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TraumaFurther Opinion

More re-operations after uncemented than cemented hemiarthroplasty used in the treatment of displaced fractures of the femoral neck

J-E. Gjertsen, S. A. Lie, T. Vinje, L. B. Engesæter, G. Hallan, K. Matre, O. Furnes

J Bone Joint Surg [Br] 2012;94-B:1113-19

 

Whether to use a press-fit or cemented femoral stem is a controversial topic.  Surgeons in favouring press-fit femoral stems cite lower intraoperative mortality, shorter operative times, and potential for better long-term survival.1,2  Those that prefer cemented stems rely on equivalent one-year mortality rates, quicker return to function, less thigh pain, and potential for antibiotic cement.3  This study provides support for cemented hemiarthroplasties’ early superiority over press-fit stems, and further illustrates the need to have long-term studies comparing modern uncemented and cemented femoral stems.

The study utilized the Norwegian Hip Fracture Registry to identify 11,116 hemiarthroplasties that were performed between January 1, 2005 and January 1, 2011 on patients 70 years or older.  Patients that received unipolar hemiarthroplasties or that received cement that was not impregnated with antibiotics were excluded.  The prostheses were followed for 0-6 years, with a mean follow-up of 1.4 years.

The authors found that uncemented hemiarthroplasties have a 2.1 times increased risk of reoperation.  The most common reoperation for both uncemented and cemented prostheses was drainage of haematoma or infection.

Intraoperative fracture was the most frequently reported complication for uncemented hemiarthroplaties, and much more common than in the cemented group.  However, intraoperative death, severe cardiac and respiratory problems were more prevalent in the cemented hemiarthroplasties group.  The one-year mortality was nearly identical at 26.5% and 25.6% for patients that received uncemented and cemented hemiarthroplasties respectively.

The main strength of the study is it size.  11,116 is a lot of patients.  Their primary weakness is the length of follow-up.  Proponents of uncemented hemiarthroplasties will argue that one of the benefits of press-fit prostheses is their good long-term survival.4  However, many of the studies showing long-term survival in press-fit prosthesis are in younger patients that were having hip replacements for avascular necrosis4 or degenerative joint disease.2  Elderly, fragility fracture patients have thinner bone that puts them at risk for periprosthetic fractures.

Although this study provides evidence for surgeons that prefer to cement their femoral stems, it is difficult to know if it will slow the growing trend of the use of press fit hemiarthroplasties.  A large study following modern uncemented and cemented hemiarthroplasties with long-term follow-up is needed to put this question to rest.

References

1. Azegami S, Gurusamy KS, Parker MJ. Cemented versus uncemented hemiarthroplasty for hip fractures: a systematic review of randomised controlled trials. Hip Int 2011;21:509-17.
2. Corten K, Bourne RB, Charron KD, Au K, Rorabeck CH. Comparison of total hip arthroplasty performed with and without cement: a randomized trial: a concise follow-up, at twenty years, of previous reports. J Bone Joint Surg [Am] 2011;20-A:1335-8.
3. Parker MI, Pryor G, Gurusamy K. Cemented versus uncemented hemiarthroplasty for intracapsular hip fractures: a randomised controlled trial in 400 patients. J Bone Joint Surg [Br] 2010;92-B:116-22.
4. Kim YH, Kim JS, Park JW, Joo JH. Contemporary total hip arthroplasty with and without cement in patients with osteonecrosis of the femoral head: a concise follow-up, at an average of seventeen years, of a previous report. J Bone Joint Surg [Am] 2011;93-A:1806-10.

 

Dr Sean Burns MD, Orthopedic Trauma Fellow, Denver Health Medical Center

Dr Cyril Mauffrey MD, FRCS, Assistant Professor in Orthopedics, Director of Orthopedic Research, Denver Health Medical Center.

Email: Cyril.mauffrey@dhha.org