6 Reasons Why Cemented Stems Still Make Sense in Total Hip Arthroplasty
There’s no reason to abandon cemented femoral components in primary total hip arthroplasty (THA), but there are plenty of reasons – well, at least 6 really good reasons – why cement is still relevant.
Speaking at Essential Hip Topics: Cradle to Grave, ICJR’s 1-day pre-course for the Mid-American Orthopaedic Association’s annual meeting, Robert T. Trousdale, MD, said that registry data from the American Joint Replacement Registry show a decline in the use of cemented hip designs, while the use of cementless implants has been gradually increasing.
He also noted that 47% of attendees at a meeting of the American Association of Hip & Knee Surgeons (AAHKS) had never done a cemented THA, while another 47% said they use cemented stems in fewer than 25% of their patients.
Dr. Trousdale, from Mayo Clinic in Rochester, Minnesota, said the American registry data and the feedback from AAHKS meeting attendees strongly contrast with European data: The UK joint registry, for example, shows that cemented stems are used in about 50% of THAs, while in Sweden, the number is about 70%.
But the number of cemented stems used in the US is not zero, Dr. Trousdale said, nor should it be.
With that in mind, here are his top 6 reasons not to abandon cemented stems for THA.
No. 1: Survivorship
Research and registry data have shown that select cemented femoral stem designs have excellent survivorship – more than 90% – at 30 to 40 years. [1,2]
No. 2: Versatility
Cemented stems can be used in all bones (different geometry, size, and bone quality), in patients of all ages, and in patients with all types of hip pathology, including osteoarthritis, fracture, and osteonecrosis. [3,4]
No. 3: Periprosthetic Fractures
The risk of periprosthetic fracture is higher with cementless than with cemented femoral stems. A study from Mayo Clinic found a 3% rate of intraoperative periprosthetic fractures when a cementless stem was used, compared with 0.25% for cemented stems.  Nordic registry data show that the risk ratio is 6.7 times higher for cementless than for cemented stems. 
No. 4: Antibiotic Cement
Some studies support the addition of antibiotics to cement to decrease the risk of PJI,  while others show that it makes no difference. Dr. Trousdale prefer to use antibiotics with cemented stems because it’s easy, quick, and inexpensive at his institution.
No. 5: Revision Procedures
In select revision procedures, with select tampered stems, Dr. Trousdale will use a cement-in-cement technique; he uses this technique 5 to 10 times a year. The most appropriate patients are those with a failed cemented primary THA that has an intact cement mantle.
No. 6: Forgiving Technique
Although cementing a femoral stem in THA is a forgiving technique, it is also a lost art, Dr. Trousdale said. He quoted Shen from The Journal of Bone and Joint Surgery: 
“The taper slip system seems to be more forgiving, with less rigid requirements for a satisfactory cement mantle.”
Click the image above to watch Dr. Trousdale’s presentation and learn more about cemented femoral stems in THA.
Disclosures: Dr. Trousdale has disclosed that he receives royalties from and is a paid consultant for DePuy Synthes.
- Callaghan JJ, Bracha P, Liu SS, Piyaworakhun S, Goetz DD, Johnston RC. Survivorship of a Charnley total hip arthroplasty. A concise follow-up, at a minimum of thirty-five years, of previous reports. J Bone Joint Surg Am. 2009 Nov;91(11):2617-21. doi: 10.2106/JBJS.H.01201.
- Ling RS, Charity J, Lee AJ, Whitehouse SL, Timperley AJ, Gie GA. The long-term results of the original Exeter polished cemented femoral component: a follow-up report. J Arthroplasty. 2009 Jun;24(4):511-7. doi: 10.1016/j.arth.2009.02.002. Epub 2009 Mar 17.
- Sathappan SS, Teicher ML, Capeci C, Yoon M, Wasserman BR, Jaffe WL. Clinical outcome of total hip arthroplasty using the normalized and proportionalized femoral stem with a minimum 20-year follow-up. J Arthroplasty. 2007 Apr;22(3):356-62. Epub 2007 Jan 22.
- Warth LC, Callaghan JJ, Liu SS, Klaassen AL, Goetz DD, Johnston RC. Thirty-five-year results after Charnley total hip arthroplasty in patients less than fifty years old. A concise follow-up of previous reports. J Bone Joint Surg Am. 2014 Nov 5;96(21):1814-9. doi: 10.2106/JBJS.M.01573.
- Abdel MP, Watts CD, Houdek MT, Lewallen DG, Berry DJ. Epidemiology of periprosthetic fracture of the femur in 32 644 primary total hip arthroplasties: a 40-year experience. Bone Joint J. 2016 Apr;98-B(4):461-7. doi: 10.1302/0301-620X.98B4.37201.
- Thien TM, Chatziagorou G, Garellick G, et al. Periprosthetic femoral fracture within two years after total hip replacement: analysis of 437,629 operations in the nordic arthroplasty register association database. J Bone Joint Surg Am. 2014 Oct 1;96(19):e167. doi: 10.2106/JBJS.M.00643.
- Jiranek WA, Hanssen AD, Greenwald AS. Antibiotic-loaded bone cement for infection prophylaxis in total joint replacement. J Bone Joint Surg Am. 2006 Nov;88(11):2487-500. Review.
- Shen G. Femoral stem fixation. J Bone Joint Surg Br. 1998;80-B(5):754-6.