Variation in the Use of Cemented Versus Uncemented Hemiarthroplasty and Total Hip Arthroplasty for Treatment of Femoral Neck Fractures in the United States.

Abstract

Practice guidelines in the United States (US) recommend cemented femoral fixation in hemiarthroplasty (HA) and total hip arthroplasty (THA) to treat femoral neck fractures (FNFs) for older patients. The purpose of this study was to assess regional variation and hospital characteristics associated with cement use for HA and THA used to treat FNFs and to determine the impact of cement use on adverse outcomes. All FNF patients ≥ 65 years treated with HA or THA from 2012 to 2021 in the American Joint Replacement Registry (AJRR) were analyzed. There were 81,610 cases included: 15,282 THAs and 66,328 HAs. Patient demographics, cement use stratified by region and hospital type, and adverse outcomes were recorded. Multivariate analyses were performed. Cemented femoral fixation was used in 39.8% of combined HA and THA cases with greater frequency in HA (44.5%) compared with THA (19.2%, P < 0.001). Cement utilization ranged from 6 to 83% by state with 2-fold variation comparing Midwest and Southern regions (56 versus 29%, respectively, P < 0.001). Major teaching centers were more likely to use cement than non-teaching institutions (odds ratio (OR) 1.84, P < 0.001). Cemented compared with cementless fixation had a lower hazard ratio for all-cause revision (hazard ratio (HR): 0.75; P < 0.001), revision at three months (HR: 0.64; CI [confidence interval]: 0.554 to 0.75, P < 0.001), and revision for periprosthetic fracture (HR: 0.21; CI: 0.15 to 0.30, P < 0.001). Cemented fixation had an 8.9% higher hazard for mortality (HR: 1.089; CI: 1.06 to 1.12; P = 0.001). There is significant regional variation regarding the prevalence of cemented femoral fixation used to treat FNFs with either HA or THA in the US. Cemented fixation resulted in a lower risk of periprosthetic fracture and revision surgery. Higher mortality was associated with cemented fixation, but may relate to selection bias. The observed variation in clinical practice and lack of conformity to published guidelines is an opportunity for quality improvement.