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Uncemented femoral stems in THA patients potentially linked to elevated revision rate
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The risk and rate of revision for total hip arthroplasty were found to be higher in patients who received uncemented femoral stems compared with those who received cemented femoral stems, according to study findings.
Researchers included 437,629 patients who underwent primary total hip arthroplasty between 1995 and 2009 in the study. Of those, 325,730 had received cemented femoral stems and 111,899 had received uncemented stems. Patient data were culled from the Nordic Arthroplasty Register Association database to evaluate whether age, sex, preoperative diagnosis, fixation and implant design were influential on the risk for revision arthroplasty due to periprosthetic fracture within 2 years after primary total hip replacement.
Both cemented and uncemented femoral stems were found to have a low revision rate (0.07% and 0.47%, respectively) at 2-year follow-up. The relative risk of revision was 8.72 higher in uncemented stems vs. cemented stems, according to the researchers.
Although age did not consistently impact this risk in cemented stems, those receiving uncemented stems had an increase in revision rates as age increased. Additionally, women had a lower risk of revision than men when receiving cemented stems, whereas men exhibited a lower risk than women when receiving uncemented stems.
After adjusting for both demographic factors and fixation, patients who underwent total knee arthroplasty from 2003 to 2009 had an elevated relative risk of revision compared with those who underwent surgery from 1995 to 2002.
Disclosure: The authors have no relevant financial disclosures.
Perspective
Back to TopArthur L. Malkani, MD
This is an excellent study from the Nordic Arthroplasty Register Association database on the incidence of periprosthetic femoral fractures following primary total hip arthroplasty. The study includes a total of 437,629 hip replacements and demonstrates a low incidence of fracture. The authors highlight that uncemented femoral stems have a statistically higher incidence of periprosthetic fractures (0.47% vs. 0.07%). The authors further conclude that of the five uncemented stems analyzed, the ABG II (Stryker) stem (proximally filling) had an increased risk of fracture and of the two cemented stems evaluated the Exeter stem (Stryker) had a higher fracture risk.
This study reinforces previous literature that cementless femoral stems in elderly patients have a higher fracture incidence. It would be interesting to know from their registry if there is a difference in long-term survivorship between their cemented and cementless groups and, given the learning curve with use of cementless stems, did the fracture incidence decline over time in the uncemented group.
The authors caution that attention should be placed on type of fixation and stem design in high risk groups, namely female gender and elderly patients undergoing hip arthroplasty. The conclusion reached by the authors to exercise caution with cementless femoral stems in high-risk groups to minimize the incidence of periprosthetic hip fractures is important given the global expected increase in the numbers of hip arthroplasty procedures. Revision hip surgery for periprosthetic femur fractures especially in the elderly has a high complication rate, and this study highlights the importance of identifying and minimizing the incidence of fracture in high risk patients undergoing cementless total hip arthroplasty.
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