Abstract
Background:
Complications following elective total hip arthroplasty (THA) are rare but potentially devastating. The impact of femoral component cementation on the risk of periprosthetic femoral fractures and early perioperative death has not been studied in a nationally representative population in the United States.
Methods:
Elective primary THAs performed with or without cement among elderly patients were identified from Medicare claims from 2017 to 2018. We performed separate nested case-control analyses matched 1:2 on age, sex, race/ethnicity, comorbidities, payment model, census division of facility, and exposure time and compared fixation mode between (1) groups with and without 90-day periprosthetic femoral fracture and (2) groups with and without 30-day mortality.
Results:
A total of 118,675 THAs were included. The 90-day periprosthetic femoral fracture rate was 2.0%, and the 30-day mortality rate was 0.18%. Cases were successfully matched. The risk of periprosthetic femoral fracture was significantly lower among female patients with cement fixation compared with matched controls with cementless fixation (OR = 0.83; 95% CI, 0.69 to 1.00; p = 0.05); this finding was not evident among male patients (p = 0.94). In contrast, the 30-day mortality risk was higher among male patients with cement fixation compared with matched controls with cementless fixation (OR = 2.09; 95% CI, 1.12 to 3.87; p = 0.02). The association between cement usage and mortality among female patients almost reached significance (OR = 1.74; 95% CI, 0.98 to 3.11; p = 0.06).
Conclusions:
In elderly patients managed with THA, cemented stems were associated with lower rates of periprosthetic femoral fracture among female patients but not male patients. The association between cemented stems and higher rates of 30-day mortality was significant for male patients and almost reached significance for female patients, although the absolute rates of mortality were very low. For surgeons who can competently perform THA with cement, our data support the use of a cemented stem to avoid periprosthetic femoral fracture in elderly female patients.
Level of Evidence:
Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.
Total hip arthroplasty (THA) is a highly successful operation with expanding utilization1,2. The procedure is nonetheless associated with serious complications, including periprosthetic femoral fracture and death3,4. Periprosthetic femoral fracture is itself associated with a mortality rate of up to 18%5-7. While periprosthetic femoral fracture can occur in association with any method of femoral component fixation, the use of cement fixation has been linked to lower fracture risk8-10. The increased risk of periprosthetic femoral fracture with cementless fixation is especially relevant among patients with poor bone quality, including elderly patients and female patients11-14. However, studies have linked cement use to embolization of marrow contents, causing detrimental effects on the cardiopulmonary system and potentially even early perioperative death15-18, although these concerns have been challenged by studies of THA in the setting of modern anesthetic and perioperative protocols9,19,20. Overall, the rates of mortality after elective THA remain relatively low21,22.
Choice of femoral fixation strategy varies according to geography and surgeon familiarity. Cementless fixation has become the preferred method for the majority of surgeons in the United States, with a study of >100,000 primary THAs showing that use of a cementless femoral component increased from 49% to 94% between 2001 and 201223. In a 2018 poll of arthroplasty surgeons, >90% of respondents reported using a cementless stem in at least 75% of the elective THAs that they performed24. Possible advantages of cementless femoral fixation include shorter operative times, the potential for osseointegration, and the avoidance of cardiopulmonary complications related to cementation25,26. The trend toward the use of cementless fixation has occurred despite the excellent track record of cement fixation; data from multiple registries have shown favorable early and long-term revision rates compared with cementless stems among elderly patients27-30.
While the putative risks and benefits of each option have been explored in the literature, there is no consensus on the optimal choice of femoral fixation for elective THA. Also lacking are studies examining the associations between cement usage and periprosthetic femoral fracture and mortality in the United States. Therefore, we sought to characterize the scope of use and risk of periprosthetic femoral fracture and mortality in a nationally representative sample of elderly patients undergoing elective primary THA in the United States. We hypothesized that the use of cemented femoral components would be associated with lower rates of periprosthetic femoral fracture and mortality.
Materials and Methods
Data Sources and Cohort Selection
Medicare claims data from the Centers for Medicare & Medicaid Services (CMS) were used to identify all primary THA procedures among fee-for-service beneficiaries during calendar years 2017 and 2018. Primary THA admissions were selected as those associated with a Diagnosis Related Group code of 469 or 470 and an International Classification of Diseases (ICD)-10 procedure code for primary THA. Arthroplasties for fracture, neoplasm, infection, or revision (i.e., non-elective procedures) were excluded according to CMS methodology for quality reporting31. Patients were required to be enrolled in fee-for-service Medicare for at least 12 months prior to admission for THA in order to calculate comorbidity. From this THA population, we identified cohorts for 2 separate matched case-control analyses.
Outcomes
Periprosthetic femoral fracture within 90 days postoperatively and death within 30 days postoperatively were the main outcomes. ICD-10-CM (Clinical Modification) codes were used to identify periprosthetic femoral fractures with the same laterality as the index procedure. The date of death was obtained from Medicare enrollment files.
Matching Variables
Patient age, sex, and race/ethnicity (African American/Black, Hispanic, White non-Hispanic, other) were identified from the Medicare enrollment file. Medicare claims files were used to calculate comorbidity for the 12 months prior to THA admission with use of the Elixhauser index32,33. Dual enrollment, as a proxy for low-income status, was identified from the Medicare enrollment file and was considered to be positive if the beneficiary was also enrolled in Medicaid and/or a state buy-in program during the month of admission for THA34. To identify facilities within mandatory bundling areas, the Metropolitan Statistical Area (MSA) of the facility was identified with use of CMS Provider of Services files. The census division of the facility was also identified using the CMS Provider of Services files. The use of cement was identified with use of ICD-10 procedure codes that were recorded at the time of the index admission for THA, with cement fixation being indicated by codes 0SR9019, 0SR9029, 0SR9039, 0SR9049, 0SR9069, 0SR90J9, 0SRB019, 0SRB029, 0SRB039, 0SRB049, 0SRB069, and 0SRB0J9 and uncemented fixation being indicated by codes 0SR901A, 0SR902A, 0SR903A, 0SR904A, 0SR906A, 0SR90JA, 0SRB01A, 0SRB02A, 0SRB03A, 0SRB04A, 0SRB06A, and 0SRB0JA.
Analysis
To circumvent the inherent selection bias resulting from observational data, we performed separate matched case-control analyses when examining the associations between cement fixation and (1) 90-day periprosthetic femoral fracture and (2) 30-day mortality. For the fracture outcome, cases were identified as patients who experienced a periprosthetic femoral fracture during the 90-day period following surgery. Cases were matched 1:2 to controls on the basis of sex, age (±3 years), race (Black/African American, Hispanic, other, White), number of comorbidities (0 to 3 versus ≥4), payment model (facility subject to mandatory bundling payment for joint replacement versus not), census division of facility, and exposure time (time to fracture for cases, time observed without fracture for controls); controls were selected from among the patients who did not experience a periprosthetic femoral fracture during the 90-day period following THA by means of random sampling with no replacement35-38. For the mortality outcome, cases were identified as patients who died during the 30-day period following THA. Cases were matched 1:2 to controls with use of an analogous approach to that described above, with exposure time defined as time to death for cases and time observed alive for controls during the 30-day period following surgery. For both outcomes, cases were successfully matched (Fig. 1).
Fig. 1.
Case-control cohorts for 90-day fracture complication and 30-day mortality analyses.
Cement fixation was assessed for each matched pair member. For both outcomes, the odds ratios (ORs) between cement fixation and (1) 90-day periprosthetic femoral fracture and (2) 30-day mortality were estimated with conditional logistic regression to account for the matching, with covariate adjustments for low-income status, a factor on which case-control matching was not feasible. Following the literature, we stratified the sample by sex to account for the known differences in bone quality between males and females39-41. All analyses were performed with use of Stata 16 (StataCorp) within the CMS Virtual Research Data Center (VRDC).
Source of Funding
This study was funded by NIH grant R01AG058718.
Results
A total of 118,675 THA cases were included; 73,523 (62.0%) were female and 45,152 (38.0%) were male. The rate of femoral cement fixation was 10.9% in females and 6.1% in males. The 90-day overall rate of periprosthetic fracture was 2.0%, with 1,836 fractures in females (fracture rate, 2.5%) and 509 fractures in males (fracture rate, 1.1%). The rate of 30-day mortality was 0.18%, with 110 deaths in females (mortality rate, 0.15%) and 104 deaths in males (mortality rate, 0.23%).
Patient characteristics for the 90-day fracture outcome are shown in Table I. With the exception of slightly older age among female cases (mean and standard deviation, 76.3 ± 6.4 years for cases versus 75.2 ± 6.5 years for controls; p < 0.001), there were no significant differences between female or male cases and controls with respect to matching or control variables. For females, the rate of cement usage was 10.1% among fracture cases compared with 11.8% among controls (p = 0.06). Although lower than that for females, cement usage among males did not differ between cases and controls (6.7% versus 6.8%; p = 0.94). ORs from the conditional logit models indicated that, while cement use was associated with a significantly lower risk of a periprosthetic femoral fracture among females (OR = 0.83; 95% confidence interval [CI], 0.69 to 1.00; p = 0.05), it had no effect among males (OR = 0.98; 95% CI, 0.63 to 1.54; p = 0.94) (Table II).
TABLE I.
Admission Characteristics for 90-Day Fracture Analyses*
| Female Patients | Male Patients | |||||||
|---|---|---|---|---|---|---|---|---|
| Total (N = 73,332) |
Cases (N = 1,836) |
Controls (N = 3,672) |
P Value | Total (N = 45,029) |
Cases (N = 509) | Controls (N = 1,018) |
P Value | |
| Age† (yr) | 74.9 ± 6.3 | 76.3 ± 6.4 | 75.2 ± 6.5 | <0.001 | 74.2 ± 6.0 | 76.0 ± 6.6 | 75.2 ± 6.7 | 0.036 |
| Race (no. of patients) | >0.999 | >0.999 | ||||||
| Non-Hispanic White | 68,090 (92.8%) | 1,740 (94.8%) | 3,480 (94.8%) | 42,291 (93.9%) | 485 (95.3%) | 970 (95.3%) | ||
| Black/African American | 2,781 (3.8%) | 52 (2.8%) | 104 (2.8%) | 1,444 (3.2%) | 12 (2.4%) | 24 (2.4%) | ||
| Hispanic | 1,390 (1.9%) | 27 (1.5%) | 54 (1.5%) | 722 (1.6%) | <15 (<2.9%) | <30 (<2.9%) | ||
| Other | 1,071 (1.5%) | 17 (0.9%) | 34 (0.9%) | 572 (1.3%) | <15 (<2.9%) | <30 (<2.9%) | ||
| Comorbidity (no. of patients) | >0.999 | >0.999 | ||||||
| 0-3 | 56,948 (77.7%) | 1,315 (71.6%) | 2,630 (71.6%) | 34,009 (75.5%) | 350 (68.8%) | 700 (68.8%) | ||
| 4+ | 16,384 (22.3%) | 521 (28.4%) | 1,042 (28.4%) | 11,020 (24.5%) | 159 (31.2%) | 318 (31.2%) | ||
| Low income (no. of patients) | 3,049 (4.2%) | 86 (4.7%) | 172 (4.7%) | >0.999 | 958 (2.1%) | 16 (3.1%) | 32 (3.1%) | >0.999 |
| Cement (no. of patients) | 8,000 (10.9%) | 186 (10.1%) | 434 (11.8%) | 0.06 | 2,753 (6.1%) | 34 (6.7%) | 69 (6.8%) | 0.94 |
| Bundling MSA‡ (no. of patients) | 24,364 (33.2%) | 620 (33.8%) | 1,240 (33.8%) | >0.999 | 14,764 (32.8%) | 180 (35.4%) | 360 (35.4%) | >0.999 |
| Census division (no. of patients) | >0.999 | >0.999 | ||||||
| Northeast | 4,570 (6.2%) | 114 (6.2%) | 228 (6.2%) | 2,658 (5.9%) | 30 (5.9%) | 60 (5.9%) | ||
| Mid-Atlantic | 10,299 (14.0%) | 264 (14.4%) | 528 (14.4%) | 5,893 (13.1%) | 68 (13.4%) | 136 (13.4%) | ||
| South Atlantic | 14,005 (19.1%) | 321 (17.5%) | 642 (17.5%) | 8,916 (19.8%) | 96 (18.9%) | 192 (18.9%) | ||
| East North Central | 13,661 (18.6%) | 351 (19.1%) | 702 (19.1%) | 8,275 (18.4%) | 99 (19.4%) | 198 (19.4%) | ||
| East South Central | 3,575 (4.9%) | 79 (4.3%) | 158 (4.3%) | 2,172 (4.8%) | 29 (5.7%) | 58 (5.7%) | ||
| West North Central | 6,175 (8.4%) | 158 (8.6%) | 316 (8.6%) | 3,815 (8.5%) | 35 (6.9%) | 70 (6.9%) | ||
| West South Central | 6,026 (8.2%) | 181 (9.9%) | 362 (9.9%) | 3,731 (8.3%) | 51 (10.0%) | 102 (10.0%) | ||
| Mountain | 6,166 (8.4%) | 152 (8.3%) | 304 (8.3%) | 3,912 (8.7%) | 46 (9.0%) | 92 (9.0%) | ||
| Pacific | 8,855 (12.1%) | 216 (11.8%) | 432 (11.8%) | 5,657 (12.6%) | 55 (10.8%) | 110 (10.8%) | ||
Cases (fracture within 90 days) and controls (no fracture within 90 days) were matched at a 1:2 ratio on the basis of age (±3 years), race (Black/African American, Hispanic, other, White), dichotomous comorbidity (0-3 vs. 4+), payment model (facility subject to mandatory bundling payment for joint replacement versus not), census division of facility, and exposure time (time to fracture for cases, time observed without fracture during the 90-day period following surgery for controls).
The values are given as the mean and the standard deviation.
MSA = Metropolitan Statistical Area.
TABLE II.
Conditional Logit Model Results for Association of Cement Usage with 90-Day Fracture and 30-Day Mortality*
| Cement Effect | Female Patients | Male Patients | ||||
|---|---|---|---|---|---|---|
| OR | 95% CI | P Value | OR | 95% CI | P Value | |
| Effect on 90-day fracture rate | 0.83 | 0.69–1.00 | 0.05 | 0.98 | 0.63–1.54 | 0.94 |
| Effect on 30-day mortality rate | 1.74 | 0.98–3.11 | 0.06 | 2.09 | 1.12–3.87 | 0.02 |
Both models include an additional adjustment for low-income status.
Patient characteristics for the outcome of 30-day mortality are shown in Table III. Consistent with the successful matching, there were no significant differences in any characteristics between female or male cases and controls. However, cement fixation was markedly higher among male cases compared with controls (21.2% versus 11.1%; p = 0.017). Results from the conditional logit model adjusting for low-income status confirmed these unadjusted findings: males who received femoral cement fixation were more than twice as likely to die within 30 days postoperatively than their counterparts who received cementless fixation (OR = 2.09; 95% CI, 1.12 to 3.87; p = 0.02) (Table II). The association between cement usage and 30-day mortality for female cases nearly reached significance (OR = 1.74; 95% CI, 0.98 to 3.11; p = 0.06).
TABLE III.
Admission Characteristics for 30-Day Mortality Analyses*
| Female Patients | Male Patients | |||||||
|---|---|---|---|---|---|---|---|---|
| Total (N = 73,523) | Cases (N = 110) | Controls (N = 220) | P Value | Total (N = 45,152) | Cases (N = 104) | Controls (N = 208) | P Value | |
| Age† (yr) | 74.9 ± 6.3 | 80.0 ± 7.4 | 79.6 ± 7.0 | 0.63 | 74.3 ± 6.0 | 78.9 ± 7.5 | 78.2 ± 7.4 | 0.44 |
| Black/African American (no. of patients) | 2,801 (3.8%) | <12 (<12%) | <24 (<12%) | >0.999 | 1,451 (3.2%) | <12 (<12%) | <24 (<12%) | >0.999 |
| Comorbidity (no. of patients) | >0.999 | >0.999 | ||||||
| 0-3 | 57,098 (77.7%) | 57 (51.8%) | 114 (51.8%) | 34,101 (75.5%) | 36 (34.6%) | 72 (34.6%) | ||
| 4+ | 16,425 (22.3%) | 53 (48.2%) | 106 (48.2%) | 11,051 (24.5%) | 68 (65.4%) | 136 (65.4%) | ||
| Low income (no. of patients) | 3,077 (4.2%) | <12 (<12%) | <24 (<12%) | 0.87 | 962 (2.1%) | <12 (<12%) | <24 (<12%) | 0.07 |
| Cement (no. of patients) | 8,014 (10.9%) | 23 (20.9%) | 29 (13.2%) | 0.07 | 2,758 (6.1%) | 22 (21.2%) | 23 (11.1%) | 0.017 |
| Bundling MSA‡ (no. of patients) | 24,431 (33.2%) | 33 (30.0%) | 66 (30.0%) | >0.999 | 14,813 (32.8%) | 34 (32.7%) | 68 (32.7%) | >0.999 |
| Census division (no. of patients) | >0.999 | >0.999 | ||||||
| Northeast | 4,594 (6.3%) | <12 (<12%) | <24 (<12%) | 2,669 (5.9%) | <12 (<12%) | <24 (<12%) | ||
| Mid-Atlantic | 10,329 (14.0%) | 21 (19.1%) | 42 (19.1%) | 5,918 (13.1%) | 15 (14.4%) | 30 (14.4%) | ||
| South Atlantic | 14,031 (19.1%) | 15 (13.6%) | 30 (13.6%) | 8,933 (19.8%) | 30 (28.8%) | 60 (28.8%) | ||
| East North Central | 13,692 (18.6%) | 22 (20.0%) | 44 (20.0%) | 8,312 (18.4%) | 15 (14.4%) | 30 (14.4%) | ||
| East South Central | 3,581 (4.9%) | <12 (<12%) | <24 (<12%) | 2,174 (4.8%) | <12 (<12%) | <24 (<12%) | ||
| West North Central | 6,185 (8.4%) | <12 (<12%) | <24 (<12%) | 3,822 (8.5%) | <12 (<12%) | <24 (<12%) | ||
| West South Central | 6,048 (8.2%) | <12 (<12%) | <24 (<12%) | 3,739 (8.3%) | 13 (12.5%) | 26 (12.5%) | ||
| Mountain | 6,192 (8.4%) | <12 (<12%) | <24 (<12%) | 3,919 (8.7%) | <12 (<12%) | <24 (<12%) | ||
| Pacific | 8,871 (12.1%) | 13 (11.8%) | 26 (11.8%) | 5,666 (12.5%) | <12 (<12%) | <24 (<12%) | ||
| In-hospital mortality (no. of patients) | 31 (0.04%) | 31 (28.2%) | 27 (0.06%) | 26 (25.0%) | ||||
Cases (death within 30 days) and controls (alive at 30 days) were matched at a 1:2 ratio based on age (±3 years), race (Black/African American versus all others), dichotomous comorbidity (0-3 vs. 4+), payment model (facility subject to mandatory bundling payment for joint replacement versus not), census division of facility, and exposure time (time to death for cases, time observed alive during the 30-day period following surgery for controls).
The values are given as the mean and the standard deviation.
MSA = Metropolitan Statistical Area.
Discussion
Complications following elective THA are rare but potentially devastating. Periprosthetic femoral fracture is a leading cause of early reoperation and carries with it a substantial risk of mortality. The choice of femoral fixation strategy is an important variable that can influence the risks of both fracture and mortality. This large national study is critically important because, to our knowledge, it is the first to use a rigorous experimental design to evaluate the outcomes of cement fixation among a nationally representative sample of elderly persons undergoing THA. We found that, among female patients who were enrolled in Medicare, the use of cement fixation was linked to a 17% lower risk of periprosthetic femoral fracture and that, among male patients who were enrolled in Medicare, the use of cement fixation was associated with a greater than twofold increase in the risk of death.
Data from national arthroplasty registries have shown lower rates of revision following primary THA with use of cemented femoral components in at-risk patients. In the National Joint Registry from the United Kingdom, for example, female patients >75 years of age who underwent primary THA had a 1-year all-cause revision rate of 1.27% (95% CI, 1.17% to 1.37%) in association with cementless femoral components, compared with 0.75% (95% CI, 0.67% to 0.83%) in association with cemented femoral components29. In the New Zealand registry, the revision rate per 100 component-years in patients >75 years of age was 0.74 (95% CI, 0.64 to 0.85) for cementless femoral components, compared with 0.50 (95% CI, 0.46 to 0.55) for cemented femoral components28. Tanzer et al., in a review of patients >75 years of age undergoing THA who were included in the Australian Orthopaedic Association National Joint Replacement Registry, reported that the risk of revision in the first month following elective procedures was markedly higher in association with cementless stems compared with cemented stems (hazard ratio [HR], 8.82; p < 0.001)39. Finally, in a study from the American Joint Replacement Registry (AJRR), cementless femoral stems were linked to 596 of 628 periprosthetic femoral fractures that required revision with 3 months after primary hip replacement42. Our results, based on a rigorous case-control matched design that was applied to nationally representative United States data, are consistent with those reported from these registries, indicating that the use of cementless stems is associated with higher risk of periprosthetic femoral fracture in at-risk patients, namely, elderly females.
There have been conflicting data on the risks of cardiopulmonary events and early mortality with cementation during THA. Reported all-cause, 90-day mortality rates following THA have ranged from 0% to 0.45%21,22,43-46. Some studies have pointed to an elevated risk of acute cardiopulmonary complications, venous thromboembolism, and mortality related to the use of cement during THA45,47. A study based on the Swedish Arthroplasty Registry showed an increase of 5 deaths per 10,000 observations during the first 14 days following THA with cement, but not after THA without cement, a trend that reversed after 14 days48. Other studies have challenged the association between the use of cement and early perioperative mortality. A study based on nearly 62,000 primary THAs from Finland showed no increased early mortality among patients who had cement fixation compared with those who had cementless fixation49. There was also no evidence of increased cardiovascular causes of death among the cement group. Our results showed that, in a Medicare sample, male patients who received cement fixation had more than a twofold higher risk of early mortality. The same association did not reach significance among female patients (p = 0.06). Absolute 30-day mortality rates were low (<0.25%) and were consistent with previously reported data.
The choice of cemented or uncemented femoral fixation is multifactorial. Patient characteristics associated with poor bone quality, such as older age, female sex, and the presence of certain comorbidities, impact the risk of early failure and therefore may influence the fixation strategy50. Surgeon familiarity and comfort with the procedure are also important factors in the selection of stem type. Data from the AJRR showed that cementless stems were used for >99% of patients <70 years of age in the United States and that cemented stems were used for <25% of patients >90 years of age42. For surgeons who can competently perform THA with cement, our data support the use of a cemented stem to avoid periprosthetic femoral fracture in elderly female patients. However, our results suggest that there is a competing risk of early mortality among male patients (for female patients, the competing risk of early mortality almost reached significance), although the absolute 30-day mortality rates are very low.
The present study had limitations. First, our analysis relied on information from Medicare, and therefore the data were limited to what was available in the Medicare dataset. It is possible that there were errors in coding in the dataset, although these were unlikely to have been appreciable. Second, the present study focused on the subset of patients in the Medicare dataset who had a specified cement status. However, a comparison of patients with specified and unspecified cement codes indicated that the groups were similar in distribution according to sociodemographic and geographic characteristics. Third, the patient matching that we performed, although extensive, was limited to variables that were available in the Medicare dataset; it is possible that the groups might have differed with respect to other relevant cofounders that were unobservable in our claims data (e.g., body mass index). Fourth, some of our findings had marginal significance, which, in a dataset of this size, may limit the strength of the identified associations. Finally, we focused on the most severe adverse outcomes (i.e., periprosthetic femoral fracture and mortality), but there are other outcomes that could be impacted by stem fixation choice, including revision rates and cost, which were not assessed here.
In conclusion, we report the first nationally representative study of periprosthetic femoral fracture and mortality rates after THA performed with use of cemented or uncemented stems in elderly patients in the United States. Our findings support the use of cement fixation among elderly female patients as it is associated with lower fracture rates, with no definitive difference in terms of mortality risk. In contrast, the recommendation does not apply to male patients, for whom the use of cement was associated with increased 30-day mortality rates with no fracture reduction benefits.
Footnotes
Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G862).
References
- 1.Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007. Apr;89(4):780–5. [DOI] [PubMed] [Google Scholar]
- 2.Ling RS, Charity J, Lee AJ, Whitehouse SL, Timperley AJ, Gie GA. The long-term results of the original Exeter polished cemented femoral component: a follow-up report. J Arthroplasty. 2009. Jun;24(4):511–7. [DOI] [PubMed] [Google Scholar]
- 3.Zmistowski B, Restrepo C, Hess J, Adibi D, Cangoz S, Parvizi J. Unplanned readmission after total joint arthroplasty: rates, reasons, and risk factors. J Bone Joint Surg Am. 2013. Oct 16;95(20):1869–76. [DOI] [PubMed] [Google Scholar]
- 4.Mantilla CB, Horlocker TT, Schroeder DR, Berry DJ, Brown DL. Frequency of myocardial infarction, pulmonary embolism, deep venous thrombosis, and death following primary hip or knee arthroplasty. Anesthesiology. 2002. May;96(5):1140–6. [DOI] [PubMed] [Google Scholar]
- 5.Drew JM, Griffin WL, Odum SM, Van Doren B, Weston BT, Stryker LS. Survivorship After Periprosthetic Femur Fracture: Factors Affecting Outcome. J Arthroplasty. 2016. Jun;31(6):1283–8. [DOI] [PubMed] [Google Scholar]
- 6.Boylan MR, Riesgo AM, Paulino CB, Slover JD, Zuckerman JD, Egol KA. Mortality Following Periprosthetic Proximal Femoral Fractures Versus Native Hip Fractures. J Bone Joint Surg Am. 2018. Apr 4;100(7):578–85. [DOI] [PubMed] [Google Scholar]
- 7.Shields E, Behrend C, Bair J, Cram P, Kates S. Mortality and Financial Burden of Periprosthetic Fractures of the Femur. Geriatr Orthop Surg Rehabil. 2014. Dec;5(4):147–53. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 8.Moerman S, Mathijssen NMC, Niesten DD, Riedijk R, Rijnberg WJ, Koëter S, van de Hei KK, Tuinebreijer WE, Molenaar TL, Nelissen RGHH, Vochteloo AJH. More complications in uncemented compared to cemented hemiarthroplasty for displaced femoral neck fractures: a randomized controlled trial of 201 patients, with one year follow-up. BMC Musculoskelet Disord. 2017;18:169. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 9.Taylor F, Wright M, Zhu M. Hemiarthroplasty of the hip with and without cement: a randomized clinical trial. J Bone Joint Surg Am. 2012. Apr 4;94(7):577–83. [DOI] [PubMed] [Google Scholar]
- 10.Langslet E, Frihagen F, Opland V, Madsen JE, Nordsletten L, Figved W. Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures: 5-year followup of a randomized trial. Clin Orthop Relat Res. 2014. Apr;472(4):1291–9. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 11.Watts CD, Abdel MP, Lewallen DG, Berry DJ, Hanssen AD. Increased risk of periprosthetic femur fractures associated with a unique cementless stem design. Clin Orthop Relat Res. 2015. Jun;473(6):2045–53. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 12.Gromov K, Bersang A, Nielsen CS, Kallemose T, Husted H, Troelsen A. Risk factors for post-operative periprosthetic fractures following primary total hip arthroplasty with a proximally coated double-tapered cementless femoral component. Bone Joint J. 2017. Apr;99-B(4):451–7. [DOI] [PubMed] [Google Scholar]
- 13.Taunton MJ, Dorr LD, Long WT, Dastane MR, Berry DJ. Early Postoperative Femur Fracture After Uncemented Collarless Primary Total Hip Arthroplasty: Characterization and Results of Treatment. J Arthroplasty. 2015. Nov;30(11):2008–11. [DOI] [PubMed] [Google Scholar]
- 14.Herndon CL, Nowell JA, Sarpong NO, Cooper HJ, Shah RP, Geller JA. Risk Factors for Periprosthetic Femur Fracture and Influence of Femoral Fixation Using the Mini-Anterolateral Approach in Primary Total Hip Arthroplasty. J Arthroplasty. 2020. Mar;35(3):774–8. [DOI] [PubMed] [Google Scholar]
- 15.Cadle D, James ML, Ling RS, Piper RF, Pryer DL, Wilmshurst CC. Cardiovascular responses after methylmethacrylic cement. Br Med J. 1972. Oct 14;4(5832):107–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 16.Kepes ER, Undersood PS, Becsey L. Intraoperative death associated with acrylic bone cement. Report of two cases. JAMA. 1972. Oct 30;222(5):576–7. [PubMed] [Google Scholar]
- 17.Svartling N Detection of embolized material in the right atrium during cementation in hip arthroplasty. Acta Anaesthesiol Scand. 1988. Apr;32(3):203–8. [DOI] [PubMed] [Google Scholar]
- 18.Wheelwright EF, Byrick RJ, Wigglesworth DF, Kay JC, Wong PY, Mullen JB, Waddell JP. Hypotension during cemented arthroplasty. Relationship to cardiac output and fat embolism. J Bone Joint Surg Br. 1993. Sep;75(5):715–23. [DOI] [PubMed] [Google Scholar]
- 19.Kim YH, Oh SW, Kim JS. Prevalence of fat embolism following bilateral simultaneous and unilateral total hip arthroplasty performed with or without cement : a prospective, randomized clinical study. J Bone Joint Surg Am. 2002. Aug;84(8):1372–9. [DOI] [PubMed] [Google Scholar]
- 20.Miyamoto S, Nakamura J, Iida S, Shigemura T, Kishida S, Abe I, Takeshita M, Harada Y, Orita S, Ohtori S. Intraoperative blood pressure changes during cemented versus uncemented bipolar hemiarthroplasty for displaced femoral neck fracture: a multi-center cohort study : The effect of bone cement for bipolar hemiarthroplasty in elderly patients. Arch Orthop Trauma Surg. 2017. Apr;137(4):523–9. [DOI] [PubMed] [Google Scholar]
- 21.Nunley RM, Lachiewicz PF. Mortality after total hip and knee arthroplasty in a medium-volume university practice. J Arthroplasty. 2003. Apr;18(3):278–85. [DOI] [PubMed] [Google Scholar]
- 22.Parvizi J, Johnson BG, Rowland C, Ereth MH, Lewallen DG. Thirty-day mortality after elective total hip arthroplasty. J Bone Joint Surg Am. 2001. Oct;83(10):1524–8. [DOI] [PubMed] [Google Scholar]
- 23.Lehil MS, Bozic KJ. Trends in total hip arthroplasty implant utilization in the United States. J Arthroplasty. 2014. Oct;29(10):1915–8. [DOI] [PubMed] [Google Scholar]
- 24.Abdel MP, Berry DJ. Current Practice Trends in Primary Hip and Knee Arthroplasties Among Members of the American Association of Hip and Knee Surgeons: A Long-Term Update. J Arthroplasty. 2019. Jul;34(7S):S24–7. [DOI] [PubMed] [Google Scholar]
- 25.Khanuja HS, Vakil JJ, Goddard MS, Mont MA. Cementless femoral fixation in total hip arthroplasty. J Bone Joint Surg Am. 2011. Mar 2;93(5):500–9. [DOI] [PubMed] [Google Scholar]
- 26.Ahn J, Man LX, Park S, Sodl JF, Esterhai JL. Systematic review of cemented and uncemented hemiarthroplasty outcomes for femoral neck fractures. Clin Orthop Relat Res. 2008. Oct;466(10):2513–8. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 27.Kärrholm J, Rogmark C, Naucler E, Vinblad J, Mohaddes M, Rolfson O. Swedish Hip Arthroplasty Register Annual Report 2018. Swedish Hip Arthroplasty Register; 2019. [Google Scholar]
- 28.McKie J The New Zealand Joint Registry. 20-Year Report. 2019. Accessed 2021 Nov 15. https://www.nzoa.org.nz/sites/default/files/DH8328_NZJR_2019_Report_v4_7Nov19.pdf [Google Scholar]
- 29.Powers-Freeling L National Joint Registry. 16th Annual Report. 2019. Accessed 2021 Nov 15. https://reports.njrcentre.org.uk/portals/0/pdfdownloads/njr%2016th%20annual%20report%202019.pdf [Google Scholar]
- 30.Graves S Australian Orthopaedic Association National Joint Replacement Registry. 20th Annual Report. 2019. Accessed 2021 Nov 15. https://aoanjrr.sahmri.com/annual-reports-2019 [Google Scholar]
- 31.U.S. Department of Health and Human Services. Procedure-Specific Measure Updates and Specifications Report Hospital-Level Risk-Standardized Complication Measure: Elective Primary Total Hip Arthroplasty (THA) and/or Total Knee Arthroplasty (TKA). 2018. [Google Scholar]
- 32.Elixhauser A, Steiner C, Harris DR, Coffey RM. Comorbidity measures for use with administrative data. Med Care. 1998. Jan;36(1):8–27. [DOI] [PubMed] [Google Scholar]
- 33.Quan H, Sundararajan V, Halfon P, Fong A, Burnand B, Luthi JC, Saunders LD, Beck CA, Feasby TE, Ghali WA. Coding algorithms for defining comorbidities in ICD-9-CM and ICD-10 administrative data. Med Care. 2005. Nov;43(11):1130–9. [DOI] [PubMed] [Google Scholar]
- 34.Li Y, Ying M, Cai X, Kim Y, Thirukumaran CP. Trends in Postacute Care Use and Outcomes After Hip and Knee Replacements in Dual-Eligible Medicare and Medicaid Beneficiaries, 2013-2016. JAMA Netw Open. 2020. Mar 2;3(3):e200368. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 35.Karvonen M, Laaksonen I, Pulkkinen P, Eskelinen A, Haapakoski J, Puhto AP, Kettunen J, Manninen M, Mäkelä KT. Implant Survival of Constrained Acetabular Device in Primary Total Hip Arthroplasty Based on Data From the Finnish Arthroplasty Register. J Arthroplasty. 2020. Jan;35(1):219–23. [DOI] [PubMed] [Google Scholar]
- 36.Aali Rezaie A, Blevins K, Kuo FC, Manrique J, Restrepo C, Parvizi J. Total Hip Arthroplasty After Prior Acetabular Fracture: Infection Is a Real Concern. J Arthroplasty. 2020. Sep;35(9):2619–23. [DOI] [PubMed] [Google Scholar]
- 37.Ferbert T, Jaber A, Gress N, Schmidmaier G, Gotterbarm T, Merle C. Impact of intraoperative femoral fractures in primary hip arthroplasty: a comparative study with a mid-term follow-up. Hip Int. 2020. Sep;30(5):544–51. [DOI] [PubMed] [Google Scholar]
- 38.Fessy MH, Putman S, Viste A, Isida R, Ramdane N, Ferreira A, Leglise A, Rubens-Duval B, Bonin N, Bonnomet F, Combes A, Boisgard S, Mainard D, Leclercq S, Migaud H; SFHG. What are the risk factors for dislocation in primary total hip arthroplasty? A multicenter case-control study of 128 unstable and 438 stable hips. Orthop Traumatol Surg Res. 2017. Sep;103(5):663–8. [DOI] [PubMed] [Google Scholar]
- 39.Tanzer M, Graves SE, Peng A, Shimmin AJ. Is Cemented or Cementless Femoral Stem Fixation More Durable in Patients Older Than 75 Years of Age? A Comparison of the Best-performing Stems. Clin Orthop Relat Res. 2018. Jul;476(7):1428–37. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 40.Hartman C, Gilbert B, Paprosky W. Gender Issues in Total Hip Arthroplasty: Length, Offset, and Osteoporosis. Semin Arthroplasty. 2009;20(1):62–5. [Google Scholar]
- 41.Peacock M, Liu G, Carey M, Ambrosius W, Turner CH, Hui S, Johnston CC Jr. Bone mass and structure at the hip in men and women over the age of 60 years. Osteoporos Int. 1998;8(3):231–9. [DOI] [PubMed] [Google Scholar]
- 42.Springer BD, Etkin CD, Shores PB, Gioe TJ, Lewallen DG, Bozic KJ. Perioperative Periprosthetic Femur Fractures are Strongly Correlated With Fixation Method: an Analysis From the American Joint Replacement Registry. J Arthroplasty. 2019. Jul;34(7S):S352–4. [DOI] [PubMed] [Google Scholar]
- 43.Dearborn JT, Harris WH. Postoperative mortality after total hip arthroplasty. An analysis of deaths after two thousand seven hundred and thirty-six procedures. J Bone Joint Surg Am. 1998. Sep;80(9):1291–4. [DOI] [PubMed] [Google Scholar]
- 44.Parry M, Wylde V, Blom AW. Ninety-day mortality after elective total hip replacement: 1549 patients using aspirin as a thromboprophylactic agent. J Bone Joint Surg Br. 2008. Mar;90(3):306–7. [DOI] [PubMed] [Google Scholar]
- 45.Sharrock NE, Cazan MG, Hargett MJ, Williams-Russo P, Wilson PD Jr. Changes in mortality after total hip and knee arthroplasty over a ten-year period. Anesth Analg. 1995. Feb;80(2):242–8. [DOI] [PubMed] [Google Scholar]
- 46.Sierra RJ, Timperley JA, Gie GA. Contemporary cementing technique and mortality during and after Exeter total hip arthroplasty. J Arthroplasty. 2009. Apr;24(3):325–32. [DOI] [PubMed] [Google Scholar]
- 47.Ries MD, Lynch F, Rauscher LA, Richman J, Mick C, Gomez M. Pulmonary function during and after total hip replacement. Findings in patients who have insertion of a femoral component with and without cement. J Bone Joint Surg Am. 1993. Apr;75(4):581–7. [DOI] [PubMed] [Google Scholar]
- 48.Garland A, Gordon M, Garellick G, Kärrholm J, Sköldenberg O, Hailer NP. Risk of early mortality after cemented compared with cementless total hip arthroplasty: a nationwide matched cohort study. Bone Joint J. 2017. Jan;99-B(1):37–43. [DOI] [PubMed] [Google Scholar]
- 49.Ekman E, Palomäki A, Laaksonen I, Peltola M, Häkkinen U, Mäkelä K. Early postoperative mortality similar between cemented and uncemented hip arthroplasty: a register study based on Finnish national data. Acta Orthop. 2019. Feb;90(1):6–10. [DOI] [PMC free article] [PubMed] [Google Scholar]
- 50.Bozic KJ, Lau E, Ong K, Chan V, Kurtz S, Vail TP, Rubash HE, Berry DJ. Risk factors for early revision after primary total hip arthroplasty in Medicare patients. Clin Orthop Relat Res. 2014. Feb;472(2):449–54. [DOI] [PMC free article] [PubMed] [Google Scholar]