Orthopedics

Cementless hip implants do not perform better or worse than cemented implants, particularly in patients with rheumatoid arthritis, according to a recent study in the Archives of Orthopaedic and Trauma Surgery journal.

A retrospective cementless implant literature survey of arthritic patients using the EMBASE, Medline and Cochrane Library databases showed that there was no evidence to suggest better performance in either cementless or cemented implants in 23 case series and 5 implant registry studies.

In 22 case series examining the acetabular cup, 9 of 22 series saw acetabular fractures and cup migration. In 20 stem series observed, proximal femoral fractures and or subsidence occurred in 14 cases.

When studying the failure rate in 6 series, the overall failure rate ratio was 0.6 for the cup and 0.71 for the stem, which the authors concluded favored uncemented fixation, according to the abstract. Overall, the failure rate was 0.97 for the cup and 0.79 for the stem.

In cases where there was no control group, the NICE criteria were used. The failure rate was reported as being higher than 1 in 6 of 26 acetabular cup studies and in 2 of 25 stem studies, favoring cemented fixation, according to the abstract.

“In all these studies, the inferior implant designs were blamed and not the type of fixation or the quality of the bone,” the authors wrote.

This is a well-done systematic review of the literature over the last 45 years, supporting the use of cementless total hip arthroplasty in rheumatoid arthritis patients. Cemented hips have seen improvements in alternative bearings and improved metallurgy while recent cementing techniques have not experienced many changes. At the same time, more improvements have been made to uncemented fixation, including the use of hydroyapatite, circumferential porous coating, improved locking mechanism on the acetabulum, and advanced fixation surfaces in addition to advances shared with cemented hips (i.e., alternative bearings and improved metallurgy). This progress has led to continued improvements in outcomes of cementless total hips, while outcomes of cemented hips have somewhat stayed the same. In our practice at the Cleveland Clinic, we rarely use cemented techniques for hips. Notable exceptions are cases when it is not possible to get fixation with press-fit implants or in tumor cases. In addition, as the cost of implants decrease the purported advantages of cemented fixation from a cost perspective will likely be minimized.

— Wael Barsoum, MD
Cleveland Clinic
Cleveland, OH

Disclosure: Barsoum receives research support from Stryker, Zimmer, Salient Surgical Technologies, Cool Systems, Orthovita and Active Implants. He is also a consultant with Stryker and Shukla Medical, receives royalties from Stryler, Zimmer, Exactech, Wright Medical and Shukla Medical and has stock options or company equity in Otismed, Custom Arthroplasty Solutions and Custom Orthopaedic Solutions.