RecommendationUse cemented implants in patients undergoing surgery with arthroplasty
Relative values of different outcomesThe outcomes considered were mortality, functional status, quality of life, pain, requirement for reoperation, non-healing and requirement for surgical revision, total length of stay (i.e. the time in hospital plus any time spent in rehabilitation). Mortality was of particular importance because of reported deaths by the NPSA.
Trade off between clinical benefits and harmsThere is no significant difference in mortality. There is evidence of less pain at 3 months and 1 to 2 years and better mobility score at 12 months with the older designs of cemented hemiarthroplasties. There was no significant difference for length of stay, failure to return to the same place of residence and failure to regain mobility. None of the reported outcomes showed any advantage of uncemented arthroplasty over cemented.

More evidence is available for older designs than newer designs of arthroplasty. Only one study was identified in newer designs. This showed no statistical difference for any reported outcomes. The direction of effect varies depending on the outcome: cemented implants are favoured for mortality, number of reoperations, length of stay, ability to walk unaided at 12 months; uncemented for need for pain medication at 12 months and Barthel index. The Eq-5d visual analogue score also favours uncemented. However, the Eq-5d index score shows no difference with tight confidence intervals. In light of this uncertainty in newer designs, the increased costs and lack of evidence or clinical reason to suggest a difference between the use of cement in newer and older stem designs the GDG considered that cemented implants should be recommended for all arthroplasties.

There is no direct evidence comparing the use of cemented and uncemented stems in total hip replacement for displaced intracapsular fractures. However, the GDG did not consider there would be a difference in the performance of cemented stems between outcomes for total hip replacement and hemiarthroplasty. Also, all the studies which looked at total hip replacements in other comparisons (section 10.3.2) used cemented femoral stems for total hip replacement.

No RCT evidence was found to raise concerns about the safety of the use of cement.
Economic considerationsOne study with potentially serious limitations and partial applicability found that the older cemented hemiarthroplasty are cost saving compared to uncemented hemiarthroplasty.

The NCGC cost analysis on cemented stems versus uncemented stems for newer designs of arthroplasty has considered several cost components, such as the cost of the implants, length of stay in hospital, rate of re-operations, accessories costs for the cemented implants.

As the clinical evidence did not show any advantage of uncemented over cemented arthroplasty in the newer design, and as the cost of new designs of cemented implants was shown to be lower than that of uncemented implants, the GDG consider cemented implants cost-effective based on the outcomes reported though these are not statistically significant.

One outcome reported in Figved showed a higher level of blood loss with cemented hemiratrhoplasty. However, the GDG did not consider the higher level of blood loss reported in Figved et al (2009)94 for patients receiving cemented implants (89mL) to be significant in terms of both patients' outcomes and costs.
Quality of evidenceThe evidence was of low or moderate quality. All but one of the studies comparing older arthroplasty designs used a Thompson or Austin Moore hemiarthroplasty (these are the first generation of implants to be used). The other study used an unspecified bipolar hemiarthroplasty. The evidence for modern stem designs is low quality mainly due to the lack of certainty around the effect size and only evidence being identified in bipolar hemiarthroplasty.

Overall, the GDG felt there was sufficient evidence to recommend the use of cemented arthroplasties over uncemented.
Other considerationsAll studies comparing the effectiveness of internal fixation with THR and hemiarthroplasty with THR used cemented THR (see section 10.3.2)

All patients should be allowed to be mobilised full weight bearing after hip fracture surgery (see section 10.2). All modern implants are designed to be load sharing devices to facilitate this.

From: 10, Surgical procedures

Cover of The Management of Hip Fracture in Adults
The Management of Hip Fracture in Adults [Internet].
NICE Clinical Guidelines, No. 124.
National Clinical Guideline Centre (UK).
Copyright © 2011, National Clinical Guideline Centre.

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