To cement or not to cement, that is the question in elderly!

Osteoarthritis and osteoporosis are two chronic, progressive diseases of which the prevalence increases with age,[1] as well as hip fractures. Hip arthroplasty is a successful treatment method for end-stage osteoarthritis and hip fractures in elderly. Once the surgeon decides to apply hip arthroplasty, cementation is one of the main concerns to decide and there are a variety of fixation techniques such as cementless, hybrid, reverse hybrid, and cemented.[2]

Age is one of the determinants for the fixation technique and cementless total hip arthroplasty is usually preferred over a cemented technique in patients younger than 70 years old with hip osteoarthrosis.[3] In older patients, osteoporosis is the main problem with the accompanying low quality of the bone, leading to the failure of osseointegration in cementless fixation of the acetabular cup and femoral stem.[1,4] Examining the acetabular cup, the cemented technique has excellent long-term result and, therefore, the widespread preference for cementless fixation of the acetabulum cannot be explained by a superior survival of cementless fixation technique.[5,6]

The femoral stem is one of the two main components of total hip arthroplasty. In a recent cadaveric study, cemented stem increased the load-to-failure force by 25% compared to the cementless stem, being one of the other explanations of the higher failure rate of the cementless technique.[7] While comparing the modern uncemented femoral stem designs and cemented stems, the latter has lower rates of periprosthetic fracture.[8] This is another disadvantage of the cementless technique that leads to higher re-operation rates in total hip arthroplasty.[3,8]

As a result, the cementless fixation technique is associated with an increased risk of revision; that is why the cemented technique is suggested to be the gold standard in older patients with 10- to 20-year survival rates exceeding 90% in patients 75 years and older.[1,4] Despite the advantages of the cemented fixation technique in older patients, some drawbacks exist such as bone cement implantation syndrome-induced early postoperative mortality.[3,9,10] Although there is a widespread-dating back-belief of higher mortality after cementation, recent data from 188,606 surgeries in the Nordic Arthroplasty Register Association database[9] and a recent randomized- controlled trial comparing cementless versus cemented techniques[10] reported similar mortality rates, as well as a study examining the mortality rates in 4,509 octogenarian patients after total hip arthroplasty.[4] In a large-scale study including 12,491 patients who underwent hemiarthroplasty, cemented technique choice did not influence hospital mortality (1.7% for uncemented fixation vs. 2.0% for cemented fixation; p=0.61) and overall mortality (cumulative incidence at one year after the operation: 20.0% for uncemented fixation vs. 22.8% for cemented fixation; p=0.08) in hip fracture patients.[11]

Aging of the population inevitably leads to the increase in the incidence of hip fractures, and a progressive increase in the cumulative cost of the treatment causes a heavy burden for the hospitals and social security system; that is why costs are another concern for the choices of the cemented or cementless technique. While evaluating the Medicare patients, cemented femoral fixation outperformed cementless fixation in terms of the length of hospital stay, readmission, cost of care, and reoperation.[12] Revisions after hip replacement is another cause of the increased cost, cemented fixation should be considered for the elder total hip arthroplasty patients[1,4] and the hemiarthroplasty treatment of displaced femoral neck fractures,[8,11] unless contraindicated.

Why do surgeons insist to use cementless fixation for all the patients, despite the strong evidence in favor of cementation for the elder total and partial arthroplasty patients? There may have been selection bias based upon surgeon training and experience, which we are unable to control the given available database information.[12] In a low-volume education center, one can finish a fellowship or residency program without experiencing any cemented fixation; therefore, he/she may concern about his/her sufficiency of the surgical skill in applying the cemented technique. At least 10 cases per annum need to ensure the preservation of the surgical skill in cementation to minimize revision risk.[6] In elder groups, poor bone biology is challenging in cementless fixation, and cemented fixation is the better choice with less complication, low cost, and better clinical outcomes. Therefore, surgeons should be versatile between these two techniques in their surgical skills. Surgical training programs should be organized to provide this surgical technique versatility during the residency and fellowship education.