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Review

Femoral Neck Fractures in Elderly Patients: Dual Mobility Cup Arthroplasty or Hemiarthroplasty? A Narrative Review of the Literature

by
Calogero Cicio
1,
Gianluca Testa
1,*,
Giancarlo Salvo
2,
Benedetta Liguori
1,
Andrea Vescio
1,
Vito Pavone
1 and
Marco Sapienza
1
1
Department of General Surgery and Medical Surgical Specialties, Section of Orthopaedics and Traumatology, Policlinico Rodolico-San Marco, University of Catania, 95123 Catania, Italy
2
Department of Orthopedic Surgery, Trauma Center, Cannizzaro Hospital, 95100 Catania, Italy
*
Author to whom correspondence should be addressed.
Appl. Sci. 2025, 15(9), 4844; https://doi.org/10.3390/app15094844
Submission received: 28 March 2025 / Revised: 23 April 2025 / Accepted: 24 April 2025 / Published: 27 April 2025
(This article belongs to the Section Biomedical Engineering)
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Abstract

:
Proximal femoral fractures (PFFs) are the most frequent type of bone injury among the elderly. In Italy alone, 906,111 hospital admissions for hip fractures were recorded between 2007 and 2017. Globally, due to the aging population, the number of cases is expected to rise to 21.3 million by 2050. In older individuals, fractures of the femoral neck are commonly managed with prosthetic implants. While hemiarthroplasty has long been the standard treatment, total hip arthroplasty (THA) is increasingly favored for more active or functionally demanding patients. Among the surgical options, dual mobility THA (DM-THA) stands out for its potential to significantly reduce postoperative complications, particularly dislocations, when compared to both conventional THA and hemiarthroplasty. This study aimed to determine the most effective surgical strategy—dual mobility THA versus hemiarthroplasty—for managing femoral neck fractures in elderly patients. A thorough literature review was conducted using PubMed, Web of Science, and Scopus, focusing on the most recent and relevant publications. The findings highlight a consistent trend: patients treated with DM-THA generally experience better outcomes than those receiving hemiarthroplasty. Based on current evidence, DM-THA should be regarded as the preferred intervention for elderly individuals with femoral neck fractures, except in cases where severe comorbidities or anesthesia-related risks require a more conservative approach.

1. Introduction

Proximal femoral fractures (PFFs) represent one of the most common orthopedic issues in the elderly population, with a significant impact on quality of life and healthcare systems. These fractures are often the result of low-energy trauma, such as falls, which become increasingly frequent with aging. In Italy, between 2007 and 2017, there were 906,111 hospitalizations due to hip fractures, with fracture rates increasing by 14.3% in women and 29.4% in men over 11 years [1]. This trend reflects a global phenomenon, as several studies [2,3] report a rising incidence of proximal femur fractures among the elderly, a trend expected to continue with the aging global population. According to some estimates, the total number of proximal femoral fractures could reach 21.3 million globally by 2050 [4], with the incidence particularly high among older adults, as the risk of fractures increases significantly with age.
A study conducted by Oulianski et al. [5] reported a 21.64% decrease in the weekly incidence of PFFs during the COVID-19 pandemic compared to the pre-pandemic period, suggesting that external factors such as social restrictions and isolation may influence fracture rates. This decrease could also reflect the impact of containment measures on the daily habits of the elderly population, which saw a reduction in accidental falls due to decreased mobility. Despite this decline, data still show that the incidence of fractures remains high among the elderly, with a median age of 83 years among hospitalized PFF patients, and that incidence rates increase with age [6].
Proximal femoral fractures are more prevalent in women, primarily due to factors such as postmenopausal osteoporosis, which increases the risk of bone fractures. These fractures most commonly occur in the 85–89-year-old age group, with a marked exacerbation in individuals with cognitive disabilities or those institutionalized [7]. However, some recent studies, such as the study by Walter et al. [8], suggest a general decrease in the incidence of head/neck fractures, with a 26.6% reduction between 2009 and 2019. This may be attributed to improvements in prevention policies and orthopedic treatments.
Beyond the clinical and social impact, proximal femoral fractures impose a significant economic burden on healthcare systems worldwide [9]. The combined healthcare and productivity loss costs are substantial: in 2011, hip fracture treatment was the 13th most expensive diagnosis for Medicare in the United States [10]. The growing costs, which follow the pattern of incidence, are particularly pronounced with the aging population, emphasizing the need for more efficient prevention and treatment strategies.
This study aimed to further explore the factors contributing to the incidence of proximal femoral fractures, their clinical and socioeconomic implications, and opportunities for improvement in managing these fractures in older adults, comparing two surgical approaches—dual mobility cup arthroplasty and hemiarthroplasty—in order to reduce the devastating impact of this condition on patients and healthcare systems.

2. Methods

The main electronic databases (PubMed, Web of Science, and Scopus) were explored by all the authors (C.C., B.L., and M.S.). This research was conducted from June 2024 to December 2024, and the keywords used were ((“femoral neck fractures in elderly” OR “proximal femoral fractures in elderly”) AND (“dual mobility cup arthroplasty” OR “hemiarthroplasty “)) NOT (osteoarthritis). MesSH terms were included. The study had no temporal limitation regarding the time of publication. A total of n = 194 articles were found. The PRISMA flowchart is shown in Figure 1. Studies providing any level of evidence about femoral neck fractures in the elderly were considered eligible for this study. The most recent and relevant studies on the topic were included, excluding duplicates, those not in English, and studies not closely related to the topic. Therefore, 48 studies were included in the final analysis (Table 1).

3. Anatomic Reference

The hip joint is encapsulated by a joint capsule that serves to stabilize and protect the structures within. This capsule is attached medially to the margin of the acetabulum, laterally to the intertrochanteric line on the anterior aspect of the femur, and posteriorly to the base of the femoral neck. These attachment points help maintain the integrity of the joint while allowing for the dynamic range of movement required for the normal function of the hip [59].
In terms of vascular supply, the proximal femur is nourished by a complex network of blood vessels that form a vascular ring around the femoral head. This vascular ring is primarily composed of the medial and lateral femoral circumflex arteries. These arteries give rise to terminal branches that provide the blood supply to the femoral head, ensuring the health and function of the bone. However, in the case of displaced hip fractures, these blood vessels can be damaged, which can interrupt the blood flow to the femoral head. This disruption of vascular supply can lead to osteonecrosis, a condition characterized by the death of bone tissue due to a lack of blood flow, which significantly complicates the healing process and can lead to long-term joint dysfunction [60,61].

4. Diagnosis

Proximal femoral fractures (PFFs) are often preceded by a history of low-energy trauma or falls, which typically results in pain localized to the hip or groin area [62]. However, in 2–3% of cases, no clear history of trauma is noted, and the fracture may be pathological or the result of a stress fracture [63]. This distinction is important because stress fractures often occur in individuals with underlying bone conditions, such as osteoporosis, and may not present with the same clear traumatic event as displaced fractures.
Patients who present with displaced femoral neck fractures usually exhibit a shortened, externally rotated limb and often have an inability to bear weight on the affected side [64]. Physical examination may reveal tenderness upon palpation over the groin and anterior hip, along with pain during the log roll maneuver, which involves passive internal and external rotation of the lower leg. However, it is important to note that ecchymosis (bruising) is typically not observed in the early stages of the injury [65].
For patients with non-displaced or impacted fractures, particularly stress fractures, the physical presentation may be less obvious. These patients might not exhibit any noticeable deformity and may still be able to bear weight, although they often experience non-specific symptoms, such as groin pain or discomfort during axial compression [66]. This can make diagnosis more challenging, as the physical findings in these cases can be similar to those seen in extracapsular fractures, making it difficult to differentiate between the two based solely on clinical examination.
Due to these challenges, radiological imaging plays a crucial role in accurately diagnosing proximal femoral fractures (PFFs). Initial diagnostic tests typically include the cross-table lateral view and anterior–posterior (AP) X-rays of the hip (Figure 2). A frog-leg view is generally avoided in these cases, as the positioning of the limb can cause significant pain [67]. On the AP pelvis X-ray, when evaluating Shenton’s arch, the smooth curve of the medial femoral neck and the superior aspect of the obturator foramen can be particularly helpful. A disruption in the integrity of this arch may suggest an undisplaced intracapsular fracture [68].
Magnetic resonance (MR) imaging is considered to be more sensitive than computed tomography (CT) scans in detecting femoral neck fractures. However, there are still insufficient data comparing MR imaging with the more advanced CT technology currently available, which offers thinner slices and higher-quality reconstructions. Due to its wider availability and the ability to provide rapid results, CT imaging is often preferred for first-line screening in many clinical settings [69,70].

5. Classification

Classifications play a crucial role in the field of orthopedic surgery, as they assist surgeons in accurately diagnosing fractures and making informed decisions regarding appropriate treatment strategies [71]. Proximal femoral fractures can be classified based on their relationship with the hip joint capsule. These fractures are categorized into two main types: extracapsular fractures (also known as trochanteric fractures) and intracapsular fractures (which include femoral neck fractures) [72]. The type of fracture significantly influences the treatment approach, with each requiring a tailored surgical intervention. This paper focuses specifically on intracapsular fractures, which are commonly associated with more complex management due to their involvement with the hip joint capsule and blood supply.
One of the most widely used classification systems for femoral neck fractures is Garden’s classification, which is based on the appearance of the fracture on the anteroposterior (AP) X-ray [73] (Table 1). The classification includes the following types:
  • Type 1: Incomplete and undisplaced fracture, where the bone is not fully fractured and remains in proper alignment;
  • Type 2: Complete, undisplaced fracture, where the bone is fully fractured but maintains its original position without displacement (Figure 1);
  • Type 3: Partial displacement with misalignment of the trabecular bone, where the fracture fragments begin to shift out of alignment but are not fully displaced;
  • Type 4: Complete displacement, where the fracture results in significant separation and displacement of the bone fragments.
Another commonly used classification is Pauwels’ classification [74], which categorizes femoral neck fractures based on the angle of the fracture line relative to the horizontal plane (Table 1). The angle is measured between a tangential line drawn to the most superior aspect of the femoral head and the fracture line. The classification includes three types:
  • Type 1: The fracture angle is less than 30°, typically representing a stable fracture;
  • Type 2: The fracture angle ranges between 30° and 50°, indicating an intermediate level of stability;
  • Type 3: The fracture angle is greater than 50°, which is associated with an unstable fracture and a higher risk of complications.
These classifications provide important information that guides treatment decisions, surgical planning, and the management of potential complications in patients with femoral neck fractures [75] (Table 2).

6. Treatment

6.1. Conservative Treatment

Currently, the gold standard for the treatment of displaced femoral neck fractures is surgical intervention. Surgical treatment is considered essential in most cases due to its ability to restore hip function, reduce pain, and prevent complications such as nonunion or avascular necrosis of the femoral head. However, there are certain exceptional situations where non-surgical treatment may be considered appropriate. These cases are generally rare and are determined based on specific clinical factors, including the following:
  • Short life expectancy: In patients with a limited life expectancy, the risks associated with surgery may outweigh the potential benefits. In such cases, where the patient may not survive long enough to fully recover from surgery, conservative management might be preferred to avoid unnecessary complications.
  • Chronic fractures with signs of consolidation: In cases where the fracture has occurred long ago (inveterate fractures), and there are signs of partial or complete consolidation (healing) of the fracture, non-surgical management may be considered. This could be appropriate when the bone is healing in a satisfactory position and there is no need for surgical realignment.
  • Patients who are bedridden: For patients who are continuously bedridden and unable to bear weight, the need for surgical intervention might be reduced. In these cases, the focus would be on pain management and maintaining mobility to the extent possible, with surgery being deemed unnecessary due to the patient’s inability to benefit from functional recovery post-surgery.
  • Patient refusal of surgical treatment: In some cases, patients may refuse surgery for personal, medical, or psychological reasons. When a patient makes an informed decision to decline surgical treatment, non-surgical management, including pain control and rehabilitation, may be pursued as an alternative, provided the patient understands the risks and limitations of this approach.
In these exceptional cases, the decision to opt for non-surgical treatment requires careful consideration of the individual patient’s health status, prognosis, and preferences, and should be made collaboratively between the patient and the healthcare team.

6.2. Hemiarthroplasty (HA)

Endoprostheses, partial prostheses, or hemiarthroplasty involve the partial replacement of the hip joint. After the femoral head is removed, the femoral canal is prepared, and the femoral stem is inserted. These procedures are categorized into unipolar prostheses, which are increasingly rare, and bipolar prostheses. In a bipolar hip prosthesis (BHP), the femoral head consists of a steel outer shell with a polyethylene liner and an inner steel head that moves inside the shell [11,76]. In this surgery, no intervention is performed on the acetabulum. The femoral stem can be fixed to the femur either through press fit or cementation. Hemiarthroplasty (HA) is typically recommended for patients with limited independence and low physical activity [12]. The benefits of this approach include shorter surgical times and less invasive procedures compared to total hip replacement. However, it carries some risks. Common complications include dislocation, periprosthetic fractures, acetabular erosion, and leg-length discrepancy. Rare complications may include neurovascular injuries and capsular interposition [13]. Kizkapan et al. [14] reported that both pelvic anatomy and surgical variables influence the risk of dislocation. Similarly, Graulich et al. [15] identified dementia and a reduced posterior wall angle as significant contributors to dislocation following hemiarthroplasty (HA). Olesen et al. [16] emphasized dementia as the sole major predictor of dislocation in HA patients. Falsetto et al. [17] also associated dementia, along with a low preoperative lateral center-edge angle, with an elevated dislocation risk after femoral neck fractures. Furthermore, lumbar spinal fusion (LSF) was recognized as an independent factor in increasing joint-related complications in patients treated with either total hip arthroplasty (THA) or HA for displaced femoral neck fractures [18]. Research by Macheras et al. [19,20] highlighted age as a determinant of acetabular wear post-HA, with younger patients (under 75) exhibiting greater wear than older individuals.

6.3. Total Hip Arthroplasty (THA)

In total hip arthroplasty (THA), portions of the upper femur and the acetabulum are replaced with biocompatible materials, such as metal, ceramic, or polyethylene, to restore joint function and alleviate pain [21]. THA is generally considered the gold standard for treating severe hip arthritis or fractures, particularly in patients who are younger and more active. These patients tend to have better outcomes following THA, as the procedure helps restore mobility and improves quality of life. For these individuals, the slightly increased risk of complications associated with the procedure is often deemed acceptable, given the potential benefits [22].
Several studies have suggested that THA should be strongly considered for patients with displaced femoral neck fractures, especially if the patient is younger than 80 years and has a life expectancy of more than four years. This approach is recommended because THA not only addresses the fracture but also provides long-term solutions to hip joint degeneration, which may be especially beneficial in younger patients who are likely to outlive other treatment options [23].
However, the use of THA to treat femoral neck fractures in elderly patients presents certain challenges. Specifically, elderly individuals undergoing THA for femoral neck fractures are at a significantly higher risk of complications such as hip dislocation, particularly in the first 12 months following surgery. Studies have shown that the risk of dislocation is considerably elevated in this population [24], which can complicate recovery and prolong the rehabilitation process. As such, careful consideration of the patient’s overall health, functional needs, and life expectancy is essential when deciding whether THA is the most appropriate treatment for elderly patients with femoral neck fractures. According to the high risk of complications described in the literature, we focused on the comparison between HA and dual mobility total hip arthroplasty (DM-THA).

6.4. Dual Mobility Total Hip Arthroplasty (DM-THA)

The concept of the DM-THA was first introduced by Professor Gilles Bousquet in 1974 as an innovative solution to enhance the stability and function of hip replacements [47]. The design of the dual mobility cup features a large-head articulation, which is combined with an increased jumping distance between the ball and socket. This design allows for a significantly higher range of motion in the hip joint while also reducing the risk of dislocation and improving overall stability [25]. The increased range of motion provided by DM-THAs allows patients to engage in a greater variety of activities before reaching the point of impingement or dislocation, which is particularly beneficial in younger, more active patients.
Despite the advantages, there are potential complications associated with dual mobility hip implants that orthopedic surgeons must be aware of. One such complication is intraprosthetic dislocation, where the inner bearing components of the dual mobility system become dislocated from one another, which can result in severe pain and dysfunction [26,27]. Another issue is the risk of corrosion, which can occur due to wear between the moving parts of the implant, potentially leading to a release of metal ions and subsequent complications such as local tissue reactions or implant failure [28,29]. Additionally, femoral notching, which refers to a notch or groove forming in the femoral neck during surgery, is another complication that can compromise the long-term stability of the implant and increase the risk of fracture or failure [28,29].
Furthermore, some studies have highlighted that patients who undergo dual mobility total hip arthroplasty (DM-THA) for femoral neck fractures may experience higher rates of heterotopic ossification compared to those who receive standard THA. Heterotopic ossification refers to the abnormal growth of bone in soft tissues around the hip joint, which can lead to stiffness and discomfort, ultimately affecting the range of motion and the overall function of the joint [29]. This phenomenon is an important consideration when deciding whether to use a dual mobility implant in patients with femoral neck fractures.

7. Discussion

In this paper, we aimed to assess the pros and cons of HA and DM-THA, and we wanted to offer our opinion about the best treatment in elderly (over 65 years old) patients with femur neck fractures.
Usually, hip HA has been the first choice in patients with age >65 years and several comorbidities. With the current trend of healthy aging, many individuals over the age of 65 who sustain hip fractures remain physically active and maintain high functional demands. For this population, total hip arthroplasty (THA) has emerged as the most suitable treatment, offering superior medium-term functional outcomes, enhanced quality of life, and a lower rate of acetabular erosion. In contrast, hemiarthroplasty (HA) is associated with shorter hospital stays, reduced operative time, less blood loss, and a lower incidence of dislocations [31].
Dual mobility total hip arthroplasty (DM-THA) may represent an optimal solution to address the issue of dislocation. This technique allows for a greater range of motion, increased jump distance, and a reduced risk of postoperative instability. Boukebous et al. [32], in a retrospective case–control study, found that frail patients undergoing DM-THA had a low dislocation rate without a corresponding increase in one-year mortality. In contrast, for non-frail individuals, no significant differences were observed in outcomes between HA and standard THA.
Similarly, Kim et al. [33], through a retrospective cohort analysis, reported that the DM-THA group achieved better clinical outcomes, as measured by the Harris Hip Score (HHS), without increased rates of mortality or dislocation during short-term follow-up when compared to HA. Fahad et al. [34] also supported the use of DM-THA as a primary treatment in relatively younger, active elderly patients with displaced femoral neck fractures. Their findings indicated improved functional recovery without added mortality or morbidity compared to HA.
Bensen et al. [35] observed significantly lower rates of dislocation and reoperation in patients treated with DM-THA versus those receiving HA. Rotini et al. [36], in a case–control study assessing surgical duration and hemoglobin loss, noted that although DM-THA procedures were, on average, 12 min longer, they were associated with less blood loss. Importantly, DM-THA did not result in higher mortality, morbidity, bleeding, or dislocation rates compared to bipolar HA. Based on these findings, the authors proposed that DM-THA could be considered the preferred approach for managing displaced femoral neck fractures, especially in healthy and functionally active elderly patients.
Ukaj et al. [37] found a significant difference in dislocation rates and postoperative HHS in a case–control study. Rates were better in the DM-THA group compared to the HA group. No significant differences were found in operative time and hemoglobin loss in either group. Valcaregni et al. [38] found a lower cumulative incidence of reoperation for any reason in the DM-THA group (9%) than in the HA group (19%) with femur neck fracture. They did not find higher postoperative mortality in the DM-THA group compared to the HA group. Albanese et al. [39] conducted a systematic review and meta-analysis of the literature, reporting a lower overall risk of dislocation with DM-THA compared to both THA and HA. Additionally, they found that DM-THA was associated with lower rates of revision surgery compared to HA. Other case studies have also demonstrated positive outcomes and high patient satisfaction [40,41,42,43,44,45,46,47].
Jinnai et al. [48] reported favorable clinical outcomes in patients with femoral neck fractures treated with dual mobility total hip arthroplasty (DM-THA) using a direct anterior approach. These patients experienced rapid recovery of walking ability, no dislocations, and a low one-year mortality rate. Assi et al. [49] examined the impact of DM-THA on clinical and functional outcomes in a population engaged in specific rituals involving extreme hip positions as part of their daily activities. Their study found that DM-THA provided excellent clinical and functional results, enabling patients to resume their customary activities. Additionally, these patients experienced a low mortality rate following the procedure.
Carulli et al. [50] studied the results of revisions by dual mobility cups in unstable HA. They found no recurrence of dislocation, the American Society of Anesthesiologists (ASA) score remained unchanged, and they also noted an improvement in HHS postoperatively. They reported that DM-THA is a successful option in HA revision for dislocation.
The advantages of DM-THA over HA in patients with neurological disorders remain a topic of debate. El-Deeb et al. [51] conducted a prospective cohort study on patients over 60 years old with PFFs, neuromuscular disorders, and cognitive dysfunction who were candidates for THA. They found that DM-THA effectively prevents early dislocation in this patient population. Similarly, Zhuang et al. [52] studied the outcomes of PFFs in patients with ipsilateral residual poliomyelitis treated with DM-THA, concluding that DM-THA enhances stability and reduces the risk of dislocation, making it a suitable option for patients with neuromuscular conditions.
Henawy et al. [53] studied the outcome of DM-THA in hemiplegic patients with osteoarthritis or femur neck fracture. They showed that DM-THA provides both efficacy and stability with good outcomes. Other authors described a rare case report about a patient with a femur neck fracture and neurological disease treated with DM-THA and reported good functional outcomes [54,55]. On the other hand, Cnudde et al. [56] showed similar rates of dislocation in patients with femur neck fracture and neurological disease treated both with HA and DM-THA. However, there are studies in the literature that have not shown a clear improvement in DM-THA compared to HA in femur neck fracture [57]. Mufarrih et al. [58] found similar dislocation and mortality rates between DM-THA and HA, but no study has revealed better results with HA compared to DM-THA.

Limitations

The studies included were heterogeneous, with varying follow-up periods and durations, which complicates the assessment of long-term outcomes and the identification of complications. Additionally, the lack of standardization in the clinical outcome measures across the studies further hinders the ability to consistently evaluate and compare the clinical results.

8. Conclusions

Femoral neck fractures will increasingly pose a challenge to traumatologists as the average life expectancy and patients’ demands are increasing. In this literature review, we found many works that show better results in patients treated with DM-THA compared to HA. In elderly people with femoral neck fractures, DM-THA may be preferable to HA in certain patient profiles, but the decision should be individualized based on risk–benefit.

Author Contributions

Conceptualization, G.T. and M.S.; methodology, A.V.; software, C.C.; validation, G.S.; formal analysis, M.S.; investigation, B.L.; resources, C.C.; data curation, M.S.; writing—original draft preparation, C.C.; writing—review and editing, M.S.; visualization, G.S.; supervision, G.T.; project administration, V.P. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Conflicts of Interest

The authors declare no conflicts of interest.

Abbreviations

The following abbreviations are used in this manuscript:
PFFProximal femur fracture
HAHemiarthroplasty
THATotal hip arthroplasty
DM-THADual mobility total hip arthroplasty
AOArbeitsgemeinschaft für Osteosynthesefragen

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Figure 1. The PRISMA flowchart for the selection and screening of the articles.
Figure 1. The PRISMA flowchart for the selection and screening of the articles.
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Figure 2. AP view of undisplaced PFF.
Figure 2. AP view of undisplaced PFF.
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Table 1. Summary of selected studies.
Table 1. Summary of selected studies.
Author and YearTitleType of StudyN° of PatientsHA/THA/DM-THA/HA vs. DM-THA/HA vs. THA/HA vs. THA vs. DM THAOUTCOMESFollow-Up (Months)
Zofka
2007 [11]		[Bipolar hip hemiarthroplasty]Case series79HADM-THA offers less stress and strain on patients compared to THA. It provides greater stability and a lower risk of acetabular protrusion than THA.36
Guyen
2019 [12]		Hemiarthroplasty or total hip arthroplasty in recent femoral neck fractures?Review HA vs. DM-THAHA is recommended for patients who had limitations in physical activity, self-sufficiency, and walking ability prior to the fracture.
Domingue
2023 [13]		Complications of Hip HemiarthroplastyReview HACommon complications associated with HA treatment include dislocation, periprosthetic fractures, acetabular erosion, and leg-length discrepancy. Less frequent complications are neurovascular injury and capsular interposition.
Kizkapan
2020 [14]		Factors affecting dislocation after bipolar hemiarthroplasty in patients with femoral neck fractureRetrospective case–control study208HAFactors influencing dislocation in HA include pelvic morphological features and surgical factors.30.8 (12–48)
Graulich
2021 [15]		Risk factors for dislocation after bipolar hemiarthroplasty: a retrospective case–control study of patients with CT dataRetrospective case–control study39HAAll patients underwent pelvic computed tomography. Dementia and an insufficient posterior wall angle are associated with an increased risk of dislocation in HA.2
Sapienza
2024 [16]		Comparative Analysis of Cemented and Cementless Straight-Stem Prostheses in Hip Replacement Surgery for Elderly Patients: A Mid-Term Follow-up Study.Retrospective cohort study80 The cemented group demonstrated better clinical outcomes, including higher Harris Hip Scores, WOMAC scores, and lower Visual Analog Scale, compared to the non-cemented group.42 (13–72)
Falsetto
2022 [17]		Instability after hip hemiarthroplasty for femoral neck fracture: an unresolved problem.Retrospective case–control study18HAPatient factors linked to an increased risk of dislocation following hip HA include dementia and a low preoperative lateral center-edge angle.24
Ofa
2023 [18]		Complications following total hip arthroplasty and hemiarthroplasty for femoral neck fractures in patients with a history of lumbar spinal fusion.Case–control study HALumbar spine fusion is an independent risk factor for complications following hemiarthroplasty (HA) after a femoral neck fracture.
Macheras 2024 [19]Acetabular erosion after bipolar hip hemiarthroplasty for femoral neck fracture in elderly patients: a retrospective studyRetrospective study813HAThe authors assessed acetabular erosion through radiological examinations and evaluated functional deterioration using the modified Harris Hip Score (mHHS).12
Biscevic
2005 [20]		Structural differences between hip endoprostheses, and implications on a hip kineticsComparative study90HAComparison of the kinetic characteristics of unipolar, bipolar, and total hip endoprostheses implanted following a dislocated femoral neck fracture3.6 years
Slavkovic
2012 [21]		[Total hip arthroplasty]Review THA tips and tricksSurgical technique, biomaterials, design of the prosthesis, and fixation techniques in THA
Neri
2018 [22]		Dual mobility acetabular cups for total hip arthroplasty: advantages and drawbacksreview DM THADiscusses the advantages and disadvantages of dual mobility THA based on its 40-year history
Lewis
2019 [23]		Hemiarthroplasty vs. Total Hip Arthroplasty for the Management of Displaced Neck of Femur Fractures: A Systematic Review and Meta-Analysis.Systematic review and meta-analysis1364HA vs. THAHarris Hip Score and quality of life (Short Form 36), risk of dislocation
Eldestein
2023 [24]		Hemiarthroplasty Versus Total Hip Arthroplasty for Femoral Neck Fracture in Elderly Patients: Twelve-Month Risk of Revision and Dislocation in an Instrumental Variable Analysis of Medicare Data.Retrospective study HA vs. THA12-month dislocation rate between HA and THA following femur neck fractures12
Bellova
2023 [25]		Dual Mobility Cups in Primary Total Hip ArthroplastyReview DM-THAAdvantages of DM-THA
Lima
2022 [26]		Early Intraprosthetic Dislocation of Total Hip Arthroplasty with Double Mobility Implant: Case ReportCase report1DM-THAA complication after DM-THA: Intraprosthetic dislocation
Shaikh
2023 [27]		Intraprosthetic Dislocation of Dual Mobility Total Hip Arthroplasty: A Case Report and Review of Literature.Case report + Literature review1DM THAA complication after DM-THA: Intraprosthetic dislocation
Clair
2022 [28]		Dual Mobility in Total Hip Arthroplasty DM-THAAdvantages and complication of dual mobility cup
Rashed
2020 [29]		Is dual mobility cup total hip replacement associated with increased incidence of heterotopic ossification compared to conventional total hip replacements in fracture neck of femur patients?Retrospective cohort study334DMTHARisk of heterotopic ossifications after DM THA
Van Heumen
2015 [30]		Dual mobility acetabular component in revision total hip arthroplasty for persistent dislocation: no dislocations in 50 hips after 1–5 yearsRetrospective cohort study49DM THADislocation rate in revision total hip arthroplasty with dual mobility cup29 (12–66)
Tang
2020 [31]		The comparison between total hip arthroplasty and hemiarthroplasty in patients with femoral neck fractures: a systematic review and meta-analysis based on 25 randomized controlled trialsMeta-analysis3223HA vs. THAHarris Hip Score, Quality-of-Life EuroQol 5-Dimension (EQ-5D) scores, rate of dislocation, acetabular erosion, blood loss, hospital length of stay24
Boukebous
2018 [32]		Comparison of dual mobility total hip arthroplasty and bipolar arthroplasty for femoral neck fractures: A retrospective case–control study of 199 hipsRetrospective case–control study193HA vs. DM THAComplication (dislocation, infection, medical complications, mortality) rate comparison24.2
Kim
2018 [33]		Dual mobility hip arthroplasty provides better outcomes compared to hemiarthroplasty for displaced femoral neck fractures: a retrospective comparative clinical studyRetrospective cohort study168HA vs. DM THAIntraoperative Blood loss, length of operation, one-year mortality. Harris Hip Score22
Fahad
2019 [34]		Comparison of bipolar hemiarthroplasty and total hip arthroplasty with dual mobility cup in the treatment of old active patients with displaced neck of femur fracture: A retrospective cohort study.Retrospective cohort study104HA vs. DM THAPostoperative surgical complications, including dislocation, fracture, surgical site infection, and medical complications, as well as one-year mortality and functional outcomes, were analyzed using the Harris Hip Score.12
Bensen
2014 [35]		Dual mobility cup reduces dislocation and reoperation when used to treat displaced femoral neck fracturesRetrospective cohort study346DM-THA vs. HARate of dislocation, reoperation rate18
Rotini
2022 [36]		Is Dual Mobility Total Hip Arthroplasty Surgery More Aggressive than Hemiarthroplasty when Treating Femoral Neck Fracture in the Elderly?Multicentric retrospective study302HA vs. DM THASurgical time, blood loss and transfusion, dislocation rate, mortality, and thromboembolic events6
Ukaj
2019 [37]		Dual Mobility Acetabular Cup Versus Hemiarthroplasty in Treatment of Displaced Femoral Neck Fractures in Elderly Patients: Comparative Study and Results at Minimum 3-Year Follow-up.prospective, comparative interventional single-blinded study 94HA vs. DM THAPrimary outcomes assessed were the rate of postoperative dislocation, Functional Independence Measure (FIM), and Harris Hip Score (HHS). Secondary outcomes included operative time, estimated intraoperative blood loss, time to achieve full weight-bearing post-surgery, time to ambulation with and without crutches, as well as rates of mortality and postoperative infection.36
Valcaregni
2022 [38]		Hip fracture reoperation compared with death at two years in elderly patients: lowest risk of revision with dual mobility total hip arthroplasty than with bipolar hemiarthroplasty or internal fixation of Garden I and II.Retrospective cohort study317HA vs. DM THAMortality rate and reoperation rate24
Albanese
2021 [39]		Dual Mobility Articulations in Femoral Neck Fractures: A Systematic Review of the Literature and Meta-analysis of the OutcomesMeta-analysis DM THApostoperative dislocation, revision, and revision surgery rates.
Tabori Jensen
2018 [40]		Good function and high patient satisfaction at mean 2.8 years after dual mobility THA following femoral neck fracture: a cross-sectional study of 124 patientsCross-sectional study124DM THAOutcome measures included the Oxford Hip Score (OHS), Harris Hip Score (HHS), the EQ-5D for assessing health-related quality of life (HRQoL), and two functional performance tests: the Timed Up and Go (TUG) and the Sit-to-Stand test (10 repetitions).2.8 years
Canton
2018 [41]		Dual Mobility Total Hip Arthroplasty in the Treatment of Femoral Neck Fracture: A Systematic Review of the LiteratureRetrospective study53DM THAHarris Hip Score (HHS) and the Oxford Hip Score (OHS), radiographic evaluation5, 67 years
Adam
2012 [42]		Dual mobility cups hip arthroplasty as a treatment for displaced fracture of the femoral neck in the elderly. A prospective, systematic, multicenter study with specific focus on postoperative dislocationMulticenter prospective study214DM THARate of dislocation9
Uriarte
2021 [43]		Dual mobility cups in total hip arthroplasty after femoral neck fractures: A retrospective study comparing outcomes between cemented and cementless fixationRetrospective cohort study105DM THAHarris Hip Score (HHS) and Merlé D’Aubigné-Postel score (MDP)24
Rashed
2018 [44]		Functional Outcome and Health-Related Quality of Life after Dual Mobility Cup total hip replacement for displaced femoral neck fractures in middle-aged Egyptian patientsCase series31DM THAFunctional evaluation was conducted using the Harris Hip Score (HHS) and the SF-36 questionnaire to assess health-related quality of life (HRQoL), with support from a physiotherapist.
Nich
2016 [45]		Do Dual Mobility Cups Reduce the Risk of Dislocation in Total Hip Arthroplasty for Fractured Neck of Femur in Patients Aged Older Than 75 Years?Retrospective review82DMTHAComplications such as dislocation, intraprosthetic dislocation, reoperation rate, and radiographic evaluation were considered.12
Zhang
2021 [46]		Dual Mobility Cup Total Hip Arthroplasty for Displaced Femoral Neck Fractures: A Retrospective Study With a Median Follow-Up of 5 YearsRetrospective review112DM THAHHS and main orthopedic complication rate60
Darrith
2018 [47]		Outcomes of dual mobility components in total hip arthroplasty: a systematic review of the literatureSystematic review10,783DM THAThe survivorship, along with the rates of aseptic loosening, intraprosthetic dislocation, and extra-articular dislocation in dual mobility THA, were assessed.5.4 YEARS
Jinnai
2021 [48]		Use of Dual Mobility Acetabular Component and Anterior Approach in Patients With Displaced Femoral Neck Fracture.Case series106DM THADislocation rates, perioperative complications, and mortality at 3, 6, and 12 months were evaluated, along with pre- and early postoperative walking ability. Ambulation was classified into four categories: (1) wheelchair-bound (no ambulation), (2) walking with assistance (including elder-specific walkers), (3) walking with a single cane, and (4) independent walking without aids.12
Assi
2019 [49]		Mortality Rate and Mid-Term Outcomes of Total Hip Arthroplasty Using Dual Mobility Cups for the Treatment of Femoral Neck Fractures in a Middle Eastern PopulationReview174DM THAThe mortality rate, as well as clinical and functional outcomes, were assessed in a population with specific rituals involving extreme hip positions as part of their daily activities, using the modified Harris Hip Score.39.6 ± 13.8
Carulli
2016 [50]		The use of a dual mobility cup in the management of recurrent dislocations of hip hemiarthroplasty.Retrospective study31DM THA vs. HAThe aim of this study was to assess the outcomes of revisions using dual mobility cups in unstable hemiarthroplasties. The evaluation was conducted using the American Society of Anesthesiologists (ASA) physical function score, the Harris Hip Score (HHS), and various radiological criteria.3.8 YEARS
El-Deeb
2023 [51]		Dual Mobility Cup in Fractures of the Femoral Neck in Neuromuscular Disorders and Cognitive Dysfunction Patients above 60 years old.Prospective cohort study20DM THAClinical and radiographic outcomes were assessed at the clinic using the Harris Hip Score (HHS) in skeletally mature patients over 60 years old with femoral neck fractures, neuromuscular disorders, and cognitive dysfunction who are candidates for THA.24
Zhuang
2022 [52]		Outcomes of dual mobility articulation total hip arthroplasty in ipsilateral residual poliomyelitis.Retrospective study17DM THAClinical outcomes were assessed using the Visual Analog Scale (VAS) pain score, the Oxford Hip Score, and the University of California Los Angeles (UCLA) activity score. Radiographic outcomes were evaluated through radiographs. Complications and reoperations following THA were recorded in patients with residual poliomyelitis who underwent THA with a dual mobility cup.77
Henawy
2017 [53]		Dual mobility total hip arthroplasty in hemiplegic patients.Case series24DM THAClinical results and complication rate in hemiplegic patients treated with DM THA12
Bhosale
2024 [54]		Central Fracture Dislocation of the Hip with Ipsilateral Femoral Neck Fracture in an Elderly Patient with Parkinsonism Managed with Dual Mobility Total Hip Arthroplasty: A Case Report and Review of LiteratureCase report and review of the literature1DM THAClinical (HHS) and radiological outcomes were evaluated in a patient with a neurological disorder and a neglected post-traumatic central fracture dislocation of the right hip, along with an ipsilateral femoral neck fracture, treated with DM-THA.12
Mahajan
2021 [55]		The Neck of Femur Fracture in an Elderly Patient with Schizophrenia and Parkinsonism Managed with Dual Mobility Total Hip Replacement: A Rare Case ReportCase report1DM THAFunctional outcomes (Harris Hip Score) were evaluated in patients with (1) schizophrenia and parkinsonism, and (2) femoral neck fractures with associated greater trochanter (GT) fractures, managed with total hip replacement using a dual mobility cup and tension band wiring for the GT fracture.18
Cnudde
2022 [56]		Total, hemi, or dual mobility arthroplasty for the treatment of femoral neck fractures in patients with neurological disease: analysis of 9638 patients from the Swedish Hip Arthroplasty RegisterLongitudinal cohort study9638DM THA vs. HA vs. THAThe dislocation rate, as well as the revision, reoperation, and mortality rates at one and three years, were recorded.12
Saleem
2024 [57]		Arthroplasty treatment options for femoral neck fractures in the elderly: A network meta-analysis of randomized control trialsMeta-analysis1490DM THA vs. HA vs. THAProsthetic dislocation, mortality, operating time, intraoperative blood loss, revision rate, and Harris Hip Score (HHS).
Mufarrih
2021 [58]		Outcomes of total hip arthroplasty using dual mobility cups for femoral neck fractures: a systematic review and meta-analysisSystematic review and meta-analysis DM THADislocation and mortality rates in patients with femoral neck fractures treated with DM-THA.12
Abbreviations: total hip arthroplasty (THA); hemiarthroplasty (HA); dual mobility total hip arthroplasty (DM-THA). Harris Hip Score (HHS); Functional Independence Measure (FIM); Oxford Hip Score (OHS; health-related quality of life (HRQoL); Quality-of-Life EuroQol 5-Dimension (EQ-5D); Timed Up and Go (TUG); Sit-to-Stand 10 times (STS); Visual Analog Scale (VAS); the University of California Los Angeles (UCLA).
Table 2. Classification systems for femoral neck fractures.
Table 2. Classification systems for femoral neck fractures.
ClassificationType/DescriptionDetails
Garden’s ClassificationType 1: Incomplete and undisplacedFracture is incomplete and the femur remains in its original position.
Type 2: Complete, undisplacedFull fracture but no displacement of the femoral head (Figure 1)
Type 3: Partial displacement with misalignmentPartial displacement and misalignment of trabecular bone
Type 4: Completely displacedComplete displacement of the fracture
Pauwels’ ClassificationType 1: Angle < 30°Fracture with a stable fracture angle
Type 2: Angle between 30 and 50°Intermediate stability of the fracture angle
Type 3: Angle > 50°Fracture with high instability due to the large fracture angle
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MDPI and ACS Style

Cicio, C.; Testa, G.; Salvo, G.; Liguori, B.; Vescio, A.; Pavone, V.; Sapienza, M. Femoral Neck Fractures in Elderly Patients: Dual Mobility Cup Arthroplasty or Hemiarthroplasty? A Narrative Review of the Literature. Appl. Sci. 2025, 15, 4844. https://doi.org/10.3390/app15094844

AMA Style

Cicio C, Testa G, Salvo G, Liguori B, Vescio A, Pavone V, Sapienza M. Femoral Neck Fractures in Elderly Patients: Dual Mobility Cup Arthroplasty or Hemiarthroplasty? A Narrative Review of the Literature. Applied Sciences. 2025; 15(9):4844. https://doi.org/10.3390/app15094844

Chicago/Turabian Style

Cicio, Calogero, Gianluca Testa, Giancarlo Salvo, Benedetta Liguori, Andrea Vescio, Vito Pavone, and Marco Sapienza. 2025. "Femoral Neck Fractures in Elderly Patients: Dual Mobility Cup Arthroplasty or Hemiarthroplasty? A Narrative Review of the Literature" Applied Sciences 15, no. 9: 4844. https://doi.org/10.3390/app15094844

APA Style

Cicio, C., Testa, G., Salvo, G., Liguori, B., Vescio, A., Pavone, V., & Sapienza, M. (2025). Femoral Neck Fractures in Elderly Patients: Dual Mobility Cup Arthroplasty or Hemiarthroplasty? A Narrative Review of the Literature. Applied Sciences, 15(9), 4844. https://doi.org/10.3390/app15094844

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