Association Between the Femoral Stem Design Type and the Risk of Aseptic Revision After Hemiarthroplasty.

INTRODUCTION: Although noncemented hemiarthroplasty has been associated with a higher risk of revision surgery as compared with cemented fixation, it remains uncertain whether this increased risk applies to all noncemented stem design types or only a subset. The purpose of this study was to assess the risk of aseptic revision associated with three common types of noncemented stem designs as compared with cemented fixation in the hemiarthroplasty treatment of femoral neck fractures in the elderly patients. METHODS: This was a retrospective cohort study of patients aged 60 years and older who sustained a hip fracture and underwent hemiarthroplasty between 2009 and 2018 at one of 35 hospitals owned by a large US health maintenance organization. Hemiarthroplasty fixation was categorized as cemented or noncemented, with the noncemented stems further classified as single wedge without collar, fit and fill without collar, or fit and fill with collar. The primary outcome was aseptic revision, and the median follow-up time was 4.8 years. RESULTS: Of 12,071 patients who underwent hemiarthroplasty during the study period (average age 82.0 ± 8.4 years, 67.9% women), 807 (6.7%) received a single-wedge stem without collar, 2,124 (17.6%) received a fit-and-fill stem without collar, 2,453 (20.3%) received a fit-and-fill stem with collar, and 6,687 (55.4%) received a cemented stem. Compared with cemented fixation, all the noncemented stem design types were associated with a markedly higher risk of aseptic revision in the multivariable analysis, including single wedge without collar (hazard ratio [HR] 2.00, 95% confidence interval [CI], 1.38 to 2.89, P < 0.001), fit and fill without collar (HR 1.52, 95% CI, 1.14 to 2.04, P = 0.005), and fit and fill with collar (HR 2.11, 95% CI, 1.63 to 2.72, P < 0.001). CONCLUSION: In the hemiarthroplasty treatment of elderly patients with hip fracture, all routinely used noncemented stem design types were associated with a higher risk of aseptic revision as compared with cemented fixation.

Association Between Uncemented vs Cemented Hemiarthroplasty and Revision Surgery Among Patients With Hip Fracture.

IMPORTANCE: Consensus guidelines and systematic reviews have suggested that cemented fixation is more effective than uncemented fixation in hemiarthroplasty for displaced femoral neck fractures. Given that these recommendations are based on research performed outside the United States, it is uncertain whether these findings also reflect the US experience. OBJECTIVE: To compare the outcomes associated with cemented vs uncemented hemiarthroplasty in a large US integrated health care system. DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 12 491 patients aged 60 years and older who underwent hemiarthroplasty treatment of a hip fracture between 2009 and 2017 at 1 of the 36 hospitals owned by Kaiser Permanente, a large US health maintenance organization. Patients were followed up until membership termination, death, or the study end date of December 31, 2017. EXPOSURES: Hemiarthroplasty (prosthetic replacement of the femoral head) fixation via bony growth into a porous-coated implant (uncemented) or with cement. MAIN OUTCOMES AND MEASURES: The primary outcome measure was aseptic revision, defined as any reoperation performed after the index procedure involving exchange of the existing implant for reasons other than infection. Secondary outcomes were mortality (in-hospital, postdischarge, and overall), 90-day medical complications, 90-day emergency department visits, and 90-day unplanned readmissions. RESULTS: Among 12 491 patients in the study cohort who underwent hemiarthroplasty for hip fracture (median age, 83 years; 8660 women [69.3%]), 6042 (48.4%) had undergone uncemented fixation and 6449 (51.6%) had undergone cemented fixation, and the median length of follow-up was 3.8 years. In the multivariable regression analysis controlling for confounders, uncemented fixation was associated with a significantly higher risk of aseptic revision (cumulative incidence at 1 year after operation, 3.0% vs 1.3%; absolute difference, 1.7% [95% CI, 1.1%-2.2%]; hazard ratio [HR], 1.77 [95% CI, 1.43-2.19]; P < .001). Of the 6 prespecified secondary end points, none showed a statistically significant difference between groups, including in-hospital mortality (1.7% for uncemented fixation vs 2.0% for cemented fixation; HR, 0.94 [95% CI, 0.73-1.21]; P = .61) and overall mortality (cumulative incidence at 1 year after operation: 20.0% for uncemented fixation vs 22.8% for cemented fixation; HR, 0.95 [95% CI, 0.90-1.01]; P = .08). CONCLUSIONS AND RELEVANCE: Among patients with hip fracture treated with hemiarthroplasty in a large US integrated health care system, uncemented fixation, compared with cemented fixation, was associated with a statistically significantly higher risk of aseptic revision. These findings suggest that US surgeons should consider cemented fixation in the hemiarthroplasty treatment of displaced femoral neck fractures in the absence of contraindications.