Does THA Offer Clinically Important Benefits Over Hemiarthroplasty for Femoral Neck Fracture in Patients Age 65 Years or Older? A Systematic Review and Meta-analysis

Multiple meta-analyses have compared THA with hemiarthroplasty for displaced femoral neck fractures in patients over 65 years of age; however, clinical equipoise persists. We posit that this persistent uncertainty does not reflect a paucity of evidence but rather stems from critical methodological limitations in prior syntheses-including incomplete evidence searches, inadvertent inclusion of duplicate outcome data from overlapping patient cohorts, and inappropriate pooling of RCTs with nonrandomized or retrospective studies. An updated, rigorously conducted meta-analysis of RCTs-designed to rectify these flaws-is therefore needed to inform evidence-based clinical decision-making. (1) Is THA associated with a reduced risk of revision surgery and death compared with hemiarthroplasty? (2) Is THA associated with fewer hip-related complications-including dislocation, periprosthetic fracture, and infection? (3) Does THA result in clinically important improvements in functional outcomes as measured by validated hip scores (such as the Harris hip score [HHS])? (4) Does hemiarthroplasty result in reduced operative time and estimated blood loss? Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines were followed, and the study protocol was published online at PROSPERO under registration number CRD42022344531. We searched the Medline, Embase, Cochrane Library, and Web of Science databases for papers published between January 2000 and October 2025, and the searches were performed from August 2024 to October 2025. We included RCTs that directly compared the postoperative outcomes of the two prosthesis types. Two independent reviewers performed title and abstract screening, full-text assessment, and data extraction. To eliminate duplication and inflated precision, we identified and excluded all reports deriving from the same patient cohort-including secondary publications, subgroup analyses, and extended follow-up reports. A systematic search retrieved 4016 records. After assessment for eligibility against prespecified criteria, 18 RCTs involving 2908 participants (mean &#xb1; SD age 78 &#xb1; 8 years; 69% female patients) were included in the meta-analysis. Baseline age and sex did not differ between THA and hemiarthroplasty groups. Risk of bias was evaluated using the Cochrane Risk of Bias tool for RCTs, revealing an overall moderate to low risk of bias. Pooled effect estimates were computed using inverse-variance random-effects models (p &#x2264; 0.1 or I2 &#x2265; 50%); otherwise, a fixed-effects model was used. Heterogeneity was quantified using the I2 statistic. Substantial heterogeneity was observed for the HHS (I2 = 76%), operative time (I2 = 98%), and blood loss (I2 = 98%), for which random-effects models were used. Heterogeneity was low for all other outcomes (I2 &#x2264; 41%), and fixed-effects models were applied. Publication bias was evaluated using funnel plots and the Egger test, which did not suggest publication bias. The certainty of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) framework, which suggested moderate certainty of evidence for revision risk, mortality, hip-related complications, and dislocation and low for functional outcomes (HHS). For the main outcomes score we used the HHS (range 0 to 100, with higher scores representing less pain and better function; the minimum clinically important difference was taken to be 10 points). The composite endpoint of hip-related complications included dislocation, periprosthetic fracture, implant failure (loosening or subsidence), and abductor mechanism failure-events directly related to the arthroplasty procedure and of comparable clinical importance. Compared with hemiarthroplasty, THA was not associated with an increased risk of revision surgery (risk ratio [RR] 1.10 [95% confidence interval (CI) 0.82 to 1.49]; p = 0.52) or all-cause mortality (RR 0.99 [95% CI 0.81 to 1.22]; p = 0.54). No difference was observed in the composite endpoint of hip-related complications (RR 0.89 [95% CI 0.74 to 1.08]; p = 0.25). However, THA was associated with a higher risk of dislocation (RR 0.57 [95% CI 0.37 to 0.89]; p = 0.01). We found no clinically important difference in HHS between patients undergoing THA and those undergoing hemiarthroplasty (mean difference 5 points [95% CI 3 to 7]; p < 0.001). Operative time was shorter with hemiarthroplasty (mean difference 31 minutes [95% CI -44.13 to -18.81]; p < 0.001) and blood loss was less (mean difference 115 mL [95% CI -165.87 to -64.15]; p < 0.001) than for those in the THA group. Sensitivity analyses-excluding high risk-of-bias trials, restricting to intention-to-treat analyses, and applying alternative effect models-confirmed the consistency and robustness of these results. For patients age 65 years or older with displaced femoral neck fractures, THA offers no clinically important functional benefit over hemiarthroplasty and increases the risk of dislocation. Hemiarthroplasty can be performed by most call-taking orthopaedic surgeons, whereas THA often requires a specialist; therefore, hemiarthroplasty is the better choice for most older patients. Future research should assess long-term outcomes (&#x2265; 10 years) and compare dual-mobility THA with bipolar hemiarthroplasty to determine whether modern techniques narrow the dislocation gap and how late complications alter the risk-benefit balance. Level I, therapeutic study.