Jorge H. Nuñez MD1, Tony Fraguas MD2, Ernesto Guerra‐Farfán MD1, and Diego Collado MD1 1 Vall d’Hebron University Hospital, Barcelona, Spain 2 Teknon Medical Center, Barcelona, Spain THA is one of the most common procedures performed in orthopedic surgery. Over the last decade, there has been a trend toward an increasing number of uncemented THA with a subsequent decline in the overall use of cemented implants for primary THA.1 Hence, this question sought to analyze if patient‐reported outcome measures differ depending on the type of fixation. This can be concerning for the patient and surgeon alike because the method of fixation itself may affect patient outcomes. The choice of optimal implant fixation in THA – fixation with or without cement – has been the subject of much debate2 as the method of fixation itself may influence outcomes.1–3 In cemented joint replacement polymethylmethacrylate (PMMA) is used to fix the prostheses to the bone. In cementless or uncemented joint replacement, hydroxyapatite (HA), porous coatings, or trabecular metal avoid the need for cement as bony in or on‐growth occurs. The primary fixation is anatomic/press‐fit technique, with secondary biological bone ingrowth producing long‐term stable fixation. In hybrid fixation, one component is cemented and the other is uncemented. The quality of literature addressing appropriate investigations for cemented versus uncemented in primary THA is highly variable with level I–IV evidence. There are some randomized trials; however, the majority of the outcome studies are multicenter cohort studies or single‐center cohort studies. The patient’s experience in the short‐term is important. Multiple studies have demonstrated better pain relief and short‐term clinical outcomes, including earlier weight bearing, with cemented THA. Abdulkarim et al., in a meta‐analysis of randomized controlled trials (RCTs; mean age 60.5 years, postoperative follow‐up mean 4.3 years) comparing cemented and uncemented hips found a significantly improved pain score with cemented fixation compared to uncemented fixation (p = 0.04).3 In contrast, in a study of the Swedish Hip Arthroplasty Register, 3118 patients with uncemented THA due to primary osteoarthritis with complete one‐year follow‐up were matched with a control group of patients with cemented THA (n = 3118). The authors reported that uncemented fixation is associated with better patient‐reported outcomes including the EQ‐5D, a Visual Analog Scale (VAS) on hip pain, as well as a VAS addressing satisfaction with the outcome of the procedure.4 Meding et al, found that the 5‐, 10‐, and 20‐year Harris Hip Score (HHS) was not significantly different between cemented and uncemented groups and the 15‐year HHS only differed (on average) by four points (p = 0.0054). The pain scores were not different at 5, 10, or 15 years, but the 20‐year average pain score were significantly lower (more pain) in the uncemented group (p <0.0001).5 The early postoperative mortality after THA is low and has been decreasing.1,3 However, cemented fixation is associated with potential perioperative morbidity in the form of bone cement implantation syndrome and even death of the patient. The Finland National Hip Arthroplasty Register analyzed 73 915 patients they found that adjusted perioperative and short‐term mortality was similar between patients treated with cemented THA and patients treated with uncemented (odds ratio [OR] = 0.5; 95% confidence interval [CI]: 0.3–1.1) or hybrid (OR = 0.6; 95% CI: 0.3–1.6) THA. The mean age of the patients in that register was 68.3 years old.6 The Swedish Hip Arthroplasty Register found that, after adjustment for age, gender, co‐morbidities, and socioeconomic background, there was a small but statistically significant increased relative risk of death in patients who underwent cemented, but not cementless, THA, up to 14 days after surgery (OR = 1.3; 95% CI :1.11–1.44). Between days 15 and 29, this increased risk of mortality in those with a cemented THA was reverted, and from day 30 after the operation all patients, irrespective of the mode of fixation, had a lower risk of mortality than their controls.7 Aseptic loosening is the most common reason for revision, accounting for nearly half of all cases, followed by pain and instability.8 A known disadvantage of cemented prostheses, however, is the risk of aseptic loosening. Cemented THAs have a significantly higher rate of aseptic loosening when compared to uncemented prostheses.9 The Health East Joint Registry of USA (6498 THA) found that uncemented stems were associated with fewer revisions for aseptic loosening in patients <70 years old, but when all‐cause revision was considered, neither group demonstrated superior survival (mean follow‐up of 6.5 years).9 Evidence suggests that the increasing usage of uncemented stems may be associated with a higher rate of periprosthetic femoral fracture (PFF) when compared to cemented stems.10 In a prospective multicenter study found that uncemented femoral components were associated with an increased risk of early PFFs (<90 days; risk ratio [RR] = 4.1; 95% CI: 2.3–7.2), especially in elderly (RR = 1.4 per 10 years; CI: 1.2–1.6), female (RR = 1.6; CI: 1.1–2.2), and osteoporotic patients (RR = 2.8; CI: 1.6–4.8).10 Also Thien et al. studied the incidence of periprosthetic fracture around the femoral component in cemented and uncemented hips in the two years following implantation. They found a rate of 0.07% for cemented stems and 0.47% for uncemented stems (RR = 8.72; 95% CI: 7.37–10.32; p <0.0005).11 The National Joint Registry for England, Wales, Northern Ireland and the Isle of Man, using univariate and multivariate Cox models, found an unadjusted hazard ratio (HR) for PFF for cementless compared to cemented stems of 1.43 (95% CI: 1.29–1.58). After adjustment for age, gender, and American Society of Anesthesiologists (ASA) grade, the HR was 1.68 (95% CI: 1.51–1.87). Also, comparing the rate of PFF revision within and beyond the first three months following primary THA in cementless versus cemented stems, the covariate‐adjusted HRs were 8.82 (95% CI: 6.89–11.30) and 0.84 (95% CI: 0.49–1.41), respectively.9
26 Cement in Total Hip Arthroplasty
Clinical scenario
Top three questions
Question 1: In patients undergoing primary total hip arthroplasty (THA), does a cemented femoral stem, compared to an uncemented femoral stem, provide better function and patient outcomes?
Rationale
Clinical comment
Available literature and quality of the evidence
Findings
Clinical outcomes
Morbidity and mortality
Aseptic loosening
Periprosthetic fracture
Resolution of clinical scenario
Question 2: In patients undergoing primary THA, does a cemented femoral stem, compared to an uncemented femoral stem, provide longer‐term survival?
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