JOA - 2026-08-19 - Journal Article
Increased Risk of Periprosthetic Femoral Fracture with Cementless Collared Metadiaphyseal-Filling Stems Compared to Cemented Fixation for Femoral Neck Fractures in Patients Aged 65 Years or Older: An American Joint Replacement Registry Analysis.
Deckey DG, Kelly M, Zaniletti I, Hegde V, Springer BD, Kagan RP, Bingham JS
Topics
Key Takeaway
Cementless collared metadiaphyseal-filling stems carry a 70% higher hazard of revision for periprosthetic femoral fracture compared to cemented stems in patients ≥65 years undergoing arthroplasty for femoral neck fracture (aHR 1.7, 95% CI 1.1–2.7).
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Summary
This registry study compared periprosthetic femoral fracture (PPFx) revision risk between cementless collared metadiaphyseal-filling (CMDF) stems and cemented stems in patients ≥65 years undergoing hemiarthroplasty or THA for femoral neck fracture using AJRR-CMS linked data. Cause-specific Cox proportional hazard models adjusted for confounders showed CMDF stems had a significantly higher hazard of revision for PPFx (aHR 1.7, 95% CI 1.1–2.7, P=0.02) but a significantly lower hazard of revision for aseptic loosening (aHR 0.5, 95% CI 0.2–0.9, P=0.04). No significant differences were found for all-cause revision or revision for dislocation.
Key Limitation
The registry-based design cannot account for bone quality differences between groups, which is the primary biological driver of both stem selection bias and periprosthetic fracture risk, making residual confounding a critical concern.
Original Abstract
INTRODUCTION
Cemented femoral fixation is recommended when treating a femoral neck fracture with arthroplasty. Prior studies have shown collared, metadiaphyseal-filling (CMDF) cementless stems to have an equivalent periprosthetic fracture risk compared to cemented stems in primary total hip arthroplasty (THA). This study assessed the associated risk of periprosthetic femoral fracture (PPFx) after hemiarthroplasty or THA for femoral neck fracture comparing CMDF stems to cemented stems utilizing the American Joint Replacement Registry (AJRR).
METHODS
All femoral neck fractures in patients aged ≥ 65 years treated with arthroplasty in the AJRR were linked to Centers for Medicare and Medicaid Services data from 2012 to 2022. Patients were included if they received a cementless CMDF stem or a cemented stem. Patient demographics, revision or open reduction and internal fixation (ORIF) for PPFx, and revision for aseptic loosening or dislocation were recorded. Cause-specific Cox proportional hazard models, were used to evaluate the association of stem design with all-cause revision, revision or ORIF due to PPFx, and revision for aseptic loosening or dislocation while adjusting for potential confounders.
RESULTS
Compared to cemented stems, cementless CMDF stems were associated with a higher hazard of revision for PPFx (aHR [adjusted hazard ratio] 1.7, 95% CI [confidence interval] 1.1 to 2.7, P = 0.02). Analysis of secondary outcomes indicated that the two groups significantly differed in terms of revision for aseptic loosening, with cementless CMDF stems indicating a much lower event rate than cemented stems (aHR 0.5, 95% CI 0.2 to 0.9, P = 0.04). There were no significant differences found on adjusted analyses of other secondary outcomes.
CONCLUSIONS
Cementless CMDF stems were associated with an increased risk of revision for PPFx in the treatment of femoral neck fractures when compared to cemented stems. While this finding supports the use of cemented stems for the treatment of femoral neck fractures, it should be assessed against an increased risk of aseptic loosening when compared to cementless CMDF stems.