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

There has been an evolution in revision hip arthroplasty towards cementless reconstruction. Whilst cemented arthroplasty works well in the primary setting, the difficulty with achieving cement fixation in femoral revisions has led to a move towards removal of cement, where it was present, and the use of ingrowth components. These have included proximally loading or, more commonly, distally fixed stems. We have been through various iterations of these, notably with extensively porous coated cobalt chrome stems and recently with taper-fluted titanium stems. As a result of this, cemented stems have become much less popular in the revision setting. Allied to concerns about fixation and longevity of cemented fixation revision, there were also worries in relation to bone cement implantation syndrome when large cement loads were pressurised into the femoral canal at the time of stem cementation. This was particularly the case with longer stems. Technical measures are available to reduce that risk but the fear is nevertheless there. In spite of this direction of travel and these concerns, there is, however, still a role for cemented stems in revision hip arthroplasty. This role is indeed expanding. First and foremost, the use of cement allows for local antibiotic delivery using a variety of drugs both instilled in the cement at the time of manufacture or added by the surgeon when the cement is mixed. This has advantages when dealing with periprosthetic infection. Thus, cement can be used both as interval spacers but also for definitive fixation when dealing with periprosthetic hip infection. The reconstitution of bone stock is always attractive, particularly in younger patients or those with stove pipe canals. This is achieved well using impaction grafting with cement and is another extremely good use of cement. In the very elderly or those in whom proximal femoral resection is needed at the time of revision surgery, distal fixation with cement provides a good solution for immediate weight bearing and does not have the high a risk of fracture seen with large cementless stems. Cement is also useful in cases of proximal femoral deformity or where cement has been used in a primary arthroplasty previously. We have learnt that if the cement is well-fixed then the bond of cement-to-cement is excellent and therefore retention of the cement mantle and recementation into that previous mantle is a great advantage. This avoids the risks of cement removal and allows for much easier fixation. Stems have been designed specifically to allow this cement-in-cement technique. It can be used most readily with polished tapered stems - tap out a stem, gain access at the time of revision surgery and reinsert it. It is, however, now increasingly used when any cemented stems are removed provided that the cement mantle is well fixed. The existing mantle is either wide enough to accommodate the cement-in-cement revision or can be expanded using manual instruments or ultrasonic tools. The cement interface is then dried and a new stem cemented in place. Whilst the direction of travel in revision hip arthroplasty has been towards cementless fixation, particularly with tapered distally fixed designs, the reality is that there is still a role for cement for its properties of immediate fixation, reduced fracture risk, local antibiotic delivery, impaction grafting and cement-in-cement revision

Over 70,000 hip fractures occur annually in the UK. Both SIGN (111) and NICE (124) give guidance on optimal management of these patients. Both suggest cemented hemiarthroplasty should be used in those without contra-indications, as cemented implants are associated with less thigh pain, subsidence and a better functional outcome. Cardiorespiratory compromise secondary to bone cement implantation syndrome (BCIS) is however a concern in those with pre-existing cardiorespiratory disease (NYHA grade 3–4, pulmonary hypertension) or pathological fracture [3]. The aim of our study was to audit the practice of a University of Glasgow hospital with regard to cemented hemiarthroplasty. We retrospectively reviewed data on all patients treated with hemiarthroplasty for hip fracture at the Southern General Hospital between 01/01/12-02/04/12. Patient demographics, pre-operative plan, procedure performed, ASA grade and pre-morbid mobility were recorded. Results. Twenty-three hemiarthroplasties were performed. The median age was 82 (70–101). No patient aged over 90 underwent cemented hemiarthroplasty. Cemented implants (JRI, Furlong) were used in 26% (n=6) while 74% (n=17) underwent uncemented (Stryker, Austin-Moore) hemiarthroplasty. ASA grade was recorded in eight (35%). There were four ASA-2 patients (mild systemic disease not limiting activity) of which 75% underwent uncemented hemiarthroplasty. Pre-morbid mobility was recorded in eight (35%). All three independently mobile patients underwent uncemented hemiarthroplasty. Six (26%) had a documented pre-operative plan with regards to cement use. This study highlights the disparity between current recommendations and our Centres’ practice. Most notable were: poor recording of pre-operative mobility, poor documentation of a pre-operative surgical plan, the low use of cemented fixation even in fit mobile patients and the lack of ASA grade recording (stratification of risk) by our anaesthetic colleagues. We suggest a documented pre-operative discussion between the surgeon and anaesthetist to establish BCIS risk and decide on use of cemented arthroplasty taking into account age and mobility

Background. A well conducted randomised study found similar functional results for patients with displaced femoral neck fracture comparing operation with a modern uncemented bipolar hemiarthroplasty with a cemented bipolar hemiarthroplasty. The mortality associated with the two procedures has not been sufficiently investigated. Aim of study. To investigate the mortality and the risk factors for death among patients with displaced femoral neck fractures the first year after surgery, comparing operation with modern uncemented and cemented bipolar hemiarthroplasty (HA). Methods. 8,636 patients (65 years and older) with displaced femoral neck fractures (Garden 3 and 4) operated with a cemented (n = 6,907) or a uncemented bipolar HA (n = 1,729) were selected from the files of The Norwegian Hip Fracture Register 2005–2009. Mortality was assessed using Kaplan-Meier survival analysis and risk factors of death were investigated using Cox-regression analysis. A power analysis showed the study sample to be sufficient to detect a difference in mortality of 3% at one year postoperatively. Results. Overall mortality one year postoperatively was 27%. We found no difference in the risk of death when comparing operation with cemented with uncemented bipolar HA one year (RR = 0.97, p = 0.51), 240 days (RR = 1.00, p = 0.95), 120 days (RR = 1.04, p = 0.57), and 30 days (RR = 1.12, p = 0.23) postoperatively. However, 10 days postoperatively there was an increased risk of death for patients operated with cemented HA compared to those operated with uncemented bipolar HA (RR = 1.34, p = 0.03). High age, male gender, cognitive impairment, increasing ASA score, and delay in surgery >48 hours after injury were all associated with an increased risk of death one year postoperatively. Interpretation. The early increased risk of death for patients operated with a cemented HA might be caused by the bone cement implantation syndrome. Our results further indicate that the difference in mortality one year postoperatively is likely to be less than 3%

Aims

Cementing in arthroplasty for hip fracture is associated with improved postoperative function, but may have an increased risk of early mortality compared to uncemented fixation. Quantifying this mortality risk is important in providing safe patient care. This study investigated the association between cement use in arthroplasty and mortality at 30 days and one year in patients aged 50 years and over with hip fracture.

Aims

Our primary aim was to assess reoperation-free survival at one year after the index injury in patients aged ≥ 75 years treated with internal fixation (IF) or arthroplasty for undisplaced femoral neck fractures (uFNFs). Secondary outcomes were reoperations and mortality analyzed separately.

Aims

Isolated acetabular liner exchange with a highly crosslinked polyethylene (HXLPE) component is an option to address polyethylene wear and osteolysis following total hip arthroplasty (THA) in the presence of a well-fixed acetabular shell. The liner can be fixed either with the original locking mechanism or by being cemented within the acetabular component. Whether the method used for fixation of the HXLPE liner has any bearing on the long-term outcomes is still unclear.

The coronavirus disease 2019 (COVID-19) pandemic has led to unprecedented challenges to healthcare systems worldwide. Orthopaedic departments have adopted business continuity models and guidelines for essential and non-essential surgeries to preserve hospital resources as well as protect patients and staff. These guidelines broadly encompass reduction of ambulatory care with a move towards telemedicine, redeployment of orthopaedic surgeons/residents to the frontline battle against COVID-19, continuation of education and research through web-based means, and cancellation of non-essential elective procedures. However, if containment of COVID-19 community spread is achieved, resumption of elective orthopaedic procedures and transition plans to return to normalcy must be considered for orthopaedic departments. The COVID-19 pandemic also presents a moral dilemma to the orthopaedic surgeon considering elective procedures. What is the best treatment for our patients and how does the fear of COVID-19 influence the risk-benefit discussion during a pandemic? Surgeons must deliberate the fine balance between elective surgery for a patient’s wellbeing versus risks to the operating team and utilization of precious hospital resources. Attrition of healthcare workers or Orthopaedic surgeons from restarting elective procedures prematurely or in an unsafe manner may render us ill-equipped to handle the second wave of infections. This highlights the need to develop effective screening protocols or preoperative COVID-19 testing before elective procedures in high-risk, elderly individuals with comorbidities. Alternatively, high-risk individuals should be postponed until the risk of nosocomial COVID-19 infection is minimal. In addition, given the higher mortality and perioperative morbidity of patients with COVID-19 undergoing surgery, the decision to operate must be carefully deliberated. As we ramp-up elective services and get “back to business” as orthopaedic surgeons, we have to be constantly mindful to proceed in a cautious and calibrated fashion, delivering the best care, while maintaining utmost vigilance to prevent the resurgence of COVID-19 during this critical transition period.

Cite this article: Bone Joint Open 2020;1-6:222–228.