Fewer revisions found with cemented vs. uncemented hemiarthroplasty for fractures

However, researchers found higher dislocation rates for patients treated with cemented hemiarthroplasty.

Issue: June 2012

Elderly patients who underwent uncemented hemiarthroplasty for intracapsular femoral neck fractures showed a three times higher revision rate at 18 months than those who had cemented procedures, according to researchers from the United Kingdom.

Perspective from Philip F. Stahel, MD, FACS; and Cyril Mauffrey, MD, FRCS

Simon Jameson, MRCS, of Northumbria Healthcare NHS Foundation Trust in England, presented the results at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting.

“The revision rate was low in the cemented group at mid-term follow-up, and this supports evidence for the use of cemented implants in these patients,” he said.

Jameson noted that the National Institutes for Clinical Excellence in the United Kingdom produced guidelines on hip fracture management in 2011.

“The evidence for cemented hemiarthroplasty showed there was less pain at 2 years, better mobility score at 12 months, and it was more cost-effective compared to cementless implants. There were no outcomes to show any benefit of cementless [hemiarthroplasty].”

To study the complications of cemented and uncemented hemiarthroplasty, Jameson and colleagues used the Hospital Episode Statistics database to identify patients between 70 years and 90 years old with no significant comorbidities prior to fracture. The investigators matched 30,400 patients who underwent cemented hemiarthroplasty for age, gender and Charlson score with an equal number of patients who had uncemented hemiarthroplasty during the same period.

Outcome measures for the study included reoperation for infection within 30 days, dislocation at 18 months and 4 years, revision rates at 18 months and 4 years and medical complications including 30-day chest infection, stroke or myocardial infarction and 90-day pulmonary embolism (PE) rates.

The investigators found a higher revision rate at 18 months in the uncemented group compared to the cemented cohort (1.6% rate vs. 0.57%). However, they discovered a higher dislocation rate at 18 months in the cemented group (0.44% vs. 0.25%).

A subset of 22,000 patients with 4-year follow-up had similar results, with a higher dislocation rate in the cemented (0.6% vs. 0.26%) and a higher revision rate in the uncemented cohort (2.45% vs. 1.1%).

The investigators found no differences between the cemented and uncemented groups for 30-day myocardial infarctions and stroke, or 90-day PE rates. However, there was a higher rate of 30-day chest infection in the cementless group at 8.1% compared to 7.23% in the cemented group. – by Renee Blisard Buddle

Reference:

Jameson S, Jensen CD, James P, et al. Cemented versus uncemented hemiarthroplasty for intracapsular neck of femur fracture – A national analysis. Paper #760. Presented at the American Academy of Orthopaedic Surgeons 2012 Annual Meeting. Feb. 7-12. San Francisco.

For more information:

Simon Jameson, MRCS, can be reached at Northumbria Healthcare NHS Foundation Trust, Woodhorn Lane, Ashington, Northumberland, NE63 9JJ, UK; 44 844 811 8111; email: simonjameson@doctors.org.uk.
Disclosure: Jameson has no relevant financial disclosures.

Perspective

Philip F. Stahel, MD, FACS; and Cyril Mauffrey, MD, FRCS

The authors are to be commended for their excellent work, which will hopefully impact the quality of care for elderly patients with displaced femoral neck fractures and serve as a key reference for evidence-based practice in the future.

Indeed, the question of whether a hemiarthroplasty should be cemented, has been a topic of controversy and ongoing debate until present. A rising number of quality publications from prospective randomized trials have recently been published in the orthopedic literature on the same topic. The results from the present study, which is based on an encompassing national registry database from the United Kingdom, may help shed some further light on this unresolved issue. Interestingly, studies from European registries appear to confirm that cemented hemiarthroplasties should represent the standard of care for elderly patients with displaced femoral neck fractures. There is a caveat to this recommendation related to the variable use of different types of uncemented implants in those studies, which renders any retrospective analysis challenging. In fact, it is well documented that Austin Moore-type (uncoated) stems are associated with a drastically increased rate of implant failure.

This notion renders uncoated, uncemented stems a priori poor candidates for valid comparative studies against cemented stems. Therefore, any meaningful retrospective analysis from large-scale national registries must stratify for the use of coated vs. uncoated (e.g., Austin Moore) variants of uncemented hemiarthroplasties. For coated stems, the jury is still out, and long-term prospective follow-up studies are required for a final verdict.

References:

Deangelis JP, Ademi A, Staff I, Lewis CG. Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures: A prospective randomized trial with early follow-up. J Orthop Trauma. 2012; 26(3):135-140.
Taylor F, Wright M. Hemiarthroplasty or the hip with or without cement: A randomized clinical trial. J Bone Joint Surg Am. 2012; 94(7):577-583.

Philip F. Stahel, MD, FACS; and Cyril Mauffrey, MD, FRCS

Department of Orthopaedics

Denver Health Medical Center

University of Colorado, School of Medicine

Denver

Disclosures: Stahel and Mauffrey have no relevant financial disclosures.