
==== Front
Medicine (Baltimore)
Medicine (Baltimore)
MD
Medicine
0025-7974
1536-5964
Lippincott Williams & Wilkins Hagerstown, MD

MD-D-23-09159
00065
10.1097/MD.0000000000039562
3
7100
Research Article
Systematic Review and Meta-Analysis
Effect of cemented vs uncemented on outcomes for hemiarthroplasty in the elderly: A meta-analysis of randomized clinical trials
https://orcid.org/0000-0003-0109-0418
Feng Yuning MD fengyuning@cdu.edu.cn
ab
Wan Jun MD wanjun2021@hotmail.com
c
Deng Haidong MD haidong2327@outlook.com
b
Chen Lvlin MD chenlvlin1057@outlook.com
d
Xiao Yangchun MD 464468629@qq.com
b
Li Tiangui MD ltg101@163.com
ae
He Jialing MD Hejialing1024@outlook.com
b
Wang Peng MD wangpeng2021@outlook.com
b
Chong Weelic MD wxc026@jefferson.edu
f
Hai Yang MD ocean.hai2019@gmail.com
g
Jia Lu MD lujia1057@163.com
h
Zhang Yu MD b*
a Department of Orthopedics, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
b Clinical Research Center, Affiliated Hospital of Chengdu University, Chengdu University, Chengdu, Sichuan, China
c Chengdu University School of Medicine, Chengdu, China
d Department of Critical Care Medicine, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
e Department of Anesthesia, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
f Department of Medical Oncology, Thomas Jefferson University, Philadelphia, PA
g Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
h Department of Neurosurgery, Shanxi Provincial People’s Hospital, Taiyuan, Shanxi, China.
* Correspondence: Yu Zhang, Clinical Research Center, Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China (e-mail: zhangyu1057@cdu.edu.cn).
13 9 2024
13 9 2024
103 37 e3956218 10 2023
07 5 2024
14 8 2024
Copyright © 2024 the Author(s). Published by Wolters Kluwer Health, Inc.
2024
https://creativecommons.org/licenses/by-nc/4.0/ This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial License 4.0 (CCBY-NC), where it is permissible to download, share, remix, transform, and buildup the work provided it is properly cited. The work cannot be used commercially without permission from the journal.

Purpose:

In patients undergoing hemiarthroplasty in the elderly, the choice of the cemented method remains controversial. This meta-analysis was undertaken to compare the impact of cemented vs uncemented on outcomes for hemiarthroplasty in the elderly.

Methods:

This study included randomized controlled trials comparing the postoperative effects of cemented vs uncemented in patients with hemiarthroplasty. With no language restrictions, we searched Medline (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials (Cochrane Collaboration), Clinical Trials.gov, the ISRCTN registry, as well as gray literature with no language restrictions from January 1966 to April 2023. Data were quantitatively summarized using a random-effects model. The primary outcome was 1-year mortality.

Results:

This study included 13 randomized controlled trials with 3485 patients. The primary outcomes of the meta-analysis showed that cemented fixation in elderly patients undergoing hemiarthroplasty was superior to noncemented in 1-year mortality (risk ratio [RR] = 0.87, 95% confidence interval [CI]: 0.77, 0.97). Moreover, cemented was associated with a reduced risk of intraoperative periprosthetic fracture (RR = 0.19, 95% CI: 0.07, 0.50), postoperative periprosthetic fracture (RR = 0.34, 95% CI: 0.16,0.72), and loosening (RR = 0.33, 95% CI: 0.11, 0.97).

Conclusions:

Cemented hemiarthroplasty is superior to noncemented in terms of survival. Moreover, cementation reduces the incidence of some implant-related complications. More extensive trials are needed to provide adequate guidance for choosing the proper cemented method.

cement
elderly
hemiarthroplasty
mortality
OPEN-ACCESSTRUE
SDCT
==== Body
pmc- What is already known on this topic

In patients undergoing hemiarthroplasty in the elderly, the choice of the cemented method remains controversial. Although there have been previous studies on the same topic, their conclusions are limited by the number of studies and the fact that the literature is up to date.

- What this study adds

Compared with uncemented, cemented was associated with decreased mortality for hemiarthroplasty in the elderly. Moreover, cementation reduces the incidence of some implant-related complications.

- How this study might affect research, practice, or policy

Current evidence did support that cemented was associated with reduced 1-year mortality compared to uncemented in patients undergoing hemiarthroplasty in the elderly. More extensive trials are still needed to provide adequate guidance on the choice of the appropriate procedure.

1. Introduction

With the advent of an aging society, femoral neck fractures due to osteoporosis are becoming increasingly common. It is a serious challenge to the survival of patients and the development of society.[1,2] Hemiarthroplasty is the standard procedure for elderly patients with femoral neck fractures and is more acceptable to patients and families than internal femoral neck fixation or total hip replacement.[3–5] In the case of hemiarthroplasty, there is either cemented or uncemented fixation, but there has been no definitive conclusion on the effect of cemented fixation.

Recent systematic reviews and meta-analyses have shown that cemented vs uncemented fixation in elderly patients undergoing hemiarthroplasty is not significant in mortality, which was limited by imprecision (given the small numbers).[6–10] Recently, the World Hip Trauma Evaluation (WHiTE) trial was published, which was largest randomized controlled trials (RCT) on this topic involving 1225 patients. In light of the recently published WHiTE data, we conducted a systematic review and meta-analysis of randomized trials to provide an updated estimate of the effect of cemented vs uncemented for hemiarthroplasty in the elderly on death.

2. Methods

We used methods recommended by the Cochrane Collaboration to conduct the meta-analysis. The methods of reporting study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 statement.[11] Given that this is a meta-analysis of published data, institutional review committee approval was not required. The protocol was registered on the PROSPERO, and the register number was CRD42022324366.

2.1. Eligibility criteria

We included trials that met each of the following PICOS criteria:

Population: adult patients (≥60 years) who undergoing hemiarthroplasty.

Intervention: treatment modalities for cement.

Comparison: treatment modalities for uncement.

Outcome: 1-year mortality, intraoperative periprosthetic fracture, postoperative periprosthetic fracture, deep infection, superficial infection, loosening, dislocation, pneumonia/chest infection, venous thromboembolic phenomena, and acute kidney injury.

Study design: RCTs.

2.2. Information sources and search strategy

With no language restrictions, we searched Medline (Ovid), Embase (Ovid), Cochrane Central Register of Controlled Trials (Cochrane Collaboration), Clinical Trials.gov, the ISRCTN registry, as well as gray literature with no language restrictions from January 1966 to April 2023. Reference lists of previous reviews, meta-analyses, and RCTs were also searched. Details of the search strategy are given in Table S1, Supplemental Digital Content, http://links.lww.com/MD/N508. Active attempts were made to contact the authors of the included articles where unpublished data existed.

2.3. Study selection

Two reviewers (YF and HD) independently reviewed the title and abstract as well as the full text of potentially relevant studies; any disagreement between the 2 reviewers was resolved by discussion and decision by a third reviewer (YZ). We compared the cemented and uncemented groups in each of the eligible RCTs in terms of patient characteristics, fracture typing and duration of follow-up, and there were no statistically significant differences, P > .05.

2.4. Data collection process

Two reviewers (YF and JW) performed data extraction independently and extracted data using a standardized electronic form. Disagreements between the 2 reviewers were resolved by discussion and the decision of a third reviewer (YZ). Study authors were contacted when suitable data were not available. Unpublished data were included after receiving a response and additional data from study investigators.

2.5. Outcomes

The primary endpoint was 1-year mortality. Secondary outcomes were intraoperative periprosthetic fracture, postoperative periprosthetic fracture, deep infection, superficial infection, loosening, dislocation, pneumonia/chest infection, venous thromboembolic phenomena, and acute kidney injury.

2.6. Assessment of risk of bias

Two reviewers (YF and HD) independently applied the Cochrane Risk of Bias tool to the RCT.[12] Disagreements between the 2 reviewers were resolved by discussion and arbitration by a third reviewer (YZ). The risk of bias for each domain was rated as high, low, or unknown.

2.7. Confidence of evidence

We used the Grading of Recommendation, Assessment, Development, and Evaluation (GRADE) approach to generate an absolute and risk ratio of the outcomes. GRADE guidance used the domains of study design limitations, inconsistency, indirectness, publication bias, and imprecision in results.[13]

2.8. Data synthesis

We used RevMan version 5.4 (Cochrane Collaboration) for all meta-analyses, with a P-value < 0.05 denoting statistical significance. Analyses for all outcomes were done on an intention-to-treat basis. For dichotomous outcomes, we conducted a random-effects meta-analysis using the Mantel–Haenszel (M-H) method with 95% CI. We assessed statistical heterogeneity using the χ2 test and the I2 test. We assessed evidence of publication bias across studies using funnel plots if 10 or more studies were in a meta-analysis.

In addition, a trial sequential analysis (TSA) was performed on the primary outcome, thereby enhancing the accuracy of the conclusions by excluding type I errors.[14] TSA is a quantitative method of cumulative meta-analysis that determines whether additional clinical trials are required by the current sample size included. Two-sided TSA was used to estimate required information size with a 5% risk of type I error, a risk of type II error of 20%, and power of 90%. The effect measure was set to risk ratio, and the model was random random-effects. The trial sequential analyze was conducted with software TSA 0.9.

2.9. Subgroup analysis

We conducted subgroup analyses based on mortality in age (>83 years vs ≤ 83 years); patient sample size (≥200 patients vs < 200 patients); issuing time (>2010 year vs ≤2010 year).

2.10. Sensitivity analyses

Sensitivity analyses were carried out for the primary results using the following methods, including excluding trials with fewer than 200 patients; excluding studies with the largest sample sizes (Fernandez 2022)[15]; using fixed-effects models; excluding studies with high or unknown risk of bias in the different domains.

3. Results

3.1. Study selection

A total of 627 relevant studies were identified based on the search strategy. However, 173 articles were excluded after checking for duplication and ineligibility. Of the remaining 454 papers, 416 were excluded after checking titles and abstracts. The eligibility of 38 studies for which full text was available was then assessed, resulting in 25 studies being excluded. Finally, 13 RCTs[15–27] between 1966 and 2022, with a total of 3485 patients, met our inclusion criteria and were included in the meta-analysis. A flowchart of the study selection process is shown in Figure 1.

Figure 1. Search strategy and final included and excluded studies.

3.2. Study characteristics

There were 3485 patients, of whom 13 studies[15–27] were over 60 years of age. The characteristics of the included studies are shown in Table 1. The overall risk of bias was moderate across studies (Appendix Figures S1 and S2, Supplemental Digital Content, http://links.lww.com/MD/N508). Bias analysis through funnel plots and TSA (Appendix Figures S5 and S6, Supplemental Digital Content, http://links.lww.com/MD/N508). Due to the nature of the study interventions, it was not possible to blind patients and their physicians. GRADE summary conclusions for all outcomes are presented in Table 2, and the quality of evidence for the primary outcomes was moderate.

Table 1 Baseline patient characteristics and treatment parameters by the time of publication in included randomized trials.

Sources	Year	Country	Cemented	Uncemented	Study period	Mean (age)	Female ratio (%)	Garden grade	Name of the implant manufacturer	Follow-up (mo)	P value	
Sadr and Arden	1977	UK	20	20	/	77.7	75	III, IV	Thompson/Thompson	17	>.05	
Emery	1991	UK	27	26	/	73.3	80.7	III, IV	Thompson/Austin Moore	17	>.05	
Harper	1994	UK	71	66	/	83.2	74.5	III, IV	/	12	>.05	
Santini	2005	Italy	53	53	September 2000 to December 2001	80.7	77.4	/	/	12	>.05	
Figved	2009	Norway	112	108	September 2004 to August 2006	83.2	76		Spectron/HA-coated	12	>.05	
Parker	2010	UK	200	200	March 2001 to November 2006	83	77	/	Thompson/Austin Moore	60	>.05	
DeAngelis	2012	USA	66	64	March 2005 to May 2008	84.1	76.9	/	LD/FX/beaded full coat	12	>.05	
Taylor	2012	New Zealand	80	80	May 2006 to November 2008	85.2	69	III, IV	Exeter stem/Alloclassic stem	24	>.05	
Talsnes	2013	Norway	162	172	2005 to 2010	84.2	75.5	III, IV	Landos Titan/Landos Corail	12	>.05	
Vidovic	2013	Croatia	30	30	January 2007 to December 2010	82.7	100	III, IV	Modular/modular Austin Moore	12	>.05	
Moerman	2017	Netherlands	110	91	August 2008 to June 2012	83.5	71.1	III, IV	Muller straight stem/DB-10	12	>.05	
Parker	2020	UK	200	200	August 2013 to June 2018	84.8	68.3	/	Exeter stem/JRI	12	>.05	
Fernandez	2022	UK	610	615	March 2017 to December 2019	84.4	67.9	III, IV	/	12	>.05	

Table 2 Summary of Findings and Strength of Evidence.

Outcome	No. Of patients (trials)	RR (95%CI)	Absolute effect estimates (per 1000)	Quality of the evidence	
Uncemented	Cemented	Difference	
1-yr mortality	3485 (13)	0.87 [0.77,0.97]	281	244	-36 [-8, −65]	Moderate*	
Intraoperative periprosthetic fracture	1511 (6)	0.19 [0.07,0.50]	69	13	-56 [-34,-64]	Moderate*	
Postoperative periprosthetic fracture	2552 (6)	0.34 [0.16,0.72]	23	8	-15 [-6,-19]	Moderate*	
Deep infection	824 (6)	1.59 [0.53,4.82]	10	16	6 [-5,38]	Low*,†	
Superficial infection	2926 (9)	1.23 [0.73,2.09]	17	21	4 [-5,19]	Low*,†	
Loosening	446 (3)	0.33 [0.11,0.97]	103	34	-69 [-3,-92]	Moderate*	
Dislocation	2874 (9)	1.04 [0.57,1.87]	15	16	1 [-6,13]	Low*,†	
Pneumonia/chest infection	2789 (8)	0.78 [0.50,1.21]	33	26	-7 [-16,7]	Low*,†	
Venous thromboembolic phenomena (DVT)	2576 (6)	1.28 [0.56,2.90]	8	10	2 [-3,15]	Low*,†	
Acute kidney injury	2226 (4)	1.23 [0.76,2.00]	26	32	6 [-6,26]	Low*,†	
CI = confidence interval, RR = risk ratio.

* Imprecisions.

† Inconsistencies.

3.3. Primary mortality

Based on 13 studies including 3485 patients, difference was found between the 2 methods with regard to 1-year mortality (hazard ratio [RR] = 0.87, 95% confidence interval [CI]: 0.77–0.97, I2 = 0) (Fig. 2). This study did not assess the existence of possible publication bias because of the small number of included trials. In sensitivity analyses, overall results for mortality were similar when we excluded from sensitivity analyses, excluded trials with fewer than 200 patients, excluded study with the largest sample sizes (Fernandez 2022),[15] or pooled trials using the fixed-effects model (Table S2, Supplemental Digital Content, http://links.lww.com/MD/N508). Subgroup analyses of the primary outcome did not reveal any interaction between variables on age, patient sample size, issuing time (Table S2 and Figure S3, Supplemental Digital Content, http://links.lww.com/MD/N508).

Figure 2. Primary outcome 1-yr mortality.

3.4. Secondary outcomes

Results of secondary outcomes are detailed in Figure 3 and Figure S4, Supplemental Digital Content, http://links.lww.com/MD/N508. Intraoperative periprosthetic fracture was associated with the closer connection of cement for hemiarthroplasty (RR = 0.19, 95% CI = 0.07,0.50), Postoperative periprosthetic fracture (RR = 0.34; 95% CI = 0.16,0.72), and Loosening (RR = 0.33, 95% CI: 0.11,0.97). However, there was no significant difference between cement and uncement in deep infection (RR = 1.59, 95% CI = 0.53,4.82), superficial infection (RR = 1.23, 95% CI = 0.73–2.09); dislocation (RR = 1.04, 95% CI = 0.57–1.87); pneumonia/chest infection (RR = 0.78, 95% CI = 0.50–1.21); venous thromboembolic phenomena (DVT) (RR = 1.28, 95% CI = 0.56–2.90); acute kidney injury (RR = 1.23, 95% CI = 0.76–2.00); duration of surgery; (MD = 8.51, 95% CI = 5.90–11.11); length of hospital stay (MD = -0.40, 95% CI: -1.03–0.23) (Figure 3 and Figure S4, Supplemental Digital Content, http://links.lww.com/MD/N508.).

Figure 3. Secondary outcomes.

4. Discussion

In this systematic meta-analysis of 13 RCTs with a total of 3485 patients, our meta-analysis found that cement for hemiarthroplasty was superior to noncemented in 1-year mortality, as well as intraoperative periprosthetic fracture, postoperative periprosthetic fracture, and loosening.

In recent years, some systematic reviews and meta-analyses have compared cemented with uncemented fixation in elderly patients undergoing hemiarthroplasty.[6–10] A meta-analysis conducted the comparison with or without cement for hemiarthroplasty concluded that no statistical difference in 1-year mortality between cement and uncement by Wu et al[6] in 2021.Viberg et al conducted a population-based cohort study on this topic and their results showed there was a higher relative mortality on the first postoperative day for cemented hemiarthroplasty vs uncemented hemiarthroplasty. There was no difference in mortality after 7 days up until 5 years after surgery in 2022.[28] The latest meta-analysis and retrospective studies have certain limitations

This study focused on data published in the current era, and additionally included 1 recently published large trial with about 1225 patients.[15] The data improved the precision concerning the effects and provided a higher quality of evidence than previous meta-analyses. The TSA showed that the number of hemiarthroplasties in this study at 1-year reached the required information level. This study had a comprehensive search strategy, and we contacted all study authors for any unpublished clinical data. This improves the precision and overall certainty of effect estimates. Our study rigorously assessed the quality of evidence and relative and absolute risks, which have important implications for clinical guidance.

This study has some limitations. First, with advances in bioengineering, changes in cement materials and improvements in surgical instrumentation have had an impact on the prognosis of hemiarthroplasty in the elderly. Second, the average age of the included patients was around 80 years, which is an advanced age group in the international definition of age and would have an impact on the data on some of the complications associated with the study.

5. Conclusions

Cemented hemiarthroplasty is superior to noncemented in terms of survival. Moreover, cementation reduces the incidence of some implant-related complications. More extensive trials are needed to provide adequate guidance for choosing the proper cemented method.

Author contributions

Conceptualization: Yuning Feng, Yang Hai.

Data curation: Yuning Feng, Jun Wan.

Formal analysis: Yuning Feng, Haidong Deng.

Investigation: Yuning Feng, Lvlin Chen.

Methodology: Yuning Feng, Yangchun Xiao, Lu Jia.

Project administration: Yuning Feng.

Resources: Tiangui Li.

Software: Yuning Feng, Jialing He.

Supervision: Yuning Feng.

Validation: Yuning Feng, Peng Wang.

Visualization: Yuning Feng, Weelic Chong, Yang Hai.

Writing – original draft: Yuning Feng, Yu Zhang.

Writing – review & editing: Yuning Feng, Yu Zhang.

Supplementary Material

Abbreviations:

CI confidence interval

M-H Mantel–Haenszel

RCT randomized controlled trials

RR risk ratio

TSA trial sequential analysis

WHiTE the World Hip Trauma Evaluation

The authors have no funding and conflicts of interest to disclose.

All data generated or analyzed during this study are included in this published article [and its supplementary information files].

Supplemental Digital Content is available for this article.

How to cite this article: Feng Y, Wan J, Deng H, Chen L, Xiao Y, Li T, He J, Wang P, Chong W, Hai Y, Jia L, Zhang Y. Effect of cemented vs uncemented on outcomes for hemiarthroplasty in the elderly: A meta-analysis of randomized clinical trials. Medicine 2024;103:37(e39562).

YF, JW, and HD contributed equally to this work.
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