Cemented versus cementless hemiarthroplasty for a displaced fracture of the femoral neck: a systematic review and meta-analysis of current generation hip stems

Traumaplasty: When and How to Perform Acute Arthroplasty for Fractures Around the Hip in the Elderly Patient

Acute fractures around the hip are prevalent injuries associated with potentially devastating outcomes. The growing utilization of arthroplasty for femoral neck fractures in the elderly is likely a result of improvements in reoperation rates and postoperative function. Compared to hemiarthroplasty, total hip arthroplasty is associated with a slight functional benefit that is unlikely noticeable for many patients, as well as minimal differences in complications and patient reported outcome measures. However, the evidence supporting cement use in femoral stem fixation is robust. Multiple high power randomized controlled trial-based studies indicate cement fixation brings more predictable outcomes and fewer reoperations. In the setting of acute acetabular fracture, total hip arthroplasty is a favorable approach for elderly patients and fracture patterns associated with increased risk of revision after open reduction and internal fixation. Variations in patient characteristics and fracture patterns demand careful consideration whenever selecting the optimal treatment. In fracture patient populations, comanagement is an important consideration when seeking to reduce complications and promote cost-effective quality care.

Comparative assessment of bone cement implantation syndrome in cemented bipolar hemiarthroplasty: impact in patients with and without preexisting heart disease

Background

With the increasing incidence of hip fractures in older adults, hip replacement with a cemented femoral stem has become a viable treatment option. However, concerns regarding potential complications, particularly bone cement implantation syndrome (BCIS), especially in patients with preexisting medical conditions, have prompted orthopedic surgeons to explore alternative approaches.

Objective

The research question of this retrospective study is whether BCIS incidence in patients with preexisting heart disease undergoing cemented bipolar hemiarthroplasty is higher than that of patients without preexisting heart disease.

Methods

We retrospectively analyzed data from 311 patients undergoing cemented bipolar hemiarthroplasty, including 188 without preexisting heart disease and 123 with heart disease. Anesthetic records were reviewed to assess parameters related to BCIS. BCIS severity was graded systematically, emphasizing key metrics, such as hypotension, arterial desaturation, and the loss of consciousness.

Results

Among the patients, no perioperative deaths occurred. Grade 1 BCIS was observed in 13 patients (4.18 %), without instances of grade 2 or 3. Notably, grade 1 BCIS was observed in only 2 patients with preexisting heart disease (1.63%) and 11 patients (5.85%) without preexisting heart disease.

Conclusion

BCIS incidence after cemented bipolar hemiarthroplasty was minimal, with a predominantly low severity. Importantly, preexisting heart disease did not pose a significant increase in the risk of BCIS. This finding confirms the safety of cemented bipolar hemiarthroplasty in older adults.

Level of Evidence

III.

Cemented Versus Cementless Femoral Fixation for Total Hip Arthroplasty Following Femoral Neck Fracture in Patients Aged 65 and Older

BACKGROUND

Femoral neck fractures are common in individuals over 65, necessitating quick mobilization for the best outcomes. There's ongoing debate about the optimal femoral component fixation method in total hip arthroplasty (THA) for these fractures. Recent U.S. data shows a preference for cementless techniques in over 93% of primary THAs. Nonetheless, cemented fixation might offer advantages like fewer revisions, reduced periprosthetic fractures, lesser thigh pain, and enhanced long-term implant survival for those above 65. This study compares cementless and cemented fixation methods in THA, focusing on postoperative complications in patients aged 65 and older.

METHODS

We analyzed a national database to identify patients aged 65+ who underwent primary THA for femoral neck fractures between 2016 and 2021, using either cementless (n = 2,842) or cemented (n = 1,124) techniques. A 1:1 propensity-matched analysis was conducted to balance variables such as age, sex, and comorbidities, resulting in two equally sized groups (n = 1,124 each). We evaluated outcomes like infection, venous thromboembolism (VTE), wound issues, dislocation, periprosthetic fracture, etc., at 90 days, 1 year, and 2 years post-surgery. A P-value < 05 indicated statistical significance.

RESULTS

The cemented group initially consisted of older individuals, more females, and higher comorbidity rates. Both groups had similar infection and wound complication rates, and aseptic loosening. The cemented group, however, had lower periprosthetic fracture rates (2.5 versus 4.4%, P = .02) and higher VTE rates (2.9 versus 1.2%, P = .01) at 90 days. After 1 and 2 years, the cementless group experienced more aseptic revision surgeries.

CONCLUSIONS

This study, using a large, national database and propensity-matched cohorts, indicates that cemented femoral component fixation in THA leads to fewer periprosthetic fractures and aseptic revisions, but a higher VTE risk. Fixation type choice should consider various factors, including age, sex, comorbidities, bone quality, and surgical expertise. This data can inform surgeons in their decision-making process.

Cemented Versus Uncemented Hemiarthroplasty for Displaced Intracapsular Neck of Femur Fractures in the Elderly: Outcomes and Costings

Background

Hemiarthroplasty (HA) is a common form of treatment for displaced neck of femur fractures. There is ongoing debate as to whether cemented or uncemented HA is a more superior treatment modality. The aim of this study was to compare the outcomes between patients that underwent cemented HA to uncemented HA. Secondarily, we analysed the costs associated of each treatment option.

Methods

This was a retrospective study conducted at a busy district general hospital. The study included 335 patients that were treated with either a cemented or uncemented HA for a displaced neck of femur fracture between January 2017 and December 2018. Data collected included age, sex, American Society of Anesthesiologist (ASA) score, treatment modality, length of stay (LOS) and general costs.

Results

197 (58.8%) of the cohort underwent cemented HA and 138 (41.2%) underwent uncemented HA. Mean age for the cemented cohort was 84.7 years and 85.9 years in the uncemented group (p = 0.31). There was no significant differences between the groups with regard to mean LOS and discharge disposition (p = 0.44). There were no significant difference in 30-day and 1-year mortality between the two groups (p = 0.2). We did find a statistically significant difference in the costings between the two procedures, with cemented HAs costing £66 more than uncemented HAs (p < 0.001).

Conclusion

We found that both cemented and uncemented HAs produced comparable results. We found a statistically significant reduction in operative time and costs associated with uncemented HA. Uncemented HA implants may be considered where a shorter operation duration is essential.

Osteoporotic Patients Undergoing Total Hip Arthroplasty Have a Similar 5-Year Cumulative Incidence Rate of Periprosthetic Fracture Regardless of Cemented Versus Cementless Femoral Stem Fixation

BACKGROUND

In osteoporotic patients, surgeons may utilize cemented femoral fixation to minimize risk of fracture. The purpose of this study was to compare 5-year implant survivability in patients who have osteoporosis who underwent elective total hip arthroplasty (THA) with cementless versus cemented fixation.

METHODS

A retrospective analysis of patients who have osteoporosis undergoing THA with either cemented or cementless femoral fixation was conducted using a national administrative claims database. Of the 18,431 identified THA patients who have osteoporosis, 15,867 (86.1%) underwent cementless fixation. The primary outcome was a comparison of the 5-year cumulative incidences of aseptic revision, mechanical loosening, and periprosthetic fracture (PPF). Kaplan-Meier and Multivariable Cox Proportional Hazard Ratio analyses were used, controlling for femoral fixation method, age, sex, a comorbidity scale, use of osteoporosis medication, and important comorbidity.

RESULTS

There was no difference in aseptic revision (Hazard's Ratio (HR): 1.13; 95% Confidence Interval (CI): 0.79 to 1.62; P value: .500) and PPF (HR: 0.96; 95% CI: 0.64 to 1.44; P value: .858) within 5 years of THA between fixation cohorts. However, patients who had cemented fixation were more likely to suffer mechanical loosening with 5 years post-THA (HR: 1.79; 95% CI: 1.17 to 2.71; P-value: .007).

CONCLUSIONS

We found a similar 5-year rate of PPF when comparing patients who underwent cementless versus cemented femoral fixation for elective THA regardless of preoperative diagnosis of osteoporosis. While existing registry data support the use of cemented fixation in elderly patients, a more thorough understanding of the interplay between age, osteoporosis, and implant design is needed to delineate in whom cemented fixation is most warranted for PPF prevention.

What Are the Mortality, Infection, and Nonunion Rates After Periprosthetic Femoral Fractures in the United States?

BACKGROUND

Periprosthetic femoral fractures are a serious complication that put a high burden on patients. However, comprehensive analyses of their incidence, mortality, and complication rates based on large-registry data are scarce.

QUESTIONS/PURPOSES

In this large-database study, we asked: (1) What is the incidence of periprosthetic femoral fractures in patients 65 years and older in the United States? (2) What are the rates of mortality, infection, and nonunion, and what factors are associated with these outcomes?

METHODS

In this retrospective, comparative, large-database study, periprosthetic femoral fractures occurring between January 1, 2010, and December 31, 2019, were identified from Medicare physician service records encompassing services rendered in medical offices, clinics, hospitals, emergency departments, skilled nursing facilities, and other healthcare institutions from approximately 2.5 million enrollees. These were grouped into proximal, distal, and shaft fractures after TKA and THA. We calculated the incidence of periprosthetic femur fractures by year. Incidence rate ratios (IRR) were calculated by dividing the incidence in 2019 by the incidence in 2010. The Kaplan-Meier method with Fine and Gray subdistribution adaptation was used to calculate the cumulative incidence rates of mortality, infection, and nonunion. Semiparametric Cox regression was applied with 23 measures as covariates to determine factors associated with these outcomes.

RESULTS

From 2010 to 2019, the incidence of periprosthetic femoral fractures increased steeply (TKA for distal fractures: IRR 3.3 [95% CI 1 to 9]; p = 0.02; THA for proximal fractures: IRR 2.3 [95% CI 1 to 4]; p = 0.01). One-year mortality rates were 23% (95% CI 18% to 28%) for distal fractures treated with THA, 21% (95% CI 19% to 24%) for proximal fractures treated with THA, 22% (95% CI 19% to 26%) for shaft fractures treated with THA, 21% (95% CI 18% to 25%) for distal fractures treated with TKA , 22% (95% CI 17% to 28%) for proximal fractures treated with TKA, and 24% (95% CI 19% to 29%) for shaft fractures treated with TKA. The 5-year mortality rate was 63% (95% CI 54% to 70%) for distal fractures treated with THA, 57% (95% CI 54% to 62%) for proximal fractures treated with THA, 58% (95% CI 52% to 63%) for shaft fractures treated with THA, 57% (95% CI 52% to 62%) for distal fractures treated with TKA , 57% (95% CI 49% to 65%) for proximal fractures treated with TKA, and 57% (95% CI 49% to 64%) for shaft fractures treated with TKA. Age older than 75 years, male sex, chronic obstructive pulmonary disease (HR 1.48 [95% CI 1.32 to 1.67] after THA and HR 1.45 [95% CI 1.20 to 1.74] after TKA), cerebrovascular disease after THA, chronic kidney disease (HR 1.28 [95% CI 1.12 to 1.46] after THA and HR 1.50 [95% CI 1.24 to 1.82] after TKA), diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis were clinical risk factors for an increased risk of mortality. Within the first 2 years, fracture-related infections occurred in 5% (95% CI 4% to 7%) of patients who had distal fractures treated with THA, 5% [95% CI 5% to 6%]) of patients who had proximal fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had shaft fractures treated with THA, 6% (95% CI 5% to 7%) of patients who had distal fractures treated with TKA , 7% (95% CI 5% to 9%) of patients who had proximal fractures treated with TKA, and 6% (95% CI 4% to 8%) of patients who had shaft fractures treated with TKA. Nonunion or malunion occurred in 3% (95% CI 2% to 4%) of patients with distal fractures treated with THA, 1% (95% CI 1% to 2%) of patients who had proximal fractures treated with THA, 2% (95% CI 1% to 3%) of patients who had shaft fractures treated with THA, 4% (95% CI 3% to 5%) of those who had distal fractures treated with TKA, , 2% (95% CI 1% to 4%) of those who had proximal fractures treated with TKA, and 3% (95% CI 2% to 4%) of those who had shaft fractures treated with TKA.

CONCLUSION

An increasing number of periprosthetic fractures were observed during the investigated period. At 1 and 5 years after periprosthetic femur fracture, there was a substantial death rate in patients with Medicare. Conditions including cerebrovascular illness, chronic kidney disease, diabetes mellitus, morbid obesity, osteoporosis, and rheumatoid arthritis are among the risk factors for increased mortality. After the surgical care of periprosthetic femur fractures, the rates of fracture-related infection and nonunion were high, resulting in a serious risk to affected patients. Patient well-being can be enhanced by an interdisciplinary team in geriatric traumatology and should be improved to lower the risk of postoperative death. Additionally, it is important to ensure that surgical measures to prevent fracture-related infections are followed diligently. Furthermore, there is a need to continue improving implants and surgical techniques to avoid often-fatal complications such as fracture-associated infections and nonunion, which should be addressed in further studies.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Bipolar hip arthroplasty using conjoined tendon preserving posterior lateral approach in treatment of displaced femoral neck fractures

BACKGROUND

Hip fractures account for 23.8% of all fractures in patients over the age of 75 years. More than half of these patients are older than 80 years. Bipolar hemiarthroplasty (BHA) was established as an effective management option for these patients. Various approaches can be used for the BHA procedure. However, there is a high risk of postoperative dislocation. The conjoined tendon-preserving posterior (CPP) lateral approach was introduced to reduce postoperative dislocation rates.

AIM

To evaluate the effectiveness and safety of the CPP lateral approach for BHA in elderly patients.

METHODS

We retrospectively analyzed medical data from 80 patients with displaced femoral neck fractures who underwent BHA. The patients were followed up for at least 1 year. Among the 80 patients, 57 (71.3%) were female. The time to operation averaged 2.3 d (range: 1-5 d). The mean age was 80.5 years (range: 67-90 years), and the mean body mass index was 24.9 kg/m2 (range: 17-36 kg/m2). According to the Garden classification, 42.5% of patients were type Ⅲ and 57.5% of patients were type Ⅳ. Uncemented bipolar hip prostheses were used for all patients. Torn conjoined tendons, dislocations, and adverse complications during and after surgery were recorded.

RESULTS

The mean postoperative follow-up time was 15.3 months (range: 12-18 months). The average surgery time was 52 min (range: 40-70 min) with an average blood loss of 120 mL (range: 80-320 mL). The transfusion rate was 10% (8 of 80 patients). The gemellus inferior was torn in 4 patients (5%), while it was difficult to identify in 2 patients (2.5%) during surgery. The posterior capsule was punctured by the fractured femoral neck in 3 patients, but the conjoined tendon and the piriformis tendon remained intact. No patients had stem varus greater than 3 degrees or femoral fracture. There were no patients with stem subsidence more than 5 mm at the last follow-up. No postoperative dislocations were observed throughout the follow-up period. No significance was found between preoperative and postoperative mean Health Service System scores (87.30 ± 2.98 vs 86.10 ± 6.10, t = 1.89, P = 0.063).

CONCLUSION

The CPP lateral approach can effectively reduce the incidence of postoperative dislocation without increasing perioperative complications. For surgeons familiar with the posterior lateral approach, there is no need for additional surgical instruments, and it does not increase surgical difficulty.

Aseptic revisions and pulmonary embolism after surgical treatment of femoral neck fractures with cemented and cementless hemiarthroplasty in Germany: an analysis from the German Arthroplasty Registry (EPRD)

BACKGROUND

Femoral neck fractures (FNF) are among the most common fractures in Germany and are often treated by hemiarthroplasty (HA). The aim of this study was to compare the occurrence of aseptic revisions after cemented and uncemented HA for the treatment of FNF. Secondly, the rate of pulmonary embolism was investigated.

METHODS

Data collection for this study was performed using the German Arthroplasty Registry (EPRD). HAs after FNF were divided into subgroups stratified by stem fixation (cemented vs uncemented) and paired according to age, sex, BMI, and the Elixhauser score using Mahalanobis distance matching.

RESULTS

Examination of 18,180 matched cases showed a significantly increased rate of aseptic revisions in uncemented HA (p < 0.0001). After 1 month 2.5% of HAs with uncemented stems required an aseptic revision, while 1.5% were reported in cemented HA. After 1 and 3 years' follow-up 3.9% and 4.5% of uncemented HA and 2.2% and 2.5% of cemented HA needed aseptic revision surgery. In particular, the proportion of periprosthetic fractures was increased in cementless implanted HA (p < 0.0001). During in-patient stays, pulmonary emboli occurred more frequently after cemented HA [0.81% vs 0.53% in cementless HA (OR: 1.53; p = 0.057)].

CONCLUSION

For uncemented hemiarthroplasties a statistically significantly increased rate of aseptic revisions and periprosthetic fractures was evident within a time period of 5 years after implantation. During the in-hospital stay, patients with cemented HA experienced an increased rate of pulmonary embolism, but without statistically significant results. Based on the present results, with knowledge of prevention measurements and correct cementation technique, cemented HA should be preferred when using HA in the treatment of femoral neck fractures.

TRAIL REGISTRATION

The study design of the German Arthroplasty Registry was approved by the University of Kiel (ID: D 473/11).

LEVEL OF EVIDENCE

Level III, Prognostic.

[Aseptic revisions and pulmonary embolism after surgical treatment of femoral neck fractures with cemented and cementless hemiarthroplasty in Germany : An analysis from the Germany Arthroplasty Registry (EPRD)]

BACKGROUND

Femoral neck fractures (FNF) are among the most common fractures in Germany and are often treated by hemiarthroplasty (HA). The aim of this study was to compare the occurrence of aseptic revisions after cemented and uncemented HA for the treatment of FNF. Secondly, the rate of pulmonary embolism was investigated.

METHODS

Data collection for this study was performed using the German Arthroplasty Registry (EPRD). HAs after FNF were divided into subgroups stratified by stem fixation (cemented vs uncemented) and paired according to age, sex, BMI, and the Elixhauser score using Mahalanobis distance matching.

RESULTS

Examination of 18,180 matched cases showed a significantly increased rate of aseptic revisions in uncemented HA (p < 0.0001). After 1 month 2.5% of HAs with uncemented stems required an aseptic revision, whereas 1.5% were reported in cemented HA. After 1 and 3 years' follow-up 3.9% and 4.5% of uncemented HA and 2.2% and 2.5% of cemented HA needed aseptic revision surgery. In particular, the proportion of periprosthetic fractures was increased in cementless implanted HA (p < 0.0001). During in-patient stays, pulmonary emboli occurred more frequently after cemented HA (0.81% vs 0.53% in cementless HA [OR: 1.53; p = 0.057]).

CONCLUSION

For uncemented hemiarthroplasties a statistically significantly increased rate of aseptic revisions and periprosthetic fractures was evident within a time period of 5 years after implantation. During the in-hospital stay, patients with cemented HA experienced an increased rate of pulmonary embolism compared with patients with cementless HA, but this difference was not statistically significant. Based on the present results, with knowledge of prevention measures and the correct cementation technique, the use of cemented HA should be preferred in the treatment of femoral neck fractures.

Femoral shaft fractures in eldery patients - An epidemiological risk analysis of incidence, mortality and complications

OBJECTIVES

This work aimed at answering the following research questions: (1) What is the incidence of femoral shaft fractures in the geriatric population in the U.S.? (2) What is the rate of mortality, mechanical complications, nonunion and infection, and what are the associated risk factors?

STUDY DESIGN AND SETTING

In this cross-sectional study, femoral shaft fractures occurred between January 1, 2009, and December 31, 2019, were identified from Medicare records. Rates of mortality, nonunion, infection, and mechanical complications were calculated with the Kaplan-Meier method with Fine and Gray sub-distribution adaptation. Semiparametric Cox regression was applied with twenty-three covariates to determine risk factors.

RESULTS

Between 2009 through 2019 the incidence of femoral shaft fractures decreased by 12.07% to 40.8/100,000 inhabitants (p = 0.549). The 5-year mortality risk was 58.5%. Male sex, age over 75 years, chronic obstructive pulmonary disease, cerebrovascular disease, chronic kidney disease, congestive heart failure, diabetes mellitus, osteoporosis, tobacco dependence, and lower median household income were significant risk factors. The infection rate was 2.22% [95%CI: 1.90-2.58] and the union failure rate 2.52% [95%CI: 2.17-2.92] after 24 months.

CONCLUSION

An early assessment of individual patient risk factors may be beneficial in the care and treatment of patients with these fractures.

The Comparison between Cemented and Uncemented Hemiarthroplasty in Patients with Femoral Neck Fractures: A Systematic Review and Meta-analysis of Randomized Controlled Trials

BACKGROUND

Hemiarthroplasty is the standard treatment for patients with femoral neck fractures (FNFs). Controversy exists over the use of bone cement in hip fractures treated with hemiarthroplasty.

OBJECTIVE

We performed an updated systematic review and meta-analysis to compare cemented and uncemented hemiarthroplasty in patients with femoral neck fractures.

METHODS

A literature review was conducted using Cochrane Library, ScienceDirect, PubMed, Embase, Medline, Web of Science, CNKI, VIP, Wang Fang, and Sino Med databases. Studies comparing cemented with uncemented hemiarthroplasty for FNFs in elderly patients up to June 2022 were included. Data were extracted, meta-analyzed, and pooled as risk ratios (RRs) and weighted mean differences (WMDs) with a 95% confidence interval (95% CI).

RESULTS

Twenty-four RCTs involving 3471 patients (1749 cement; 1722 uncemented) were analyzed. Patients with cemented intervention had better outcomes regarding hip function, pain, and complications. Significant differences were found in terms of HHS at 6 weeks (WMD 12.5; 95% CI 6.0-17.0; P < 0.001), 3 months (WMD 3.3; 95% CI 1.6-5.0; P < 0.001), 4 months (WMD 7.3; 95% CI 3.4-11.2; P < 0.001), and 6 months (WMD 4.6; 95% CI 3.3-5.8; P < 0.001) postoperatively. Patients with cemented hemiarthroplasty had lower rates of pain (RR 0.59; 95% CI 0.39-0.9; P = 0.013), prosthetic fracture (RR 0.24; 95% CI 0.16-0.38; P < 0.001), subsidence/loosening (RR 0.29; 95% CI 0.11-0.78; P = 0.014), revisions (RR 0.59; 95% CI 0.40-0.89; P = 0.012), and pressure ulcers (RR 0.43; 95% CI 0.23-0.82; P = 0.01) at the expense of longer surgery time (WMD 7.87; 95% CI 5.71-10.02; P < 0.001).

CONCLUSION

This meta-analysis demonstrated that patients with cemented hemiarthroplasty had better results in hip function and pain relief and lower complication rates at the expense of prolonged surgery time. Cemented hemiarthroplasty is recommended based on our findings.

Cemented vs Uncemented hemiarthroplasties for femoral neck fractures: An overlapping systematic review and evidence appraisal

BACKGROUND

The purpose of our study is to assess the methodology of overlapping systematic reviews related to cemented vs uncemented hip hemiarthroplasties for the treatment of femoral neck fractures to find the study with the best evidence. Also, we assess the gaps in methodology and information to help with direction of future studies.

METHODS

A systematic search was conducted in September 2022 using Pubmed, Embase, and Cochrane Library. Clinical outcome data and characteristics of each study were extracted to see which treatment had better favorability. The outcomes and characteristics extracted from each study includes, first author, search date, publication journal and date, number of studies included, databases, level of evidence, software used, subgroup analyses that were conducted, and heterogeneity with the use of I2 statistics Methodological quality information was extracted from each study using four different methodologic scores (Oxford Levels of Evidence; Assessment of Multiple Systematic Reviews (AMSTAR); Quality of reporting of meta-analyses (QUROM); Oxman and Guyatt. After that, the Jadad decision algorithm was used to identify which studies in our sample contained the best available evidence. Finally, overlap of each systematic review was assessed using Corrected Covered Area (CCA) to look at redundancy and research waste among the systematic reviews published on the topic.

RESULTS

After screening, 12 studies were included in our sample. For the Oxford Levels of Evidence, we found that all the studies were Level I evidence. For the QUORUM assessment, we had 1 study with the highest score of 18. Additionally, we did the Oxman and Guyatt assessment, where we found 4 studies with a maximum score of 6. Finally, we did an AMSTAR assessment and found 2 studies with a score of 9. After conducting the methodological scores; the authors determined that Li. L et al 2021 had the highest quality. In addition, it was found that the CCA found among the primary studies in each systematic review calculated to .22. Any CCA above .15 is considered "very high overlap".

CONCLUSIONS

The best available evidence suggests that Cemented HAs are better at preventing Prosthesis-related complications. Conversely, the best evidence also suggests that Cemented HA also results in longer operative time and increased intraoperative blood loss. When conducting future systematic reviews related to the topic, we ask that authors restrict conducting another systematic review until new evidence emerges so as not to confuse the clinical decision-making of physicians.

A systematic review and meta-analysis of cemented and uncemented bipolar hemiarthroplasty for the treatment of femoral neck fractures in elderly patients over 60 years old

Background

Currently, whether bone cement can be applied in bipolar hemiarthroplasty to treat femoral neck fractures (FNFs) in elderly patients is controversial. The aim of this systematic review and meta-analysis was to compare the effectiveness and safety of cemented bipolar hemiarthroplasty (CBH) versus uncemented bipolar hemiarthroplasty (UCBH) in the treatment of FNFs among elderly patients over 60 years old.

Materials and methods

The Pubmed, Web of science, Cochrane Library and EMBASE databases were searched comprehensively for relevant articles from their inception to May 2022. Studies about comparing outcomes between CBH and UCBH for FNFs in elderly patients aged more than 60 years were included. Outcomes including operation time, intra-operative blood loss, length of hospital stay, wound infections, residual pain, revisions, re-operations, complications related to prosthesis, general complications, and mortality. The Review Manager 5.3 software provided by the Cochrane Collaboration Network was used to perform the meta-analysis of comparable data.

Results

A total of 6 randomized controlled trials (RCTs) and 9 observational studies were included in this analysis, with 33,118 patients (33,127 hips). Results of the meta-analysis indicated that the operation time [WMD = 13.01 min, 95% CI (10.79, 15.23)], intra-operative blood loss [WMD = 80.57 ml, 95% CI (61.14, 99.99)], incidence of heterotrophic ossification [OR = 2.07, 95% CI (1,14, 3.78)], were increased in the CBH group but the incidence of intra-operative fractures [OR = 0.24, 95% CI (0.07, 0.86)], periprosthetic fractures [OR = 0.24, 95% CI (0.18, 0.31)], aseptic loosening of prosthesis [OR = 0.20, 95% CI (0.09, 0.44)], wound infections [OR = 0.80, 95% CI (0.68, 0.95)] and re-operation rates [OR = 0.61, 95% CI (0.54, 0.68)] were lower in the CBH group by comparison with the UCHB group. However, there were no significant differences in residual pain, length of hospital stay, prosthetic dislocation, prosthetic subsidence (> 5 mm), acetabulum erosion, revisions, pulmonary infections, pulmonary embolisms, urinary tract infections, deep venous thromboses, decubitus, cardiovascular accidents (arrhythmia/myocardial infarction), and respiratory failure between the two groups. In terms of mortality, perioperative mortality (within 72 h) [OR = 2.39, 95% CI (1.71, 3.32)] and 1-week mortality postoperatively [OR = 1.22, 95% CI (1.05, 1.41)] in CBH group were higher than those in UCBH group, but there were no significant differences in mortality at 1 month, 3 months, 1 year, and 2 years postoperatively between CBH group and UCBH group.

Conclusion

This meta-analysis found that elderly patients over 60 years old with FNFs who underwent CBH had longer operation time, higher incidence of heterotrophic ossification, intra-operative blood loss, and mortality within 72 h of operation and at 1-week postoperatively, but lower incidence of periprosthetic fractures, aseptic loosening of prosthesis, intra-operative fractures, wound infections and re-operations. Other outcomes were not significantly different between the two groups.

Systematic review registration

https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42021274253.

Salvage hip replacement after cut-out failure of cephalomedullary nail fixation for proximal femur fractures: a case series describing the technique and results

BACKGROUND

Cut-out failure following proximal femoral fracture fixation is a compromising complication warranting surgical treatment. We describe 24 patients with cut-out failure after cephalomedullary nail fixation managed with salvage hip replacement.

METHODS

Twenty-four consecutive patients who had sustained a proximal femoral fracture from December 2009 to December 2019, were managed with cephalomedullary nail fixation and experienced a cut-out failure were reviewed retrospectively. Data on demographics, comorbidities, injury characteristics, treatment, and post-operative course were analysed.

RESULTS

Among 2802 proximal femoral fractures assessed, 28 fixations failed due to cut-out, with 24/28 patients subsequently undergoing salvage hip replacement. Intertrochanteric fractures (66.7%) managed with short nails predominated (79.2%). The median tip-to-apex distance (TAD) was 19 mm, but only two fractures had a good quality of reduction. Inverse correlations were identified between patient age and the time from fixation to cut-out (r =  - 0.57; p = 0.02), and between the time of nailing to failure among patients with a greater TAD (r =  - 0.43; p = 0.04). Most patients were managed via cemented hemiarthroplasty (66.7%). Surgical time was longer for total hip replacements (175.4 vs. 136.8 min; p < 0.01), but no bleeding or blood transfusion requirement differences were found. Two patients had orthopaedic complications, and three patients died within the first follow-up year.

CONCLUSION

In our series, 1% of the proximal femoral fractures managed with a cephalomedullary nail failed due to cut-out. Salvage hip replacement appeared to be a relatively safe and reliable procedure for managing this challenging complication in patients who typically are elderly and physically frail.

Application of machine learning model to predict lacunar cerebral infarction in elderly patients with femoral neck fracture before surgery

BACKGROUND

Femoral neck fracture and lacunar cerebral infarction (LCI) are the most common diseases in the elderly. When LCI patients undergo a series of traumas such as surgery, their postoperative recovery results are often poor. Moreover, few studies have explored the relationship between LCI and femoral neck fracture in the elderly. Therefore, this study will develop a ML (machine learning)-based model to predict LCI before surgery in elderly patients with a femoral neck fracture.

METHODS

Professional medical staff retrospectively collected the data of 161 patients with unilateral femoral neck fracture who underwent surgery in the Second Affiliated Hospital of Wenzhou Medical University database from January 1, 2015, to January 1, 2020. Patients were divided into two groups based on LCI (diagnosis based on cranial CT image): the LCI group and the non-LCI group. Preoperative clinical characteristics and preoperative laboratory data were collected for all patients. Features were selected by univariate and multivariate logistic regression analysis, with age, white blood cell (WBC), prealbumin, aspartate aminotransferase (AST), total protein, globulin, serum creatinine (Scr), blood urea nitrogen (Bun)/Scr, lactate dehydrogenase (LDH), serum sodium and fibrinogen as the features of the ML model. Five machine learning algorithms, Logistic regression (LR), Gradient Boosting Machine (GBM), Extreme Gradient Boosting (XGBoost), Random Forest (RF), and Decision tree (DT), were used in combination with preoperative clinical characteristics and laboratory data to establish a predictive model of LCI in patients with a femoral neck fracture. Furthermore, indices like the area under the receiver operating characteristic (AUROC), sensitivity, specificity, and accuracy were calculated to test the models' performance.

RESULTS

The AUROC of 5 ML models ranged from 0.76 to 0.95. It turned out that the RF model demonstrated the highest performance in predicting LCI for femoral neck fracture patients before surgery, whose AUROC was 0.95, sensitivity 1.00, specificity 0.81, and accuracy 0.90 in validation sets. Furthermore, the top 4 high-ranking variables in the RF model were prealbumin, fibrinogen, globulin and Scr, in descending order of importance.

CONCLUSION

In this study, 5 ML models were developed and validated for patients with femoral neck fracture to predict preoperative LCI. RF model provides an excellent predictive value with an AUROC of 0.95. Clinicians can better conduct multidisciplinary perioperative management for patients with femoral neck fractures through this model and accelerate the postoperative recovery of patients.

The Influence of a Modified 3rd Generation Cementation Technique and Vaccum Mixing of Bone Cement on the Bone Cement Implantation Syndrome (BCIS) in Geriatric Patients with Cemented Hemiarthroplasty for Femoral Neck Fractures

Background and Objectives: Cemented hemi arthroplasty is a common and effective procedure performed to treat femoral neck fractures in elderly patients. The bone cement implantation syndrome (BCIS) is a severe and potentially fatal complication which can be associated with the implantation of a hip prosthesis. The aim of this study was to investigate the influence of a modified cementing technique on the incidence of BCIS. Material and Methods: The clinical data of patients which were treated with a cemented hip arthroplasty after the introduction of the modified 3rd generation cementing technique were compared with a matched group of patients who were treated with a 2nd generation cementing technique. The anesthesia charts for all patients were reviewed for the relevant parameters before, during and after cementation. Each patient was classified as having no BCIS (grade 0) or BCIS grade 1,2, or 3 depending on the severity of hypotension, hypoxia loss of consciousness. Results: A total of 92 patients with complete data sets could be included in the study. The mean age was 83 years. 43 patients (Group A) were treated with a 2nd and 49 patients (Group B) with a 3rd generation cementing technique. The incidence of BCIS grade 1,2, and 3 was significantly higher (p = 0,036) in group A (n = 25; 58%) compared to group B (n = 17; 35%). Early mortality was higher in group A (n = 4) compared to group B (n = 0). Conclusions: BCIS is a potentially severe complication with a significant impact on early mortality following cemented hemiarthroplasty of the hip for the treatment of proximal femur fracture. Using a modified 3rd generation cementing technique, it is possible to significantly reduce the incidence of BCIS and its associated mortality.

Comparing Outcomes in Cemented and Press-Fit Hemiarthroplasty

INTRODUCTION

Arthroplasty has become the standard of care for displaced femoral neck fractures in the geriatric cohort. However, details regarding optimal implant design and fixation strategy continue to be debated. We sought to determine whether cemented or press-fit hemiarthroplasties were more advantageous in terms of revision surgery, contralateral hip fractures, hospital length of stay, mortality rates, and survival.

METHODS

All geriatric fragility hip fractures at a level 1 trauma center (2014 to 2019) were retrospectively reviewed for the fracture pattern, fixation methodology, and outcome, yielding 707 femoral neck fractures treated with hemiarthroplasty (309 cemented and 398 press fit). The final follow-up was either date of death or final encounter. Major end points were revision surgery, contralateral fracture, and death. A Z-score test of two proportions was used for dichotomous variables, and a two-tailed t -test was used for continuous variables. Cox proportional hazard was used for revision surgery-free survival between groups, adjusting for age, sex, and American Society of Anesthesiologists status.

RESULTS

Patients who underwent press-fit hemiarthroplasty had a significantly higher rate of revision surgery (7.8% vs 3.9%; P = 0.006). Press-fit cases had a trend toward a decreased risk of contralateral fracture (13% vs 9.8%; P = 0.12), although this did not reach significance. Both groups had similar length of stay ( P = 0.08) and death rates ( P = 0.39). Of those who died, there was a trend toward longer survival in patients who received a press-fit hemiarthroplasty (413 vs 615 days; P < 0.001). There was a trend toward longer survival without repeat surgery in the cemented group without reaching significance (hazard ratio, 0.66 [0.34 to 1.23]; P = 0.201).

CONCLUSION

In this study, we found a markedly longer survival time after press-fit hemiarthroplasty, which we believe reflects surgeons' tendencies to cement the femoral prosthesis in patients with more comorbidities. However, press-fit hemiarthroplasties were more likely to result in repeat procedures on the same hip. Displaced geriatric femoral neck fractures may benefit from a cemented rather than press-fit hemiarthroplasty.

A Systematic Review and Meta-Analysis of Non-database Comparative Studies on Cemented Versus Uncemented Femoral Stems in Primary Elective Total Hip Arthroplasty

BACKGROUND

Cemented and uncemented femoral stems have shown excellent survivorship and outcomes in primary total hip arthroplasty (THA). Cementless stems have become increasingly common in the United States; however, multiple large database studies have suggested that elderly patients may have fewer complications with a cemented stem. As conclusions from large databases may be limited due to variations in data collection, this study investigated femoral stem survivorship and complication rates based on cement status in non-database studies.

METHODS

Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines were utilized to identify articles for inclusion up until June 2021. Included articles directly compared outcomes and complications between patients undergoing primary THA without femoral stem cementing to those with cementing. Studies were excluded if they utilized large databases or consisted of patients with a preoperative diagnosis of trauma.

RESULTS

Of the 1700 studies, 309 were selected for abstract review and nineteen for full-text review. A total of seven studies were selected. Meta-analyses indicated substantial heterogeneity between studies. There were no differences in revision rates (cementless: 5.53% vs. cemented 8.91%, P = .543), infection rates (cementless: 0.60% vs. cemented: 0.90%, P = .692), or periprosthetic fracture rates (cementless: 0.52% vs. cemented: 0.51%, P = .973) between groups.

CONCLUSION

There is scarce literature comparing outcomes and complications between cemented and cementless femoral stems in primary elective THA without utilizing a database methodology. In our study, there were no differences in complications detected on meta-analyses. Given previous findings in database studies, additional high-quality cohort studies are required to determine if selected patients may benefit from a cemented femoral stem.

Complications and survival of conversion to total hip arthroplasty after failed primary osteosynthesis compared to primary total hip arthroplasty in femoral neck fractures

INTRODUCTION

Surgical treatment options for patients with an intracapsular fracture of the femoral neck (FFN) are primary osteosynthesis as a femoral head-spearing technique or primary (hemi)arthroplasty. The most common complications after primary osteosynthesis, such as avascular necrosis (AVN) or non-union, can result in conversion to Total Hip Arthroplasty (cTHA). Data concerning complications and survival rates of cTHA in comparison to primary Total Hip Arthroplasty (pTHA) after FFN are limited due to the absence of well-designed studies.

METHODS

A multicentre retrospective cohort study was conducted in three Dutch hospitals comparing the rate of postoperative dislocations, periprosthetic fractures, prosthetic joint infections, blood loss during surgery (>1000 mL), postoperative cardiac- and pulmonary complications after pTHA and cTHA in the first year after surgery. As a secondary outcome implant survival of pTHA and cTHA in terms of revision rates was evaluated.

RESULTS

In total 548 patients were included (pTHA n = 264 and cTHA n = 284) with a mean follow-up of 5 years (±3.5 SD). No significant differences were found in postoperative complications rates. The revision rate in the pTHA group was 7.2% in comparison to 7.7% in the cTHA group (p = 0.81). No difference in the short-term implant survival was found between both groups (p = 0.81).

CONCLUSION

This study showed no significant differences in terms of postoperative complication rates in the first year after pTHA and cTHA in patients with FFN. Also, no significant difference in short-term implant survival of primary and conversion total hip arthroplasty was found.

The effects of full weight-bearing mobilization on clinical outcomes and subsidence in cemented and uncemented hemiarthroplasty in osteoporotic patients: A retrospective single-center study

BACKGROUND

Early full weight-bearing mobilization is controversial in osteoporotic patients who have undergone uncemented hemiarthroplasty (UCH).

OBJECTIVES

The aim of the study was to compare the results of early full weight-bearing mobilization in CH and uncemented hemiarthroplasty (UCH). The effect of subsidence on the results was also evaluated.

METHODS

Fifty-nine patients who underwent CH and UCH were evaluated. The mean age was 79.8 years (10 females, 15 males) for CH and 75.5 years (10 females, 24 males) for UCH. All patients started immediate full weight-bearing mobilization and weight-bearing exercises.

RESULTS

There was no difference between the groups according to the Harris Hip Score. Both groups were evaluated in subgroups according to whether there is varus in the femoral stem. There was no difference between subgroups according to the Harris Hip Score. The femoral subsidence was not determined in CH group. In the UCH group, the subsidence was 1.13 ± 1.03 mm in varus femoral stem subgroup and 0.81 ± 0.85 mm in without femoral stem varus subgroup. There was no difference in subsidence between femoral stem with varus and without varus. The subsidence did not affect the Harris Hip Score.

CONCLUSION

Full weight-bearing mobilization could be safely preferred in UCH, as in CH. Femoral stem varus below 5 degrees does not affect the results and subsidence.

Are We Training Surgeons to Cement a Femoral Component in Hip Arthroplasty? The Trainees' Perspective

BACKGROUND

The importance of surgical technique is widely recognized when cementing a femoral component in hip arthroplasty. Concern exists that surgeon trainees in the United States are not being adequately trained in cement technique. The purpose of this study is to describe recent trainees' perceived experience with their training in this skill.

METHODS

Orthopedic graduate candidates attending a national board review course were polled with an anonymous 15-question survey regarding their experiences during training with cemented femoral components. Means and standard deviations were calculated for Likert scale questions, and univariate statistics were used to compare answers for select questions.

RESULTS

A total of 152 surveys were completed. Ninety percent of respondents anticipated that they would be performing hemiarthroplasty for fracture in their future practice, 99% of whom anticipated using cement for stem fixation in at least some of these cases. Only a minority of respondents planned further training in an adult reconstruction fellowship (21%). Only 37% of residents perceived their training in cement technique to be comprehensive or very comprehensive, with 17% reporting that their training was inadequate or nonexistent. Forty percent reported being less than satisfied with their training. Although 96% of residents felt prepared to implant a cementless femoral component, only 82% felt adequately trained to properly cement a femoral implant. Feeling prepared to perform a well done cemented femoral stem correlated with higher percentage of cemented stems in training and higher satisfaction with training (both P = .001).

CONCLUSION

Although most trainees feel prepared to cement a femoral component, many young surgeons do not perceive that they are receiving adequate training in femoral cement technique.

Mortality associated with cemented and uncemented fixation of hemiarthroplasty and total hip replacement in the surgical management of intracapsular hip fractures: A systematic review and meta-analysis

BACKGROUND

The use of bone cement for implant fixation in the surgical management of intracapsular hip fractures (IHFs) remains controversial. Although UK national guidance supports cementation, many surgeons remain cautious of its use. In this systematic review and meta-analysis, we aimed to evaluate evidence surrounding post-operative mortality associated with cemented and uncemented total hip replacement and hemiarthroplasty implants.

METHODS

We conducted a search of MEDLINE and Embase databases for randomised controlled trials (RCTs) from commencement until 17 June 2020. Articles reporting mortality or patient survival as an outcome following total hip replacement (THR) or hemiarthroplasty (HA) to manage IHFs were included. Articles not comparing cemented and uncemented fixation were excluded. A meta-analysis on mortality stratified by post-operative follow-up period was conducted using a fixed-effects model. The Revised Cochrane risk-of-bias tool for randomized trials was used to assess risk of bias.

RESULTS

Our initial search found 77 references, 13 of which were eligible for full-text review. Mortality data from 12 studies were pooled and included in the meta-analysis. 1 599 operations were reported: 882 involved cemented fixation; 717, uncemented. Mortality outcome reporting ranged from less than 7 days to 5 years post-operation. No significant difference was observed between the two groups in mortality at any follow-up period. Study quality assessment revealed low certainty in mortality estimates.

CONCLUSION

Existing evidence indicates that cementation has no effect on mortality at any reported follow-up time period. Even with the use of evidence synthesis, the sample size remains relatively low for mortality outcomes and insufficiently powered to reliably determine differences between groups.

Revisiting Cemented Femoral Fixation in Hip Arthroplasty

➤

The primary means of femoral fixation in North America is cementless, and its use is increasing worldwide, despite registry data and recent studies showing a higher risk of periprosthetic fracture and early revision in elderly patients managed with such fixation than in those who have cemented femoral fixation.

➤

Cemented femoral stems have excellent long-term outcomes and a continued role, particularly in elderly patients.

➤

Contrary to historical concerns, recent studies have not shown an increased risk of death with cemented femoral fixation.

➤

The choice of femoral fixation method should be determined by the patient's age, comorbidities, and bone quality.

➤

We recommend considering cemented femoral fixation in patients who are >70 years old (particularly women), in those with Dorr type-C bone or a history of osteoporosis or fragility fractures, or when intraoperative broach stability cannot be obtained.

Cemented or Uncemented Hemiarthroplasty for Intracapsular Hip Fracture

BACKGROUND

Controversy exists over the use of bone cement in hip fractures treated with hemiarthroplasty. Only limited data on quality of life after cemented as compared with modern uncemented hemiarthroplasties are available.

METHODS

We conducted a multicenter, randomized, controlled trial comparing cemented with uncemented hemiarthroplasty in patients 60 years of age or older with an intracapsular hip fracture. The primary outcome was health-related quality of life measured with the use of utility scores on the EuroQol Group 5-Dimension (EQ-5D) questionnaire at 4 months after randomization (range of scores, -0.594 to 1, with higher scores indicating better quality of life; range for minimal clinically important difference, 0.050 to 0.075).

RESULTS

A total of 610 patients were assigned to undergo cemented hemiarthroplasty and 615 to undergo modern uncemented hemiarthroplasty; follow-up data were available for 71.6% of the patients at 4 months. The mean EQ-5D utility score was 0.371 in patients assigned to the cemented group and 0.315 in those assigned to the uncemented group (adjusted difference, 0.055; 95% confidence interval [CI], 0.009 to 0.101; P = 0.02). The between-group difference at 1 month was similar to that at 4 months, but the difference at 12 months was smaller than that at 4 months. Mortality at 12 months was 23.9% in the cemented group and 27.8% in the uncemented group (odds ratio for death, 0.80; 95% CI, 0.62 to 1.05). Periprosthetic fractures occurred in 0.5% and 2.1% of the patients in the respective groups (odds ratio [uncemented vs. cemented], 4.37; 95% CI, 1.19 to 24.00). The incidences of other complications were similar in the two groups.

CONCLUSIONS

Among patients 60 years of age or older with an intracapsular hip fracture, cemented hemiarthroplasty resulted in a modestly but significantly better quality of life and a lower risk of periprosthetic fracture than uncemented hemiarthroplasty. (Funded by the National Institute for Health Research; WHiTE 5 ISRCTN number, ISRCTN18393176.).

Does the Risk of Death Within 48 Hours of Hip Hemiarthroplasty Differ Between Patients Treated with Cemented and Cementless Implants? A Meta-analysis of Large, National Registries

BACKGROUND

Although current recommendations suggest that hip hemiarthroplasties performed for femoral neck fractures be implanted with bone cement, it is known to cause cardiorespiratory and hemodynamic reactions that in some patients can be fatal. Older patients may be at particular risk of this complication, but because of its relative infrequency, large studies-perhaps even larger than can be achieved in the context of single-country national registries-are needed to get reasonably precise estimates as to its frequency. Pooling results from national registries reporting on death within 48 hours of cement exposure in this setting may therefore be helpful.

QUESTION/PURPOSE

In a systematic review of studies based on large national registries, we asked: Does the risk of death within 48 hours of hip hemiarthroplasty differ between patients treated with cemented and cementless implants?

METHODS

MEDLINE and Embase data sources were searched for cohort studies on patients with hip fractures treated with cement or cementless hip hemiprostheses based on results from national registries that tracked perioperative deaths within 48 hours of surgery, from 2010 or later (to include only studies that used contemporary cement techniques). We excluded registry research on elective THAs for other indications (such as degenerative joint disease), mixed populations (registries that combined patients having arthroplasty for fracture and for other diagnoses like osteoarthritis, such that we could not separate them), and overlapping data from the same registers (to avoid double and triple publications of similar data). Five studies met our inclusion criteria. The cohorts ranged from about 11,000 to about 25,000 patients. About 31% of the patients were in the cementless group. Two studies reported the age ranges of participating patients, and three studies communicated mean ages (which were 82 years for both sexes). Twice as many females as males were present in both the cemented and cementless group. When reported, more than 50% in both groups were in the American Society of Anesthesiologists physical status classification 3 or 4. Study quality was deemed good according to the Newcastle-Ottawa Scale. Publication bias was assessed using a funnel plot and the Egger test, and study heterogeneity was evaluated using the I2 heterogeneity statistic and Cochran Q heterogeneity test. There was some heterogeneity between the studies, with a Cochran Q statistics of 8.13 (degrees of freedom = 4; p = 0.08) and an I2 statistic of 50.8%. There was evidence for a small amount of publication bias (Egger test; p = 0.02). The pooled risk ratio (RR) from a random-effects model is presented with 95% confidence intervals. The primary endpoint was the occurrence of any fatalities within 48 hours of hip fracture treatment with cementless compared with cemented prostheses. We performed a sensitivity analysis to assess the needed association of a potential unmeasured or uncontrolled confounding, and we made an estimate of the amount of unmeasured confounding that would need to be present in order to change the direction of the result. We summarized this using a parameter known as the "E-value." Based on that sensitivity analysis, we found it unlikely that an unmeasured hypothetical confounder could explain the significant association between cemented and cementless implants and risk of death within 48 hours of hip hemiarthroplasty.

RESULTS

Compared with the cementless group, mortality was increased in the cemented group (RR 1.63 [95% CI 1.31 to 2.02]; p < 0.001). The number needed to harm from the pooled data was 1 of 183 operated patients; that is, for every 183 patients treated with cemented implants, one death would be expected.

CONCLUSION

Bone cement is associated with a higher risk of fatalities within 48 hours of surgery compared with cementless prostheses. However, numerous prior studies have found a higher risk of serious complications resulting in additional surgical procedures associated with cementless devices in this population; those complications, as well, may result in death. Based on our study alone, we cannot recommend cementless implants in this setting. Large, national registries should evaluate fixation choice in older patients with hip fractures, and those studies should consider both early death and the potential for later harms.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Age-Associated Changes in Proximal Femur Morphology Affect Femoral Component Sizing in Cementless Hip Arthroplasty

Background

In cementless hip arthroplasty, the femoral component should obtain firm fixation within the endosteal bone and achieve adequate reconstruction of hip joint biomechanics simultaneously. Previous anatomical studies described age-related changes of the proximal femoral canal, such as canal widening, which theoretically necessitates the use of larger stem sizes in elderly patients. This study examines a potential association between patients’ age at surgery and the implant size of a cementless femoral component.

Material and methods

A total of 13,423 primary hip arthroplasties with a single cementless stem registered in the Dutch Arthroplasty Register (LROI) were included. Patient characteristics (ie patients’ age, sex, height and weight at time of surgery) and femoral component size were derived. A one-way ANCOVA was used to compare the mean stem size between age groups, and multivariable linear regression analysis was used in order to investigate to which extent ageing impacted stem size.

Results

Each subsequent age- group (ten-year intervals) had a significantly larger mean stem size than the prior age- group. Multivariable linear regression analysis revealed that age is positively correlated with stem size and that this correlation is more prominent in females than in males (beta = .046, P < .001 and beta = .028, P < .001 respectively).

Interpretation

Implant size is positively correlated with age, in particular in females and independently from investigated anthropometric characteristics. The present study endorses that the femoral canal morphology is related to patients’ characteristics such as age and sex. The morphology will subsequently influence implant sizing and therefore may have biomechanical and clinical implications.

A Comparison of Risks and Benefits Regarding Hip Arthroplasty Fixation

Since the field-changing invention of noncemented hip arthroplasty fixation in the 1980s, noncemented fixation has been progressively replacing cemented fixation. However, analyses of fixation frequencies reveal new patterns in cement versus noncemented preferences. Although cementation is again gaining ground in the United States, noncemented models remain the dominant fixation mode, seen in more than 90% of all hip arthroplasties. This stark preference is likely driven by concerns regarding implant durability and patient safety. Although advances in surgical techniques, intensive perioperative care, and improved instrument have evolved in both methods, data from large arthroplasty registries reveal shifting risks in contemporary hip arthroplasty, calling the use of noncemented fixation into question. Varying risk profiles regarding sex, age, or health comorbidities and morphological and functional differences necessitate personalized risk assessments. Furthermore, certain patient populations, based on the literature and data from large registries, have superior outcomes from cemented hip arthroplasty techniques. Therefore, we wanted to critically evaluate the method of arthroplasty fixation in primary hip arthroplasties for unique patient populations.

Cemented Vs Cementless Femoral Fixation for Total Hip Arthroplasty After Displaced Femoral Neck Fracture: A Nationwide Analysis of Short-Term Complications and Readmission Rates

BACKGROUND

Active patients with displaced femoral neck fractures are often treated with total hip arthroplasty (THA). However, optimal femoral fixation in these patients is controversial. The purpose of this study was to compare early complication and readmission rates in patients with hip fracture treated with THA receiving cemented vs cementless femoral fixation.

METHODS

The National Readmissions Database was queried to identify patients undergoing primary THA for femoral neck fracture from 2016 to 2017. Postoperative complications and unplanned readmissions at 30, 90, and 180 days were compared between patients treated with cemented and cementless THA. Univariate and multivariate analyses were performed to compare differences between groups and account for confounding variables.

RESULTS

Of 17,491 patients identified, 4427 (25.3%) received cemented femoral fixation and 13,064 (74.7%) cementless. The cemented group was significantly older (77.2 vs 71.1, P < .001), had more comorbidities (Charlson comorbidity index: 4.44 vs 3.92, P < .001), and had a greater proportion of women (70.5% vs 65.2%, P < .001) compared with the cementless group. On multivariate analysis, cemented fixation was associated with reduced rates of periprosthetic fracture (odds ratio: 0.052, 95% confidence interval: 0.003-0.247, P = .004) at 30 days but similar readmission rates at 30, 90, and 180 days (odds ratio range: 1.012-1.114, P > .05) postoperatively compared with cementless fixation. Cemented fixation was associated with greater odds of medical complications at 180 days postoperatively (odds ratio:: 1.393, 95% confidence interval: 1.042-1.862, P = .025).

CONCLUSION

Cemented femoral fixation was associated with a lower short-term incidence of periprosthetic fractures, higher incidence of medical complications, and equivalent unplanned readmission rates within 180 days postoperatively compared with cementless fixation in patients undergoing THA for femoral neck fracture.

LEVEL OF EVIDENCE

Level III.

Are functional outcomes and reoperation rates really better than those of cementless stems in displaced femoral neck fractures? An updated systematic review and meta-analysis of randomized controlled trials in current-generation stem designs

BACKGROUND

The aim of the study was to conduct a systematic review and meta-analysis to compare the functional outcomes and reoperation rates of cemented and cementless hip arthroplasty for treating displaced femoral neck fractures in elderly patients.

METHODS

Systematic searches were conducted of literature up to December 2018 on PubMed, Embase, Cochrane, and Web of Science for randomized controlled trials (RCTs) concerning current-generation stem designs only. Two reviewers independently determined eligibility, extracted the outcome data and assessed the risk of bias of eligible studies. The follow-up data and complication rates were pooled by using random-effects models and fixed-effects models, with mean differences and risk ratios for continuous and dichotomous variables, respectively.

RESULTS

Eight RCTs involving 1361 patients (1361 hips) were included in the meta-analysis. Cemented stems were associated with fewer implant-related complications (odds ratio [OR] = 0.303; 95% confidence interval [CI], 0.185%-0.496%; p < 0.001) and reoperations (OR = 0.492; 95% CI, 0.247%-0.977%; p = 0.043). There were no statistically significant differences between groups in functional outcomes, including those assessed by the EuroQol(EQ)-5D and Harris Hip Score, mortality rates, major systemic complications, minor local complications, operation times, intraoperative blood losses, and lengths of hospital stays.

CONCLUSION

In treating displaced femoral neck fracture in elderly patients with hip arthroplasty with current-generation stems, cemented stems were found to have fewer implant-related complications and reoperations than those of cementless stems. Functional outcomes and mortality rates were similar between the groups.

Does Proximal Femoral Morphology Impact Morbidity and Mortality? A Cohort Study of Uncemented Hemiarthroplasties in the Treatment of Femoral Neck Fractures

Background

To assess outcomes after uncemented hemiarthroplasty stems in the treatment of intracapsular femoral neck fractures over an 11-year period. Mortality rates were assessed, and whether proximal femoral geometry and stem alignment were factors in intraoperative or postoperative periprosthetic fracture (PPF) needs to be identified.

Materials and Methods

A retrospective single-center observational study was conducted of all patients who underwent intracapsular femoral neck fracture treatment using an uncemented prosthesis between January 2008 and December 2018. Primary endpoints included mortality rate, Dorr classification, prosthesis alignment, intraoperative fracture, and reoperation rate for any reason. Subanalysis on collared and uncollared implants was also conducted. Multivariate logistic regression was performed based on Dorr classification for stem alignment, fracture incidence, reoperation rate, implant sizing, and patient mortality.

Results

A total of 536 patients received an uncemented hemiarthroplasty in the study period. The mean patients age was 80.4 years, of which 71% were female. The 30-day mortality rate was 5.2%, with no deaths on day zero or day one. Twenty patients (3.7%) sustained an intraoperative calcar fracture, and 14 patients a PPF (2.6%) at a mean of 1.3 years from surgery. Dorr C type femurs were more likely to develop a PPF (P = .001), while valgus stem alignment was associated with PPF (P = .049).

Conclusions

This implant has low reoperation rates, low early postoperative mortality, and low 30-day mortality. This large single-center study provides up-to-date information using a contemporary stem in patients with multiple comorbidities. Dorr C femoral morphology and valgus stem malalignment were risk factors for postoperative fractures.

Association Between Cemented vs Cementless Hemiarthroplasty and Short-Term Change of In-Hospital Mortality in Elderly Patients with Femoral Neck Fracture: A Propensity-Score Matching Analysis in a Multicenter Database

Objective

Cemented hemiarthroplasty is recommended for the vulnerable hip fracture population because of beneficial long-term outcomes. However, the association between cemented hemiarthroplasty and short-term mortality is controversial. To increase a preparedness of potential complication after cemented hemiarthroplasty, we aimed to evaluate the trajectory of the effect of cemented hemiarthroplasty on short-term in-hospital outcomes.

Methods

We investigated in-hospital mortality and complications between cemented hemiarthroplasty and cementless hemiarthroplasty using a nationwide multicenter database from 2010 to 2016 with a propensity-score matching analysis. We analyzed in-hospital mortality from 1 to 14 days after surgery. We also investigated in-hospital complications that may associate with mortality.

Results

After matching of 31,322 cases, we found no significant difference in 30-day in-hospital mortality between the cemented and cementless hemiarthroplasty groups (hazard ratio, HR [95% confidence interval, CI], 1.2 [0.89-1.6], p = 0.23). However, the 1- to 10-day postoperative mortality rates were significantly higher in the cemented group and the association becomes weaker as the postoperative period increased (day 1; HR [95% CI]: 3.5 [1.6-7.68]; day 10; HR [95% CI]: 1.59 [1.07-2.37]). The incidence of stroke and intensive care unit (ICU) admission was also significantly higher in the cemented group.

Conclusion

Cemented hemiarthroplasty was not significantly associated with an increase in overall in-hospital mortality but was significantly associated with short-term mortality from 1-day to 10-day after surgery. The incidence of stroke and ICU admission was also significantly higher in the cemented group. Surgeons should pay more attention to the risk of mortality and stroke in patients undergoing cemented hemiarthroplasty, especially in the early days of hospitalization.

Perioperative Mortality and Periprosthetic Fracture: A Single-Center Experience of 857 Uncemented Hemiarthroplasties for Displaced Femoral Neck Fractures

BACKGROUND

Uncemented hemiarthroplasty (UHA) for displaced femoral neck fracture (FNF) is favored by some surgeons because of the reduced rate of perioperative mortality and operative time. However higher rates of intraoperative and postoperative periprosthetic fractures (PPFs) have been reported. The aim of the study was to review day-0, day-1, day-2, day-30, and one-year mortality as well as intraoperative and postoperative PPF after UHA for displaced FNF and compare this with cemented hemiarthroplasties (CHAs) performed. Secondary objectives were to assess whether femoral stem geometry and alignment were associated with PPF in UHA.

METHODS

A retrospective observational study was conducted of patients treated with a hemiarthroplasty for a displaced FNF over an eleven-year period. Radiographic analysis was conducted of femoral geometry and stem alignment.

RESULTS

Over the 11-year study period, 857 UHAs and 247 CHAs were performed. There were no on-table, day-0, day-1, or day-2 deaths in UHA. Intraoperative PPF occurred in 3.6% UHA and 2% CHA and postoperative PPF in 2.4% UHA and 4.8% CHA. Intraoperative PPF was not associated with increased mortality (P = .15), postoperative PPF, or all-cause revision in UHA. Valgus stem alignment was a risk factor for a postoperative PPF and additional surgery in UHA (P = .004).

CONCLUSION

UHA was associated with no perioperative deaths and a 30-day mortality rate of 5% in this series. It can be considered in patients with multiple medical comorbidities. Careful surgical planning and technique is important to optimize stem alignment particularly in Dorr C type femurs.

Cemented versus uncemented hemiarthroplasty for the management of femoral neck fractures in the elderly: a meta-analysis and systematic review

INTRODUCTION

Hemiarthroplasty is commonly used to treat unstable femoral neck fractures in older patients. However, there is no consensus on the use of cement during hemiarthroplasty. Therefore, we performed a systematic review to focus on the outcomes of cemented and uncemented hemiarthroplasty for the treatment of femoral neck fractures in older patients.

MATERIALS AND METHODS

Pubmed, Cochrane Central Register of Controlled Trials, and Ovid were searched for studies related comparison of cemented versus uncemented hemiarthroplasty for unstable femoral neck fractures from inception to Jan 20, 2020. The quality of the included randomized controlled trials (RCTs) was assessed using the Cochrane Collaboration tool. The meta-analysis was performed using the RevMan 5.2 software.

RESULTS

Eleven RCTs were included in the meta-analysis. Cemented hemiarthroplasty was found to be superior to uncemented arthroplasty with respect to reoperation rate (RR 0.6, 95% CI 0.38-0.96, p = 0.03), complications related to prosthesis (RR 0.39, 95% CI 0.23-0.68, p = 0.0008), residual pain (RR 0.66, 95% CI 0.52-0.83, p = 0.0004), and operation time (MD 8.22, 95% CI 6.30-10.14, p < 0.00001). There were no significant between-group differences with respect to local and general complications, duration of hospital stay, hip function, and mortality.

CONCLUSIONS

This meta-analysis showed cemented hemiarthroplasty might be an optimum choice for treating unstable femoral neck fractures in older patients. However, the results of this meta-analysis should be interpreted cautiously owing to some limitations. Further studies are required to provide more robust evidence.

Cost-effectiveness analyses comparing cemented, cementless, hybrid and reverse hybrid fixation in total hip arthroplasty: a systematic overview and critical appraisal of the current evidence

Background: This study aims to present an overview and critical appraisal of all previous studies comparing costs and outcomes of the different modes of fixation in total hip arthroplasty (THA). A secondary aim is to provide conclusions regarding the most cost-effective mode of implant fixation per gender and age-specific population in THA, based on high quality studies.Methods: A systematic search was conducted to identify cost-effectiveness analyses (CEAs) comparing different modes of implant fixation in THA. Analysis of results was done with solely CEAs that had a high methodological quality.Results: A total of 12 relevant studies were identified and presented, of which 5 were considered to have the methodological rigor for inclusion in the analysis of results. These studies found that either cemented or hybrid fixation was the most cost-effective implant fixation mode for most age- and gender-specific subgroups.Conclusion: Currently available well performed CEAs generally support the use of cemented and hybrid fixation for all age-groups relevant for THA and both genders. However, these findings were mainly based on a single database and depended on assumptions made in the studies' methodology. Issues discussed in this paper have to be considered and future work is needed.

Revision Risk After Unipolar or Bipolar Hemiarthroplasty for Femoral Neck Fractures: An Instrumental Variable Analysis of 62,875 Procedures from the Australian Orthopaedic Association National Joint Replacement Registry

BACKGROUND

There remains much international practice variation regarding the choice of a unipolar or bipolar prosthesis design for displaced femoral neck fractures that are treated with hemiarthroplasty. The purpose of the present study was to compare revision rates following primary hemiarthroplasty for femoral neck fracture to determine if the unipolar hemiarthroplasty design increases the risk of revision arthroplasty for all causes.

METHODS

Instrumental variable analysis was performed with use of data that had been entered into the Australian Orthopaedic Association National Joint Replacement Registry from September 1, 1999, to December 31, 2018. Sixty-two thousand, eight hundred and seventy-five patients with femoral neck fractures that were treated with primary modular unipolar or bipolar hemiarthroplasty procedure were analyzed. Hospital preference for prosthesis design in the 12 months prior to the index procedure was used as an instrument to adjust for unmeasured confounding. The primary outcome was time to first revision for any cause. Secondary analyses were performed on the reason for revision (infection, dislocation, periprosthetic fracture, or acetabular erosion), the use of cement femoral stem fixation, and the type of stem (polished or matte).

RESULTS

Modular unipolar hemiarthroplasty was associated with a higher rate of revision at >2.5 years (hazard ratio [HR], 1.86; 95% confidence interval [CI], 1.46 to 2.36; p < 0.001), but there was no difference between the groups before 2.5 years (HR, 0.98; 95% CI, 0.85 to 1.13; p = 0.79). Protective factors for revision included female sex (HR, 0.82; 95% CI, 0.74 to 0.9), use of cemented fixation (HR, 0.69; 95% CI, 0.62 to 0.77), and surgery performed in a public hospital setting (HR 0.79; 95% CI, 0.70 to 0.89). Modular unipolar prostheses had a greater risk of revision for acetabular erosion, particularly in later time periods (HR at ≥5.5 years, 5.10; 95% CI, 2.40 to 10.83; p < 0.001), while being protective against periprosthetic fractures (HR, 0.72; 95% CI, 0.59 to 0.87; p < 0.001) at all time points. There was no difference in terms of the risk of revision for infection, dislocation, or stem type.

CONCLUSIONS

Bipolar hemiarthroplasty designs resulted in a lower risk of revision than unipolar designs. Unipolar hemiarthroplasties are justified for patients with femoral neck fracture and a shorter life expectancy (≤2.5 years).

LEVEL OF EVIDENCE

Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Perioperative Mortality After Cemented or Uncemented Hemiarthroplasty for Displaced Femoral Neck Fractures-A Systematic Review and Meta-analysis

BACKGROUND

Debate surrounds the use of cemented or uncemented prostheses for the treatment of displaced femoral neck fractures (FNF). Many guidelines recommend the use of the cemented hemiarthroplasty (CHA). Proponents of CHA point out the increased re-operation rate while proponents of uncemented hemiarthroplasty (HA) highlight the increased mortality rate in the perioperative period. The aim of this study was to systematically review the literature to evaluate perioperative mortality after HA for displaced FNFs.

METHODS

A systematic review and meta-analysis was performed of MEDLINE, Cochrane Library, and Embase databases evaluating perioperative mortality after HA for displaced FNFs. Randomized control trials and observational studies were included comparing current-generation stem designs. A meta-analysis was performed on studies that directly compared the different modes of fixation.

RESULTS

Twenty-two studies were included (seven randomized control trials and 15 observational studies), with a total of 183,167 HAs for treatment of a displaced FNF. Fourteen studies were included in the meta-analysis. There was a higher cumulative odds of death within the first 48 hours in those with CHA compared with uncemented HA (OR: 1.64; 95% CI: 1.35, 2.00; P ≤ .01). No difference was found in mortality at 7 days, 30 days, and one year.

CONCLUSION

CHA is associated with an increased mortality rate within the first two days of surgery with no difference at 7 days, 30 days, and one year. Surgeons should consider tailoring their stem choice based on the physiological status of the patient when planning HA for FNFs. Techniques to reduce the risk of bone cement implantation syndrome should be used.

Hemiarthroplasty versus total hip arthroplasty for displaced femoral neck fracture in patients older than 80 years: A randomized trial protocol

BACKGROUND

The forms of treatment which are available for these patients include internal fixation, hemiarthroplasty (HA), or total hip arthroplasty (THA). Both HA and THA are widely used methods of hip replacement after displaced femoral neck fracture (DFNF). Our purpose is to analyze the long-term outcomes of these 2 different forms of treatment, which are suitable for active patients with femoral neck intracapsular fractures ≥80 years of age without advanced osteoarthritis or rheumatoid arthritis.

METHODS

This study is designed as a single-center randomized controlled trial. The participants will be randomly assigned to either the THA group or the HA group. Information will be collected from all participants after obtaining written informed consent in accordance with the Declaration of Helsinki and ethical board approval. Inclusion criteria include: displaced intracapsular femoral neck fracture, capability to obtain informed consent, no known metastatic disease, no contraindications to anesthesia, age ≥80 years, and ability to understand written Chinese. Patients will be evaluated at 3 months, 6 months, 1 year, and 3 years after surgery. At the time of the final follow-up, patients were assessed with use of the Harris hip score (HHS) and walking distance. Secondary outcomes of interest include postoperative complications, including 90-day medical complications (acute myocardial infarction, deep vein thrombosis, pulmonary embolism, intestinal obstruction, renal failure, and pneumonia) and surgical complications within 1 year (dislocation, infection, and revision replacement).

RESULTS

This trial is expected to be the largest randomized trial assessing the efficacy of THA and HA and powered to detect a potential difference in the primary outcome.

TRIAL REGISTRATION

This study protocol has been registered in Research Registry (researchregistry6203).

Cementless Hemiarthroplasty for Intracapsular Femoral Neck Fractures in the Octa- and Nonagenarians

Backgroud

Current evidence supports the use of cemented hemiarthroplasty for treatment of intracapsular femoral neck fractures since it is associated with a lower risk of implant-related complications. However, many medical centers employ the cementless technique for the frail elderly population because it is faster and has lower cardiovascular risks and perioperative mortality. This observational study reports the outcomes of cementless bipolar hemiarthroplasty for intracapsular femoral neck fractures in patients aged 80 years and older.

Methods

A total of 424 patients (female, 77.1%) with a mean age of 86.9 years were operated for intracapsular femoral neck fractures between January 2009 and December 2017. Of those, 66.7% had an American Society of Anaesthesiologists (ASA) score of 3 or more. All operations were performed with the posterolateral surgical approach and all patients received a cementless stem. Intraoperative and perioperative values and in-hospital outcomes were evaluated, and clinical and radiographical follow-up was done at 40 days, 90 days, and when possible between 5 months and 12 months postoperatively. Multivariate analysis was performed to evaluate if there were factors affecting mortality.

Results

The mean operative time was 50 minutes. There were no deaths intraoperatively. Intraoperative periprosthetic fractures occurred in 2.1% of the cases with 66.7% of them fixed through cerclage wires intraoperatively. The median length of hospitalization was 11 days (interquartile range, 8.75–15) and 2.4% of patients died while in hospital after surgery. Approximately 91.5% of patients presented with perioperative anemia. Only 1.9% of the complications were related to the implant, 62.5% of which were dislocations. More than 90% of patients were ambulatory either autonomously or with support at each follow-up assessment. Age, male sex, and higher ASA score were related to increased mortality.

Conclusions

Despite some limitations, this observational study underlines that a cementless femoral stem of modern design can give good clinical outcomes, thus being an appropriate solution especially for the frail elderly.

Does total hip arthroplasty provide better outcomes than hemiarthroplasty for the femoral neck fracture? A systematic review and meta-analysis

PURPOSE

By comparing the outcomes of total hip arthroplasty with hemiarthroplasty in elderly patients with a femoral neck fracture to investigate the one-year mortality, dislocation, infection, reoperation rate, and thromboembolic event.

METHODS

The PubMed, EMBASE databases, and Cochrane library were systematically searched from the inception dates to April 1, 2020 for relevant randomized controlled trials in English language using the keywords: "total hip arthroplasty", "hemiarthroplasty" and "femoral neck fracture" to identify systematic reviews and meta-analyses. Two reviewers independently selected articles, extracted data, assessed the quality evidence and risk bias of included trials using the Cochrane Collaboration' stools, and discussed any disagreements. The third reviewer was consulted for any doubts or uncertainty. We derived risk ratios and 95% confidence intervals. Mortality was defined as the primary outcome. Secondary outcomes were other complications, dislocation, infection, reoperation rate, and thromboembolic event.

RESULTS

This meta-analysis included 10 studies with 1419 patients, which indicated that there were no significant differences between hemiarthroplasty and total hip arthroplasty in reoperation, infection rate, and thromboembolic event. However, there was a lower mortality and dislocation rate association with total hip arthroplasty at the one-year follow-up.

CONCLUSION

Based on our results, we found that total hip arthroplasty was better than hemiarthroplasty for a hip fracture at one-year follow-up.

Increased Mortality with the Use of Cementless Fixation for Femoral Neck Fractures: Analysis of 5883 Hip Arthroplasty Cases

BACKGROUND

The use of cemented fixation for hip arthroplasty for femoral neck fractures has been advocated to limit the postoperative and intraoperative risk of periprosthetic fractures. However, there are concerns with the potential effects of cementing on patient mortality, particularly at the time of cementation.

METHODS

This study examined the mortality rates of cemented compared to cementless hip arthroplasty fixation in a group of 5883 femoral neck fracture patients from 2001 to 2017. The data were derived from large administrative databases and census data. Confounders were identified and controlled with a multivariate analysis. The data were also stratified into 2 time frames, 2001-2008 and 2009-2017, to determine if there was an effect of more recent improvements in patient care or implant technology.

RESULTS

Cemented fixation had a statistically significant reduction in mortality rates at 30, 90, and 365 days after surgery. There was no difference in mortality in 0, 1, or ≤7 days after discharge or during the admission. The mortality rate decreased but was still significantly increased with cementless fixation when the subjects were grouped from 2001 to 2008 and 2009 to 2017.

CONCLUSION

Based on this evidence, the cemented fixation of hip arthroplasty should be considered for patients with femoral neck fractures.

Hip fracture treatment in Norway: deviation from evidence-based treatment guidelines: data from the Norwegian Hip Fracture Register, 2014 to 2018

Aims

The aim of this study was to describe variation in hip fracture treatment in Norway expressed as adherence to international and national evidence-based treatment guidelines, to study factors influencing deviation from guidelines, and to analyze consequences of non-adherence.

Methods

International and national guidelines were identified and treatment recommendations extracted. All 43 hospitals routinely treating hip fractures in Norway were characterized. From the Norwegian Hip Fracture Register (NHFR), hip fracture patients aged > 65 years and operated in the period January 2014 to December 2018 for fractures with conclusive treatment guidelines were included (n = 29,613: femoral neck fractures (n = 21,325), stable trochanteric fractures (n = 5,546), inter- and subtrochanteric fractures (n = 2,742)). Adherence to treatment recommendations and a composite indicator of best practice were analyzed. Patient survival and reoperations were evaluated for each recommendation.

Results

Median age of the patients was 84 (IQR 77 to 89) years and 69% (20,427/29,613) were women. Overall, 79% (23,390/29,613) were treated within 48 hours, and 80% (23,635/29,613) by a surgeon with more than three years' experience. Adherence to guidelines varied substantially but was markedly better in 2018 than in 2014. Having a dedicated hip fracture unit (OR 1.06, 95%CI 1.01 to 1.11) and a hospital hip fracture programme (OR 1.16, 95% CI 1.06 to 1.27) increased the probability of treatment according to best practice. Surgery after 48 hours increased one-year mortality significantly (OR 1.13, 95% CI 1.05 to 1.22; p = 0.001). Alternative treatment to arthroplasty for displaced femoral neck fractures (FNFs) increased mortality after 30 days (OR 1.29, 95% CI 1.03 to 1.62)) and one year (OR 1.45, 95% CI 1.22 to 1.72), and also increased the number of reoperations (OR 4.61, 95% CI 3.73 to 5.71). An uncemented stem increased the risk of reoperation significantly (OR 1.23, 95% CI 1.02 to 1.48; p = 0.030).

Conclusion

Our study demonstrates a substantial variation between hospitals in adherence to evidence-based guidelines for treatment of hip fractures in Norway. Non-adherence can be ascribed to in-hospital factors. Poor adherence has significant negative consequences for patients in the form of increased mortality rates at 30 and 365 days post-treatment and in reoperation rates.Cite this article: Bone Joint Open 2020;1-10:644-653.

What Factors Increase Revision Surgery Risk When Treating Displaced Femoral Neck Fractures With Arthroplasty: A Secondary Analysis of the HEALTH Trial

OBJECTIVES

HEALTH was a randomized controlled trial comparing total hip arthroplasty with hemiarthroplasty in low-energy displaced femoral neck fracture patients aged ≥50 years with unplanned revision surgery within 24 months of the initial procedure being the primary outcome. No significant short-term differences between treatment arms were observed. The primary objective of this secondary HEALTH trial analysis was to determine if any patient and surgical factors were associated with increased risk of revision surgery within 24 months after hip fracture.

METHODS

We analyzed 9 potential factors chosen a priori that could be associated with revision surgery. The factors included age, body mass index, major comorbidities, independent ambulation, type of surgical approach, length of operation, use of femoral cement, femoral head size, and degree of femoral stem offset. Our statistical analysis was a multivariable Cox regression using reoperation within 24 months of index surgery as the dependent variable.

RESULTS

Of the 1441 patients included in this analysis, 8.1% (117/1441) experienced reoperation within 24 months. None of the studied factors were found to be predictors of revision surgery (P > 0.05).

CONCLUSION

Both total and partial hip replacements are successful procedures in low-energy displaced femoral neck fracture patients. We were unable to identify any patient or surgeon-controlled factors that significantly increased the need for revision surgery in our elderly and predominately female patient population. One should not generalize our findings to an active physiologically younger femoral neck fracture population.

LEVEL OF EVIDENCE

Prognostic Level II. See Instructions for Authors for a complete description of levels of evidence.

The Effect of Type of Femoral Component Fixation on Mortality and Morbidity after Hip Hemiarthroplasty: A Systematic Review and Meta-Analysis

BACKGROUND

Hip hemiarthroplasty is a well-established treatment of displaced femoral neck fracture, although debate exists over whether cemented or uncemented fixation is superior. Uncemented prostheses have typically been used in younger, healthier patients and cemented prostheses in older patients with less-stable bone. Also, earlier research has suggested that bone cement has cytotoxic effects and may trigger cardiovascular and respiratory adverse events.

QUESTIONS/PURPOSES

The aim of this systematic review and meta-analysis was to compare morbidity and mortality rates after cemented and uncemented hemiarthroplasty for the treatment of displaced femoral neck fractures in elderly patients.

METHODS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines, we searched seven medical databases for randomized clinical trials and observational studies. We compared cemented and uncemented hemiarthroplasty using the Harris Hip Score (HHS), as well as measures of postoperative pain, mortality, and complications. Data were extracted and pooled as risk ratios or standardized mean difference with their corresponding 95% confidence intervals in a meta-analysis model.

RESULTS

The meta-analysis included 34 studies (12 randomized trials and 22 observational studies), with a total of 42,411 patients. In the pooled estimate, cemented hemiarthroplasty was associated with less risk of postoperative pain than uncemented hemiarthroplasty. There were no significant differences between groups regarding HHS or rates of postoperative mortality, pulmonary embolism, cardiac arrest, myocardial infarction, acute cardiac arrhythmia, or deep venous thrombosis.

CONCLUSIONS

While we found that cemented hemiarthroplasty results in less postoperative pain than uncemented hemiarthroplasty in older patients with femoral neck fracture, the lack of significant differences in functional hip scores, mortality, and complications was surprising. Further high-level research is needed.

In-Bundle Surgeons More Likely Select Cemented Femoral Fixation in Total Hip Arthroplasty for At-Risk Patients: The Medicare Comprehensive Care for Joint Replacement Bundled Model

Background

Bundled payment models for lower-extremity arthroplasty have been shown to lower costs but have not reliably improved quality. It is unknown how the bundled payment model may affect surgeons' decisions that impact the quality of arthroplasty care. The purpose of this study was to compare the utilization of femoral component fixation modes by surgeons performing total hip arthroplasties (THAs) in at-risk patients in areas subject to Medicare's Comprehensive Care for Joint Replacement (CJR) bundled payment model compared with patients treated by surgeons in areas exempt from the policy.

Methods

Elective, primary THAs among elderly persons were identified from Medicare claims during 2017 and 2018, including the use of cemented or cementless femoral fixation. Multivariable regression models, applied to samples stratified by sex, were used to assess the association between CJR bundle participation and the use of femoral fixation mode. Analyses were adjusted for patient age, race or ethnicity, comorbidity burden, low-income status, and Census division of the hospital.

Results

Of 118,676 Medicare patients who underwent THA, 9.1% received cemented femoral components, and use of cement varied significantly by geographic region (p < 0.001). Patients who received cemented fixation, compared with patients who received cementless fixation, had significant differences in mean age (and standard deviation) at 78.3 ± 6.9 years compared with 74.5 ± 6.1 years (p < 0.001) for female patients and 77.3 ± 6.8 years and 74.2 ± 5.9 years (p < 0.001) for male patients; were more likely to be White at 94.0% compared with 92.7% (p < 0.001) for female patients and 95.1% compared with 93.8% (p = 0.046) for male patients; and had higher mean Elixhauser comorbidity index at 2.6 ± 2.2 compared with 2.3 ± 2.0 (p < 0.001) for female patients and 2.8 ± 2.4 compared with 2.4 ± 2.1 (p < 0.001) for male patients. In adjusted analyses, female patients in the CJR bundled payment model were more likely to have cemented fixation compared with female patients not in the CJR model (odds ratio [OR], 1.11 [95% confidence interval (CI), 1.05 to 1.16]; p < 0.001), whereas male patients in the CJR bundled payment model were less likely to have cemented fixation compared with male patients not in the CJR model (OR, 0.91 [95% CI, 0.83 to 0.99]; p = 0.029).

Conclusions

In the bundled environment, surgeons were more likely to choose cemented femoral fixation for elderly female patients. This may be due to in-bundle surgeons being more risk-averse and avoiding cementless fixation in patients at risk for fracture or implant-related complications. Further research is needed to directly examine the impact of the bundle on surgeon decision-making.

Retrospective cohort trial protocol of screw fixation compared with hemiarthroplasty for displaced femoral neck fractures in elderly patients

BACKGROUND

There is limited evidence for the evaluation of the efficacy and safety of the hemiarthroplasty versus screw fixation in elderly patients with the displaced femoral neck fractures. Our current investigation aimed at assessing the complications, functional outcome, and revision rate of the patients (over 65 years old) who received internal fixation or hemiarthroplasty via a same senior surgeon.

METHODS

A retrospective study was conducted on elderly patients with displaced femoral neck fractures from May 2014 to February 2018. The current study was carried out at our hospital and it was approved through our institutional review committee of West China Hospital. Inclusion criteria were as follows: the patients were 65 years or older, this is the anesthesia grade. The higher grade of the patients,the greater risk of surgery. level I-III, and the patients with displaced intracapsular fractures of the femoral neck, with the radiographic and clinical follow-up of 12 months or more. The major outcome was the revision rate between the 2 groups. And the secondary outcomes contained the life quality and functional outcome detected via utilizing the interview-administered and self-administered questionnaires, length of hospital stay, surgery time, and hip-related complications (such as hip dislocation, loosening or breakage of implant, wound problems, infection, osteolysis, neurovascular injury, and bone nonunion).

RESULTS

It was assumed that hemiarthroplasty would result in fewer revisions or complications and better functional scores in comparison with internal fixation technique.

Effectiveness and safety of cemented and uncemented hemiarthroplasty in the treatment of intracapsular hip fractures

Aims

We conducted a systematic review and meta-analysis to compare the mortality, morbidity, and functional outcomes of cemented versus uncemented hemiarthroplasty in the treatment of intracapsular hip fractures, analyzing contemporary and non-contemporary implants separately.

Methods

PubMed, Medline, EMBASE, CINAHL, and Cochrane Library were searched to 2 February 2020 for randomized controlled trials (RCTs) comparing the primary outcome, mortality, and secondary outcomes of function, quality of life, reoperation, postoperative complications, perioperative outcomes, pain, and length of hospital stay. Relative risks (RRs) and mean differences (with 95% confidence intervals (CIs)) were used as summary association measures.

Results

A total of 18 studies corresponding to 16 non-overlapping RCTs with a total of 2,819 intracapsular hip fractures were included. Comparing contemporary cemented versus uncemented hemiarthroplasty, RRs (95% CIs) for mortality were 1.32 (0.44 to 3.99) perioperatively, 1.01 (0.48 to 2.10) at 30 days, and 0.90 (0.71 to 1.15) at one year. The use of contemporary cemented hemiarthroplasty reduced the risk of intra- and postoperative periprosthetic fracture. There were no significant differences in the risk of other complications, function, pain, and quality of life. There were no significant differences in perioperative outcomes except for increases in operating time and overall anaesthesia for contemporary cemented hemiarthroplasty with mean differences (95% CIs) of 6.67 (2.65 to 10.68) and 4.90 (2.02 to 7.78) minutes, respectively. The morbidity and mortality outcomes were not significantly different between non-contemporary cemented and uncemented hemiarthroplasty.

Conclusion

There are no differences in the risk of mortality when comparing the use of contemporary cemented with uncemented hemiarthroplasty in the management of intracapsular hip fractures. Contemporary cemented hemiarthroplasty is associated with a substantially lower risk of intraoperative and periprosthetic fractures. Cite this article: Bone Joint J 2020;102-B(9):1113–1121.

Cemented versus uncemented hemiarthroplasty for elderly patients with displaced fracture of the femoral neck: A PRISMA-compliant meta-analysis of randomized controlled trial

BACKGROUND

This meta-analysis was performed to incorporate newly published, high-quality randomized controlled trials (RCTs) to determine the effects of cemented versus uncemented hemiarthroplasty for elderly patients with displaced fracture of the femoral neck.

METHODS

The following electronic databases were extensively searched from the inception of the database through December 2018: EMBASE, Medline, the Cochrane Library, and Web of Science. RCTs focusing on the outcomes of cemented and uncemented hemiarthroplasty were reviewed and screened for eligibility. We used the Cochrane Collaboration's Review Manager Software to perform meta-analyses. Two independent reviewers extracted the data and assessed the study quality and bias risk through the Cochrane Collaboration tool. Use fixed effect model or random effect model to pooled data. Cochran's Q statistic was used to evaluate heterogeneity, and I statistic was used to quantify heterogeneity.

RESULTS

Fifteen RCTs were enrolled (n = 3790) (uncemented hemiarthroplasty group = 1015; cemented hemiarthroplasty group = 1037) (mean age ranged from 70-85.3 years; all patients > 65 years). The meta-analysis showed that cemented hemiarthroplasty has a longer operating time (weighted mean difference, 8.03; 95% confidence interval (CI) 4.83-11.23; P < .00001), less pain (odds ratio, 0.48; 95% CI 4.83-11.23; P = .02), lower mortality 1-year (odds ratio, 0.78; 95% CI 0.62-0.98; P = .03) and fewer implant-related complications (odds ratio, 0.20; 95% CI 0.13-0.30; P < .00001) than Uncemented hemiarthroplasty. However, there are still some limitations in our study, such as the uniformity of the surgery administration programme and rehabilitation scheme, and the small sample size of the included studies.

CONCLUSIONS

Cemented hemiarthroplasty for elderly patients with displaced fracture of femoral neck may acquire better functional results.

Korean epidemiology and trends in hip joint replacements

This study aimed to analyze the epidemiologic characteristics of patients who underwent hip arthroplasty using the Korean nationwide database and investigate the recent trends in implant fixation methods and bearing surface selection. We aimed to compare clinical characteristics and differences with the results from the registry of other western countries. We analyzed the data collected by the Health Insurance Review and Assessment Service database of Korea from 2007 to 2011 and the Main Surgery Statistical Yearbook from 2014 to 2018, published by the National Health Insurance Service. The number and rate of patients who underwent hip joint arthroplasty per 10,000 persons have been steadily increasing since 2007. There was a big difference in mean age and preoperative diagnosis of patients between the bipolar hemiarthroplasty and total hip arthroplasty groups. Most patients underwent surgery using a cementless biological fixation method, and the cemented fixation method was selectively used for a small portion of old aged osteoporotic patients. In relation to the use of bearing surfaces, the registry data showed that ceramic-ceramic bearings were used at an overwhelmingly high rate (81%) in Korea compared to other countries. The reason was attributable to various factors, such as patient’s age or economic status, differences in the health insurance system between countries, and recently reported complications, such as ceramic fracture or noise.