Study: Higher Fracture Risk After Total Hip Replacement When Cementless Implant Used to Treat Femoral Neck Fracture

A study by Hospital for Special Surgery (HSS) and other centers found that total hip replacement performed with a cementless prosthesis for a femoral neck fracture led to a higher rate of a second fracture and subsequent revision surgery. The research was presented today at the American Academy of Orthopaedic Surgeons (AAOS) Annual Meeting in Las Vegas. The results were also published online in The Journal of Arthroplasty in October 2022.

Treatments for a femoral neck fracture range from nonoperative management to total hip replacement. When hip replacement is the best treatment option, it can be performed with or without bone cement to secure the prosthesis.

“Femoral neck fractures are very common in the elderly and are a major cause of morbidity and mortality in this population,” explained Alexander McLawhorn, MD, a hip and knee orthopedic surgeon at HSS and study author. “Several national registry studies have demonstrated a lower risk of overall revision surgery, and specifically revision for periprosthetic fracture, with cemented femoral fixation. Despite this overwhelming data, many patients in the United States receive cementless fixation, including patients who have sustained femoral neck fractures.”

“To our knowledge, this was the first non-registry study comparing outcomes of cemented versus cementless total hip replacement for acute femoral neck fractures examining the influence of various patient factors, including bone quality,” explained Michael Kheir, MD, who presented the study at the AAOS meeting and played a leading role in the research during his fellowship at HSS. “The primary purpose was to compare complication rates between both groups, including periprosthetic fractures, aseptic revision, dislocation and mortality rates.” Dr. Kheir is currently an orthopedic surgeon specializing in hip and knee replacement at the University of Michigan.

The retrospective study analyzed 709 total hip replacement cases (199 cemented, 510 cementless) for femoral neck fractures from 2006 to 2020 at three large academic institutions: Hospital for Special Surgery, Indiana University Health and University Hospitals Cleveland Medical Center. Patient demographics, perioperative characteristics and x-rays were reviewed. The Dorr classification system, widely used to evaluate femoral bone quality, categorized patients with Dorr type A, B or C, with type C indicating the weakest bone. 

The average age of study participants was 71 years; 66.9% of patients were women. The prevalence of Dorr type bone was 21.1% type A; 66.3% type B; and 12.6% type C. Patients receiving cemented implants were older, had a lower BMI, were more often women and were more likely to have a pre-existing diagnosis of osteoporosis and Dorr C bone type.

Cementless implant stems had a higher all-cause aseptic femoral revision rate (5.1 versus 0.5%,) and periprosthetic femoral fracture rate (4.3 versus 0%). Bone classification played a major role: Each successive Dorr grade had a higher fracture rate with cementless implants (Dorr A =2.3%; Dorr B = 3.7%; Dorr C = 15.9%). There was no difference in rates of dislocation, revision due to infection or mortality rate between groups. The study found an equal distribution of male and female patients who sustained a fracture.

“While femoral fractures occurred in patients with all types of bone quality, Dorr C bone was particularly prone, with an alarmingly high fracture rate when using cementless stems,” Dr. Kheir noted. “All of the fractures requiring a revision surgery occurred in cementless cases, suggesting that cemented stems may minimize this complication, regardless of patient sex or Dorr classification.”

Authors: Alexander McLawhorn, MD, MBA; Emile-Victor Kuyl, BS, (HSS); George Ochenjele, MD, FAAOS, (UH Cleveland Medical Center); Jacob Speybroeck, MD; Julian Dilley, MD, (Indiana University Health); Michael M. Kheir, MD, (University of Michigan); R M. Meneghini, MD, FAAOS, (Indiana University Health Phys)

About HSS

HSS is the world’s leading academic medical center focused on musculoskeletal health. At its core is Hospital for Special Surgery, nationally ranked No. 1 in orthopedics (for the 13th consecutive year), No. 3 in rheumatology by U.S. News & World Report (2022-2023), and the best pediatric orthopedic hospital in NY, NJ and CT by U.S. News & World Report “Best Children’s Hospitals” list (2022-2023). In a survey of medical professionals in more than 20 countries by Newsweek, HSS is ranked world #1 in orthopedics for a third consecutive year (2023). Founded in 1863, the Hospital has the lowest complication and readmission rates in the nation for orthopedics, and among the lowest infection rates. HSS was the first in New York State to receive Magnet Recognition for Excellence in Nursing Service from the American Nurses Credentialing Center five consecutive times. An affiliate of Weill Cornell Medical College, HSS has a main campus in New York City and facilities in New Jersey, Connecticut and in the Long Island and Westchester County regions of New York State, as well as in Florida. In addition to patient care, HSS leads the field in research, innovation and education. The HSS Research Institute comprises 20 laboratories and 300 staff members focused on leading the advancement of musculoskeletal health through prevention of degeneration, tissue repair and tissue regeneration. The HSS Innovation Institute works to realize the potential of new drugs, therapeutics and devices. The HSS Education Institute is a trusted leader in advancing musculoskeletal knowledge and research for physicians, nurses, allied health professionals, academic trainees, and consumers in more than 145 countries. The institution is collaborating with medical centers and other organizations to advance the quality and value of musculoskeletal care and to make world-class HSS care more widely accessible nationally and internationally. www.hss.edu.