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Uncemented Arthroplasty in the Treatment of Hip Fractures: Too much risk, and too little reward
Uncemented Arthroplasty in the Treatment of Hip Fractures: Too much risk, and too little reward
Vol: | Issue: | Number: | ISSN#: 2563-5972
July 31, 2021 | Article No. 63
Uncemented Arthroplasty in the Treatment of Hip Fractures: Too much risk, and too little reward
July 31, 2021 | Article No. 92
Contributors
Anna Miroshnychenko HBSc, MSc
Mohit Bhandari MD, PhD
There are few areas in arthroplasty where the evidence is so unequivocal, favouring the use of cemented arthroplasty fixation for femoral neck fractures. Variation in rates of cemented femoral fixation between and within nations illustrates an ad hoc approach to the problem and represents an epistemological barrier. It is time for a general consensus and standardization towards the best practice of cemented femoral fixation for improved outcomes of this vulnerable population.
Michael Dunbar MD, PhD
Dalhousie University
Insights
- Hip fractures, including femoral neck fractures, are prevalent injuries.
- Treatment options for femoral neck fractures include internal fixation and arthroplasty.
- Evidence suggests that arthroplasty is superior to internal fixation for the treatment of femoral neck fractures.
- The two methods of fixation of an arthroplasty stem are cemented and uncemented.
- There seems to be no consensus on which of these two methods, cemented or uncemented, is superior.
- A growing body of evidence suggests superiority of cemented fixation over uncemented in terms of mortality, revision surgery and implant-related complications.
“There are approximately 1.6 million hip fractures annually. Seventy percent of all hip fractures occur in women. Hip fracture risk increases exponentially with age and is more common in white females.”
O. Johnell, Osteoporosis International Journal
Hip fractures are prevalent injuries, especially in the elderly, seen in the emergency settings (Kazley 2021). Femoral neck fractures are a specific type of intracapsular hip fracture. The femoral neck connects the femoral shaft with the femoral head. The hip joint is the articulation of the femoral head with the acetabulum. The junctional location makes the femoral neck prone to fracture. The blood supply of the femoral head is an essential consideration in displaced fractures as it runs along the femoral neck. Surgical treatment of femoral neck fracture is one of the most common procedures performed by orthopedic surgeons (Kazley 2021). Current treatment options for the displaced femoral neck fracture include reduction and internal fixation, hemiarthroplasty, and total hip arthroplasty.
Arthroplasty vs Internal Fixation
“Hemi- or total joint arthroplasty is associated with a lower rate of repeat surgery than internal fixation and is often the better option for older patients.”
Simon Mears, M.D.,
John Hopkins Hospital
Numerous studies have provided evidence for better outcomes after arthroplasty compared to internal fixation in terms of overall functional scores, function of abductor muscles, independent ambulation without walking aids and quality of life (Rogmark 2002; Keating 2006; Baumgaertner 2001; Parker 1992; Healy 2004; Greenough 1988; Delamarter 1987; Taine 1985; Lee 1998; Hudson 1998; Bhandari 2003; Bhandari 2005; Johansson 2000; Soreide 1979; Tidermark 2003; Jain 2008).
Several systematic reviews and meta-analyses suggest superiority of arthroplasty to internal fixation for treatment of the femoral neck fractures. A systematic review and meta-analysis of randomized controlled trials demonstrated that patients treated with arthroplasty for displaced femoral neck fracture had a lower risk of short-term and long-term reoperation and postoperative complications compared to individuals treated with internal fixation (Deng 2020; Jiang 2015; Rogmark 2006). Further, most of the included studies found better function and less pain after arthroplasty (Rogmark 2006). Similarly, a comparison of hemiarthroplasty to internal fixation for the treatment of nondisplaced and minimally displaced femoral neck fractures via a systematic review and meta-analysis found that patients treated with hemiarthroplasty had a significantly lower risk of reoperation when compared with those treated with internal fixation (Richards 2020).
Cemented vs Uncemented Fixation of an Arthroplasty for Femoral Neck Fractures
If arthroplasty is the superior treatment for femoral neck fractures in comparison to internal fixation, should the cemented or the uncemented fixation method of arthroplasty be used? There is a continued debate whether one or the other method results in better outcomes. There is also a great variation in the number of surgeons using cemented versus uncemented stem fixation techniques. Emerging evidence suggests that the cemented stem fixation of an arthroplasty for femoral neck fractures is superior to the uncemented approach.
“The use of cemented fixation for hip arthroplasty for femoral neck fractures has been advocated to limit the postoperative and intraoperative risk of periprosthetic fractures. However, there are concerns with the potential effects of cementing on patient mortality, particularly at the time of cementation.”
Glen Richardson, M.D.,
The Journal of Arthroplasty
Uncemented Arthroplasty and Mortality Risk
“By 1 week, there is no longer a mortality advantage to avoiding cement, and by 1 year, mortality is less when cement is used. This may be due to a higher overall revision rate with uncemented monoblock components. When modular components are compared, there is no difference in mortality at any time analyzed, although there is a higher implant revision rate when uncemented components are used. These data support the use of cemented hemiarthroplasty components in patients with hip fracture.”
Darren J Costain, Acta Orthopaedica
Mortality is an important outcome to consider when comparing cemented versus uncemented stem fixation of an arthroplasty. There are several randomized controlled trials and systematic reviews that did not show a difference in mortality between the cemented and cementless fixation methods - however, it should be noted that the sample size of these trials were small where a type II error is likely (See Table 1) (Talsnes 2013; Inngul 2015; Chammout 2016; Lin 2019; Veldman 2017). A difference in mortality has been shown in studies with larger patient numbers as part of administrative or national joint replacement registries (Yli-Kyyny 2014; Costain 2011). In these studies, mortality rates were higher for cemented fixation at first postoperative day, however at later follow up times (i.e., 1 week, 1 month and 1 year postoperatively), mortality rates were either not different between the uncemented and cemented fixation methods or higher for the uncemented fixation. The results of a recent systematic review echo these findings – where cemented hemiarthroplasty was associated with higher mortality rates within the first 48 hours compared to uncemented hemiarthroplasty – however, there were no differences in mortality rates at 7 days, 30 days, and one year.
A recent retrospective analysis of 5,883 patients examined mortality rates of cemented compared to uncemented fixation of an arthroplasty for the treatment of femoral neck fractures (Richardson 2020). Cemented fixation had a statistically significant reduction in mortality rates at 30 days (odds ratio (OR) 0.580, confidence interval (CI) 0.483-0.695, P < 0.001), 90 days (OR 0.576, CI 0.492-0.674, P < 0.001) and 356 days (OR 0.583, CI 0.511-0.665, P < 0.001) after surgery. The subgroup analysis with the two-time frames, 2001-2008 and 2009-2017, demonstrated smaller mortality rates in both subgroups, however a significant reduction in the cemented fixation group compared to uncemented was still detected. The authors suspect that the survival benefit of cementing was not as large with the subgroup analysis due to improvement in cementless stem technology or decreased use of the monoblock cementless hip arthroplasty.
Table 1. Mortality in cemented versus uncemented stem fixation of an arthroplasty
| Study ID | Time point | Mortality (cemented vs uncemented) |
| Talsnes 2013 | 12 months | Hazard ratio (HR) 0.77, 95 % CI 0.51–1.18, P = 0.233 |
| Inngul 2015 |
4 months 12 months |
4 months - Mortality rate (MR) in cemented: 4/67; MR in uncemented: 1/74, P = 0.20 12 months - MR in cemented: 7/67; MR in uncemented: 4/74, P = 0.40 |
| Chammout 2017 | 24 months | MR in cemented: 2/35; MR in uncemented: 2/34, P > 0.05 |
| Lin 2019 |
Perioperatively 1 year |
Perioperatively - Odds ratio (OR) 1.38, 95% CI 0.56–3.40; P = 0 .49 1 year - OR = 1.18, 95% CI, 0.85–1.63; P = 0.32 |
| Veldman 2017 |
1 month 1 year |
1 month - OR 1.11, 95% CI 0.17 to 7.10, P = 0.92 1 year - OR 0.82, 95% CI 0.61 to 1.09, P = 0.17 |
Revision Surgery Risk Is the Likely Driver of Mortality
Revision surgery is another important outcome to examine when comparing cemented versus uncemented fixation methods. A retrospective cohort study of 12,491 patients who underwent hemiarthroplasty for treatment of femoral neck fractures compared the cemented versus uncemented femoral stem fixation (Okike 2020). The uncemented fixation was associated with a significantly higher risk of aseptic revision. In this study, aseptic revision was defined as any reoperation performed after the index procedure, involving exchange of the existing implant for reasons other than infection. In another retrospective cohort study of 22,356 individuals, where mortality and revision rate of cemented and uncemented hemiarthroplasty after femoral neck fractures were assessed, a significant reduction in 9-year revision rate was detected in the cemented compared to the uncemented fixation group (Duijnisveld 2020).
“With the survival advantage of cement fixation over cementless fixation for preventing periprosthetic fractures, the evidence points to the use of cemented fixation for hip arthroplasty in patients with femoral neck fractures.”
Glen Richardson, M.D.,
The Journal of Arthroplasty
More Complications With Uncemented Stems
Several complications are possible with the cemented and uncemented fixation methods for treatment of femoral neck fractures. A systematic review and meta-analysis of randomized controlled trials comparing cemented versus uncemented techniques demonstrated that cemented hemiarthroplasty was superior with respect to complications related to prosthesis and revision rate (Li 2021). Another systematic review and meta-analysis of randomized controlled trials comparing cemented versus uncemented hemiarthroplasty for a displaced fracture of the femoral neck showed that uncemented stems were associated with more implant-related complications compared to cemented stems (Veldman 2017). In addition to the beforementioned meta-analyses, a multicenter randomized controlled trial compared cemented and uncemented hemiarthroplasty for displaced femoral neck fractures in 201 patients, with 1 year follow up (Moerman 2017). The uncemented group showed more major local complications such as intra- and postoperative fractures and dislocations—many requiring revision surgery.
“Uncemented hip arthroplasty is associated with more frequent mechanical complications and reoperations.”
Tero Yli-Kyyny, Acta Orthopaedica
“The use of cementless fixation for fractures of the femoral neck is initially compelling with the decreased operating room time, decreased blood loss, and reduced incidence of BCIS. However, these benefits are offset by the increased rates of periprosthetic fractures and reoperations in this fragile population.”
Glen Richardson, M.D.,
The Journal of Arthroplasty
“We do not recommend uncemented femoral stems for the treatment of elderly patients with displaced femoral neck fractures.”
Ghazi Chammout, Acta Orthopaedica
In summary, although a debate of using cemented versus uncemented fixation of an arthroplasty for femoral neck fractures persists, cemented fixation may be superior and should be considered for patients with femoral neck fractures. Nonetheless, consistent with emerging literature, we highlight the importance of tailoring stem choice based on the physiological status of the patient to minimize the risk of adverse outcomes when planning to perform hemiarthroplasty for femoral neck fractures.
Contributors
Anna Miroshnychenko HBSc, MSc
Anna completed her graduate training from the Health Research Methodology Program in the Department of Health Research Methods, Evidence, and Impact at McMaster University. She is a Data Scientist at OrthoEvidence.
Mohit Bhandari MD, PhD
Dr. Mohit Bhandari is a Professor of Surgery and University Scholar at McMaster University, Canada. He holds a Canada Research Chair in Evidence-Based Orthopaedic Surgery and serves as the Editor-in-Chief of OrthoEvidence.
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