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Intracapsular and extracapsular fracture types and inpatient mortality in failed hemiarthroplasty

BMC Musculoskeletal Disorders volume 26, Article number: 120 (2025) Cite this article

Abstract

Background

Increasing life expectancy has led to a rise in hip fractures and an associated increase in hemiarthroplasty procedures aimed at restoring mobility and preventing muscle loss. Despite the extensive literature on failed hemiarthroplasty, limited data address the influence of pre-operative fracture types—intracapsular versus extracapsular—on outcomes, including inpatient mortality. This study investigates the revisions of uncemented bipolar hemiarthroplasties concerning fracture type and identifies risk factors for inpatient mortality.

Methods

This retrospective cohort study included 68 patients (16 males and 52 females) who underwent revision of uncemented bipolar hemiarthroplasties at a single institution between 2017 and 2024. Data on demographics, comorbidities, fracture type, surgical details and outcomes were analysed. Statistical analyses included t tests, chi-square tests and logistic regression, with significance set at p < 0.05.

Results

Of 1,690 hemiarthroplasties performed, 68 required revision (revision rate: 4%). Revisions for extracapsular fractures were associated with a higher prevalence of diabetes mellitus (p = 0.01) and elevated Almelo Hip Fracture Score (AHFS; p = 0.01). The overall inpatient mortality rate was 19%, significantly higher in males (43.75%) than females (11.54%; p = 0.00). Deceased patients demonstrated higher AHFS and American Society of Anaesthesiologists scores but lower Parker Mobility Scores (p = 0.01). Prolonged intensive care unit (ICU) stays were also linked to increased mortality (p = 0.02). Logistic regression identified male sex as an independent predictor of mortality (odds ratio: 9.37; p < 0.05).

Conclusions

Pre-operative fracture type significantly influences revision outcomes in failed hemiarthroplasties. Moreover, extracapsular fractures are linked to diabetes mellitus and higher AHFS, whereas male sex, ICU stay duration and comorbidity scores predict inpatient mortality. These findings highlight the need for tailored perioperative care to mitigate risks.

Trial registration

Not applicable.

Peer Review reports

Background

The incidence of hip fractures has risen alongside increased life expectancy, leading to a corresponding surge in hemiarthroplasty procedures [1, 2]. These surgeries aim to alleviate pain swiftly and enable early mobilisation, especially in elderly patients who risk a 40% reduction in muscle strength during 4–6 weeks of bed rest [3]. Recent research indicates that hemiarthroplasty may be a viable treatment option for intracapsular fractures and extracapsular fractures. Studies suggest that the procedure is associated with effective outcomes and relatively low rates of intraoperative and postoperative complications [4]. The use of hemiarthroplasty for both extracapsular and intracapsular fractures has garnered attention due to its role in preventing muscle loss [5,6,7].

Revisions of hemiarthroplasty are relatively uncommon, with primary causes including acetabular wear, periprosthetic fractures, infection, dislocation and aseptic loosening [3, 8,9,10,11,12,13]. The literature encompasses several studies on failed hemiarthroplasty, addressing topics such as the choice of cemented versus uncemented techniques [14], the differences between unipolar and bipolar designs [9, 15], the frequency of reoperations [10], and the conversion of failed hemiarthroplasty to total hip arthroplasty [8, 16]. However, the role of pre-operative fracture type—specifically intracapsular versus extracapsular—in the context of failed hemiarthroplasty remains inadequately explored.

This study aimed (a) to analyse uncemented bipolar hemiarthroplasties revised at our institution over an 8-yr period, (b) determine differences in revision outcomes between intracapsular and extracapsular fractures and (c) evaluate inpatient mortality rates and associated risk factors.

Methods

This retrospective cohort study was conducted at a single institution. Between 2017 and 2024, 1,690 patients underwent bipolar hemiarthroplasty for hip fractures; 68 patients who required revision hemiarthroplasty were included in the analysis. All patients were initially treated with uncemented bipolar hemiarthroplasty for either intracapsular or extracapsular hip fractures.

Data were extracted from institutional records, including age, body mass index (BMI), gender, side of fracture, comorbidities, primary fracture type, type of hemiarthroplasty, time from initial surgery to revision, reason for revision, American Society of Anaesthesiologists (ASA) score, length of hospital stay and intensive care unit (ICU) admission, surgical delay, number of procedures and follow-up duration. Comorbidity indices, such as the Charlson Comorbidity Index (CCI), Age-Adjusted Charlson Comorbidity Index (aCCI), Elixhauser Comorbidity Index (ECI), Almelo Hip Fracture Score (AHFS) and Parker Mobility Score (PMS), were calculated. Comorbidities were categorised as cardiovascular, diabetes mellitus, respiratory or neurological diseases.

Failure types were classified based on the system proposed by Morsi et al., [8] which includes five categories (Type I to V). A stable, well-fixed femoral component with acetabular and protrusion issues was categorised as Type I, with two distinct subtypes. Type IA failure pertains to cases involving monoblock femoral components. Notably, the present study excluded all Thompson or Austin Moore monoblock prostheses. Type IB failure involves bipolar hemiarthroplasty cases with associated acetabular issues. Type II failure relates to femoral complications without acetabular involvement. Subtypes of Type II include the following:

  • Type IIA: Aseptic loosening without adequate bone stock.

  • Type IIB: Aseptic loosening accompanied by bone stock loss.

  • Type IIC: Periprosthetic fractures.

Revisions necessitated by combined acetabular and femoral complications were classified as Type III. Type IV failures included instability and dislocations, with intraprosthetic dissociations, whether primary or secondary to reduction, also encompassed. Lastly, revisions for infection were designated as Type V.

Patients were categorised based on fracture type as intracapsular or extracapsular. The dataset included information on patients who succumbed in the hospital postoperatively. Ethical approval for the study protocol was obtained from the University of Health Sciences Kayseri City Training and Research Hospital Clinical Research Ethics Committee (Approval No. 10.09.2024/182). The study adhered to the principles outlined in the Declaration of Helsinki.

Statistical analysis

All data were recorded and analysed using Statistical Package for the Social Sciences (SPSS) for Windows (version 22). In the data analysis, the initial step involved verifying the assumptions required to determine whether parametric or nonparametric tests were appropriate. Statistical tests were chosen based on the normality of data distribution and evaluated using the Kolmogorov–Smirnov test, kurtosis and skewness values and histogram graphs. For independent two-group comparisons, the chi-square test or Fisher’s exact test was used for categorical variables, while t tests were employed for continuous variables. Logistic regression analysis was conducted to assess the effects on the two-category dependent variable. A p value of < 0.05 was considered statistically significant.

Results

Between 2017 and 2024, 68 of the 1,690 hemiarthroplasties performed at the institution (16 males and 52 females) underwent revision surgery, reflecting a 4% revision rate. Among these, 31 patients (9 males and 22 females) had extracapsular fractures and 37 patients (7 males and 30 females) had intracapsular fractures. All patients received uncemented hemiarthroplasty.

The mean patient age was 79.35 ± 9.29 year. Comorbidities were present in 88% of the patients, with cardiovascular diseases in 29% (n = 20), neurological disorders in 36% (n = 25), diabetes mellitus in 38% (n = 26) and respiratory diseases in 20% (n = 14). Most revisions (60%, n = 41) occurred within 6 months of the initial hemiarthroplasty. Patients were classified as ASA-2 (n = 10), ASA-3 (n = 45) or ASA-4 (n = 13).

The posterolateral approach was used in 85% (n = 58) of cases. Revision indications included Type I (n = 3), Type II (n = 16), Type III (n = 1), Type IV (n = 34) and Type V (n = 14). All patients classified as Type I (5%) underwent total hip replacement. For Type II (24%) patients, who were further subclassified as Type IIc (i.e., periprosthetic fractures), monoblock revision femoral stem and plate application were performed. Type III (1%) cases involved total hip replacement. In Type IV (50%) cases, all components were replaced in 22 cases; in two cases, only the femoral head was replaced, and in two other cases, only the acetabular cup and liner were replaced. The remaining two cases involved the replacement of both the femoral head and the acetabular cup. Five patients underwent total hip replacement, while one patient underwent the Girdlestone procedure. Among Type V (20%) patients, a two-stage exchange procedure was conducted in seven cases, while the Girdlestone procedure was performed in seven cases. The mean time to surgery was 1.66 ± 0.97 days, and the mean hospital stay was 16.90 ± 16.89 days. The mean BMI was 27.84 kg/m2, while the mean CCI and aCCI were 1.49 ± 1.09 and 5.21 ± 1.33, respectively. A total of 64% of the patients (n = 44) required admission to the ICU, with an average ICU stay of 8.47 days. The mean follow-up duration was 11.19 months.

The presence of diabetes mellitus and high AHFS were the only factors that differed between intracapsular and extracapsular fractures. Diabetes mellitus was more frequently diagnosed in cases of hemiarthroplasty revision surgery due to extracapsular fractures compared with intracapsular fractures (p = 0.01). Among patients undergoing revision surgery, the mean AHFS was 9.19 ± 2.93 for extracapsular fractures and 7.05 ± 3.95 for intracapsular fractures (p = 0.01). The rationale for revision surgery was similar in both groups, and the results are summarised in Table 1.

Table 1 Demographics, clinical and pre-operative data of the overall study population and comparison between the extracapsular and intracapsular groups
Full size table

The inpatient mortality rate in this study was 19% (n = 13). Of these, six patients belonged to the extracapsular group, while seven were in the intracapsular group. Male patients had a significantly higher inpatient mortality rate than females (43.75% vs. 11.54%, respectively; p = 0.00). The mean age of deceased patients was similar to that of those discharged alive (81.15 ± 5.87 year vs. 78.93 ± 9.92 year; p > 0.05). However, the mean hospital stay was longer for deceased patients (22.46 days vs. 15.58 days; p > 0.05).

No significant differences were observed in the number of comorbidities or the presence of cardiovascular, neurological, respiratory or diabetes-related conditions between patients who died in the hospital and those who were discharged (p > 0.05). Similarly, no significant differences were noted in the CCI, aCCI or ECI scores between the two groups (p > 0.05). However, significant differences were found in the ASA score, PMS and AHFS. The AHFS was higher in deceased patients (10.46 ± 3.23) than in those discharged (7.45 ± 3.54; p = 0.01). Conversely, the PMS was lower among deceased patients (3.46 ± 2.30) than those discharged (5.36 ± 2.50; p = 0.01).

Regarding ASA scores, seven deceased patients were classified as ASA-3, six as ASA-4 and none as ASA-2. All patients who died had been admitted to ICUs, with a significantly longer mean ICU stay (15.15 days) than discharged patients (5.75 days; p = 0.02). The number of revision surgeries, surgical approaches and time to surgery did not significantly differ between the two groups (p > 0.05). These results are detailed in Table 2.

Table 2 Comparison of demographic, clinical and pre-operative data between ex- and discharged patients
Full size table

Logistic regression analysis indicated that the model constructed with independent variables had a 63.6% accuracy in predicting mortality status. The Hosmer–Lemeshow test confirmed the model’s compatibility (p > 0.05), and the Omnibus test produced significant results (X2(3) = 10.7; p < 0.05). Nagelkerke R [2] showed that the independent variables explained 33% of the variance in pre-operative fracture type status, while the − 2 log-likelihood value was 38.15.

The regression model incorporated variables that demonstrated a relationship with the outcome variable, while those with multiple connections were excluded to refine the prediction of mortality status. Gender (referent: female) emerged as a significant predictor of mortality (B = 2.24, SE = 0.94, Wald = 5.72, p < 0.05). Male patients were found to have a 9.37-fold higher risk of mortality than female patients (Exp(B) = 9.37; 95% CI, 1.50–58.62). However, the AHFS did not significantly influence mortality (B = 0.03, SE = 0.14, Wald = 0.05, p > 0.05), as increases in the score did not alter the risk of mortality (Exp(B) = 1.03; 95% CI, 0.78–1.36). Similarly, the duration of intensive care stay did not significantly predict mortality (B = 0.02, SE = 0.03, Wald = 0.27, p > 0.05), with no notable change in mortality probability linked to longer intensive care stays (Exp(B) = 1.02; 95% CI, 0.95–1.08). These results are summarised in Table 3.

Table 3 Factors influencing inpatient mortality by logistic regression analysis
Full size table

Discussion

Revision surgery following hemiarthroplasty is less frequently required than after internal fixation to hip fractures, with rates reported to range from 1.3 to 9% in the literature [10, 17,18,19]. Recent studies suggest that revision rates for uncemented hip replacements may increase over time, from 1.1% in the first month to 5.1% after 9 year [13]. The indications for hemiarthroplasty revision are typically classified into five main categories: acetabular erosion, dislocation or instability, periprosthetic fractures, infections and aseptic loosening [8,9,10,11,12]. The present study identified a revision rate of 4% for uncemented bipolar hemiarthroplasty, with the most common indication being instability or dislocation across both intracapsular and extracapsular fracture groups.

Risk factors for hemiarthroplasty revision include male gender, age below 80 year, ASA classification 1–2, posterolateral approach and cementless fixation [12, 19, 20]. In contrast, this study observed a higher prevalence of female patients and ASA classifications 3–4 among those requiring revision. Although evidence indicates that extracapsular and intracapsular fracture patterns in hip fractures vary by gender and age [21], our study did not identify any differences in the failure rates of hemiarthroplasties performed for these fracture patterns The mean age at revision was 79 year. A posterolateral approach and cementless fixation were employed for all patients, aligning with the preference for bipolar and uncemented stems in Turkey.

Acetabular erosion, a significant cause of revision in unipolar hemiarthroplasty, is less common in bipolar procedures [11]. Its incidence decreases with age, from 6.13% in patients aged 70–75 year to 1.96% in those aged 80 year or older [22]. Revisions were performed in 1% of patients with both femoral and acetabulum issues and 3% of patients with isolated acetabular problems. All patients requiring solely for acetabular problems were in the intracapsular group, whereas those with both acetabular and femoral issues were in the extracapsular group.

The incidence of dislocation in bipolar hemiarthroplasties has been reported to range from 1–16% [3, 23]. Dementia has been identified as a significant risk factor for dislocation in patients undergoing this procedure [23,24,25]. Moreover, comorbidities other than dementia as well as the CCI, Almelo hip score and Parker score, have not been shown to constitute significant risk factors for dislocation [24, 25]. While most studies indicate that dislocation rates are higher in patients with larger cup sizes, some findings suggest otherwise [24]. The posterior surgical approach has also been identified as a risk factor for dislocation [25]. Despite these factors, recent large-scale studies have reported dislocation rates of 1.1% and 1.6% [25, 26].

In this study, the incidence of dislocation requiring revision in bipolar hemiarthroplasty was 2%, with approximately half of the cases attributed to implant-related dissociation, which was not associated with surgical or patient factors. The overall dissociation rate was 0.8% across all hemiarthroplasties but accounted for 22% of revision cases. Emerging technologies, such as the Robotic Arm-Assisted System, offer promising advancements in hip fracture management. These innovations may enhance surgical precision and reduce non-implant-related errors in procedures like hemiarthroplasty and total hip replacement [27].

The ECI and CCI, commonly used in orthopaedics, demonstrate similar sensitivity in predicting inpatient mortality [28]. The ASA score has proven useful in predicting readmissions, infections and cardiovascular complications associated with hip fractures [29]. Recently, the AHFS has gained prominence as it integrates the PMS and ASA scores [30]. Analysis of the AHFS revealed that patients who succumbed to hip fractures had a mean score of 9.5, compared with 11.5 among those who underwent arthroplasty [30]. This study found that the ASA score, PMS and AHFS were significantly higher in deceased patients, whereas the CCI and aCCI were not significantly associated with inpatient mortality. Sociodemographic factors may play a significant role in influencing mortality. Patients undergoing surgery for hip fractures caused by falls often develop a fear of falling, which can lead to increased fragility and reduced mobility [31]. As a result, these individuals tend to have lower PMS and AHFS scores.

The mean inpatient mortality rate following hip fractures in patients with dementia was 2.01%, compared with 1.87% in those undergoing hemiarthroplasty [28]. For periprosthetic fractures after cemented hemiarthroplasty, an inpatient mortality rate of 6.3% was reported, increasing to 12.5% within the first 1 month [32]. Length of hospitalisation was the only factor significantly influencing first month mortality, with delayed surgery identified as a modifiable risk factor for reducing mortality [32, 33].

Patients requiring revision surgery due to dislocation or infection often undergo multiple procedures following a failed hemiarthroplasty [10]. Mortality rates are particularly elevated among individuals who have undergone the Girdlestone procedure [34]. At our institution, the inpatient mortality rate was 19%. Prolonged ICU stays and male gender were identified as significant contributors to this outcome, with male patients showing a 9.37-fold higher risk of inpatient mortality. Among the 14 patients who underwent revision surgery due to infection, 50% required the Girdlestone procedure, and two (28%) of these patients died in the hospital.

Limitations

This study has several limitations. First, it was conducted at a single centre, which may restrict the generalisability of the findings. Second, the surgical procedures were performed by multiple surgeons employing diverse approaches, fixation methods and prosthesis systems, which could have influenced the outcomes. Further, multi-centre studies and randomised controlled trials with larger sample sizes are essential to validate these results.

Conclusion

The study findings reveal that pre-operative fracture type is not a significant factor for uncemented bipolar prosthesis revisions. Furthermore, regarding the hemiarthroplasty performed due to extracapsular fracture type, a higher rate of revision was observed in patients with diabetes mellitus. Moreover, several factors that affect inpatient mortality were identified, including the patient’s gender, the need for ICU admission, the ASA score, the PMS, the AHFS and the length of time spent in the ICU.

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

Abbreviations

AHFS:

Almelo hip fracture score

ASA:

American society of anaesthesiologists

BMI:

Body mass index

CCI:

Charlson comorbidity index

ECI:

Elixhauser comorbidity index

ICU:

Intensive care unit

PMS:

Parker mobility score

SPSS:

Statistical package for the social sciences

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Authors and Affiliations

  1. Department of Orthopaedics and Traumatology, Yozgat Sorgun State Hospital, Ahmet Efendi Mah. Şehit Cemal Şimşek Cad. No 37, Yozgat, Turkey

    Kürşat Tuğrul Okur

  2. Department of Orthopaedics and Traumatology, University of Health Sciences Kayseri City Training and Research Hospital, Kayseri, Turkey

    Koray Özdemir, Ahmet Yesevi Sarıaslan & Fırat Ozan

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  1. Kürşat Tuğrul Okur
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  2. Koray Özdemir
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  3. Ahmet Yesevi Sarıaslan
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Contributions

KTO and FO conceptualised the study and analysed the data. KÖ and AYS collected the data. KTO, FO, and KÖ contributed to data analysis. KTO, AYS, and FO performed data analysis. KTO and FO were major contributors in writing the manuscript. All authors read and approved the final manuscript.

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Correspondence to Kürşat Tuğrul Okur.

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Ethics approval and consent to participate

Ethical approval for the study was obtained from the University of Health Sciences Kayseri City Training and Research Hospital Clinical Research Ethics Committee (Approval No. 10.09.2024/182). The study adhered to the principles outlined in the Declaration of Helsinki. Informed consent was obtained from all participants prior to their inclusion in the study.

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The authors declare no competing interests.

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Okur, K.T., Özdemir, K., Sarıaslan, A.Y. et al. Intracapsular and extracapsular fracture types and inpatient mortality in failed hemiarthroplasty. BMC Musculoskelet Disord 26, 120 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12891-025-08364-x

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  • DOI: https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12891-025-08364-x

Keywords

BMC Musculoskeletal Disorders

ISSN: 1471-2474

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