CORR Insights®: Cemented or Uncemented Hemiarthroplasty for Femoral Neck Fracture? Data From the Norwegian Hip Fracture Register

Where Are We Now? Kristensen and colleagues [7] performed a retrospective analysis of the Norwegian Hip Fracture Register, a longitudinally maintained database shown to have high completion rate (93%) and nearly complete followup of deaths (100%). The authors found that despite no differences in pain, quality of life, or 1-year mortality in patients after uncemented compared to cemented hemiarthroplasty, patients undergoing an uncemented hemiarthroplasty have a higher overall risk of reoperation with the most common reasons for reoperation being periprosthetic fracture or infection [7]. These findings support the recommendation to use cemented hemiarthroplasty in elderly hip fracture patients from the American Academy of Orthopaedic Surgeons [1] and the United Kingdom’s National Institute for Health and Care Excellence [10]. This study raises two thought-provoking questions: (1) Despite mounting evidence and prestigious societal recommendations to use cemented hemiarthroplasty in elderly hip fracture patients, why does there continue to be notable variation in care? (2) As global healthcare systems continue to move towards alternative payment models that aim to reward value—defined as health outcome achieved per dollar spent [11]—how may the variation in uncemented versus cemented hemiarthroplasty progress? It is important to consider why surgical variation exists. In a recent CORR® Guest Editorial, Dr. Charles N. Cornell speculates three key reasons: (1) surgeon convenience as a means of saving time; (2) transfer bias because patients with complications from uncemented stems may seek revisions elsewhere; and (3) the potential of bone cement implantation syndrome (BCIS) in older patients with cardiovascular comorbidities or pathologic fractures [2]. Indeed, if we assume that surgeons always seek to deliver the best care for their patients, this variation of care is not done with any ill intent; however, the evidence against uncemented stems in hemiarthroplasty for femoral neck fractures continues to grow, including the most recent work by Kristensen and colleagues [7]. Therefore, such surgical variation should not persist—all hemiarthroplasties in patients with femoral neck fractures should be performed with cemented stems. Where Do We Need To Go? Healthcare expenditures continue to increase globally, and surgical decisions are likely to come under further scrutiny. This is particularly true if available evidence suggests one treatment has higher complication rates leading to higher costs compared to another for the same condition. Indeed, as alternative payment models, such as bundled payment programs, gain traction and show promising initial results [8], there will likely be increased pressure to standardize treatment in an attempt to try to maximize value (better outcomes for fewer dollars spent). As such decisions are made, surgeons should not only be at the table but lead discussions about care delivery and policy, as no other stakeholder has the unique perspective surgeons have on patient surgical care. The authors of the current study demonstrated that uncemented hemiarthroplasty in older patients with hip fractures were more likely to need reoperation [7]. This adds another well-done study to the growing body of literature demonstrating that the use of cemented stems in hemiarthroplasty leads to decreased reoperations and complications, pain, and periprosthetic fracture [3-6, 9, 13]. The evidence is convincing and robust, and in an era of alternative payment models, reoperation can lead to not only patient safety concerns but also financial issues, as the cost surpasses the predetermined bundled payment amount. Therefore, effort must continue to grow the proportion of orthopaedic surgeons in the United States and globally who use cemented stems in hemiarthroplasty. How Do We Get There? While the evidence is quite convincing in support of cemented stems in hemiarthroplasty, the same studies that demonstrate such benefit also show that some surgeons continue to use uncemented stems in hemiarthroplasty [3-7, 9, 13]. The onus is now on these surgeons to articulate what has not yet been studied that might demonstrate superiority—or at least equivalence—of the uncemented stem approach to the cemented stem approach. Not only must these thoughts be shared with the orthopaedic surgery community at large, but also rigorously studied. While randomized controlled trials are considered the gold standard of research in many scenarios, surgeons who favor uncemented stems may find the large numbers provided by registries to be more useful. This is especially true if arguments for uncemented stems in hemiarthroplasty are based on the presence of rare comorbidities, for example. However, it would be crucial that surgeons verify the accuracy and completeness of any registry ultimately used. Lastly, it is important to note the growing role for today’s orthopaedic surgeon to be involved in advocacy [12]. While the evidence appears clearly in favor of cemented stems in hemiarthroplasty, those who disagree may seek to conduct the necessary studies to argue otherwise now. This would be ever more important for these surgeons if hospitals, payers, or other healthcare stakeholders seek to limit reimbursement for uncemented stems in hemiarthroplasty to a case-by-case basis or not at all. Indeed, surgeons must seek opportunities to advocate for themselves and their patients using data to support their positions. These experiences include volunteering on hospital panels to review protocols and processes, lobbying representatives at the local, state, and federal level, or serving on expert committees that advise reimbursement for payers. This will ensure the surgeon voice and our colleagues’ important research is heard as part of the policy-making process.