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

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

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.

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.

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

Introduction. Cemented hemiarthroplasty for neck of femur fractures has been advocated over uncemented hemiarthroplasty due to better post-operative recovery and patient satisfaction. However, studies have shown adverse effects of bone cement on the cardio-respiratory system which may lead to higher morbidity and mortality. Therefore, in some institutes, the use of an uncemented prosthesis has been adopted for patients with a high number of co-morbidities. The aim was to compare early mortality rates for cemented vs. uncemented hemiarthroplasties. Method. Cohort study of displaced intracapsular hip fractures treated with hemiarthroplasty between 1999–2009 at one institute. A total of 3094 hemiarthroplasties performed; out of which 1002(32.4%) were cemented and 2092(67.6%) were uncemented. 48hour and 30day mortality rates for the two groups were compared and a multivariate Cox regression model used to eliminate confounding factors. Significant confounding factor included age, sex, mini mental test score, medical co-morbidities, Nottingham Hip Fracture Score and delay to surgery. Results. The study showed that, after eliminating confounding factors, 48hour mortality in the cemented group was 0.3% compared to 0.5% in the uncemented group (p=0.388). However, the adjusted 30day mortality rate for the cemented group (4%) was shown to be significantly lower than for the uncemented group (10.8%) (p< 0.001). Conclusion. The use of cement in hip hemiarthroplasty is not associated with an increased rate of mortality at 48hours or at 30days. Along with emerging evidence of better post-op recovery and patient satisfaction with the use of a cemented prosthesis, we support the use of cement for all patients undergoing hip hemiarthroplasty

A retrospective review was conducted of patients undergoing either total hip replacement or hemiarthroplasty for intra-capsular neck of femur fractures between April 2013 and April 2014; identified from entries into the National Hip Fracture Database. PACS and the electronic database encompassing operation notes and discharge summaries were reviewed. 309 patients were identified, 3 of whom fractured both hips during the study period giving a total of 312 operations. The age range was 46 to 102 with a mean age of 82. 59 cemented bipolar hemiarthroplasties, 143 cemented unipolar hemiarthroplasties, 2 uncemented hemiarthroplasties and 108 total hip replacements were performed. 10 patients required further operations. There have been 5 dislocations: 2 underwent MUA only, 2 treated by excision arthroplasty and 1 converted to THR. 1 patient developed a haematoma requiring wound washout. There were 4 wound infections - 1 treated by a washout, 2 by excision arthroplasty and one patient has undergone first stage revision; an overall reoperation rate of 3.2% comparing well with data published elsewhere

Introduction. Proximal humeral fracture occurs most frequently in elderly and usually unite within 12 weeks. Malunion is more common than nonunion. And even if nonunion occurs, we usually treat it by the blade plate. Norris et al. reported hemiarthroplasty is indicated for severe degenerative changes of the articular surface, osteonecrosis of the humeral head, or osteopenia severe enough to jeopardize fixation in order patients. Therefore, it is not common that hemiarthroplasty is used for primary treatment of the proximal humeral pseudoarthrosis. We report a case of proximal humerus pseudoarthrosis which was treated by hemiarthroplasty. Case. A patients is 75 years old male. He was injured by falling from ladder. He was diagnosed proximal humeral fracture Neer type2. After he was followed conservatively for one year, he was referred to our hospital. In X-ray film and CT, the humeral head was scraped by the humeral shaft that was tucked inward to humeral head.(Figure 1) In MRI, rotator cuff muscles were left. The fatty infiltration was stage 1 in the Gourtallier classification. (Figure 2)And osteoarthritis of shoulder was not so severe. Therefore, we decided to do hemiarthroplasty. We used the SMR implant (Lima Corporate, Milano, Italy). Surgical reconstruction was done using a deltpectral approach. Lesser tuberosity was cut from greater tuberosity with subscaplaris muscle. We used the cementless stem. Each fragments and stem was fixed using FiberWire (Arthrex, Florida USA), after autograft which scraped from the reseceted humeral head was stuffed. After the operation, the shoulder was fixed by brace for 4weeks. The passive ROM exercise was started from 21 days later. The Active ROM exercise was started at 28 days later. Three months later, the pseudoarthrosis united successfully. (Figure 3) The active flexion was improved from 20 degrees to 110 degrees. The active abduction was from 20 degrees to 90 degrees. USLA score was improved from 10 to 26. Discussion. In this case, the pseudoarthrosis is united successfully. Therefore, the cementless hemiarthroplasty is useful for treatment for the proximal humerus pseudoarthrosis with severe humeral head bone defect

Displaced fractures of the neck of femur are routinely treated in the elderly by either cemented hemiarthoplasty, in the fit, or uncemented hemiarthroplasty, in the less fit. In Scotland the Scottish Intercollegiate Guidelines Network (SIGN) guidelines are followed to identify which patients should have a cemented prosthesis. This is based on cardiovascular status, and the age and fragility of the patient. An uncemented prosthesis should be a final operation. A peri-prosthetic fracture is considered a failure of treatment as the patient then has to undergo an operation with a far greater surgical insult. We looked at all neck of femur fractures over a period of Jan 2007 to June 2010. The number of the peri-prosthetic fractures for uncemented hip hemiarthroplasties was established and a case note review was carried out. There was 1397 neck of femur fractures. 546 hemiarthroplasties were carried out, of which 183 were cemented, and 363 uncemented. 14 patients (4% of uncemented hemiarthoplasties) had peri-prosthetic fractures. The case notes of these patients were analysed. We found there was a common link of significant cardiovascular risk, lack of falls assessment (only 14% of patients had a completed falls assessment and 35% sustained their fracture during an admission to hospital) and confusion (43% had a degree of dementia that caused significant confusion). Cemented implants should be considered in those who have failed falls assessment, or are confused; even if the cardiovascular risk is significant. This decision should be made in conjunction with a senior anaesthetist. This is being implemented in our unit and a prospective audit is being carried out over the same time period (July 2010 to Dec 2013) to assess the benefit

Introduction. The Oxford Total Meniscal Knee (TMK by Biomet), is a total knee replacement with a multidirectional mobile bearing. As part of the evaluation of the TMK we compared our group of TMK knee replacements with an equivalent cohort of AGC total knee replacements. Methods. Patients recruited to AGC trial from 1994 to 2001. 254 AGC knee replacements sequentially recruited in 210 patients. Patients recruited to TMK trial from 2001 to 2007. 221 TMK knee replacements sequentially recruited in 193 patients. Patients prospectively randomised to having uncemented HA coated (HAC) or cemented versions in both groups. Each patient was reviewed pre-operatively, at 6 weeks, 6 months, 1 year and then annually. All AGC & TMK TKR's were assessed clinically using HSS scores and radiographically. TMK group also assessed using AKSS and OKQ scores. Results. AGC; 254 TKR (118 cemented, 136 HAC) Mean Age 67.5 (47–75yrs). Follow up 7–14 years (Mean 9.2yrs). 4 revisions TMK; 221 TKR (106 cemented, 115 HAC) Mean Age 67 (47–75yrs). Follow up 4–10 years (Mean 6.2 yrs). 8 revisions and 2 bearing exchanges. 4 revisions were for aseptic loosening, 1 for unexplained pain, 1 for bearing fracture and 2 for infection. 6 revisions in HAC group. No significant differences in functional outcome scores between cemented and HAC in TMK or AGC groups. HSS scores in the TMK group were lower than in the AGC group (82 vs 85, p = 0.007 2 tailed unequal variance t test). Discussion. The TMK appears to have a higher revision rate that the AGC with shorter follow-up. This particularly affects the HAC group. Although Functional outcome scores for the TMK are good they are still lower than the AGC. We aim to continue to follow up the TMK knee replacement to assess its survival