Medicine is constantly evolving and changing including techniques used in orthopedic surgeries like total hip arthroscopy (THA). But is newer necessarily better?
Cementless THA is one advanced technique that many in the orthopedic community think offers better patient outcomes and streamline the surgical process; however, data show that periprosthetic fractures in the first few months postop are a serious concern, raising the question of whether surgeons should go back to cemented THA.
Joseph T. Moskal, M.D, FACS, chairman, department of orthopedic surgery at the Carilion Clinic Medical Center and chief of Adult Reconstruction at the Carilion Clinic Medical Center in Roanoke, Virginia, recently talked about why orthopedic surgeons should revisit the role of cemented stems in THA.
The Epiphany
On November 21, 2012, Moskal had an epiphany about the THA techniques he uses in the OR when he saw three patients back to back: Two had cemented THAs and were doing extremely well, while the third patient, who just recently had a cementless THA and was only two weeks post-op, was experiencing pain and would need a revision.
He said that his mission as a doctor has always been to maximize patient outcomes and satisfaction, minimize patient complications and revision rates, maintain control of the patient care and maintain the ability to do what he enjoyed, so he really started to question himself.
“I needed to convince myself that I am not a bad guy and I am going to learn from this. I am most influenced by my last complication and I was committed to change,” he said.
Realizing he never had this problem after performing a cemented THA, he asked himself what made him switch to cementless in the first place.
“So why did I switch from cemented to all cementless THA? To save time, to be able to do more procedures.”
So, he looked closely at the patient outcomes from both types of THAs and found the biggest difference was in the number of periprosthetic fractures that occurred.
He compared his last 1,000 cementless THA using the direct anterior approach (2 to 5 years of follow-up) to his last 1,000 cemented THA with the Exeter Stem (12 to 20 years of follow-up). According to the data he compiled, more patients with cementless stems experienced a periprosthetic fracture, which tended to occur early postoperatively. There were nine intra-operative calcar fractures in this group. The rates of loosening and thigh pain were also higher in the cementless stem patient group.
The Data Don’t Lie
Moskal wondered if it was just he who was experiencing these issues, but when he went digging, he found that other surgeons also have serious concerns about fractures with cementless THA.
According to an audience survey from International Congress for Joint Reconstruction’s (ICJR) 7th Annual Winter Hip and Knee Course in Vail, Colorado, in 2015, when asked what potential THA complication they worry the most often about, 100% of the audience responded intra-operative or early post-operative femoral fracture.
Moskal said that THA registry data also tells the same story. Cementless stems have twice the revision rate as the cemented stems, primarily resulting from twice the number of fractures.
He also pointed to the Australian registry data, which reported a higher rate of revision among patients with cementless implants than those with cemented in the first month after surgery. The Australian cementless fixation group had a higher rate of revision than the hybrid fixation group in all age groups, with the biggest difference registering in the oldest age group.
Data from the Finnish Registry published in “High Early Failure Rate After Cementless Hip Replacement in the Octogenarian” in Clinical Orthopaedics and Related Research in 2014, showed outcomes which were consistent with the Australian data.
In the Finnish study of 4,777 primary THAs in 4,509 octogenarian patients between 1998 and 2009, the cementless THAs had a higher, early revision rate (meaning less than 1 year) when compared with cemented THA, particularly in women and the leading reason for failure was periprosthetic fracture. After the first year though, there were no differences in the survival rates. (“High Early Failure Rate After Cementless Hip Replacement in the Octogenarian”)
French Registry data published in “Association Between Total Hip Replacement Characteristics and 3-Year Prosthetic Survivorship: A Population-Based” in Journal of American Medical Association Surgery in 2015 reported that antibiotic-impregnated cemented THAs offer a better prognosis than uncemented THAs. The registry included 100,191 patients 40 years of age or older who underwent THA in the French national health insurance system.
