|Year : 2018 | Volume
| Issue : 1 | Page : 23-28
Comparative study of functional outcome of cemented and uncemented total hip replacement
Divyanshu Goyal, Mahesh Bansal, Ravindra Lamoria
Department of Orthopaedics, SMS Medical College and Attached Hospitals, Jaipur, Rajasthan, India
|Date of Web Publication||17-Aug-2018|
Dr. Divyanshu Goyal
B-21, Vaishali Nagar, Jaipur - 302 021, Rajasthan
Source of Support: None, Conflict of Interest: None
Background: To compare functional outcome of cemented and uncemented total hip replacement (THR). Materials and Methods: In this hospital based, randomized, comparative type of observational study, 25 patients were included in each group. Each patient examined thoroughly and underwent radiological assessment. Follow-up done at 6 weeks, 3 months, 6 months, and 2 years and pain score, Harris Hip Score (HHS), subjective complaints, and joint stability were recorded. Results: Mean age of the patient in cemented group was 60.64 years and in uncemented group was 59.72 years. Pain score was compared at each follow-up which came out significant at 6 weeks (P ≤ 0.05) and 3 months (P = 0.002) explaining better early bone integration with cemented THR. However, at 6 months difference in pain score between two groups was nonsignificant (P = 0.176). Difference in function score between cemented and uncemented group was significant at 6 weeks (P = 0.003) and 3 months (P ≤ 0.05) which later become nonsignificant at 6 months (P = 0.38). The difference of HHS between cemented and uncemented group was significant at 6 weeks (P ≤ 0.05) and 3 months (P = 0.011). This difference became nonsignificant at 6 months. HHS is further divided into four grading – poor (<70), fair (70–79), good (80–89), and excellent (90–100). Overall in our study, 88% of patients in cemented group showed excellent and good results and 84% in uncemented group showed excellent and good results. There was one case of excessive blood loss during surgery in uncemented group and one case of foot drop in cemented group. Conclusion: Cemented implants are cheaper than the uncemented implants. Better short-term clinical outcomes mainly improved pain and early pain-free full weight bearing was obtained from cemented fixation.
Keywords: Cemented total hip replacement, hip replacement, total hip replacement, uncemented total hip replacement
|How to cite this article:|
Goyal D, Bansal M, Lamoria R. Comparative study of functional outcome of cemented and uncemented total hip replacement. J Orthop Traumatol Rehabil 2018;10:23-8
|How to cite this URL:|
Goyal D, Bansal M, Lamoria R. Comparative study of functional outcome of cemented and uncemented total hip replacement. J Orthop Traumatol Rehabil [serial online] 2018 [cited 2018 Sep 18];10:23-8. Available from: http://www.jotr.in/text.asp?2018/10/1/23/239250
| Introduction|| |
In bipeds, the hip has the great responsibility of transmitting the ground reaction against the body weight while at the same time presenting mobility. To mechanically accommodate this postural change, the head and neck of femur undergo angulation and rotation at the base. Any affection of the hip is of much concern to the patient since it affects locomotion from the very beginning., The patient mostly tries to accommodate the disabilities following such pathology as far as practicable by various compensatory mechanisms. There are various conditions which affect the normal functioning of hip and results in long-term morbidity. So for correction, various treatment modalities have been used. Out of them, here, we focused on total hip replacement (THR).
THR is one of the most successful and cost-effective of surgical procedures with the primary goals of pain relief and restoration of function. Since THRs were introduced, there has been steady improvement in the technology associated with it, leading to better functional outcome and implant survivorship. Cemented implants achieve stability from cement-bone mechanical interlock, once the polymethylmethacrylate has cured,, whereas cementless fixation relies on primary press-fit stability with long-term stability occurring secondary to endosteal microfractures at the time of preparation and subsequent bone ongrowth or ingrowth.,
Charnley ,,, did pioneering work in all aspects of total hip arthroplasty (THA), including the concept of low-frictional torque arthroplasty, surgical alteration of hip biomechanics, lubrication, materials, design, and operating room environment. A major advancement was his use of cold-curing acrylic cement (polymethyl methacrylate) for fixation of the components. In response to the problem of loosening of the stem and cup based on the alleged failure of cement, press-fit, porous-coated, and hydroxyapatite-coated stems and cups have been investigated as ways to eliminate the use of cement and to use bone ingrowth or ongrowth as a means of achieving durable skeletal fixation. Many different techniques have evolved to improve cemented femoral fixation, including injection of low-viscosity cement, occlusion of the medullary canal, reduction of porosity, pressurization of the cement, and centralization of the stem.,,,
There have been massive advancements in the field of THR, but still very basic question remains unanswered, cemented or uncemented? In our institute and also other institutes have reported number of uncemented THR to be >95%. In some institutes, it is even >98%. Yes, there is advantage of uncemented THR in young patients as they require revision. However, in old patients who are older than 50 years, cemented THR being cheaper can be better option if there is no difference in functional outcome. We excluded Dorr type C femur to make it a nonbias study. We compared cemented and uncemented THR in terms of functional (pain score or Harris hip score [HHS]) outcome.
| Materials and Methods|| |
It was hospital-based, randomized, comparative type of observational study with 50 cases randomized into two groups with 25 cases in each group. Randomization was done by lottery method. All the patients of 50–80 years in which THR was indicated were included in the study while the patients with neurovascular deficit, active infection, and Dorr type C were excluded from this study. In Group 1, cemented THR was done while in Group 2 uncemented THR was done. All the surgeries were done by single surgeon using posterolateral approach. Follow-up was done at 6 weeks, 3 months, 6 months, and 2 years in which complete functional examination in terms of pain score and HHS was done.
| Results|| |
Mean age of patients in Group 1 was 60.64 years. All cases were above 50 years and maximum number was between 50 and 55 years [Table 1]. There were 18 males (72%) and 7 (28%) females. Out of 25 cases, 11 cases had pathology of the left side (44%) and 14 cases had right side pathology (56%). Mean duration of pathology was 9.52 months. A total of 10 patients had associated medical problems including diabetes mellitus and hypertension. Two patients had a history of previous surgery for fracture neck of femur with cannulated cancellous (CC) screw and one with dynamic hip screw (DHS).
|Table 1: Randomized distribution of cases in two groups according to age|
Click here to view
In uncemented group, mean age of the patient was 59.72 years and range was 50–81 years. There were 15 (60%) males and 10 (40%) females. Out of 25 cases, 9 had pathology of the left side (36%) and 16 had right side pathology (64%). Mean duration of pathology was 8 months. Totally, nine patients had associated medical problems including diabetes mellitus and hypertension and thyroid disease. Two patients had a history of previous surgery for fractured neck of femur with CC screw and one with bipolar.
The relationship age, sex, and duration of disease between two groups were found statistically insignificant to affect outcome of the study.
Among 25 cases of cemented Group, 1 (4%) had fracture dislocation hip, 3 (12%) had fracture neck of femur, 3 (12%) had arthritis, 14 (56%) had avascular necrosis (AVN) head of femur, 1 (4%) had displaced DHS, 1 (4%) had rheumatoid, 1 (4%) had nonunion neck of femur, and 1 (4%) had tuberculosis hip. Among 25 cases of uncemented Group, 4 (16%) had fracture neck of femur, 1 (4%) had arthritis hip joint, 16 (64%) had AVN head of femur, 1 (4%) had infected bipolar, 1 (4%) had nonunion I/T femur, 1 (4%) had nonunion neck of femur, and 1 (4%) had periprosthetic fracture around hip joint. For all these conditions, THR was done [Graph 1].
After surgery, pain score was compared at each follow up which came out significant at 6 weeks (P ≤ 0.05) and 3 months (P = 0.002) explaining better early bone integration with cemented THR. However, at 6 months difference in pain score between two groups was nonsignificant (P = 0.176) [Table 2].
|Table 2: Comparison of pain score at 6 weeks, 3 months and 6 months follow up|
Click here to view
Difference in function score between cemented and uncemented group was significant at 6 weeks (P = 0.003) and 3 months (P ≤ 0.05) which later become nonsignificant at 6 months (P = 0.38) [Table 3].
|Table 3: Comparison of function score at 6 weeks, 3 months and 6 months follow up|
Click here to view
The difference of HHS between cemented and uncemented group was significant at 6 weeks (P ≤ 0.05) and 3 months (P = 0.011). This difference became nonsignificant at 6 months [Table 4]. HHS is further divided in four grading – poor (<70), fair (70–79), good (80–89), and excellent (90–100). Overall in our study, 88% of patients in cemented group showed excellent and good results and 84% in uncemented group showed excellent and good results [Table 4].
In our study, no case showed radiological evidence of osteolysis and implant loosening. As it is well-known fact that the major complications of THA such as aseptic loosening, periprosthetic osteolysis appears late, therefore 2 years' follow-up period is very short and further studies with a longer period of follow-up are required for deriving any meaningful conclusion.
Various complications that developed during surgery and postoperatively in both groups of THR are as follows: there was one case of excessive blood loss during surgery in uncemented group, and there was one case of foot drop in cemented group (2%). In this case, sensation was intact and plantar flexion was present. Foot drop was probably attributed to neuropraxia due to faulty retraction. Conservative management was done, and the patient recovered fully in about 3 months.
All patients were operated using posterolateral approach. Meticulous repair of short external rotators was done, thus no postoperative dislocation was seen in any group [Figure 1], [Figure 2], [Figure 3], [Figure 4].
|Figure 1: Preoperative X-ray showing avascular necrosis of the right femoral head|
Click here to view
|Figure 2: Postoperative X-ray of above patient showing cemented total hip replacement with well-placed cup and stem with proper cementing|
Click here to view
|Figure 3: Preoperative X-ray of patient showing right side old fracture of neck of femur|
Click here to view
|Figure 4: Postoperative X-ray of above patient [Figure 3] managed with uncemented total hip replacement|
Click here to view
| Discussion|| |
THR surgery is a wonderful surgery for patients with hip joint destruction and has made lot of progress. Newer designs have come, each claiming its superiority over other. Cost has also increased with these advancements. But still, the basic question remains unanswered, cemented or uncemented. This question becomes even more important in elder age group patients and developing nations like India where cost-effectiveness is still a major concern.
There has been a worldwide trend toward the uncemented THR over the past 10 years. Uncemented THR was introduced to cope up with the complications of cemented THR, especially in younger patients. However, now invariably most of the institutes are performing uncemented THR >95% out of THRs.
Mäkelä et al. in his recently published article, compared survival of cemented and uncemented hip replacement prosthesis in patients older than 55 years and came up with a conclusion that cemented implants have better survival. He compared data from four nations.
Hailer et al. analyzed Swedish Hip Arthroplasty Register and stated significant difference in 10-year survival of cemented and uncemented THR with cemented being better as uncemented implants had more revisions due to aseptic loosening of cup.
Studies have also proved better outcome of cemented THR in obese and osteoporotic patients and less intraoperative femur fracture rates.
In a meta-analysis by Morshed et al., there was no significant difference in survival of two type of implants.
Zimmerma et al. published a study according to which, totally noncemented prosthesis was more costly, there were no statistically significant differences in clinical or functional outcomes between the noncemented and the cemented prostheses up to 12 months postsurgery.
Maggs and Wilson  in their recently published study stated that cemented THR has abundant evidence of excellent outcomes. Stem can be placed according to surgeon's will following patients' anatomy. It can be used in patients with femoral deformity, osteoporotic bone, or following radiotherapy, and in young or old alike. Short-term clinical outcomes in terms of pain relief and early mobilization are good. Revision in cemented THA is straightforward using the cement-in-cement technique. Many of the reasons that may have caused surgeons in the past to move away from the use of cemented implants have been found to be unwarranted, and the evidence does not support the increasing use of uncemented implants, and importantly in today's economic climate, economic analysis confirms that cemented THA is a highly cost-effective option.
Our review showed no significant difference between cemented and cementless group at 2 years' follow-up. Cemented femoral component provides an immediate postoperative advantage in terms of better integration between bone, cement and the prosthesis, which permits dramatic early relief of pain and early weight-bearing., We excluded Dorr type C femur patients. It is almost certain that better short-term clinical outcomes mainly improved pain score can be obtained from cemented fixation. In general, cemented implants were cheaper than the uncemented implants. Hence, cemented THR is more cost effective especially for poor patients. In developing countries, where cost is still a major factor, patients older than 50–55 years can be treated with cemented THR prosthesis. As it is well-known fact that the major complications  of THA such as aseptic loosening, periprosthetic osteolysis appears late, therefore 2 years' follow-up is very short and further studies with a longer period of follow-up are required.
| Conclusion|| |
We conclude with this study that Cemented implants are cheaper than the uncemented implants. Better short-term clinical outcomes mainly improved pain and early pain-free full weight bearing was obtained with cemented fi xation. But no significant difference found between two groups at 2 year follow up.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
| References|| |
Bergmann G, Deuretzbacher G, Heller M, Graichen F, Rohlmann A, Strauss J, et al.
Hip contact forces and gait patterns from routine activities. J Biomech 2001;34:859-71.
Charles MN, Bourne RB, Davey JR, Greenwald AS, Morrey BF, Rorabeck CH. Soft-tissue balancing of the hip. J Bone Joint Surg 2004;86:1078-88.
Coventry MB. The treatment of fracture-dislocation of the hip by total hip arthroplasty. J Bone Joint Surg Am 1974;56:1128-34.
Jasty M. Prosthetic Loosening in Total Hip Replacements. In: Bono J.V., McCarthy J.C., Thornhill T.S., Bierbaum B.E., Turner R.H. (eds) Revision Total Hip Arthroplasty. Springer, New York 1999;3-10. [Doi: 10.1007/978-1-4612-1406-9_1].
Banaszkiewicz PA. Improved Cementing Techniques and Femoral Component Loosening in Young Patients with Hip Arthroplasty: A 12-Year Radiographic Review. In: Banaszkiewicz P., Kader D. (eds) Classic Papers in Orthopaedics. Springer, London. Class Pap Orthop 2013;31-4. [Doi: 10.1007/978-1-4471-5451-8_7].
Morscher EW. Cementless total hip arthroplasty. Clin Orthop Relat Res 1983;76-91.
Cheng SL, Davey JR, Inman RD, Binnington AG, Smith TJ. The effect of the medial collar in total hip arthroplasty with porous-coated components inserted without cement. An in vivo
canine study. J Bone Joint Surg Am 1995;77:118-23.
Charnley J. Arthroplasty of the hip. A new operation. Lancet 1961;1:1129-32.
Charnley J. Biomechanics in orthopaedic surgery. Biomech Relat Bio Eng Top 1965. p. 99-110. [Doi: 10.1016/b978-1-4831-6701-5.50017-6].
Charnley J. Cement-bone interface. Low Friction Arthroplasty Hip 1979;1979:25-40. [Doi: 10.1007/978-3-642-67013-8_5].
Salvati EA, Wilson PD Jr., Jolley MN, Vakili F, Aglietti P, Brown GC, et al.
A ten-year follow-up study of our first one hundred consecutive Charnley total hip replacements. J Bone Joint Surg Am 1981;63:753-67.
Espehaug B, Furnes O, Havelin LI, Engesaeter LB, Vollset SE. The type of cement and failure of total hip replacements. J Bone Joint Surg Br 2002;84:832-8.
Settecerri JJ, Kelley SS, Rand JA, Fitzgerald RH Jr. Collar versus collarless cemented HD-II femoral prostheses. Clin Orthop Relat Res 2002;146-52.
Davies JP, Harris WH.In vitro
and in vivo
studies of pressurization of femoral cement in total hip arthroplasty. J Arthroplasty 1993;8:585-91.
Mäkelä KT, Matilainen M, Pulkkinen P, Fenstad AM, Havelin L, Engesaeter L, et al.
Failure rate of cemented and uncemented total hip replacements: Register study of combined nordic database of four nations. BMJ 2014;348:f7592.
Hailer NP, Garellick G, Kärrholm J. Uncemented and cemented primary total hip arthroplasty in the Swedish Hip Arthroplasty Register. Acta Orthop 2010;81:34-41.
Morshed S, Bozic KJ, Ries MD, Malchau H, Colford JM Jr. Comparison of cemented and uncemented fixation in total hip replacement: A meta-analysis. Acta Orthop 2007;78:315-26.
Zimmerma S, Hawkes WG, Hudson JI, Magaziner J, Hebel JR, Towheed T, et al.
Outcomes of surgical management of total HIP replacement in patients aged 65 years and older: Cemented versus cementless femoral components and lateral or anterolateral versus posterior anatomical approach. J Orthop Res 2002;20:182-91.
Maggs J, Wilson M. The relative merits of cemented and uncemented prostheses in total hip arthroplasty. Indian J Orthop 2017;51:377-85.
] [Full text]
Abdulkarim A, Ellanti P, Motterlini N, Fahey T, O'Byrne JM. Cemented versus uncemented fixation in total hip replacement: A systematic review and meta-analysis of randomized controlled trials. Orthop Rev (Pavia) 2013;5:e8.
Inngul C, Blomfeldt R, Ponzer S, Enocson A. Cemented versus uncemented arthroplasty in patients with a displaced fracture of the femoral neck: A randomised controlled trial. Bone Joint J 2015;97-B: 1475-80.
Pennington M, Grieve R, Sekhon JS, Gregg P, Black N, van der Meulen JH, et al.
Cemented, cementless, and hybrid prostheses for total hip replacement: Cost effectiveness analysis. BMJ 2013;346:f1026.
Thompson R, Kane RL, Gromala T, McLaughlin B, Flood S, Morris N, et al.
Complications and short-term outcomes associated with total hip arthroplasty in teaching and community hospitals. J Arthroplasty 2002;17:32-40.
[Figure 1], [Figure 2], [Figure 3], [Figure 4]
[Table 1], [Table 2], [Table 3], [Table 4]