Cementless Hemiarthroplasty for Intracapsular Femoral Neck Fractures in the Octa- and Nonagenarians

The population analyzed in this study was 80 years old or older.6) The operative time (mean, 50 minutes; SD, 17 minutes) was comparable to that of a randomized controlled trial (RCT) by Parker et al.4) (mean, 48.5 minutes; SD, 13.2 minutes). The operative time was shorter than that for cemented procedures since cementing requires polymerization, which leads to an increase in the duration of surgery.2, 4, 5)

Considering hemoglobin behavior, the result of the current study was not so precise since it was impossible to determine if the patient underwent blood transfusion during surgery. However, the difference between pre- and postoperative hemoglobin seemed low. Li et al.7) showed the same quantity of blood loss for both techniques. Figved et al.8) reported a reduced blood loss with the cementless technique.

There were no deaths intraoperatively. Bone cement implantation syndrome was not encountered.9, 10) Although some authors support the use of cement due to the improvement in surgical techniques and modern stem designs, as well as intraoperative monitoring, Middleton et al.11) reported increased perioperative mortality in patients receiving cemented rather than cementless prostheses and thus recommended cementless hemiarthroplasty in the elderly.3, 5, 12)

In our study, death occurred after surgery during hospitalization due to complications, such as septic and hypovolemic shock, followed by cardiovascular collapse. Almost all patients presented with perioperative anemia, which is commonly reported in the literature as an independent risk factor for decline in physical performance.13, 14) One third of the patients had systemic complications during hospitalization. During the postoperative period, preexisting medical conditions could exacerbate, predisposing the patient to increased mortality.15, 16) Complications related to the implant itself during hospitalization were few, with the majority being dislocations and infections. Dislocations were related to the patient characteristics or implant characteristics.17, 18) Risk factors related to the patient include dementia, cognitive dysfunction, and reduced mobility. This is because it is difficult to maintain patients with impaired cognitive function in an appropriate posture postoperatively.

The rate of dislocation in our patients was 1.2% during hospitalization. In the first 40 days of follow-up, further 2.3% dislocations occurred. Barnes et al.19) reported a comparable dislocation rate (1.5%). Dislocation is more frequent in the first few months after surgery than in the following period due to the reduced strength of soft tissues.17, 19, 20) Once a patient experiences dislocation, the risk of having recurrent dislocation increases.19) Intraoperative periprosthetic fractures were found in 2.1% and they were mainly related to the implant insertion. The majority of the fractures were fixed with cerclage wires intraoperatively, while 2 underwent subsequent revision with a plate or revision stem. The rate of aseptic loosening was low with only 1 case found at 12 months. During follow-up, complications, such as postoperative periprosthetic fractures, were few, which could be explained in part by the low follow-up rate but largely by the fact that patients who continued to be followed up were completely assisted by a multidisciplinary team made up of physiotherapists, rheumatologists and orthopedics, who helped treat osteoporosis and prevent further falling, which increases the risk for implant instability.

The main outcomes reached were the return to the ambulatory status (either in an autonomous manner or with the use of aids) and the inability to do ambulation (patients bedridden or wheelchair-bound). In literature, however, there is a tendency for the cemented procedure to produce better functional outcomes as underlined by the RCT of Parker et al.4) and by the systematic review of Luo et al.21) On the contrary, Figved et al.,8) DeAngelis et al.,22) and Grammatopoulos et al.23) reported good functional outcomes for both cemented and cementless techniques. Our study is in line with the second group of studies since at each follow-up assessment, more than 90% of patients were ambulatory either autonomously or with the use of walking aids.

Heterotopic ossification was present in one third of the X-rays of the patients, but none was reoperated. One of the main reasons could be the posterolateral surgical approach.24) In addition, according to the literature, thromboprophylaxis with LMWH 4,000 IU per day was continued for 35–40 days and patients managed it autonomously without any bleeding complications.25)

In the literature, there is a wide debate concerning the prevention of a secondary fracture after a fragility fracture.25, 26) This involves 2 main aspects: the adoption of safeguarding measures to prevent falls, thus minimizing their occurrence, and the reduction of the manifestations of severe osteoporosis.25) Thus, we prescribed basic drugs for osteoporosis at discharge and conducted a rheumatological consult in order to further evaluate the disease in time. After the calculation of mortality, we performed multivariate analysis to evaluate factors having an effect on mortality. According to Petersen et al.16) in order of significance, the 5 factors associated with increased mortality at 3 months were the following: cardiac complications, dementia, male sex, age, and waiting time for surgery. Our results were in line with the literature since the age, the male sex, and higher ASA score were associated with increased mortality risk. On the contrary, the time before surgery had no significant effect on mortality in our patients. A more focused analysis on the waiting time before surgery with other exclusion and inclusion criteria would have been necessary.

The study has some limitations, which are mainly related to the old age of the patients. First, many patients were lost during the follow-up, either because they died or because they simply did not come for follow-up visits. This could create a big bias in the study, so we tried to investigate why many patients simply did not return by surveying through phone the ones still alive: for some patients who did not regain mobility, it was difficult to come back as they were really old and did not have any assistance; the others who did really well without complications did not return to the hospital. Second, functional outcomes were not evaluated through the Harris Hip Score or the EQ-5D because many patients were already dead at the time of the study. For those who were alive, due to the advanced age, it would have been difficult to understand the questionnaires or to compile them.

In summary judging from the results obtained with the use of cementless stems, it seems that a femoral stem of modern design can give good clinical outcomes, thus being an appropriate solution especially for the frail elderly. However, the study has some limitations: patient's death, loss to follow-up, lack of functional assessment with scores. Despite these limitations, this study supports the use of cementless stems for the frail elderly and serves as a starting point for future high-quality RCTs or large multicenter RCTs, which will be necessary to determine the adequacy of the cementless technique for the frail elderly population.