Aims. Cemented hemiarthroplasty is an effective form of treatment for most patients with an intracapsular fracture of the hip. However, it remains unclear whether there are subgroups of patients who may benefit from the alternative operation of a modern uncemented hemiarthroplasty – the aim of this study was to investigate this issue. Knowledge about the heterogeneity of treatment effects is important for surgeons in order to target operations towards specific subgroups who would benefit the most. Methods. We used causal forest analysis to compare subgroup- and individual-level treatment effects between cemented and modern uncemented hemiarthroplasty in patients aged > 60 years with an intracapsular fracture of the hip, using data from the World Hip Trauma Evaluation 5 (WHiTE 5) multicentre randomized clinical trial. EuroQol five-dimension index scores were used to measure health-related quality of life at one, four, and 12 months postoperatively. Results. Our analysis revealed a complex landscape of responses to the use of a cemented hemiarthroplasty in the 12 months after surgery. There was heterogeneity of effects with regard to baseline characteristics, including age, pre-injury health status, and lifestyle factors such as alcohol consumption. This heterogeneity was greater at the one-month mark than at subsequent follow-up timepoints, with particular regard to subgroups based on age. However, for all subgroups, the effect estimates for quality of life lay within the confidence intervals derived from the analysis of all patients. Conclusion. The use of a cemented hemiarthroplasty is expected to increase health-related quality of life compared with modern uncemented hemiarthroplasty for all subgroups of patients aged > 60 years with a displaced intracapsular fracture of the hip. Cite this article: Bone Joint J 2024;106-B(7):656–661

Continued controversy exists between cemented versus uncemented hemiarthroplasty for an intracapsular hip fracture. To assist in resolving this controversy, 400 patients were randomised between a cemented polished tapered stem hemiarthroplasty and an uncemented Furlong hydroxyapatite coated hemiarthroplasty. Follow-up was by a nurse blinded to the implant used for up to three years from surgery. Results indicate no difference in the pain scores between implants but a tendency to an improved regain of mobility for those treated with the cemented arthroplasty (1.2 score versus 1.7 at 6 months, p=0.03). There was no difference in early mortality but a tendency to a higher later mortality for the uncemented implants (29% versus 24% at one year, p=0.3). Later peri-prosthetic fracture was more common in the uncemented group (3% versus 1.5%). Revision arthroplasty was required for 2% of cemented cases and 3% of uncemented cases. Surgery for an uncemented hemiarthroplasty was 5 minutes shorter but these patients were more likely to need a blood transfusion (14% versus 7%). Three patients in the cemented group had a major adverse reaction to bone cement leading to their death. These results indicated that a cemented stem hemiarthroplasty give marginally improved regain of mobility in comparison to a contemporary uncemented hemiarthroplasty. An uncemented hemiarthroplasty still has a place for those considered to be at a high risk of bone cement implantation syndrome

Aim. This paper describes the methods applied to assess the cost-effectiveness of cemented versus uncemented hemiarthroplasty among hip fracture patients in the World Hip Trauma Evaluation Five (WHiTE5) trial. Methods. A within-trial cost-utility analysis (CUA) will be conducted at four months postinjury from a health system (National Health Service and personal social services) perspective. Resource use pertaining to healthcare utilization (i.e. inpatient care, physiotherapy, social care, and home adaptations), and utility measures (quality-adjusted life years) will be collected at one and four months (primary outcome endpoint) postinjury; only treatment of complications will be captured at 12 months. Sensitivity analysis will be conducted to assess the robustness of the results. Conclusion. The planned analysis strategy described here records our intent to conduct a within-trial CUA alongside the WHiTE5 trial

Introduction. The treatment of displaced femoral neck fractures in elderly patients is under debate. Hemiarthroplasty is a recognised treatment for elderly patients with reduced capacity for mobilisation. Controversy exists around cemented or uncemented implants for hemiarthroplasty in this population. The aim of this study is to investigate outcomes of cemented vs uncemented hemiarthroplasty implants to two years post operation. Methods. All elderly patients presenting to one institution with a displaced subcapital neck of femur fracture were offered inclusion. One hundred and sixty patients (mean age, 85 years) with acute displaced femoral neck fractures were randomly allocated to be treated with cemented Exeter, or uncemented Zweymüller Alloclassic Hemiarthroplasty. Clinical and radiologic follow-up to two years with the main outcome measurements being pain, mortality, mobility, complications, reoperations, and quality of life using validated scores recorded by a blinded outcome assessor. Results. Complication rates were more frequent in uncemented implants (p< 0.016). Subsidence and perioperative fracture were significantly higher with uncemented components (p< 0.05). Visual analogue pain scores at rest were not significantly different between each group. Mortality rates were not significantly different at any time point. Oxford Hip scores at 6 weeks favoured cemented implants (p< 0.05). These trends persist but are not significant at later follow-up. Mobility measured by a timed up-and-go score favoured cemented at 6 weeks (p< 0.01), 6 months (p< 0.05) and 1 year (p< 0.005). A trend towards less dependence on walking aids also favoured cemented implants. Multifunctional assessment index and Mini-mental scores were similar in each group. Conclusion. Cemented hemiarthroplasty provides a better outcome for elderly patients with a displaced femoral neck fracture when compared with uncemented hemiarthroplasty. Complication rates were significantly lower and function and pain scores were improved at multiple time points following surgery

Purpose: The appropriate means of fixation for hemiarthroplasty of the hip is a matter of ongoing debate. Proponents of uncemented components cite the risk of perioperative mortality with cement implantation as justification for avoiding cement in certain patients. Because cement-related mortality is rare, we wished to compare the incidence of perioperative mortality in patients receiving cemented versus uncemented hemiarthroplasty using a large national database. Further, we wished to compare overall revision rate between fixation methods to assess their role in implant survivorship. Method: All recorded hemiarthroplasty cases from the AOA National Joint Replacement Registry were cross-referenced to the Australian mortality data, and deaths at 1d, 7d, 28d, and one year were compared between groups. Further, subgroup analysis of monoblock, modular, and bipolar hemiarthroplasty were compared as a surrogate measure of different patient populations. Results: Comparing all hemiarthroplasty procedures as a group, there was a a significantly increased mortality rate at day one post-operatively (p = 0.0005) when cement was used. By day 7, this trend reversed, revealing a reduced mortality risk with cement (p = 0.02). This trend reversal persisted at day 28 and one year post-operatively (p = 0.028 & p < 0.0001, respectively). With subgroup analysis, monoblock hemiarthroplasty revealed a similar trend reversal in early versus late mortality. Modular and bipolar hemiarthroplasty procedures failed to reveal a significant difference in mortality when cemented and uncemented components were compared at all time points. When fixation method was compared in different age groups, a favourable mortality rate was seen at one year when cemented monoblock components were used in patients aged 71–80, and in patients ≥81 years old (p = 0.005 & < 0.001, respectively). The opposite was true with cemented modular implants at one year in patients < 70 years old (p = 0.009). There was no significant difference in mortality between cemented and uncemented implants in any other age investigated. Revision rates were significantly higher in patients treated with uncemented hemiarthroplasty regardless of prosthesis type. Conclusion: This study demonstrates a higher overall success rate, and comparable or reduced long-term mortality risk when cement is used in hip hemiarthroplasty

Background. In 2011 20% of intracapsular fractured neck of femurs were treated with an uncemented hemiarthroplasty in the English NHS. National guidelines recommend cemented implants, based on evidence of less pain, better mobility and lower costs. We aimed to compare complications following cemented and uncemented hemiarthroplasty using the national hospital episode statistics (HES) database in England. Methods. Dislocation, revision, return to theatre and medical complications were extracted for all patients with NOF fracture who underwent either cemented or uncemented hemiarthroplasty between January 2005 and December 2008. To make a ‘like for like’ comparison all 30424 patients with an uncemented impant were matched to 30424 cemented implants (from a total of 42838) in terms of age, sex and Charlson co-morbidity score. Results. In patients with an uncemented implant, 18-month revision (1.62% versus 0.57% (OR 2.90 [2.44–3.45], p< 0.001)), 4-year revision (2.45% vs 1.11% (OR 2.28 [1.45–3.65], p< 0.001)) and 30-day chest infection (8.14% versus 7.23% (OR 1.14 [1.08–1.21], p=0.028)) were significantly higher. Interestingly, 4-year dislocation rate was higher in cemented implants (0.60% versus 0.26% (OR 0.45 [0.36–0.55], p< 0.001). No significant differences were seen in 30-day return to theatre, myocardial infarction, cerebrovascular event or 90-day pulmonary embolus. Discussion. In this national analysis of matched patients short and medium term revision rate, and perioperative chest infection was significantly higher in the uncemented group. This supports the published evidence and national guidelines recommending cement fixation of hemiarthroplasty

In this study, we reviewed the records of 881 patients with fracture neck of femur over 5 years. Of these, 372 patients underwent hemiarthroplasty (231 cemented and 141 uncemented). The aim was to analyse the factors, which may contribute towards the mortality in cemented versus uncemented group. The mean age in the cemented and uncemented group was 82 and 81 years respectively. 136 (58.8%) patients were operated within 24 hours of admission in the cemented group as compared to 63 (44.6%). The mean operative time was 81minutes for cemented hemiarthroplasty and 61 minutes for uncemented hemiarthroplasty. 77% of the cemented hemiarthroplasty was performed by Registrar grade as compared to 69% in the uncemented group. Of the 231 patients in the cemented group, 52% received general and 48% received spinal anaesthesia. Of the 141 patients in the uncemented group, 30% received general and 70% received spinal anaesthesia. There was an 8% 30-day mortality compared to 11% 30-day mortality in uncemented group (p< 0.05). The mean age of patients in the mortality group was age 86 yrs in cement and 84 yrs in uncemented group. Most operations were done within 24–48 hours. There was significant co morbidity in patients who died. The average operative time of patients who died in both groups was same. There was an increased mortality rate in the uncemented group as compared to the cemented group (p< 0.05). Based on our study, we conclude that cement is not a risk factor. Duration and timing of surgery is not associated with increased mortality. There was no difference in 30-day mortality rates between patients receiving general or spinal anaesthesia. Significant co morbid factor is associated with increased mortality

The two commonest types of hemiarthroplasty used for the treatment of a displaced intracapsular fracture are the uncemented Austin Moore Prosthesis and cemented Thompson hemiarthroplasty. To determine if any difference in outcome exists between these implants we undertook a prospective randomised controlled trial of 300 patients with a displaced intracapsular hip fractures.

All operations were performed or supervised by one orthopaedic surgeon and all by a standard anterolateral approach. Patients were followed by a nurse blinded in the type of prosthesis to assess residual pain and mobility.

The average age of the patients was 83 years and 23% were male. 73% came from their own home with the remainder from institutional care. There was no statistically significant difference in mortality between groups, with 34/151 having died at one year in the cemented group and 45/149 in the uncemented group. Pain scores (grade 1-6) were less for those treated by a cemented prosthesis (mean score 1.8 versus 2.4, p value <0.00001). Mobility change was also less for those treated with a cemented implant (p=0002). No difference was found in hospital stay. Operative complications are as listed. One case of non-fatal intraoperative cardiac arrest occurred in the cemented group.

In summary a cemented Thompson Hemiarthroplasty causes less pain and less deterioration in mobility compared to uncemented Austin Moore hemiarthroplasty, without any increase in complications. The continued use of an uncemented Austin Moore cannot be recommended.

Aim: To clarify the issue of whether or not to cement the hemiarthroplasty in the treatment of displaced intra-capsular femoral neck fractures in the elderly. Method: All patients with displaced intracapsular femoral neck fractures treated with hemiarthroplasty between January 1997 and May 1998, in 2 hospitals within the same Deanery, were reviewed. The same prosthesis was used; in hospital A they were uncemented, and in B cemented. There were 121 patients in hospital A and 123 in hospital B; all patients alive at follow-up (50 and 56 respectively) were interviewed for pre-fracture and current assessments of pain and functional ability using validated scoring systems. Follow-up was 32–36 months. Results: Patient demographics were similar. Cemented procedures took 15 minutes longer. In-patient stay was the same. Signiþcantly fewer of the cemented group had been revised or were awaiting revision (p=0.036). There was no difference in mortality rates at any point. Prospective assessment of surviving patients revealed highly statistically signiþcant greater deterioration in pain (p=0.003), walking ability (p=0.002), use of walking aids (p=0.003) and activities of daily living (p=0.009) in the uncemented group. The trend for more dependent accommodation in the uncemented group failed to reach statistical signiþcance (p=0.14). Conclusions: Our þndings support the use of cemented hemiarthroplasty for displaced intracapsular femoral neck fractures in the elderly.

Two of commonest types of hemiarthroplasty used for the treatment of a displaced intracapsular fracture are the uncemented Austin Moore Prosthesis and cemented Thompson hemiarthroplasty. We performed this trial to determine if any difference in outcome exist between these implants.

We undertook a prospective randomised controlled trial of four hundred patients with a displaced intra-capsular hip fracture. All operations were performed or supervised by one orthopaedic surgeon and all by a standard anterolateral approach. Patients were followed by a nurse blinded in the type of prosthesis to assess residual pain and mobility.

The average age of the patients was eighty-three years and 23% were male. 73% came from their own home with the remainder from institutional care. There was no statistically significant difference in mortality between groups. Pain scores were less for those treated by a cemented prosthesis (p value < 0.00001). Mobility change was also less for those treated with a cemented implant (p=0002). No difference was found in hospital stay, implant related complications, re-operations or post-operative medical complications between the two groups. One case of non-fatal intraoperative cardiac arrest occurred in the cemented group.

In summary a cemented Thompson Hemiarthroplasty causes less pain and less deterioration in mobility compared to the uncemented Austin Moore hemiarthroplasty, without any increase in complications. The continued use of an uncemented Austin Moore cannot be recommended.

Introduction: Two of commonest types of hemiarthroplasty used for the treatment of a displaced intracapsular fracture are the uncemented Austin Moore Prosthesis and cemented Thompson hemiarthroplasty.

Methods: To determine if any difference in outcome exists between these implants, we undertook a prospective randomised controlled trial of 400 patients with a displaced intracapsular hip fracture. All operations were performed or supervised by one orthopaedic surgeon and all by a standard anterolateral approach. Patients were followed by a nurse blinded in the type of prosthesis to assess residual pain and mobility.

Results: The average age of the patients was 83 years and 23% were male. 73% came from their own home with the remainder from institutional care. There was no statistically significant difference in mortality between groups. Pain scores were less for those treated by a cemented prosthesis (p value < 0.00001). Mobility change was also less for those treated with a cemented implant (p=0002). No difference was found in hospital stay, implant related complications, re-operations or post-operative medical complications between the two groups. One case of non-fatal intraoperative cardiac arrest occurred in the cemented group.

Discussion: In summary a cemented Thompson Hemiarthroplasty causes less pain and less deterioration in mobility compared to the uncemented Austin Moore hemiarthroplasty, without any increase in complications. The continued use of an uncemented Austin Moore cannot be recommended.

Current evidence suggests that we should be moving away from Thompson's hemiarthroplasties for patients with intracapsular hip fractures. Furthermore, the use of cement when inserting these prostheses is controversial. This study aims to show the Inverness experience.

We performed a retrospective review of all NHS Highland patients who underwent a hemiarthroplasty for an intracapsular neck of femur fracture over the last 15 years. Demographics and the use of cement were documented. Further analysis of this group was performed to identify any of these patients who required revision of their prosthesis. Patients requiring revision had their case-notes reviewed to identify the cause for further surgery.

From 1996 until present 2221 patients from the Highland area had a hemiarthroplasty for an intracapsular neck of femur fracture. 1708 where female (77%) and 513 male (23%). The ages ranged from 28 years to 104 years (mean 80 years, median 81). 2180 of this group had their operations in Raigmore Hospital with the remaining 41 at various centres throughout Scotland. 623 (28%)had a cemented hemiarthroplasty, with the remaining 1578 (72%) having an uncemented Thompson's hemiarthroplasty. The revision rate for the cemented group was 2% (13 of 623 patients). In the uncemented group it was 0.4% (6 of 1578). Reasons from revision included dislocation, periprosthetic fracture, infection and pain.

Current evidence from some joint registers regarding the use of Thompson's hemiarthroplasty in the elderly is discouraging. The use of bone cement in this group with multiple co-morbidities is not without it's risks. Our data suggests that uncemented Thompson's hemiarthroplasties in low demand elderly patients with multiple co-morbidities can yield excellent results with less risk to the patients.

Aims: To study clinical and radiological outcome of acetabular revision in THR with porous, hydroxyapatite-coated cups.

Methods: 50 acetabular revisions (48 patients) operated by single surgeon were reviewed. Uncemented, hydroxyapatite coated cup (Mallory/Head, Biomet) was used. Preoperative acetabular bone loss graded by Paprosky’s classification (grade 1: 12, grade 2a: 26, grade 2b: 8, 2c: 2, grade 3a: 2). Acetabulum alone was revised in 22 hips. Duration of follow up: 35 months (24–52). Clinical outcome assessment was done using Merle d’Aubigne and Postel score & QALY index questionnaire. Radiological assessment by standard X-rays taken at the latest review date. No case was lost to follow up.

Results: Merle d’Aubigne & Postel scores improved from 2.1, 2.7 and 2.4 (pre-operative) to 5.0, 4.3 and 4.5 (post-operative) respectively with significant improvement in QALYs scores. Radiological assessment showed no mechanical failures. Good trabecular formation between HA-coating and the bone seen in the majority. Non-progressive radiolucency < 1mm in 6 cases, superior migration > 2 mm in 3 cups where bone graft was used, and < 2mm migration in 9 cups was noted. 2 cases had rerevision for recurrent dislocation.

Conclusions: Hydroxyapatite coating on the implant may enhance bony ongrowth at bone-implant interface giving additional stability. Good midterm results obtained in our study using hydroxyapatite-coated components favour the use of this type of cup in acetabular revisions for moderate bone loss, but a long-term follow up is essential.

Introduction: The JRI Furlong HAC LOL hemiarthroplasty stem has shown increased periprosthetic fracture rates compared to previous literature(15.2% vs 7.4%). This study will seek to identify a measurable radiographic index, the Metaphyseal-Diaphyseal Index (MDI) score to determine whether intra-operative fracture in osteoporotic bone can be predicted to influence the type of prosthesis used (cemented or uncemented).

Methodology: Over 5 years prospectively, a cohort of 560 consecutive patients undergoing hemiarthroplasty (cemented and uncemented) were evaluated. Clinical outcomes and radiographic analysis was performed. The Vancouver Classification was used to classify peri-prosthetic fracture. The MDI score was calculated using radiographs from the uncemented group. As a control (gold standard), Yeung et al’s CBR score was also calculated. From this, a receiver operating characteristic (ROC) curve was formulated for both scores and area under the curve (AUC) compared. Intra and inter-observer correlations were determined. Cost analysis was also worked out for adverse outcomes.

Results: 407 uncemented and 153 cemented stems were implanted. 62 periprosthetic fractures occurred in the uncemented group (15.2%), 9 occurred in the cemented group (5.9%), p< 0.001. The revision rate for sustaining a periprosthetic fracture (uncemented group) was 17.7%, p< 0.001. MDI’s AUC was 0.985 compared to CBR’s 0.948, p< 0.001. The MDI score cut-off to predict fracture was 21, sensitivity 98.3%, specificity 99.8%, positive predictive value 90.5% and negative predictive value 98%. ANCOVA analysis ruled out any other confounding factors as being significant. The intra and inter-observer Pearson correlation scores were r=0.99, p< 0.001. The total extra cost due to the intra-operative fractures was ú40,140.

Discussion: The MDI score has been shown to be a potentially useful, cost effective way of preventing this serious complication from occurring. We recommend that any femur scoring 21 or less on the MDI score be considered for cemented hemiarthroplasty. Level of evidence: Level 2 Diagnostic Study: Investigating a diagnostic test against gold standard.

Introduction: The JRI Furlong HAC LOL hemiarthroplasty stem has shown increased periprosthetic fracture rates compared to previous literature (15.2% vs 7.4%) [1,2,3]. This study seeks to identify a measurable radiographic index, the Metaphyseal-Diaphyseal Index (MDI) score to determine whether intra-operative fracture in osteoporotic bone can be predicted to influence the type of prosthesis used (cemented or uncemented).

Methodology: A 5 year prospective cohort of 560 consecutive patients underwent hemiarthroplasty (cemented or uncemented). A nested case-control study to determine risk factors affecting intra-operative fracture was carried out.

Clinical outcomes and radiographic analysis was performed. The Vancouver Classification was used to classify periprosthetic fracture.

The MDI score was calculated using radiographs, as a control (gold standard), Yeung’s CBR score was calculated [4]. See Figure 1. A receiver operating characteristic (ROC) curve was formulated for both and area under the curve (AUC) compared. Intra and inter-observer correlations were determined.

Cost analysis was also worked out.

Results: 407 uncemented and 153 cemented stems were implanted. The use of uncemented implants was the main risk factor for intra-operative periprosthetic fracture.

62 periprosthetic fractures occurred in the uncemented group (15.2%), 9 in the cemented group (5.9%), p< 0.001. The revision rate for sustaining a periprosthetic fracture (uncemented group) was 17.7%, p< 0.001 and 90 day mortality 19.7%, p< 0.03.

MDI’s AUC was 0.985 compared to CBR’s 0.948, p< 0.001. See Figure 2. The MDI score cut-off to predict fracture was 21, sensitivity 98.3%, specificity 99.8%, PPV 90.5%, NPV 98%. ANCOVA ruled out any other confounding factors as being significant.

The intra and inter-observer Pearson correlation scores were r=0.99, p< 0.001.

The total extra cost due to the intra-operative fractures was £93,780.

Discussion: The MDI score is a useful, cost effective way of preventing this serious complication from occurring. We recommend that any femur scoring 21 or less on the MDI score be considered for cemented hemiarthroplasty.

Level of evidence: Level 2 Diagnostic Study: Development of diagnostic criteria on basis of consecutive patients (with universally applied reference “gold” standard).

Aims. The aim of this investigation was to compare risk of infection in both cemented and uncemented hemiarthroplasty (HA) as well as in total hip arthroplasty (THA) following femoral neck fracture. Methods. Data collection was performed using the German Arthroplasty Registry (EPRD). In HA and THA following femoral neck fracture, fixation method was divided into cemented and uncemented prostheses and paired according to age, sex, BMI, and the Elixhauser Comorbidity Index using Mahalanobis distance matching. Results. Overall in 13,612 cases of intracapsular femoral neck fracture, 9,110 (66.9%) HAs and 4,502 (33.1%) THAs were analyzed. Infection rate in HA was significantly reduced in cases with use of antibiotic-loaded cement compared with uncemented fixated prosthesis (p = 0.013). In patients with THA no statistical difference between cemented and uncemented prosthesis was registered, however after one year 2.4% of infections were detected in uncemented and 2.1% in cemented THA. In the subpopulation of HA after one year, 1.9% of infections were registered in cemented and 2.8% in uncemented HA. BMI (p = 0.001) and Elixhauser Comorbidity Index (p < 0.003) were identified as risk factors of periprosthetic joint infection (PJI), while in THA cemented prosthesis also demonstrated an increased risk within the first 30 days (hazard ratio (HR) = 2.73; p = 0.010). Conclusion. The rate of infection after intracapsular femoral neck fracture was statistically significantly reduced in patients treated by antibiotic-loaded cemented HA. Particularly for patients with multiple risk factors for the development of a PJI, the usage of antibiotic-loaded bone cement seems to be a reasonable procedure for prevention of infection. Cite this article: Bone Joint Res 2023;12(5):331–338

Recent registry data from around the world has strongly suggested that using cemented hip hemiarthroplasty has lower revision rates compared to cementless hip hemiarthroplasty for acute femoral neck hip fractures. The adoption of using cemented hemiarthroplasty for hip fracture has been slow as many surgeons continue to use uncemented stems. One of the reasons is that surgeons feel more comfortable with uncemented hemiarthroplasty as they have used it routinely. The purpose of this study is to compare the difference in revision rates of cemented and cementless hemiarthroplasty and stratify the risk by surgeon experience. By using a surgeons annual volume of Total Hip Replacements performed as an indicator for surgeon experience. The Canadian Joint Replacement Registry Database was used to collect and compare the outcomes to report on the revision rates based on surgeon volume. This is a large Canadian Registry Study where 68447 patients were identified for having a hip hemiarthroplasty from 2012-2020. This is a retrospective cohort study, identifying patients that had cementless or cemented hip hemiarthroplasty. The surgeons who performed the procedures were linked to the procedure Total Hip Replacement. Individuals were categorized as experienced hip surgeons or not based on whether they performed 50 hip replacements a year. Identifying high volume surgeon (>50 cases/year) and low volume (<50 cases/year) surgeons. Hazard ratios adjusted for age and sex were performed for risk of revision over this 8-year span. A p-value <0.05 was deemed significant. For high volume surgeons, cementless fixation had a higher revision risk than cemented fixation, HR 1.29 (1.05-1.56), p=0.017. This pattern was similar for low volume surgeons, with cementless fixation having a higher revision risk than cemented fixation, HR 1.37 (1.11-1.70) p=0.004 We could not detect a difference in revision risk for cemented fixation between low volume and high volume surgeons; at 0-1.5 years the HR was 0.96 (0.72-1.28) p=0.786, and at 1.5+ years the HR was 1.61 (0.83-3.11) p=0.159. Similarly, we could not detect a difference in revision risk for cementless fixation between low volume and high volume surgeons, HR 1.11 (0.96-1.29) p=0.161. Using large registry data, cemented hip hemiarthroplasty has a significant lower revision rate than the use of cementless stems even when surgeons are stratified to high and low volume. Low volume surgeons who use uncemented prostheses have the highest rate of revision. The low volume hip surgeon who cements has a lower revision rate than the high volume cementless surgeon. The results of this study should help to guide surgeons that no matter the level of experience, using a cemented hip hemiarthroplasty for acute femoral neck fracture is the safest option. That high volume surgeons who perform cementless hemiarthroplasty are not immune to having revisions due to their technique. Increased training and education should be offered to surgeons to improve comfort when using this technique

Recent registry data from around the world has strongly suggested that using cemented hip hemiarthroplasty has lower revision rates compared to cementless hip hemiarthroplasty for acute femoral neck hip fractures. The adoption of using cemented hemiarthroplasty for hip fracture has been slow as many surgeons continue to use uncemented stems. One of the reasons is that surgeons feel more comfortable with uncemented hemiarthroplasty as they have used it routinely. The purpose of this study is to compare the difference in revision rates of cemented and cementless hemiarthroplasty and stratify the risk by surgeon experience. By using a surgeons annual volume of Total Hip Replacements performed as an indicator for surgeon experience. The Canadian Joint Replacement Registry Database was used to collect and compare the outcomes to report on the revision rates based on surgeon volume. This is a large Canadian Registry Study where 68447 patients were identified for having a hip hemiarthroplasty from 2012-2020. This is a retrospective cohort study, identifying patients that had cementless or cemented hip hemiarthroplasty. The surgeons who performed the procedures were linked to the procedure Total Hip Replacement. Individuals were categorized as experienced hip surgeons or not based on whether they performed 50 hip replacements a year. Identifying high volume surgeon (>50 cases/year) and low volume (<50 cases/year) surgeons. Hazard ratios adjusted for age and sex were performed for risk of revision over this 8-year span. A p-value <0.05 was deemed significant. For high volume surgeons, cementless fixation had a higher revision risk than cemented fixation, HR 1.29 (1.05-1.56), p=0.017. This pattern was similar for low volume surgeons, with cementless fixation having a higher revision risk than cemented fixation, HR 1.37 (1.11-1.70) p=0.004 We could not detect a difference in revision risk for cemented fixation between low volume and high volume surgeons; at 0-1.5 years the HR was 0.96 (0.72-1.28) p=0.786, and at 1.5+ years the HR was 1.61 (0.83-3.11) p=0.159. Similarly, we could not detect a difference in revision risk for cementless fixation between low volume and high volume surgeons, HR 1.11 (0.96-1.29) p=0.161. Using large registry data, cemented hip hemiarthroplasty has a significant lower revision rate than the use of cementless stems even when surgeons are stratified to high and low volume. Low volume surgeons who use uncemented prostheses have the highest rate of revision. The low volume hip surgeon who cements has a lower revision rate than the high volume cementless surgeon. The results of this study should help to guide surgeons that no matter the level of experience, using a cemented hip hemiarthroplasty for acute femoral neck fracture is the safest option. That high volume surgeons who perform cementless hemiarthroplasty are not immune to having revisions due to their technique. Increased training and education should be offered to surgeons to improve comfort when using this technique

Aim. The aim of this investigation was to compare risk of infection in both cemented and cementless hemiarthroplasty (HA) as well as total hip arthroplasty (THA) following femoral neck fracture. Methods. Data collection was performed using the German Arthroplasty Registry (EPRD) In HA and THA following femoral neck fracture fixation method was divided into cemented and cementless protheses and paired according to age, sex, body mass index (BMI), and the Elixhauser score using Mahalanobis distance matching. Results. Overall in 13,612 cases of intracapsular femoral neck fracture, with 9,110 (66.9 %) HAs and 4502 (33.1 %) THAs were analyzed. Infection rate in HA was significantly reduced in cases with use of antibiotic-loaded cement compared to cementless fixated prosthesis (p=0.013). In patients with THA no statistical difference between cemented and cementless prothesis was registered, however after one year 2.4 % of infections were detected in cementless and 2.1 % in cemented THA. In the subpopulation of HA after one year 1.9 % of infections were registered in cemented and 2.8 % in cementless HA. BMI (p=0.001) and Elixhauser-Comorbidity-Score (p<0.003) were identified as risk factors of PJI, while in THA also cemented prosthesis demonstrated within the first 30 days an increased risk (HR=2.728; p=0.010). Conclusion. The rate of infection after intracapsular femoral neck fracture was significantly reduced in patients treated by antibiotic-loaded cemented hemiarthroplasty. In particular for patients with multiple risk factors for the development of a PJI the usage of antibiotic-loaded bone cement seems to be a reasonable procedure for prevention of infection

Gram-negative prosthetic joint infections (GN-PJI) present unique challenges in management due to their distinct pathogenesis of biofilm formation on implant surfaces. To date, there are no animal models that can fully recapitulate how a biofilm is challenged in vivo in the setting of GN-PJI. The purpose of this study is to establish a clinically representative GN-PJI in vivo model that can reliably depict biofilm formation on titanium implant surface. We hypothesized that the biofilm formation on the implant surface would affect the ability of the implant to be osseointegrated. The model was developed using a 3D-printed, medical-grade titanium (Ti-6Al-4V), monoblock, cementless hemiarthroplasty hip implant. This implant was used to replace the femoral head of a Sprague-Dawley rat using a posterior surgical approach. To induce PJI, two bioluminescent Pseudomonas aeruginosa (PA) strains were utilized: a reference strain (PA14-lux) and a mutant strain that is defective in biofilm formation (DflgK-lux). PJI development and biofilm formation was quantitatively assessed in vivo using the in vivo imaging system (IVIS), and in vitro using the viable colony count of the bacterial load on implant surface. Magnetic Resonance Imaging (MRI) was acquired to assess the involvement of periprosthetic tissue in vivo, and the field emission scanning electron microscopy (FE-SEM) of the explanted implants was used to visualize the biofilm formation at the bone-implant interface. The implant stability, as an outcome, was directly assessed by quantifying the osseointegration using microCT scans of the extracted femurs with retained implants in vitro, and indirectly assessed by identifying the gait pattern changes using DigiGaitTM system in vivo. A localized prosthetic infection was reliably established within the hip joint and was followed by IVIS in real-time. There was a quantitative and qualitative difference in the bacterial load and biofilm formation between PA14 and DflgK. This difference in the ability to persist in the model between the two strains was reflected on the gait pattern and implant osseointegration. We developed a novel uncemented hip hemiarthroplasty GN-PJI rat model. This model is clinically representative since animals can bear weight on the implant. PJI was detected by various modalities. In addition, biofilm formation correlated with implant function and stability. In conclusion, the proposed in vivo GN-PJI model will allow for more reliable testing of novel biofilm-targeting therapetics