Should all patients aged 75 years or older receive cemented femoral components for primary THA?
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Cemented components for older patients
Since the advent of the modern THA in the 1960s, it has been a life-changing surgical procedure with overwhelmingly successful results.
However, certain complications such as prosthetic joint infection and periprosthetic fracture are devastating and, in some cases, deadly. Cementless femoral fixation has had overwhelming success in the United States in the past few decades, with 4.6% of all elective primary THAs reported to the American Joint Replacement Registry (AJRR) having been performed with cemented femoral fixation in 2022. This transition from cement for nearly all elective THA patients in the U.S. has likely increased OR efficiency and decreased the already minuscule risk of bone cement implantation syndrome, but at what cost?
Postmenopausal women are at increased risk for sustaining osteoporotic fractures, and factors such as age, cognitive status and general health interact to magnify this risk. A 20-year study of more than 14,000 primary THAs found female gender was associated with increased risk for postoperative periprosthetic fracture, with cemented femoral fixation lowering this risk by as much as 30%. A recent AJRR study of approximately 280,000 patients older than 65 years undergoing primary THA reinforced these findings, showing that cementless femoral stems, age older than 80 years and female sex increased the risk of periprosthetic fracture. Revision for periprosthetic fracture after THA has been shown to have higher mortality rates than revision THA for other reasons, with one study reporting up to 60% mortality at 5 years in certain patients and recommending discussion of the risk of death when counseling patients before this procedure.
The current evidence supports that older patients undergoing primary THA benefit from cemented femoral fixation to decrease their risk for periprosthetic fracture and death. Furhermore, older patients with the additional risk factors of female sex, decreased cognitive status and difficulty with balance or overall physical function stand to benefit the most from cemented femoral fixation. Admittedly, cementless femoral stem design may play a role in periprosthetic fracture risk, and more research should be done to investigate variations between stem types. Nevertheless, after considering the increased risks of periprosthetic fracture in older patients, combined with the protective effects of cemented femoral fixation and the low risk of bone cement implantation syndrome, I recommend that all patients older than 75 years, especially women, receive a cemented femoral component for a primary THA.
- References:
- American Joint Replacement Registry (AJRR): 2023 Annual Report. https://www.aaos.org/registries/publications/ajrr-annual-report/. Published November 2023. Accessed Feb. 19, 2024.
- Barron RL, et al. Osteoporos Int. 2020;doi:10.1007/s00198-020-05294-3.
- Carli AV, et al. Bone Joint J. 2017;doi:10.1302/0301-620X.99B1.BJJ-2016-0220.R1.
- Kelly M, et al. J Arthroplasty. 2023;doi:10.1016/j.arth.2023.04.039.
- Khan T, et al. Bone Joint J. 2020;doi:10.1302/0301-620X.102B12.BJJ-2020-0367.R1.
- Singh JA, et al. J Arthroplasty. 2013;doi:10.1016/j.arth.2012.03.010.
Anna Cohen-Rosenblum, MD, MSc, is an associate professor in the department of orthopaedic surgery at LSU Health New Orleans in New Orleans.
Many factors to consider
Not all patients older than 75 years need a cemented femur in primary THA, nor should they get one. Many factors must be considered when selecting implants for primary THA. Registry studies have shown increased fracture risk with cementless femoral stems in patients who have arthroplasty for femoral neck fracture. However, Mallory C. Moore, BS, and colleagues studied matched cohorts of patients who underwent cemented vs. cementless elective THA and found higher rates of infection, aseptic revision and aseptic loosening in the cemented group but no difference in periprosthetic fracture. There are differences in THA for fracture and THA for arthritis. THA for arthritis is elective surgery, thus, we have an opportunity to optimize modifiable risk factors. Patient age, gender or race are not modifiable, but there are other factors such as nutrition, activity level and medications, among others, that can be optimized to improve bone quality and decrease fracture and complication risk with uncemented implants. We should not rely on cement to fill in cracks when we can prevent the cracks from forming in the first place.
Cement is not a one-size-fits-all approach. Stem design, surgical approach and surgeon technique play a significant role in fracture risk and outcomes of THA. A review of the AJRR found differences in fracture risk based on stem geometry and the presence of a collar in uncemented femoral stems. Patients have variable bone geometry, and we should be intentional about matching the right stem with the right patient, with or without cement. There are also patient phenotypes that may make exposure challenging in anterior vs. posterior approach, which can influence fracture risk. Just as we should not abandon cement fixation as a tool that can help decrease fracture risk, we should not abandon posterior approach, which may be safer for patients with poor bone quality. Finally, surgeon technique is critical in achieving long-term success with cemented stems. While surgeons in training should seek opportunities to learn good cement techniques, those more comfortable with press-fit techniques should be enabled to use the tools they have when appropriate.
There is certainly a role for cement fixation in THA. However, cement should not be used to fill in the gaps for patients who have not been fully optimized. Nor should it be used as a one-size-fits-all approach that detracts from critically selecting the appropriate implant, approach and technique.
- References:
- Kelly M, et al. Clin Orthop Relat Res. 2024;doi:10.1097/CORR.0000000000002985.
- Moore MC, et al. J Arthroplasty. 2023;10.1016/j.arth.2023.12.024.
Elizabeth G. Lieberman, MD, FAAOS, is from Orthopedic and Fracture Specialists in Portland.
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