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

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