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Debaters argue for and against primary cemented THA, cite outcomes, revision issues
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A classic debate about cemented vs. uncemented total hip arthroplasty held at the 15th EFORT Congress – a combined programme in partnership with the BOA highlighted several points of contention that are often argued about concerning these two methods of total hip arthroplasty fixation, including long-term survivorship, issues of anatomic restoration and revision and implantation, as well as thigh pain.
“With cement in such widespread use around the world in hundreds of thousands of databases per year, the question is surely not whether cement brings advantages, it is how cement brings advantages to those hip replacements,” said Jonathan R. Howell, MBBS, MSc, FRCS(T&Ortho), one of four participants in the symposium, which was moderated by John Timperley, MBChB, FRCS(Ed), DPhil(Oxon), of Exeter, United Kingdom.
Howell and Henrik Malchau, MD, PhD, spoke in favour of the motion that there are advantages to fixation of total hip arthroplasty (THA) using cement, and Michel P. Bonnin, MD, of Lyon, France, and Richard Field, PhD, FRCS, FRCS(Orth), of Carshalton, United Kingdom, argued against the use of cement to fix THA implants.
Bonnin gave 10 reasons why orthopaedic surgeons should perform cementless THA, which included the fact that hydroxyapatite on the surface of cementless THA prostheses helps facilitate bone bridging that promotes osteointegration and better implant stability.
He discussed his experience with the DePuy Synthes Corail Total Hip System, which he noted has success based on a compaction broaching concept that addresses the bioactive part of the bone.
“When we have primary stability, it is finished. It is done, but you have to respect the tips and tricks to have a good result. You must have good preoperative planning, use progressive size of the broaches, gentle compaction. You stop when it’s stable. You have to use a reamer only if you have very narrow canal,” Bonnin said.
“In the primary difficult situation, I think uncemented stems are easier to use and are better,” he said.
According to Howell, cemented THA provides better restoration of the original hip anatomy and allows for intraoperative correction of inclination of the acetabular cup and of version.
“We’ve got to restore our patients’ offset,” Howell said.
This, he noted, is essential to a patient’s gait and function, and the ability of the surgeon to restore leg length, which are areas that support improved patient satisfaction after primary THA.
“After 30 years’ experience with cemented and uncemented hip replacement, I am sure that the general public would expect our profession to have a very, very clear idea of which form of fixation is better at restoring anatomy. But, there is virtually nothing in the literature on this issue. However, what is written in the literature favours cemented fixation,” Howell said.
The health economics are also better with cemented THA due to the reported potential reduction in revision rates at 5 postoperative years, he said.
Reference:
Symposium: Cemented versus cementless hip: There are advantages to fixation using cement. Presented at: 15th EFORT Congress — a combined programme in partnership with the BOA; 4-6 June, 2014; London.
Michel P. Bonnin, MD, can be reached at Centre Orthopédique Santy, 24 Av Paul Santy, Lyon, 69008 France; email: bonnin.michel@gmail.com.
Jonathan Howell, MBBS, MSc, FRCS(T&Ortho), can be reached at Princess Elizabeth Orthopaedic Centre, Exeter, UK.
Disclosure:
Bonnin received royalties from Tornier SA and DePuy Synthes. Howell received institution and research support from Stryker and the Devon Orthopaedic Trust and he is a consultant to Stryker.