression model was constructed to identify independent predictors of receiving THA rather than hemiarthroplasty. The dependent variable was (1\u0026thinsp;=\u0026thinsp;THA, 0\u0026thinsp;=\u0026thinsp;hemiarthroplasty). All demographic and clinical covariates were entered simultaneously. Odds ratios (ORs) with 95% confidence intervals (CIs) and p-values were reported.\u003c/p\u003e \u003cp\u003eModel diagnostics included:\u003c/p\u003e \u003cp\u003e \u003cul\u003e \u003cli\u003e \u003cp\u003eHosmer-Lemeshow goodness-of-fit test\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eExamination of variance inflation factors for multicollinearity\u003c/p\u003e \u003c/li\u003e \u003cli\u003e \u003cp\u003eEvaluation of model convergence and stability of estimates\u003c/p\u003e \u003c/li\u003e \u003c/ul\u003e \u003c/p\u003e \u003cp\u003eA two-sided p-value\u0026thinsp;\u0026lt;\u0026thinsp;0.05 was considered statistically significant. Statistical analyses were performed using IBM SPSS.\u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eMissing Data\u003c/h2\u003e \u003cp\u003eVariables with missingness\u0026thinsp;\u0026lt;\u0026thinsp;1% were analyzed using complete-case methods. No variable exceeded HCUP thresholds requiring imputation, and patterns of missing data were determined to be random at the dataset level.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEthical Considerations\u003c/h3\u003e\n\u003cp\u003e The NRD is a publicly available, fully deidentified dataset; therefore, the study did not require institutional review board approval or informed consent according to federal guidelines.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eIn the 2022 Nationwide Readmissions Database, 142,013 patients aged 65 years or older underwent operative treatment for femoral neck fracture. Hemiarthroplasty was the most common procedure, performed in 81,003 patients (57.0%), followed by internal fixation in 30,483 patients (21.5%), total hip arthroplasty (THA) in 18,081 patients (12.7%), and other or unspecified procedures in 12,445 patients (8.8%) (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDistribution of Surgical Procedure Types in NRD 2022\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedure type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eInternal Fixation\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e30,483\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e21.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemiarthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81,003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e57.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Hip Arthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18,081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e12.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eOther procedure / No procedure\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e12,445\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e8.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e142,013\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBecause the objective of this study was to compare outcomes between hemiarthroplasty and THA, patients treated with internal fixation or other procedures were excluded. The final analytic cohort consisted of 99,084 arthroplasty patients, of whom 81,003 (81.8%) underwent hemiarthroplasty and 18,081 (18.2%) underwent THA (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eAnalytic Cohort: Hemiarthroplasty vs Total Hip Arthroplasty\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eProcedure type\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eFrequency\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003ePercent\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHemiarthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e81,003\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e81.8\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal Hip Arthroplasty\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e18,081\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e18.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e99,084\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e100.0\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eBaseline characteristics and hospitalization metrics for the analytic cohort are presented in Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e. Patients undergoing total hip arthroplasty were younger (76.6 vs 81.9 years) and slightly less often female (65.6% vs 67.6%). Medicare was the primary payer for 89.4% of THA patients and 93.2% of hemiarthroplasty patients. Length of stay was shorter after THA (6.06 vs 7.24 days), while total hospital charges were slightly higher (108,847 USD vs 103,617 USD). In-hospital mortality remained low overall but differed substantially between groups, occurring in 0.7% of THA cases compared with 1.9% among hemiarthroplasty patients.\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDemographics and Hospital Utilization Outcomes by Procedure Type\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eVariable\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHemiarthroplasty (n\u0026thinsp;=\u0026thinsp;81,003)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal Hip Arthroplasty (n\u0026thinsp;=\u0026thinsp;18,081)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003ep-value\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAge, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (years)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e81.93\u0026thinsp;\u0026plusmn;\u0026thinsp;6.97\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e76.55\u0026thinsp;\u0026plusmn;\u0026thinsp;7.27\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eFemale (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e67.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e65.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePrimary payer: Medicare (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e93.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e89.4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eLength of stay, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (days)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e7.24\u0026thinsp;\u0026plusmn;\u0026thinsp;6.21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e6.06\u0026thinsp;\u0026plusmn;\u0026thinsp;5.54\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eTotal hospital charges, mean\u0026thinsp;\u0026plusmn;\u0026thinsp;SD (USD)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e103,617\u0026thinsp;\u0026plusmn;\u0026thinsp;78,141\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e108,847\u0026thinsp;\u0026plusmn;\u0026thinsp;79,055\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eIn-hospital mortality (%)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e \u003cp\u003e\u0026lt;\u0026thinsp;0.001\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eDischarge disposition differed substantially between groups and is presented in Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e. Patients undergoing hemiarthroplasty were most commonly discharged to skilled nursing facilities, rehabilitation centers, or long-term care (73.6%), whereas this occurred in only 49.1% of total hip arthroplasty patients. Conversely, discharge home occurred nearly three times more frequently after total hip arthroplasty (17.5%) compared with hemiarthroplasty (6.2%). Use of home health services was also higher in the total hip arthroplasty group (32.2% vs 17.7%). In-hospital mortality, consistent with earlier results, was significantly more common among hemiarthroplasty patients (1.9% vs 0.7%). These differences were statistically significant (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eDischarge Disposition by Procedure Type\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDisposition category\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eHemiarthroplasty (%)\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eTotal Hip Arthroplasty (%)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e6.2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e17.5\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eShort-term hospital transfer\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eSNF / Rehab / Long-term care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e73.6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e49.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eHome health care\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e17.7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e32.2\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eAgainst medical advice\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003eDied in hospital\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e \u003cp\u003e1.9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e \u003cp\u003e0.7\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn the multivariable logistic regression model evaluating factors associated with receiving total hip arthroplasty (THA) rather than hemiarthroplasty, several patient characteristics demonstrated significant associations (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eObesity (OR 1.17, 95% CI 1.10\u0026ndash;1.25, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), sleep apnea (OR 1.12, 95% CI 1.04\u0026ndash;1.21, p\u0026thinsp;=\u0026thinsp;0.004), thyroid disorders (OR 1.08, 95% CI 1.04\u0026ndash;1.13, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), and dyslipidemia (OR 1.06, 95% CI 1.02\u0026ndash;1.09, p\u0026thinsp;=\u0026thinsp;0.003) were associated with increased odds of receiving THA. These findings indicate that patients with metabolic or endocrine comorbidities were modestly more likely to undergo THA.\u003c/p\u003e \u003cp\u003eBy contrast, a wide range of clinical conditions were associated with significantly lower likelihood of receiving THA. These included Alzheimer\u0026rsquo;s disease (OR 0.48, 95% CI 0.43\u0026ndash;0.53), peptic ulcer disease (OR 0.55, 95% CI 0.52\u0026ndash;0.59), Parkinson disease (OR 0.55, 95% CI 0.50\u0026ndash;0.60), history of myocardial infarction (OR 0.60, 95% CI 0.46\u0026ndash;0.78), and chronic kidney disease (OR 0.78, 95% CI 0.74\u0026ndash;0.82), all with p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. Several additional comorbidities showed similar associations, including congestive heart failure, chronic lung disease, liver disease, dementia, alcohol abuse, and mental disorders, with odds ratios generally ranging from 0.69 to 0.77 and all p\u0026thinsp;\u0026lt;\u0026thinsp;0.001. This pattern reflects a broad tendency to avoid THA in patients with systemic frailty or cognitive impairment.\u003c/p\u003e \u003cp\u003eAge demonstrated a strong independent effect, with each additional year lowering the odds of receiving THA by approximately 9 percent (OR 0.91, 95% CI 0.905\u0026ndash;0.909, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Female sex was also associated with lower use of THA (OR 0.92, 95% CI 0.887\u0026ndash;0.958, p\u0026thinsp;\u0026lt;\u0026thinsp;0.001).\u003c/p\u003e \u003cp\u003eOverall, the selection of THA was strongly influenced by patient frailty markers, chronic cardiopulmonary disease, cognitive disorders, and metabolic profiles. Figure\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e presents the complete set of adjusted odds ratios and confidence intervals for all predictors.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eIn this nationally representative cohort of 99,084 older adults undergoing arthroplasty for femoral neck fracture, several important findings emerged regarding real-world determinants of procedure selection. First, THA accounted for 18.2% of arthroplasty procedures, consistent with prior reports demonstrating increasing utilization of THA for fracture indications over the past decade (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). Second, substantial differences were observed in baseline characteristics between patients receiving THA and those undergoing hemiarthroplasty, underscoring the importance of patient-level factors in surgical decision-making (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Third, multivariable analysis revealed a consistent pattern in which metabolic and endocrine comorbidities were associated with slightly increased odds of THA, whereas frailty-associated, cognitive, and systemic disease factors were strongly associated with decreased THA utilization (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eConditions such as Alzheimer\u0026rsquo;s disease, dementia, Parkinson disease, chronic kidney disease, chronic lung disease, congestive heart failure, and liver disease were all associated with significantly lower odds of THA. These findings closely align with guideline recommendations and expert consensus statements that favor hemiarthroplasty for frail, medically complex, or cognitively impaired individuals who are less likely to benefit from the functional advantages of THA (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). The magnitude of the observed associations, with odds ratios frequently ranging between 0.45 and 0.75, highlights the strong and consistent influence of frailty markers on real-world procedure selection (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAge demonstrated a particularly pronounced effect, with each additional year associated with an approximately 9% reduction in the likelihood of receiving THA. Similar age-dependent patterns have been reported in prior national and regional analyses and likely reflect the combined influence of increasing frailty, comorbidity burden, and reduced postoperative functional expectations among the oldest patients (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Although age alone is an imperfect surrogate for functional status, it remains a central consideration in arthroplasty decision-making for hip fracture patients (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn contrast, obesity, dyslipidemia, sleep apnea, and thyroid disorders were associated with modest increases in THA utilization. These conditions may serve as markers of a distinct health phenotype characterized by preserved ambulation and community dwelling despite chronic disease, rather than classic frailty (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e). Alternatively, these findings may reflect residual confounding related to unmeasured functional status or social support factors that influence surgeon perception of a patient\u0026rsquo;s capacity to benefit from THA (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e). Importantly, effect sizes were small, and these associations should be interpreted as correlates of selection rather than causal drivers of procedure choice (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFemale sex was associated with slightly lower THA utilization, consistent with prior population-based studies (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). Potential explanations include sex-related differences in bone density, baseline mobility, living arrangements, or surgeon preference, although unmeasured functional variables likely contribute to this association (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eMarked differences in discharge disposition further support the role of baseline functional status in procedure selection. Patients undergoing THA were substantially more likely to be discharged home or with home health services, whereas those treated with hemiarthroplasty more frequently required skilled nursing or long-term care (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). Although discharge disposition represents a post-treatment variable and cannot be interpreted as a determinant of procedure choice, these findings are consistent with prior literature linking THA selection to higher pre fracture independence and anticipated rehabilitation potential (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e).\u003c/p\u003e \u003cp\u003ePrevious comparative studies of THA versus hemiarthroplasty have largely focused on postoperative outcomes, demonstrating modest functional advantages of THA in selected patients alongside higher risks of instability and revision (\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). The present study extends this body of work by focusing on real-world determinants of arthroplasty selection rather than outcomes, providing a contemporary nationwide assessment of how demographic and comorbidity profiles shape surgical decision-making (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e, \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e). The findings support the conclusion that surgeons preferentially offer THA to younger, healthier, cognitively intact patients while appropriately avoiding THA in those with substantial frailty or systemic disease (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eFrom a clinical perspective, these results suggest substantial concordance between real-world practice and guideline-based recommendations (\u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e). Quantifying determinants of procedure choice may help identify areas of unwarranted variation and support efforts to standardize patient selection across institutions (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e, \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). In addition, these data can inform preoperative counselling and shared decision-making by clarifying which patient characteristics are most strongly associated with THA utilization in routine practice (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eStrengths of this study include the large, nationally representative cohort, standardized coding, and rigorous survey-weighted analytic approach (\u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e). Limitations include the use of administrative data, which lack granular clinical details such as fracture displacement, pre fracture ambulatory capacity, cognitive testing, radiographic findings, and surgeon-specific factors (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). Residual confounding is therefore possible, and causal inferences cannot be drawn. Nevertheless, the consistency and magnitude of observed associations across multiple frailty and cognitive domains support the clinical plausibility and relevance of the findings (\u003cspan additionalcitationids=\"CR15\" citationid=\"CR14\" class=\"CitationRef\"\u003e14\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e).\u003c/p\u003e"},{"header":"Conclusion","content":"\u003cp\u003epatient selection for THA versus hemiarthroplasty in femoral neck fracture is strongly influenced by age, frailty, cognitive impairment, and systemic comorbidity burden, while metabolic and endocrine conditions are associated with slightly higher THA utilization. These findings emphasize the central role of functional reserve in arthroplasty decision-making and support continued refinement of patient selection frameworks as THA use in fracture care continues to evolve.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics approval and consent to participate:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe NRD is de-identified public data; the study was exempt from IRB review and informed consent under 45 CFR 46.101(b).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent for publication:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eFunding:\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNo external funding.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent to Publish declaration:\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEthics and Consent to Participate declarations:\u003c/strong\u003e not applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthor Contribution\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eConcept/design: DM, YB; Data curation/analysis: DM; Interpretation: all authors; Drafting: DM; Critical revision: all authors; Final approval: all authors\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData Availability\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eNRD data are available from HCUP by data use agreement; ICD-10 code lists and balance diagnostics can be provided as supplementary materials on request.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEbeling PR (2023) Hip fractures and aging: a global problem requiring coordinated global solutions. J Bone Min Res 38(8):1062\u0026ndash;1063. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1002/jbmr.4881\u003c/span\u003e\u003cspan address=\"10.1002/jbmr.4881\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eNational Institute for Health and Care Excellence (NICE) (2011) updated 2023) Hip fracture: management (CG124). Recommendations: total hip replacement versus hemiarthroplasty criteria. NICE guideline\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eO\u0026rsquo;Connor MI, Switzer JA (2022) AAOS clinical practice guideline summary: management of hip fractures in older adults. 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Geriatr Orthop Surg Rehabil 8(3):155\u0026ndash;160. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1177/2151458517720991\u003c/span\u003e\u003cspan address=\"10.1177/2151458517720991\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eBhandari HEALTHI, Einhorn M, Guyatt TA G, et al (2019) Total hip arthroplasty or hemiarthroplasty for hip fracture. N Engl J Med 381(23):2199\u0026ndash;2208. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1056/NEJMoa1906190\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa1906190\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eAgency for Healthcare Research and Quality (AHRQ), HCUP (2024) Introduction to the NRD, 2022. Nationwide Readmissions Database (NRD) documentation\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTohidi M, Mann SM, McIsaac MA, Groome PA (2023) Comparative Effectiveness of Total Hip Arthroplasty and Hemiarthroplasty for Femoral Neck Fracture: A Propensity-Score-Matched Cohort Study. J Bone Joint Surg Am 105(8):591\u0026ndash;599. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.22.01193\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.22.01193\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTohidi M, Mann SM, Groome PA (2023) Total hip arthroplasty versus hemiarthroplasty for treatment of femoral neck fractures: a population-based analysis of practice variation in Ontario, Canada. 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J Bone Joint Surg Am 105(21):1695\u0026ndash;1702. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.23.00247\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.23.00247\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003ePangaud C, Pioger C, Pauly V et al (2023) Total hip arthroplasty reduces the risk of dislocation after femoral neck fracture. Orthop Traumatol Surg Res 109(4):103575. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1016/j.otsr.2023.103575\u003c/span\u003e\u003cspan address=\"10.1016/j.otsr.2023.103575\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eHansson S, B\u0026uuml;low E, Garland A, K\u0026auml;rrholm J, Rogmark C (2020) More hip complications after total hip arthroplasty than after hemiarthroplasty as hip fracture treatment: analysis of 5,815 matched pairs in the Swedish Hip Arthroplasty Register. Acta Orthop 91(2):133\u0026ndash;138. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1080/17453674.2019.1690339\u003c/span\u003e\u003cspan address=\"10.1080/17453674.2019.1690339\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eInvestigators HEALTH, Bhandari M, Einhorn TA, Guyatt G et al (2019) Total Hip Arthroplasty or Hemiarthroplasty for Hip Fracture. N Engl J Med 381(23):2199\u0026ndash;2208. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1056/NEJMoa1906190\u003c/span\u003e\u003cspan address=\"10.1056/NEJMoa1906190\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLewis DP, W\u0026aelig;ver D, Thorninger R, Donnelly WJ (2019) Hemiarthroplasty vs Total Hip Arthroplasty for the Management of Displaced Neck of Femur Fractures: A Systematic Review and Meta-Analysis. Hip Int 29(4):353\u0026ndash;361. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1120700018822109\u003c/span\u003e\u003cspan address=\"10.1177/1120700018822109\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMalik AT, Jain N, Frantz TL, Quatman CE, Phieffer LS, Ly TV, Khan SN (2022) Discharge to inpatient care facilities following hip fracture surgery: incidence, risk factors, and 30-day post-discharge outcomes. Hip Int 32(1):131\u0026ndash;139. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1177/1120700020920814\u003c/span\u003e\u003cspan address=\"10.1177/1120700020920814\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eFalotico GG, Leal LF, Yamaguchi AM et al (2025) Total hip arthroplasty versus hemiarthroplasty for displaced femoral neck fracture: an overview of systematic reviews. J Orthop Surg Res 20:614. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1186/s13018-025-06144-w\u003c/span\u003e\u003cspan address=\"10.1186/s13018-025-06144-w\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eTian P, Yang Y, He T, Wang L, Zhang Q, Cai Y (2025) Impact of frailty on postoperative complications in older adults after hip fracture: a systematic review of observational studies. Front Med (Lausanne) 12:1667462. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fmed.2025.1667462\u003c/span\u003e\u003cspan address=\"10.3389/fmed.2025.1667462\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003ePMID: 41368319; PMCID: PMC12682881\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eLevi Y, Rapp K, Herrmann S et al (2020) Intensive Inpatient vs. Home-Based Rehabilitation After Hip Fracture: A Longitudinal Observational Study. Front Med (Lausanne) 7:592693. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.3389/fmed.2020.592693\u003c/span\u003e\u003cspan address=\"10.3389/fmed.2020.592693\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eMorioka N, Tamiya N, Jin X et al (2021) Dementia and patient outcomes after hip surgery in older patients: A retrospective observational study using nationwide claims data in Japan. PLoS ONE 16(4):e0249364. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.1371/journal.pone.0249364\u003c/span\u003e\u003cspan address=\"10.1371/journal.pone.0249364\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e \u003cli\u003e\u003cspan\u003eGeorgiadis GM (2023) Total Hip Arthroplasty or Hemiarthroplasty for Displaced Femoral Neck Fractures? Commentary on an article by Mina Tohidi, MD, FRCS(C), PhD. et al J Bone Joint Surg Am 105(8):e23. \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003e10.2106/JBJS.23.00007\u003c/span\u003e\u003cspan address=\"10.2106/JBJS.23.00007\" targettype=\"DOI\" 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":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Femoral neck fracture, total hip arthroplasty, Hemiarthroplasty, Patient selection","lastPublishedDoi":"10.21203/rs.3.rs-8609988/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8609988/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003ch2\u003eBackground\u003c/h2\u003e \u003cp\u003eSurgical management of displaced femoral neck fractures in older adults typically involves hemiarthroplasty or total hip arthroplasty (THA). Although guidelines recommend THA for healthier, cognitively intact, community-dwelling adults, real-world procedure selection varies widely. This study evaluated nationwide determinantsfe of receiving THA versus hemiarthroplasty using a contemporary U.S. dataset.\u003c/p\u003e\u003ch2\u003eMethods\u003c/h2\u003e \u003cp\u003eA retrospective cohort study was conducted using the 2022 Nationwide Readmissions Database (NRD). Patients\u0026thinsp;\u0026ge;\u0026thinsp;65 years hospitalized with femoral neck fracture were identified using ICD-10-CM codes. Those treated with internal fixation or non-arthroplasty procedures were excluded. Weighted analyses characterized demographics, comorbidities, and hospital utilization between THA and hemiarthroplasty groups. A multivariable logistic regression model identified independent predictors of receiving THA. All analyses accounted for NRD survey design.\u003c/p\u003e\u003ch2\u003eResults\u003c/h2\u003e \u003cp\u003eAmong 142,013 operative cases, 99,084 met inclusion criteria (81.8% hemiarthroplasty; 18.2% THA). Patients receiving THA were younger (76.6 vs 81.9 years), had shorter length of stay (6.06 vs 7.24 days), and were more frequently discharged home (17.5% vs 6.2%). Metabolic conditions were associated with increased odds of THA: obesity (OR 1.17), sleep apnea (OR 1.12), Frailty-related conditions were associated with markedly reduced THA likelihood, including Alzheimer\u0026rsquo;s disease (OR 0.48), Parkinson disease (OR 0.55), chronic kidney disease (OR 0.78), chronic lung disease (OR 0.73), and congestive heart failure (OR 0.69). Each additional year of age decreased the odds of THA by ~\u0026thinsp;9%.\u003c/p\u003e\u003ch2\u003eConclusion\u003c/h2\u003e \u003cp\u003eIn this nationwide cohort, THA selection was strongly guided by patient age, frailty, and cognitive impairment, while metabolic comorbidities were associated with slightly higher THA utilization. These findings highlight real-world adherence to guideline-based patient selection and underscore the central role of functional reserve in treatment planning.\u003c/p\u003e\u003ch2\u003eLevel of Evidence:\u003c/h2\u003e \u003cp\u003eLevel III\u003c/p\u003e","manuscriptTitle":"Determinants of Total Hip Arthroplasty Versus Hemiarthroplasty for Femoral Neck Fracture in Older Adults: A Nationwide Analysis of 99,084 Cases","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-02-13 11:59:39","doi":"10.21203/rs.3.rs-8609988/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-07T21:51:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-05T13:23:55+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-12T10:47:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"163329840881783158109497795044574765602","date":"2026-02-12T10:23:51+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"131330391206947314902608091759233892762","date":"2026-02-11T05:03:21+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-02-10T11:29:23+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"324740610656052776108012713495450565812","date":"2026-02-09T08:19:49+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-02-09T03:59:30+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-01-19T02:39:16+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-01-19T02:38:59+00:00","index":"","fulltext":""},{"type":"submitted","content":"Archives of Orthopaedic and Trauma Surgery","date":"2026-01-15T11:22:43+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"archives-of-orthopaedic-and-trauma-surgery","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"aots","sideBox":"Learn more about [Archives of Orthopaedic and Trauma Surgery](http://link.springer.com/journal/402)","snPcode":"402","submissionUrl":"https://submission.springernature.com/new-submission/402/3","title":"Archives of Orthopaedic and Trauma Surgery","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"stoa","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"99a92ae5-fc7c-40b4-95a4-67c4c429b118","owner":[],"postedDate":"February 13th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-04-14T18:39:00+00:00","versionOfRecord":[],"versionCreatedAt":"2026-02-13 11:59:39","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8609988","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8609988","identity":"rs-8609988","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}