Are current rates of uncemented fixation in total hip arthroplasty supported by the literature? An update on the uncemented paradox

Abstract

The optimal fixation method in total hip arthroplasty (THA) remains controversial. Initial concerns related to the long-term performance of cement fixation as well as cement disease led to the development of cementless implants, and registry data has indicated that the use of this type of fixation has increased in recent years. However, data from these same registries has not shown any improvement in outcomes when compared to cement fixation. On the contrary, while similar outcomes are seen when comparing these fixation types in younger patients (<70 years of age), cementless fixation has shown increased implant failure and revision rates in elderly patients (>70 years of age). Given the increased projected volume of THA in the United States over the next decade, it is important to utilise available data to make clinical decisions that minimise not only individual patient harm, but also the burden on the healthcare system itself. This review provides an overview of currently available outcomes data comparing cement and cementless fixation, as well as an updated analysis of current trends in fixation use in THA. We furthermore provide a comprehensive technique guide to help surgeons optimise cement fixation of the femoral component for THA and hemiarthroplasty.

Keywords

Cement fixation cementless uncemented fixation total hip arthroplasty

Introduction

Total hip arthroplasty (THA) has been so successful at improving patients’ quality of life that it has been called the operation of the century.¹ However, controversy remains regarding the optimal fixation method for the acetabular and femoral components used in this procedure.² Cement fixation has been widely used since the advent of the Charnley low-friction total hip replacement, showing excellent results in regards to survival and patient satisfaction with over 40 years of follow-up.^3–5 However, concerns about the long-term durability of cement fixation, “cement disease”, and stress shielding led to the development of cementless implants designed for bony ingrowth, especially in the young, active patient.^6,7

While cementless implants offer the theoretical benefit of increased long-term mechanical stability and more physiologic loading of the proximal femoral bone, few studies have shown improved survivorship or superior outcomes of these implants compared to cemented implants in any age group.^2,8,9 In addition, the increased rate of periprosthetic fracture seen with cementless component use is a significant concern.^9–11

Despite this, the rate of use of cement fixation varies widely amongst countries for which this data is available.^8,9 There are multiple factors that may contribute to this wide variability in rates of cement fixation usage. Initial concerns regarding cement disease, combined with aggressive marketing, led to the rapid development of well-performing cementless components, and decreased surgical time led many surgeons to abandon cement fixation in favour of uncemented fixation.^2,7,10 In addition, as rates of cement fixation have decreased (primarily in the United States and Canada), surgeon training and experience with this technique has also waned.¹² Furthermore, expert single-centre studies have shown excellent long-term results with cementless implants.^13–15 Despite these findings, registry data has consistently shown superior survivorship and decreased revision rates with cemented fixation. However, the paradoxical increase in cementless fixation in many countries has persisted.^8,9

Here, we review the available outcomes data for cementless and cement fixation of the femoral component using both registry data as well as published results from multiple centers. We also provide an analysis of recent trends in rates of cement fixation use in the various countries where long-term registry data is available. Finally, we provide a technical guide to help achieve optimal cement fixation of the femoral component in THA. We hope that this review serves as a guide to surgeons when considering the appropriate fixation choice for THA and provides useful tips to help ensure successful cement fixation when this technique is used.

Outcomes

Patients with osteoporosis

1 of the more clear indications for cemented femoral stem fixation is in patients with a known diagnosis of osteoporosis, where the risk of fracture with uncemented fixation may be substantially higher.^10,11 Yang et al.¹⁶ reported on outcomes in patients undergoing THA between the ages of 60-80 with an underlying osteoporosis diagnosis. In the patients with cementless femoral fixation, there was a 14.8% implant failure rate (26.6% due to aseptic loosening) while the cemented group showed a 7.6% implant failure rate (16.8% due to aseptic loosening). Furthermore, the cementless fixation patients also had inferior Harris Hip Scores at 3 months and increased pain at rest and with activity. Low bone mineral density has been shown to have a positive correlation with increased prosthetic subsidence and delayed translational stem stability.¹⁶ Furthermore, early subsidence within the first 24 months has been implicated as a risk factor for aseptic loosening.¹⁶

Geriatric patients

The 2018 Australian Joint Registry report evaluated patients greater than age 80 and found all cause revision rates were more than twice as high in cementless cases compared to those with cemented fixation.¹⁷ Of these revisions, periprosthetic fractures accounted for: 18% in patients <80, 36.9% in those 80–90, and 39% of those patients >90 years of age. Looking at this same registry data, Tanzer et al.¹¹ found that the 3 best performing cementless stems had a 9 times higher rate of revision in the first 3 months after surgery in patients older than 75 years than the 3 best performing cemented stems in the registry. In addition to the data mentioned above, the Norwegian, New Zealand, Swedish, and Kaiser Permanente Registry data have also found similar trends in revision rates and fracture risk in patients older than 75 years.^11,17

Periprosthetic fractures are 1 of the most burdensome and feared complications of THA, as they are associated with increased rates of revision which leads to increased infection risk, mortality, costs, and decreased patient functional status.¹⁰ Post-menopausal females have been noted to be at a 19-fold increased risk for revision related to periprosthetic fracture.¹⁸ Similarly, patients older than 74 years of age had twice the risk of undergoing revision for fracture in the first 3 months after surgery. The increased risk exists beyond the perioperative period. Even 10 years postoperatively, cementless fixation was associated with significantly higher rates of periprosthetic fracture.¹⁸

Durability of cemented stem fixation

Another important variable to consider when choosing implants is the durability and long-term survival of the construct. Fowler et al.¹⁹ analysed 2156 total hips performed at their institution between 1994–2004 using the New Zealand National Joint Registry and local database. They found that uncemented hips had an 8.9% all-cause revision rate at 18 years while hybrid fixation was associated with an all-cause revision rate of 6.5%. An analysis of the Swedish Hip Arthroplasty Registry by Hailer et al.²⁰ also demonstrated a similar finding with a 17% versus 6% revision rate in the first 2 years in cementless and cemented groups, respectively. 1 of the most utilised cemented stems, the Exeter stem (Stryker, Kalamazoo, MI, USA), has been reported in studies to have a survival free from revision for aseptic loosening of 97% to 99% at 25 and 33 years, respectively.¹⁷ Interestingly, a review of the 88,830 cases in the Kaiser Permanente Registry data demonstrated that, per 1000 hybrid THAs performed, they would prevent 10 revisions for periprosthetic fractures but in turn would lead to 3 revisions for aseptic loosening.²¹

Concerns related to cemented stem fixation

Another cause for concern, and commonly cited reason for avoiding cemented fixation, is the concern for bone cement implantation syndrome and mortality. Several large database studies have demonstrated that there is a slightly increased risk of death within the first 14 days in the cemented fixation group. However, there are significant confounding variables as the cemented group typically is older, have more co-morbidities, and significantly higher Charleson Comorbidity Index scores.^22,23

While cemented femoral stem fixation has a long track record of success for use in THA, it is important to note that stem design may play a role in patient outcomes, especially in regards to periprosthetic femur fractures. Recent studies have shown that collarless, tapered, highly polished stems may have a higher periprosthetic fracture rate as compared to cemented stems with a more anatomic design.^24,25 While further studies are needed to confirm these findings, some surgeons have advocated for a transition to an increased use of more anatomic stems to further reduce periprosthetic fracture rate following THA.

Trends in primary THA

Despite the growing body of literature that supports the use of cement fixation in THA, recent studies have demonstrated a trend towards increased use of uncemented femoral stems in THA worldwide. Troelsen et al.⁸ first evaluated this in 2013 using data from 7 national hip arthroplasty registries (Australia, Canada, Denmark, New Zealand, Norway, England-Wales, and Sweden) from 2006 to 2010. They found that in 2010, the use of uncemented fixation was widely variable amongst the 7 nations from as low as 15% in Sweden to as high as 82% in Canada.

All of the countries reported an overall increase in uncemented fixation use over the study period, although the magnitude of the increase varied.⁸ The absolute increase was small in countries like Sweden (from 10% to 15%) and Australia (from 60% to 65%) but almost doubled in other countries, such as Denmark (from 47% to 68%) and England-Wales (from 25% to 43%). A similar increase in uncemented fixation use was seen in those countries that reported fixation rates in patients >75 years of age (Australia, Denmark, England-Wales). In 2010, uncemented fixation was used in 47% of patients >75 years in Australia, 42% of these patients in Demark, and 29% of these patients in England-Wales.

A recent update of this analysis including data from 2010 to 2017 from a similar group of 10 countries (excluding Canada and including Finland, the Netherlands, Switzerland, and Romania) demonstrated a potential reversal of this trend in certain nations.⁹ Use of uncemented fixation in England-Wales (43–37.8%), Australia (65–63%), New Zealand (51–48%), and Finland (71–49%) slowly decreased over the study period. However, rates of uncemented fixation continued to increase in Norway (25–38%), Denmark (68–71%), Romania (43–51%, 2011–2015 only) and Sweden (15–24%).

Similar trends were seen when evaluating patients older than 75 years old, who may benefit most from the use of cemented fixation.⁹ The use of uncemented fixation in this group increased in Denmark (42–53%) and Australia (40–47%) and decreased in Finland (43–24%) and Norway (21–15%) over the study period. Uncemented fixation in this age group was stable in the remainder of the countries for which this data was available.

Cemented femoral stem fixation in primary THA in the US has increased from 2012 to 2020.²⁶ In 2012, cemented fixation was used in just 2.8% of all primary THA. This number has steadily increased every year since 2013 to 5.8% in 2020.^8,9 Increased use of cemented stem fixation is seen with increasing age according to AJRR data, with <2% of patients under the age of 70 receiving cemented stem fixation. Cemented stem fixation was used in 5% of patients between the ages of 70–79, 14.6% of patients between the ages of 80–89, and 34.2% of patients over the age of 90 years.

Trends in THA and hemiarthroplasty for femoral neck fracture

Data from the AAOS American Joint Replacement Registry (AJRR) demonstrated an increase in uncemented fixation use in hemiarthroplasty and THA for femoral neck fracture from 2012 to 2020.²⁶ For THA, cemented fixation decreased from 19.2% to 16.2%. However, this reached a nadir in 2017 (13.1%) and has been slowly increasing since that time. Similar trends were seen in regards to hemiarthroplasty for femoral neck fracture with a decrease from 51.5% in 2012 to 39.3% in 2016, followed by an increase to 44.7% in 2020. Use of cemented fixation for hemiarthroplasty increased with increasing age group but remained at only 50.2% for patients over the age of 90. This stands in stark contrast to Sweden, in which cement fixation was used in 99.2% of patients with a femoral neck fracture from 2010–2020.²⁷

Cementing technique

1 possible explanation for the discordance between rates of cemented stem fixation and registry data may be a lack of training (particularly in North America) and therefore, comfort and expertise with cement technique. A recent survey of senior residents in the U.S. showed that 16% of residents felt that training in theoretical aspects of cement technique was inadequate and 17% felt that training in cementing as a skill was inadequate.¹²

Given the relatively low rate of cemented THA performed in the United States, it should not be surprising that trainees may feel unprepared to properly place cemented femoral stems, and steps to address this for trainees and practising surgeons should be undertaken. Here, we provide some technical tips to help optimise cemented stem fixation in THA.

The goal of modern cement technique is to achieve optimal “micro-interlock” between the patient’s bone and cement. The first step in achieving a well-cemented stem is appropriate preparation of the femur. The advent of pulsatile jet-lavage prior to cementation is likely the most important development that has allowed for improved survival of cemented constructs. The inclusion of manual lavage in second-generation cementation techniques resulted in increased cement penetration and mechanical shear strength.²⁸ However, the use of pulsatile jet-lavage has proven to be significantly more effective than manual lavage.²⁹ We recommend the use of pulsatile jet-lavage in all THA when cement is used. Lavage should continue until the return fluid is clear to ensure sufficient cleaning of the cancellous bone.

Next, it is imperative to choose an appropriate cement restrictor, which may vary depending on the setting. Use of a cement restrictor has been shown to be necessary to achieve appropriate pressurisation during cementation, and this has resulted in improved implant survival.³⁰ Artificial cement restrictors are readily available and allow for high intramedullary pressures during cementation.³¹ Various cement plug designs have been employed including soft-gelatine plugs, soft polyethylene plugs, PMMA plugs, and expandable designs. The authors have found success using soft-gelatine designs and the Exeter PMMA Plug design, in addition to an expandable plug design. For most cases, use of a soft-gelatine design that is oversized or a PMMA plug design are appropriate. In all cases, the intramedullary canal should be thoroughly cleansed using pulsatile lavage prior to plug insertion and trialling to prevent fat embolism.

Once the cancellous bone has been adequately cleaned and a cement restrictor placed, rapid filling and pressurisation of the femoral canal is necessary to prevent back-bleeding from the intramedullary canal that can prevent adequate cement penetration.³² This is achieved using a cement gun. Cement guns are available from multiple manufacturers, and while there appear to be some differences in handling characteristics, no single cement gun has been shown to be superior in regards to clinical performance.³³ While cement gun performance does not appear to be dependent on the mechanism of action (i.e., ratchet vs. non-ratchet), we advocate for the use of a system with a ratchet mechanism, as non-ratcheted devices appear to be more prone to rod slippage. In addition, surgeons should use the long nozzle tips that are commonly available with modern cement guns and should not cut the nozzle prior to filling the canal.

Following retrograde filling of the canal, it is important to pressurise the cement to allow for maximal interdigitation prior to insertion of the femoral stem. At this point, the long nozzle tip can be removed or cut off. The cement in the nozzle tip should be saved to fill in defects or be added to the proximal cement mantle as needed. To achieve optimal pressurisation, a deformable seal (which are commonly available from most manufacturers) is positioned over the osteotomy site of the femoral neck creating a closed compartment. Pulling the trigger of the cement gun generates a sustained pressure that can resist the bleeding pressure. This should be performed for 2–4 minutes prior to insertion of the stem.

Once the cement has reached a high viscosity, the stem can be inserted. It is important to allow the cement to reach a high enough viscosity to prevent the cement from extruding during insertion of the prosthesis. However, the viscosity should not be too high, as this will prevent full seating of the prosthesis. The stem should be inserted by hand at a rate of approximately 1 cm per second. A mallet should not be used when inserting the stem. It is important to maintain the rotation of the stem in regards to the femur during insertion and until polymerisation has occurred. This will help prevent defects in the cement mantle that can occur when the stem is rotated during curing of the cement.

Discussion

Cement fixation, especially in regards to the femoral component, has shown excellent long-term survivorship in multiple registries.^8,9 However, cementless fixation continues to be the predominant type of fixation used in many countries around the world.^8,9 The initial transition to cementless fixation was spurred by concerns regarding cement disease and long-term fixation of cemented stems.^6,7 While the concerns related to cement disease have since been assuaged, the rapid rise in cementless fixation has been slow to reverse.⁹

Perhaps the greatest benefit with cement fixation of femoral stems is seen in patients >70 years of age, as there is a markedly lower rate of periprosthetic fracture both intraoperatively and long term.^9–11 Periprosthetic fracture remains 1 of the most common reasons for early revision following THA, especially in the elderly. A 2010 Cochrane review concluded that cementing femoral components prevented one intraoperative fracture every 18 cases.³⁴ A similar review of a large case series including 32,644 hip replacements demonstrated a 3% intraoperative fracture risk in patients undergoing cementless fixation while patients undergoing cemented fixation had only a 0.23% intraoperative fracture risk.¹⁰ While studies have shown mixed results in regards to cement versus cementless fixation in younger patients (<60 years of age),^35,36 the overwhelming majority of comparative and registry studies have shown improved survival and lower revision rates in patients over the age of 70 with cemented fixation, largely driven by the decreased rate of periprosthetic fracture.^8,9

Despite this, use of uncemented fixation remains common in the elderly population in many countries and is even increasing in some.^8,9 Although rates of cement fixation are higher amongst the elderly in all the registries for which this data is available, the prevalence of uncemented fixation in this population is concerning. This is especially true given the overwhelming amount of data that supports the use of cement fixation in this age group. One could certainly make the argument that cement fixation should be used in the vast majority of patient over the age of 70 given the data available.^10,11 Data from the AJRR in regards to fixation for femoral neck fractures is also surprising, as cement fixation was used for less than 50% of all hemiarthroplasties and THA performed for femoral neck fractures.²⁷ This patient population may have the strongest indication for cement fixation given the fact that their bone has been demonstrated to be pathologic.³⁷

It is difficult to explain the wide variability that is seen in rates of cement fixation usage in the various registries. Some authors have described a “North Atlantic Divide” in regards to cemented femoral fixation with higher rates of cementless fixation used in North American countries, including the U.S. and Canada, and higher rates of cement fixation used in European countries.³⁸ However, use of uncemented fixation has increased significantly in some European countries, such as Denmark and England-Wales over the past 15 years. In addition, rates of uncemented fixation use remain relatively high in both Australia and New Zealand.^8,9

The continued popularity of cement fixation in THA may be attributable to several factors. First, the rapid development and marketing of well-performing, uncemented implants led to their widespread adoption, especially in the U.S. The use of these implants has been supported by expert single-center studies, which has led to an enthusiasm that has not waned.^14,15 In addition, considerations related to OR efficiency may play an important role in driving uncemented fixation usage in some countries.³⁹ Historically, there have been concerns in regards to increased mortality associated with cement fixation. Although there may be a minimally increased relative risk of early mortality in cement fixation compared to uncemented fixation, this is reversed from day 15 onward.²⁴ Finally, as previously discussed, with the rapid uptake of uncemented implants, the use of cement fixation fell dramatically.⁷ This likely led surgeons to feel less comfortable with this technique and has certainly led to decreased exposure to cement fixation during training.¹²

It is also interesting to note that uncemented fixation remains prevalent (and in some cases is increasing over time) in countries whose own registry data would support the increased use of cement fixation.^8,9 It has been proposed that frequent reporting of registry data would serve as a catalyst for surgeons to adopt clinical practices that best align with currently available data.¹⁰ This would seem to be the case in Sweden, which has a long-standing registry with robust data analysis and reporting.⁹ This may explain why rates of cement fixation in Sweden were the highest of any of the countries for which registry data is available.⁹ However, even in Sweden, rates of uncemented fixation have continued to rise since 2006.^8,9 Furthermore, several other countries with long-term, annual reporting of registry data, including Australia and Denmark, have seen consistently high rates of uncemented fixation use over the same time period. This discrepancy between registry reported data and clinical practice is even more significant in regards to cement fixation in the elderly population. Rates of cement fixation in the elderly in Australia, Denmark, and England-Wales remain much higher than would be supported by their country’s registry data.

It is also interesting to examine the case of the U.S. in regards to the effect of the reporting of registry data on clinical practice. The AJRR began reporting data in 2012 from a limited number of participating centers.²⁷ The total number of procedures captured by the registry has increased dramatically since that time, making changes in the data somewhat difficult to interpret. However, since 2016, the number of surgeons represented in the AJRR has been relatively stable, indicating that registry trends since that time may represent national practice patterns. Since the AJRR began reporting data, cemented femoral fixation rates have shown a slow but consistent increase in the registry. In addition, data from the AJRR has shown similar trends in regards to outcomes of cemented versus uncemented femoral fixation as other registries (similar or improved survival of cemented stems depending on age group). Therefore, the increase in cement use in the U.S. since 2012 could be, at least in part, a response to the reported registry data.

In regards to hemiarthroplasty and THA performed for femoral neck fractures, rates of cement fixation in the U.S. are relatively low and decreased from 2012 to 2016–2017.²⁷ Rates of cement fixation in the treatment of femoral neck fractures have slowly been increasing in the U.S. since 2016, and outcomes data from the AJRR certainly supports its use in this patient population. However, the rate of cement fixation used in this setting in the U.S. remains well below what could be considered advisable based on previously published data and is much lower than rates reported in other countries.

Regardless of the reasons behind it, the “uncemented paradox” appears to still be relevant today.^8,9 This phenomenon is important to understand to help minimise the burden of arthroplasty complications on the health system. As the number of THA procedures performed annually continues to rise, rates of complications associated with these procedures will see a similar increase.^40,41 The cost of caring for the complications associated with total joint arthroplasty, and in particular THA, represent a significant burden on overall healthcare expenditures.⁴¹ Therefore, it is important for surgeons to follow best practices not just for their individual patients, but also for the healthcare system as a whole.

Conclusion

The optimal fixation for each patient needs to be assessed individually and at the population level. Ultimately, it will be important to continue to follow trends in cement use worldwide, as well as trends in the performance of cemented and uncemented components with contemporary designs using the available registries. Further studies may be needed to determine the reasons behind the discordance between clinical practice and registry data, as these reasons are not immediately clear. While THA remains a highly successful procedure,¹ it is vital that surgeons continue to work to reduce complications and improve patient outcomes using readily available data. Where there is discrepancy between clinical practice and population-level data, it is necessary to consider the various factors driving clinical decision-making. Fixation type in THA remains 1 such area where a discrepancy exists, and this is an important topic to address at societal and national levels in the coming years.

Footnotes

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship and/or publication of this article.

ORCID iD

Weston Buehring

References

Learmonth

Young

Rorabeck

The operation of the century: total hip replacement. Lancet 2007; 370: 1508–1519.

Blannkenstein

Lentine

Nelms

NJ.

The use of cement in hip arthroplasty: a contemporary perspective. J Am Acad Orthop Surg 2020; 28: e586–e594.

Charnley

Total hip replacement by low-friction arthroplasty. Clin Orthop Relat Res 1970; 72: 7–21.

Charnely

The long-term results of low-friction arthroplasty of the hip performed as a primary intervention. 1970. Clin Orthop Relat Res 2005; 430: 3–11.

Wroblewski

Siney

Fleming

PA.

Charnley low-frictional torque arthroplasty: follow-up for 30 to 40 years. J Bone Joint Surg Br 2009; 91: 447–450.

Jones

Hungerford

DS.

Cement disease. Clin Orthop Relat Res 1987; 225: 192–206.

Sporer

Paprosky

WG.

Biologic fixation and bone ingrowth. Orthop Clin North Am 2005; 36: 105–111, vii.

Troelsen

Malchau

Sillesen

, et al. A review of current fixation use and registry outcomes in total hip arthroplasty: the uncemented paradox. Clin Orthop Relat Res 2013; 471: 2052–2059.

Bunyoz

Malchau

, et al. Has the use of fixation techniques in THA changes in this decade? The uncemented paradox revisited. Clin Orthop Relat Res 2020; 478: 697–704.

10.

Scanelli

Reiser

Sloboda

, et al. Cemented femoral component use in hip arthroplasty. J Am Acad Orthop Surg 2019; 27: 119–127.

11.

Tanzer

Graves

Peng

, et al. Is cemented or cementless femoral stem fixation more durable in patients older than 75 years of age? A comparison of the best-performing stem. Clin Orthop Relat Res 2018; 476: 1428–1437.

12.

Browne

Ryan

Duensing

, et al. There has been a gap in our U.S. training: the path forward. 2022 Annual Meeting of the AAOS, The Hip Society/AAHKS Specialty Day, 26 March 2022; Chicago, IL, USA.

13.

Khanuja

Vakil

Goddard

, et al. Cementless femoral fixation in total hip arthroplasty. J Bone Joint Surg Am 2011; 93: 500–509.

14.

Corten, Bourne

Charron

, et al. Comparison of total hip arthroplasty performed with and without cement: a randomized trial. A concise follow-up, at twenty years, of previous reports. J Bone Joint Surg Am 2011; 93: 1335–1338.

15.

Della Valle

Mesko

Quigley

, et al. Primary total hip arthroplasty with a porous-coated acetabular component: a concise follow-up, at a minimum of twenty years, of previous reports. J Bone Joint Surg Am 2009; 91: 1130–1135.

16.

Yang

Han

Wang

, et al. Cemented versus uncemented femoral component total hip arthroplasty in elderly patient with primary osteoporosis: retrospective analysis with 5-year follow-up. J Int Med Res 2019; 47: 1610–1619.

17.

Blankstein

Lentine

Nelms

NJ.

The use of cement in hip arthroplasty: a contemporary perspective. J Am Acad Orthop Surg 2020; 28: e586–e594.

18.

Zhu

Chen

Sun

, et al. Risk factors for the periprosthetic fracture after total hip arthroplasty: a systematic review and meta-analysis. Scan J Surg 2015; 104: 139–145.

19.

Fowler

Gray

Gwynne-Jones

DP.

Hybrid fixation for total hip arthroplasty showed improved survival over cemented and uncemented fixation: a single-center survival analysis of 2156 hips at 12–18 years. J Arthroplasty 2019; 34: 2711–2717.

20.

Hailer

Garellick

Kärrholm

Uncemented and cemented primary total hip arthroplasty in the Swedish Hip Arthroplasty Register. Acta Orthop 2010; 81: 34–41.

21.

Kelly

Chan

Prentice

, et al. Cause-specific stem revision risk in primary total hip arthroplasty using cemented vs cementless femoral stem fixation in a US cohort. J Arthroplasty 2022; 37: 89–96.e1.

22.

Heckmann

Chen

Ballatori

, et al. Cemented vs cementless femoral fixation for total hip arthroplasty after displaced femoral neck fracture: a nationwide analysis of short-term complications and readmission rates. J Arthroplasty 2021; 36: 3667–3675.e4.

23.

Garland

Gordon

Garellick

, et al. Risk of early mortality after cemented compared with cementless total hip arthroplasty: a nationwide matched cohort study. Bone Joint J 2017; 99-B: 37–43.

24.

Scott

Salvatore

Woo

, et al. Polished, collarless, tapered, cemented stems for primary hip arthroplasty may exhibit high rate of periprosthetic fracture at short-term follow-up. J Arthroplasty 2018; 33: 1120–1125.

25.

Mohammed

Mukka

Hedbeck

, et al. Reduced periprosthetic fracture rate when changing from a tapered polished stem to an anatomical stem for cemented hip arthroplasty: an observational prospective cohort study with a follow-up of 2 years. Acta Orthop 2019; 90: 427–432.

26.

American Joint Replacement Registry. American Academy of Orthopaedic Surgeons. AAOS annual report 2021: the eighth annual report of the AJRR on hip and knee arthroplasty. https://connect.registryapps.net/2021-ajrr-annual-report (2021, accessed 22 April 2022).

27.

W-Dahl

Karrholm

Rogmark

, et al. Arsrapport 2021. Svenska Ledprotesregistret, https://registercentrum.blob.core.windows.net/slr/r/Svenska-Ledprotesregistret-Arsrapport-2021-HJljVnlWvF.pdf (2021, accessed 22 April 2022).

28.

Bannister

Miles

AW.

The influence of cementing technique and blood on the strength of the bone-cement interface. Eng Med 1988; 17: 131–133.

29.

Krause

Krug

Miller

JE.

Strength of the cement-bone interface. Clin Orthop Relat Res 1982; 163: 290–299.

30.

Dozier

Harrigan

Kurtz

, et al. Does increased cement pressure produce superior femoral component fixation? J Arthroplasty 2000; 15: 488–495.

31.

Heisel

Norman

Rupp

, et al. In vitro performance of intramedullary cement restrictors in total hip arthroplasty. J Biomech 2003; 36: 835–843.

32.

Benjamin

Gie

Lee

AJC

, et al. Cementing technique and the effects of bleeding J Bone Joint Surg Br 1987; 69; 620–624.

33.

Simpson

Breusch

SJ.

Cement gun performance matters. In: Simpson

Malchau

(eds) The well-cemented total hip arthroplasty: theory and practice. Boston, MA: Springer, 2005, pp.155–159.

34.

Parker

Gurusama

Azegami

Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 2010; 6: CD001706.

35.

Mei

Gong

Safir

, et al. Long-term outcomes of total hip arthroplasty in patients younger than 55 years: a systemic review of the contemporary literature. Can J. Surg 2019; 62: 249–258.

36.

Konan

Abdel

Haddad

FS.

Cemented versus uncemented hip implant fixation: should there be age thresholds?

Bone Joint Res 2020; 8: 604–607.

37.

Ross

Lee

Harris

, et al. Rates of osteoporosis management and secondary preventative treatment after primary fragility fractures. JBJS Open Access 2021; 6: e20.00142.

38.

Murray

DW.

Cemented femoral fixation: the North Atlantic divide. Bone Joint J 2013; 95-B(Suppl. A): 51–52.

39.

Bredow

Boese

Florkemeier

, et al. Factors affecting operative time in primary total hip arthroplasty: a retrospective single hospital cohort study of 7674 cases. Technol Health Care 2018; 26: 857–866.

40.

Sloan

Premkumar

Sheth

NP.

Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg Am 2018; 100: 1455–1460.

41.

Schwartz

Farley

Guild

, et al. Projections and epidemiology of revision hip and knee arthroplasties in the United States to 2030. J Arthroplasty 2020; 35: S79–S85.