JOA - 2026-09-07 - Journal Article
Variation in the Use of Cemented Versus Uncemented Hemiarthroplasty and Total Hip Arthroplasty for Treatment of Femoral Neck Fractures in the United States.
Anderson PA, Greenwald A, Riley C, Kates SL, Jimenez E, Pezold R, O'Donnell J, Illgen R
Topics
Key Takeaway
Cemented femoral fixation in FNF arthroplasty reduces periprosthetic fracture risk by 79% (HR 0.21) and all-cause revision by 25% (HR 0.75), yet is used in only 39.8% of US cases with up to 14-fold state-level variation.
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Summary
Using AJRR data from 2012–2021, this study examined cement utilization patterns and outcomes in patients ≥65 years undergoing HA or THA for FNF. Cemented fixation was used in only 39.8% of cases overall, with state-level prevalence ranging from 6–83% and a 2-fold regional difference between Midwest (56%) and South (29%). Cemented fixation independently reduced all-cause revision (HR 0.75), 90-day revision (HR 0.64), and periprosthetic fracture revision (HR 0.21), but carried an 8.9% higher hazard for mortality (HR 1.089), likely reflecting selection bias toward higher-risk patients receiving cement.
Key Limitation
The mortality signal (HR 1.089 for cemented fixation) cannot be causally interpreted because AJRR lacks ASA class, frailty indices, and bone quality metrics that drive surgeon selection of cement, creating unresolvable confounding by indication.
Original Abstract
INTRODUCTION
Practice guidelines in the United States (US) recommend cemented femoral fixation in hemiarthroplasty (HA) and total hip arthroplasty (THA) to treat femoral neck fractures (FNFs) for older patients. The purpose of this study was to assess regional variation and hospital characteristics associated with cement use for HA and THA used to treat FNFs and to determine the impact of cement use on adverse outcomes.
METHODS
All FNF patients ≥ 65 years treated with HA or THA from 2012 to 2021 in the American Joint Replacement Registry (AJRR) were analyzed. There were 81,610 cases included: 15,282 THAs and 66,328 HAs. Patient demographics, cement use stratified by region and hospital type, and adverse outcomes were recorded. Multivariate analyses were performed.
RESULTS
Cemented femoral fixation was used in 39.8% of combined HA and THA cases with greater frequency in HA (44.5%) compared with THA (19.2%, P < 0.001). Cement utilization ranged from 6 to 83% by state with 2-fold variation comparing Midwest and Southern regions (56 versus 29%, respectively, P < 0.001). Major teaching centers were more likely to use cement than non-teaching institutions (odds ratio (OR) 1.84, P < 0.001). Cemented compared with cementless fixation had a lower hazard ratio for all-cause revision (hazard ratio (HR): 0.75; P < 0.001), revision at three months (HR: 0.64; CI [confidence interval]: 0.554 to 0.75, P < 0.001), and revision for periprosthetic fracture (HR: 0.21; CI: 0.15 to 0.30, P < 0.001). Cemented fixation had an 8.9% higher hazard for mortality (HR: 1.089; CI: 1.06 to 1.12; P = 0.001).
CONCLUSIONS
There is significant regional variation regarding the prevalence of cemented femoral fixation used to treat FNFs with either HA or THA in the US. Cemented fixation resulted in a lower risk of periprosthetic fracture and revision surgery. Higher mortality was associated with cemented fixation, but may relate to selection bias. The observed variation in clinical practice and lack of conformity to published guidelines is an opportunity for quality improvement.