A Hybrid Fixation Technique for Primary THA Patients
In a study presented at the AAOS annual meeting, Dr. Alexander Sah and Dr. John Dearborn report positive outcomes with use of a cementless acetabular component and a cemented femoral component in select patients undergoing total hip arthroplasty.
Over the past few years, ICJR live meetings have included a session that asks the question, “why did we switch from a cemented femoral prosthesis in total hip arthroplasty?” [1-5] Cementless fixation is commonly done – and done well – but as faculty at these meetings have noted, certain patients do better with a cemented femur.
With that in mind, Alexander P. Sah, MD, and John T. Dearborn, MD, compared outcomes of a modern hybrid technique for total hip arthroplasty (THA) with those of a fully cementless technique. Their findings were presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons in New Orleans.
The 2 surgeons had performed 3378 primary THAs between 1998 and 2012: 77.9% (2631) with the fully cementless technique and 22.1% (747) with the hybrid technique consisting of cemented femoral fixation and cementless acetabular press-fit. They determined which technique would be used according to preoperative templating of bone type and intraoperative assessment of bone quality, with hybrid fixation criteria including older age, osteoporosis, type C femoral bone shape, and fracture risk, according to Dr. Sah. All patients were weight-bearing the day of surgery.
Patients in the hybrid fixation group:
- Were older than patients in the cementless group – 79 years vs 63 years, respectively
- Were more likely to be female: 77.5% vs 48.5%
- Had a similar BMI: 29 vs 28
- Experienced similar improvement in the Harris Hip Score following surgery: 60 to 93 versus 68 to 95
But patients in the cementless group were more likely to experience fractures and other complications:
- 21 intraoperative fractures in the cementless group (0.8%) compared with 5 in the cemented group (0.6%)
- 15 postoperative fractures in the cementless group (0.6%) compared with 0 in the cemented group
- 17 femoral aseptic loosenings in the cementless group (0.6%) compared with 0 in the cemented group
- 4 fat embolism complications in the cementless group (0.2%) compared with 0 in the cemented group
In addition, 1 patient in the cemented group underwent a femoral revision.
The lack of postoperative femoral fractures in the cemented group is good news, Dr. Sah noted. “While periprosthetic fractures of cementless femoral components is infrequent, it is a costly and morbid complication when it occurs,” he said. “In this study, cemented femoral fixation had zero femoral fractures. The confidence this gives the surgeon and patient in immediate weight-bearing, even in the most challenging bone types, is invaluable.”
It also has financial implications for the surgeon and institution. “In the bundled payment environment, avoidance of a single major complication can have significant positive implications,” Dr. Sah said. “The lower cost of hybrid fixation combined with avoidance of postoperative fracture or reoperation seems to make it a critically important option that surgeons should keep in their armamentarium.
“Hybrid fixation is a less commonly learned or used technique, but surgeons should consider it a viable option.”
Sah AP, Dearborn JT. To Cement or Not to Cement? Modern Hybrid Total Hip Replacement – Low Risks and Excellent Results with Cemented Femoral Fixation (Paper 027). Presented at the 2018 Annual Meeting of the American Academy of Orthopaedic Surgeons, March 6-10, 2018, New Orleans, Louisiana.
Dr. Sah has disclosed the he is paid presenter for Angiotech, ConvaTec, Mallinckrodt Pharmaceuticals, Medtronic, Pacira Pharmaceuticals; that he receives royalties from NextStep Arthropedix; and that he receives research support from Zimmer Biomet. Dr. Dearborn has disclosed that he is a paid consultant for Zimmer Biomet and an unpaid consultant for NextStep Arthropedix.
- Nelson CL. Cemented THA: Why Did We Ever Change? Presented at the Transatlantic Orthopaedic Congress, October 3-5, 2014, New York, New York.
- Perka C. Cemented THA: Why Did We Ever Change? Presented at the Transatlantic Orthopaedic Congress, October 1-4, 2015, New York, New York.
- Moskal JT. Why We Should Cement More Hips in 2016. Presented at the 8th Annual ICJR Winter Hip & Knee Course, January 14-17, 2016, Vail, Colorado.
- Schreurs WB. Cemented THA: Why Did We Ever Change? Presented at the Transatlantic Orthopaedic Congress, October 6-9, 2016, New York, New York.
- Schreurs WB. Cemented THA: Why Did We Ever Change? Presented at the Transatlantic Orthopaedic Congress, October 12-15, 2017, New York, New York.