Hip replacement: indications, prosthesis selection, surgical procedure, recovery, and prognosis

In clinical practice, the term "hip replacement" typically refers not to the replacement of the femoral neck alone as an isolated structure, but to the replacement of the entire hip joint following a femoral neck fracture. Two options are most commonly used: hemiarthroplasty, which replaces the head and neck of the femur, and total hip replacement, which additionally replaces the articular surface of the acetabulum. [1] [2]

This is one of the most important topics in modern traumatology and orthopedics, as hip fractures remain one of the leading causes of loss of independence in the elderly. The global burden of hip fractures continues to rise, and the age-standardized incidence rate in the elderly in the 2021 Global Burden of Disease analysis was higher than 30 years ago. [3]

The clinical logic here is simple: with a displaced intra-articular femoral neck fracture, the blood supply to the femoral head is disrupted, so attempts to "save" the femur do not always yield reliable results. This is why the American Academy of Orthopaedic Surgeons recommends arthroplasty over fixation for unstable, i.e., displaced, femoral neck fractures. [4] [5]

The UK's National Institute for Health and Care Excellence also recommends joint replacement for displaced intra-articular fractures. For some patients, total hip replacement, rather than hemiarthroplasty, should be considered if the individual was confidently ambulating outside the home before the injury, had no severe comorbidities that would limit surgery, and is expected to maintain independence in daily life for more than two years. [6]

In other words, hip replacement is now viewed not as a last resort, but as a basic treatment strategy for many adult patients with displaced hip fractures, especially in the elderly. The primary goal of the surgery is not only to relieve pain and stabilize the joint, but also to return the patient to weight-bearing, vertical support, and normal functioning as quickly as possible. [7] [8]

What is important to understand	Practical meaning
This is not a "cervical prosthesis" in the narrow sense.	Typically, we are talking about replacing the proximal femur, and sometimes the entire hip joint.
Main indication	Displaced intra-articular fracture of the femoral neck
The main goal	Early loading, pain reduction, reduced risk of reoperation
Main options	Hemiarthroplasty and total joint replacement
Why is the method so important?	Hip fractures are associated with high morbidity and mortality in the elderly.

Sources for the table: [9] [10] [11] [12]

When endoprosthetics are really better than fixation

For displaced femoral neck fractures, the advantage of endoprosthetics is primarily related to reliability. When fixed with screws or other structures, the bone must not only heal properly but also maintain the viability of the femoral head. With intra-articular trauma, this is not always possible, so the risk of nonunion, femoral head collapse, and reoperation is significantly higher. [13] [14]

Therefore, current recommendations formulate a rather strict position: for unstable displaced fractures in older adults, arthroplasty is preferable to fixation. This does not mean that fixation has disappeared from practice entirely, but its role is much narrower and more dependent on age, activity level, fracture type, and overall bone stock. [15] [16]

A separate question is whether to choose hemiarthroplasty or total hip replacement. According to the American Academy of Orthopaedic Surgeons, in properly selected patients, total hip replacement may provide a slight functional advantage over hemiarthroplasty, but the tradeoff is a slightly higher risk of complications. [17]

A recent review of systematic reviews from 2025 found that total hip arthroplasty was associated with better function and quality of life, as well as a lower revision rate, while hemiarthroplasty was, on average, approximately 20 minutes faster. Mortality, infectious complications, periprosthetic fractures, and, according to the aggregated data of this review, dislocation rates were generally comparable.[18][19]

However, the literature is not entirely uniform. A 2023 systematic review reported a higher risk of dislocation within 12 months after total hip arthroplasty in elderly patients with hip fracture, although the overall risk of revision at 12 months did not differ between groups. This suggests that the choice of method should not be a one-size-fits-all approach, but rather a personalized one: a more active and fit patient may benefit from total hip arthroplasty, while a more frail patient often achieves a better balance of benefit and safety with hemiarthroplasty. [20] [21]

Situation	What is usually considered more often?	Why
Displaced fracture in a frail elderly patient	Hemiarthroplasty	The operation is usually shorter and technically simpler.
Displaced fracture in an active patient with good initial walking ability	Total hip arthroplasty	Better restoration of function and quality of life is possible
High risk of reoperation after fixation	Endoprosthetics	Lower risk of failure associated with nonunion and head ischemia
The need for a quick return to support	Endoprosthetics	The method is better suited to the task of early verticalization
Low functional reserve and pronounced fragility	Most often hemiarthroplasty	Often the best risk/benefit ratio

Sources for the table: [22] [23] [24] [25]

How to choose the type of prosthesis and the design of the operation

In practice, the surgeon addresses several issues simultaneously. It must be determined whether replacing only the femoral component is sufficient, or whether total hip replacement is more appropriate for the patient. Then, the type of stem, its fixation method, access to the joint, and a number of other factors that influence stability, the risk of dislocation, and subsequent rehabilitation are selected. [26] [27]

The American Academy of Orthopaedic Surgeons indicates that unipolar and bipolar hemiarthroplasty may be equally useful for unstable displaced fractures. This is important because these approaches have long been controversial in everyday practice, but no convincing superiority of one option over the other has been demonstrated for all patients. [28]

Cemented fixation is a separate issue. Both the American Academy of Orthopaedic Surgeons and UK guidelines support the use of cemented implants in arthroplasty for femoral neck fractures. This fixation provides more reliable initial stem stability, and modern reviews link cemented hemiarthroplasty with improved quality of life and a lower incidence of certain mechanical complications compared to uncemented hemiarthroplasty. [29] [30] [31]

Cement fixation carries a specific perioperative risk: bone cement implantation syndrome. This is a rare but potentially serious complication that manifests as hypotension, hypoxia, arrhythmia, and, in severe cases, cardiac arrest. This is why modern anesthesiology and orthopedic guidelines require not simply "using cement," but doing so within the framework of a proven safety protocol. [32] [33]

The use of dual-mobility cups in total hip arthroplasty in patients with a high risk of dislocation has also generated interest. The results of several studies appear promising, but methodological concerns have already emerged around one of the 2025 meta-analyses, which cast doubt on the certainty of the conclusions. Therefore, it is currently more reasonable to consider such components as an option for carefully selected patients rather than as an undisputed universal standard. [34] [35]

Choice in operation	What is known now
Unipolar and bipolar hemiarthroplasty	The recommendations consider them comparable in terms of benefits.
Cement fixation of the stem	Supported by modern recommendations
Total hip arthroplasty	More suitable for active and functionally preserved patients
Hemiarthroplasty	Often preferred in more fragile patients
Dual mobility	Promising, but the evidence base is still being clarified

Sources for the table: [36] [37] [38] [39] [40]

How is the preparation and the operation itself carried out?

The most important principle in modern management of such patients is not to delay surgery without a compelling reason. The UK's National Institute for Health and Care Excellence recommends performing surgery on the day of admission or the next day, and the American Academy of Orthopaedic Surgeons notes that surgery within 24-48 hours of admission may be associated with better outcomes. [41] [42]

Before surgery, the team strives to quickly correct reversible problems that genuinely interfere with safe intervention: anemia, severe hypovolemia, electrolyte imbalances, decompensated heart failure, uncontrolled diabetes, acute chest infection, and other conditions. The goal is not a formal "postponement until perfection" but rather accelerated preparation to avoid wasting time. [43]

In terms of pain management, guidelines support a multimodal approach. The American Academy of Orthopaedic Surgeons recommends regimens that include preoperative nerve blocks, while the United Kingdom recommends initiating pain management immediately upon admission and regularly reassessing pain. This approach reduces patient distress and facilitates safer preoperative assessment and care. [44] [45]

The type of anesthesia is selected individually. According to the American Academy of Orthopaedic Surgeons, both spinal and general anesthesia are acceptable options for patients with hip fractures, and no definitive absolute advantage of one method for all patients has been demonstrated. Therefore, the choice depends on the clinical situation, anticoagulants, cardiac and pulmonary status, and the experience of the team. [46]

During the surgery itself, the surgeon's task is to remove damaged structures, install the prosthesis, ensure proper limb length, joint stability, and the possibility of early full weight-bearing. Additionally, current guidelines support the use of tranexamic acid to reduce blood loss and the need for blood transfusions, as well as the prevention of venous thromboembolic complications after surgery. [47] [48] [49]

Stage	What does the team do?	Why is this necessary?
Urgent assessment after admission	Confirms fracture type and overall risk	Don't waste time and choose the right method
Fast state optimization	Corrects reversible disorders	Reduce the risk of delays and complications
Anesthesia with nerve block according to indications	Reduces pain before surgery	Improves tolerability of examination and care
Choice of anesthesia	Spinal or general depending on the situation	Balance of safety and convenience
Early loading surgery	Places a stable prosthesis	Speed up recovery and reduce complications

Sources for the table: [50] [51] [52] [53] [54]

Recovery after endoprosthetics

The modern approach to rehabilitation begins very early. UK guidelines recommend performing surgery with full weight-bearing capacity immediately after the procedure, and physiotherapy assessment and, if there are no contraindications, mobilization beginning the day after surgery. [55]

Early verticalization is important not only for restoring walking ability. It reduces the risk of chronic complications, helps restore confidence in movement more quickly, and facilitates a return to self-care. This is why the recommendations specifically emphasize the need for at least daily mobilization and regular physical therapy visits. [56]

The best outcomes are achieved when the patient is managed not only by a surgeon, but also by a multidisciplinary team including a physician specializing in geriatrics and frailty, a physical therapist, and specialists in fall prevention and cognitive assessment. The American Academy of Orthopaedic Surgeons emphasizes that multidisciplinary programs reduce complications and improve outcomes, and researchers from Oxford have specifically demonstrated the importance of joint management between a surgeon and a geriatric specialist. [57] [58] [59]

After discharge, it's critical to maintain the pace of rehabilitation. The UK National Hip Fracture Database states that the next stage of the rehabilitation pathway should begin within 72 hours of discharge from the acute hospital. However, in reality, patients waited an average of 15 days for home rehabilitation, with some waiting up to 80 days. These delays directly impede the restoration of independence. [60]

Full recovery after this type of surgery is rarely immediate. In the first few weeks, the main goals are safe walking, pain control, fall prevention, and the restoration of transfers, toileting, and getting out of bed and a chair. The subsequent pace depends on age, frailty, pre-injury muscle condition, the presence of dementia, cardiovascular and pulmonary disease, and how quickly the rehabilitation process was initiated. [61] [62] [63]

Period	Main tasks
The first day after surgery	Pain control, prevention of complications, initiation of sitting and standing as indicated
1-3 days	Walking with support, safe movement training, self-care assessment
1-6 weeks	Increasing walking distance, restoring everyday activities
After discharge	Continuous rehabilitation without long breaks
The subsequent period	Preventing recurrent falls and treating bone fragility

Sources for the table: [64] [65] [66]

What complications are possible and how are they being prevented?

Even a perfectly performed hip replacement remains a major operation in an often very vulnerable patient. Therefore, the spectrum of complications includes not only purely orthopedic problems but also general surgical ones: deep vein thrombosis, pulmonary embolism, pneumonia, delirium, cardiovascular events, infection at the surgical site, and repeated falls in the early postoperative period. [67] [68]

When comparing the two main types of hip arthroplasty, the picture is not entirely clear. Some modern reviews show similar rates of mortality, infection, periprosthetic fractures, and dislocations, while others document a higher risk of dislocation within the first year with total hip arthroplasty. Therefore, surgical choice is always based on a compromise between improved function and potential joint instability. [69] [70]

When using cemented fixation, special attention is paid to bone cement implantation syndrome. The US National Cancer Institute describes it as a rare but potentially fatal perioperative complication of cemented bone procedures, characterized by hypotension, hypoxia, arrhythmia, and, in severe cases, cardiac arrest. Therefore, recommendations for cemented hemiarthroplasty emphasize step-by-step, team-based risk prevention. [71] [72]

That said, the mere fact of using cement shouldn't be more frightening than necessary. Current recommendations don't discourage cement fixation; on the contrary, they support it, as it generally offers advantages in stability and mechanical outcomes. The practical conclusion here is not "cement is bad," but "cement requires proper surgical organization, anesthesia, and monitoring." [73] [74] [75]

A separate group of complications is related not so much to the prosthesis itself as to the patient's overall condition. Dementia, severe frailty, heart failure, chronic lung disease, poor initial mobility, and late onset of rehabilitation worsen the prognosis. Even in patients with dementia, surgical treatment of femoral head and neck fractures was associated with lower 180-day mortality compared with nonsurgical management, emphasizing the importance of an individualized, but not overly passive, approach. [76]

Complication or risk	What helps reduce the risk
Dislocation	Correct selection between hemiarthroplasty and total joint replacement, precise placement of components
Thrombosis and pulmonary embolism	Thromboprophylaxis and early mobilization
Major blood loss	Tranexamic acid and careful surgical technique
Bone cement implantation syndrome	Preoperative risk assessment and team safety protocol
Loss of independence	Early rehabilitation and continuity of care after discharge

Sources for the table: [77] [78] [79] [80] [81]

What is the prognosis after surgery?

The prognosis after hip replacement is determined not only by the procedure itself, but also by the patient's underlying fragility. A 2025 educational article on hip fractures in adults noted that the mortality rate in patients over 65 years of age after a hip fracture is approximately 15% after 3 months and approximately 25% after 1 year. This does not mean that the surgery "doesn't help," but rather demonstrates how devastating the fracture itself is for the elderly. [82]

Data from the National Center for Biotechnology Information (NCBI) provides a similar estimate: the 1-year mortality rate after a hip fracture is approximately 20-30%, with the greatest risk occurring in the first 6 months. It also indicates that only about half of patients regain independent walking, while some remain non-ambulatory. [83]

An important finding of recent years is that a good prognosis is more often achieved not by simply "operated patients," but by patients who undergo prompt surgery, receive comprehensive pain relief, early mobilization, receive interdisciplinary support, and are seamlessly transferred to the next stage of rehabilitation. Essentially, success is determined by the quality of the entire care chain, and not just the surgeon's skill in the operating room. [84] [85] [86]

When comparing hemiarthroplasty and total hip replacement over the long term, total hip replacement may provide better function and quality of life in more active and fit patients. However, for more fragile patients, hemiarthroplasty often remains a very reasonable solution because it allows for a faster surgery with a predictable early outcome. The main mistake is to look for the "most fashionable" option instead of the "most suitable" one for a specific individual. [87] [88]

Therefore, the prognosis after hip replacement surgery should be discussed honestly and concretely. This procedure offers a better chance of verticalization and pain relief for many patients than conservative management or unreliable fixation of a displaced fracture. However, it is also a marker of serious age-related injury, after which the outcome depends on fragility, cognitive status, cardiovascular reserve, the quality of rehabilitation, and the prevention of recurrent falls. [89] [90] [91]

Forecast factor	How does it affect
Age and fragility	The more pronounced they are, the higher the risk of death and loss of independence.
Initial walking level	Those who were active before injury have better outcomes.
Cognitive status	Dementia worsens the overall prognosis, but does not negate the benefits of surgery.
Speed of operation	Early intervention is associated with better outcomes.
Continuity of rehabilitation	Delays slow recovery and increase the risk of readmission.

Sources for the table: [92] [93] [94] [95] [96]

FAQ

Is it possible to avoid surgery for a hip fracture?

This option is sometimes discussed, but for displaced intra-articular fractures in older adults, current guidelines generally support surgical treatment over watchful waiting. Even in patients with dementia, surgical treatment has been associated with lower 180-day mortality than non-surgical treatment.[97][98]

Which is better: hemiarthroplasty or total hip replacement?

There is no universal answer. More active and functionally intact patients may benefit from total hip replacement in terms of function and quality of life, but it may carry a higher risk of certain complications, particularly joint instability. In more fragile patients, hemiarthroplasty is often a more balanced choice. [99] [100] [101]

Why do they try to do the operation quickly?

Because delays worsen outcomes. The American Academy of Orthopaedic Surgeons indicates that surgery within 24-48 hours of admission may be associated with better outcomes, while UK guidelines recommend surgery on the day of admission or the next day. [102] [103]

Should you be afraid of a cemented prosthesis?

There's no need to be afraid, but it's important to understand the nuances. Cement fixation is supported by current guidelines, but it requires a competent anesthetic and surgical protocol due to the risk of bone cement implantation syndrome. [104] [105] [106]

When can I get up after surgery?

Usually, as soon as possible. Current recommendations encourage the surgeon to allow full weight-bearing immediately after surgery, and physical therapy assessment and mobilization should begin the following day, unless there are contraindications. [107]

How long does recovery take?

The most intensive period usually occurs in the first weeks, but full functional recovery in elderly patients can take months. Much depends on the initial independence, comorbidities, and how quickly continued rehabilitation begins after discharge. [108] [109]

Is it true that after such an injury people often never return to their previous lives?

The risk of such an outcome is indeed high. A hip fracture is not only a fracture but also a marker of overall fragility. However, high-quality endoprosthetics with early rehabilitation significantly increases the chance of maintaining walking and self-care compared to passive management. [110] [111]

Is prevention of recurrent fractures necessary after surgery?

Yes. Modern multidisciplinary programs include not only the surgery and recovery itself, but also fall prevention, memory assessment, coordination with primary care, and bone health monitoring.[112] [113]

Key points from experts

Cecilia Rogmark, Adjunct Professor, Associate Professor of Orthopaedics, Lund University.
Key point: A femoral neck fracture in adults, especially in the elderly, is not a "local bone break," but an event with a high risk of death, loss of function, and reoperation. Therefore, the choice between fixation, hemiarthroplasty, and total hip replacement should be based on a realistic goal: maximizing the patient's ability to regain early weight-bearing capacity while minimizing the risk of reintervention. [114] [115]

Matthew Costa - Matthew Costa, Professor of Orthopaedic Trauma Surgery, Honorary Consultant Trauma Surgeon, University of Oxford and John Radcliffe Hospital.
Key message: Successful hip fracture treatment is not determined by surgery alone. The best outcomes are achieved when the patient is managed jointly by a surgeon and a geriatric specialist, where falls prevention and cognitive impairment assessment are implemented, and where care itself is organized as a unified system, rather than a set of disparate stages. [116] [117]

Antony Johansen - Professor Antony Johansen, Consultant Orthogeriatrician, University Hospital of Wales, Honorary Professor, Cardiff University, Clinical Lead of the National Hip Fracture Database.
Key message: hip fracture should be managed through a comprehensive orthogeriatric model, where early surgery, daily mobilisation, ongoing rehabilitation and prevention of subsequent falls are as important as the prosthesis itself. [118] [119] [120]

Conclusion

In modern practice, hip arthroplasty is one of the central treatment methods for displaced intra-articular fractures in adults. For most elderly patients, it offers the best chance of early weight-bearing, pain relief, and a reduced risk of reoperation compared to fixation. [121] [122]

The choice between hemiarthroplasty and total hip replacement should not be a blanket one. More fit and active patients may benefit functionally from total hip replacement, while in more fragile patients, hemiarthroplasty often remains the most reasonable and safest option. [123] [124] [125]

True treatment success depends on four factors: timely surgery, proper design, competent perioperative management, and ongoing rehabilitation after discharge. This strategy best aligns with current recommendations and the real needs of patients after a hip fracture. [126] [127] [128]