Cementless Stems Increase the Risk for Stem Loosening at the time of a Periprosthetic Fracture

Periprosthetic femoral fractures (PFFs) are an emerging problem, as hip arthroplasty patients live longer and more active lives. Femoral stem stability at time of fracture guides treatment and makes the difference between fracture fixation and stem revision. We designed this study to examine whether stem stability depended on stem type used.

The records of all patients who presented with a PFF to our institution from 2005 to 2021 were retrieved. Patient demographics, stem type, fracture type and treatment performed were recorded. Correlative statistics were applied.

A total of 5640 total and partial hip arthroplasties were identified. Of these, 55 presented with a PFF, for a 0.97% fracture rate. Females constituted 84% of all patients. Average patient age at the time of arthroplasty was 69.7 years. Fractures occurred at a mean of 8.3 years after the surgery. Forty fractures (72%) occurred in patients with cementless stems and only 15 (28%) in patients with cemented stems. In 13 fractures (32.5%) in the cementless group the stem was loose (Vancouver B2), compared to none (0%) in the cemented group (p=0.012). In the cementless group, 6 patients (15%) were treated non-operatively, 22 (55%) underwent fracture fixation and 12 (30%) underwent stem revision. In contrast, in the cemented group 6 patients (40%) were treated non-operatively, 9 underwent fracture fixation (60%) and none were revised (p=0.022). Notably, the fracture rate was the same (0.97%) for both stem types.

Our results demonstrate a higher proportion of PFFs with stem loosening in patients with cementless stems, compared to cemented implants. Considering the physiologic and economic burden of revision arthroplasty, strategies are needed to reduce the number of revisions. These may call for increasing the use of cemented stems, better screening and treatment of osteoporosis, and considering osteoporosis treatment for selected patients after arthroplasty.