Choice of cemented or uncemented stems for displaced femoral neck fractures

Choice of cemented or uncemented stems for displaced femoral neck fracturesWang et al. [1] published about unplanned emergency department visits within 90 days of hip hemiarthroplasty for osteoporotic femoral neck fractures.In this article, they concluded that periprosthetic fractures (PPFs) occurred frequently when uncemented implants were replaced, indicating that cemented implants should be considered initially.Hemiarthroplasty is the conventional therapy for femoral neck fractures.However, the use of bone cement in hemiarthroplasty is controversial.Among the many reasons for concern in choosing the cemented stem, there are bone cement implantation syndrome (BCIS) and difficulties in treating PPF.The incidence of BCIS for femur neck fracture varies widely in the literature between 28% up to 38% [2,3] and an analysis of mortality from the National Hip Fracture Database has revealed that mortality within 24 hours after surgery was significantly higher among patients receiving cemented compared with uncemented hemiarthroplasty (1.6% vs 1.2%, P = 0.030), suggesting excess early mortality related to BCIS [4].Dahl et al. [5] reported that the risk of death within 48 hours of hip hemiarthroplasty between cemented and uncemented implants.Compared with the uncemented group, mortality was increased in the cemented group (RR 1.63 [95% CI 1.31 to 2.02]; P < 0.001).Rutter et al.[6] reported that 89 % (55/62) described acute deterioration occurring during or within a few minutes of cement insertion and the vast majority of deaths (33/41, 80%) occurred on the operating table.The surgical treatment of periprosthetic fractures in the femur is always a challenge for the orthopedic surgeon: either an osteosynthesis or a stem change is planned.As described in this article, PPF is known to occur more frequently in the uncemented stem [7].However, in the case of Vancouver type B2 fractures around a cemented implant, this further complicates management by altering the biomechanics and surgical technique [8].Specifically, removal of the cement mantle is required, and this potentially increases operative time, bleeding and risk of perforating the femur [9].Sattar et al. [10] reported a 35% reoperation rate in Vancouver type B2 around cemented stem.To summarize, even though periprosthetic fractures are common in the non-cemented implant group, the authors' conclusion allows readers to decide on the implant type by looking at only a very small tip of the iceberg-like complications of hemiarthroplasty.