**2. Indication**

There is little doubt, and the evidence is convincing, that arthroplasty surgery, instead of internal fixation, should be performed for the elderly suffering from displaced intracapsular hip fractures.

This decision is often influenced not only by whether one implant is superior to another, but as surgeons, we must also take into account patient's medical comorbidities, functional demands, premorbid ambulatory status, and, inevitably, financial considerations. The debate on the choice of implant is, however, never-ending.

#### **2.1 Arthroplasty vs internal fixation**

The surgical treatment of patients with a femoral neck fracture should be based on the patient's age, walking ability, comorbidities, and life expectancy. Internal fixation or different types of hip arthroplasties are the available treatment modalities.

#### *Hemiarthroplasty DOI: http://dx.doi.org/10.5772/intechopen.106400*

The degree of fracture displacement, the patient's age, functional demands, and risk profile, such as level of cognitive function and degree of physical fitness, should all be considered when deciding whether to treat displaced femoral neck fractures in the elderly with internal hemiarthroplasty, total hip artroplasty, or internal fixation [4].

For elderly patients with few functional demands who have displaced intracapsular fractures, unipolar or bipolar hemiarthroplasty appears to be the optimum technique, according to the orthopedic surgeon. However, treatment for the generally healthy, active, and cognitively alert old patient is still debatable [4].

Internal fixation is uncontroversial in patients with undisplaced fractures (Garden I-II), with a reasonable incidence of fracture healing problems and a favorable outcome in terms of function and health-related quality of life. Internal fixation is also seen to be the best treatment option for young patients with displaced fractures (Garden III-IV) [5].

Internal fixation causes less operative stress, but sequelae such as fracture displacement, non-union, and avascular necrosis may necessitate revision. Most surgeons now treat this fracture with arthroplasty, while internal fixation is still preferred in some countries.

A meta-analysis 1 of over 100 reports of displaced fractures of the neck of the femur reported a mean rate of nonunion of 33%, avascular necrosis of 16%, and a reoperation rate of 20–36% after internal fixation compared with 6–18% after hemiarthroplasty.

Randomized controlled trials (RCTs) have shown that a primary THR provides superior results to internal fixation in relation to the need for secondary surgery, hip function, and health-related quality of life for the active alert patient fractures(Garden III-IV) [6].

A recent multicenter randomized controlled trial shows THR should be thought of as the therapy of choice for the older patient in excellent condition with a displaced intracapsular fracture of the femoral neck when compared to internal fixation, bipolar hemiarthroplasty, and THR [7].

### **2.2 Hemiarthroplasty versus total hip arthroplasty**

Hemiarthroplasty (HA) and total hip arthroplasty (THA) are still the most often used procedures of hip replacement following fracture. In the long term, some HA patients will require THA conversion owing to activity-limiting thigh discomfort caused by acetabulum wear. Reduced dislocation rates, less difficult surgery, shorter operation times, less blood loss, and cheaper initial expenditures are reported benefits of HA over THA [8].

THA yields superior functional outcomes than HA in the treatment of femoral neck fractures [9] and is, therefore, increasingly performed, notably in physically active patients. Nevertheless, the outcomes of THA used to treat a fracture differ from those of THA for osteoarthritis; blood transfusion is more often required; both the operative time and the hospital stays are longer; and the risks are higher for perioperative complications, infection, re-admission, and mortality [10].

Instabilities are more prevalent during total hip arthroplasty than hemiarthroplasty. The surgeon's competence, surgical approach, component alignment, and implant selection are all factors that influence hip arthroplasty outcomes [11] A femur neck fracture is a risk factor for instability in and of itself. Dislocation is also substantially more prevalent following THA to treat a fracture than in osteoarthritis patients [12] As a result, choosing an implant for THA for fracture treatment requires extraordinary prudence. Dual-mobility cups have been found to lower dislocation risk, outperforming large-diameter heads and Constrained implants [13].

The most serious long-term issue with hemiarthroplasty is severe acetabular erosion. Acetabular erosion rates have been observed to range from 0–26% for bipolar designs and from 2.2–36% for unipolar designs. According to one study, acetabular erosion necessitated the revision of 38% of unipolar prosthetic hips. Contrarily, dislocation is the most frequent early complication of total hip arthroplasty, and it is more likely when a posterior approach is used, and the prosthetic head size is smaller. After a complete hip replacement for a displaced intracapsular femoral neck fracture, dislocation rates have ranged from 2–20% [14].

Baker's findings suggest that for the treatment of individuals who are cognitively capable, independent, and active, total hip arthroplasty is preferred to hemiarthroplasty. After a three-year average follow-up, complete hip arthroplasty was associated with superior functional results, fewer problems, and fewer revisions. Both groups had functional decline postoperatively when compared to preoperative levels; however, individuals in the total hip arthroplasty group saw less deterioration and maintained their walking distances [14].

Meta-Analysis and systemic review of randomized trials comparing all forms of THA and hemiarthroplasty done by burger shows that total hip arthroplasty for displaced femoral neck fractures in the fit elderly may lead to higher patient-based outcomes but has higher dislocation rates compared with hemiarthroplastysty in a selected group of patients suffering displaced femoral neck fractures. This review, including the most recent evidence, shows that total hip arthroplasty may be advantageous over hemiarthroplasty [8].

Hedbeck's randomized controlled trial shows that complete hip arthroplasty produces superior results in terms of hip function and health-related quality of life than bipolar hemiarthroplasty in older, lucid patients with a displaced femoral neck fracture. The findings of this study and earlier research indicate that total hip arthroplasty should be the preferred form of treatment for this fracture in an active older patient with a long-life expectancy [9].
