Should All Orthopaedists Perform Hemiarthroplasty for Femoral Neck Fractures? A Volume–Outcome Analysis

Objectives: To determine whether very low surgeon and hospital hip arthroplasty volumes are associated with unfavorable outcomes after hemiarthroplasty for femoral neck fractures. Methods: Patients ≥60 years of age and who underwent hemiarthroplasty for femoral neck fracture were identified in the New York Statewide Planning and Research Cooperative System data from 2001 to 2015. Incidence of inpatient mortality and postoperative complications were compared across both surgeon and hospital volume using multivariable Cox proportional hazards regression, adjusting for clinical and demographic factors. Results: Fifty eight thousand eight hundred fourteen patients were included. Low surgeon volume (1 case/year) was associated with increased complications [hazard ratio (HR) 1.35, 95% CI, 1.26–1.44, P < 0.0001), including dislocations (HR 1.31 95% CI, 1.04–1.65, P = 0.02) and several medical complications (P = 0.003) compared with surgeons performing at least 2 hip arthroplasties/year. Low hospital volume (<20 cases/year) was associated with increased complications (HR 1.11, 95% CI, 1.02–1.20, P = 0.02), including deep infections (HR 1.39, 95% CI, 1.02–1.89, P = 0.04) and certain medical complications (P = 0.02) compared with centers performing at least 50 hip arthroplasties/year. Hospital and surgeon volume were not associated with inpatient mortality (P = 0.98) or reoperations (P = 0.40). Conclusions: Providers who rarely perform hemiarthroplasty for femoral neck fractures should defer these cases to surgeons and hospitals who regularly perform hip arthroplasty. Additional research is needed to further characterize the thresholds for “low volume” and to determine whether there is additional benefit afforded by high-volume surgeons and hospitals (or if it is adequate that providers performing hemiarthroplasty maintain volumes above relatively low thresholds as identified here). Level of Evidence: Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.