Journal of Orthopaedic Surgery 2014;22(2):186-9
Cemented versus cementless hemiarthroplasty for femoral neck fractures in the elderly Zhaowen Dennis Ng, Lingaraj Krishna
Department of Orthopaedic Surgery, National University of Singapore, National University Hospital, Singapore
and mortality were similar between the 2 groups. ABSTRACT Purpose. To compare cemented versus cementless bipolar hemiarthroplasty in terms of operating time, blood loss, pain, functional outcome, morbidity, and mortality. Methods. Medical records of 207 patients aged ≥60 years who underwent bipolar hemiarthroplasty for displaced femoral neck fracture using a cemented (n=96) or cementless (n=111) prosthesis were reviewed. Postoperative thigh pain, ambulatory status, and complications were assessed. Results. The cemented group had significantly longer operating time (p=0.017) and greater intraoperative blood loss (p=0.024). Postoperative thigh pain was significantly higher in the cementless group (p=0.023). Conclusion. Cementless hemiarthroplasty is preferred over cemented hemiarthroplasty because of reduced operating time and intra-operative blood loss. It was associated with increased postoperative thigh pain, but functional outcomes, complications,
Key words: femoral neck fractures; hemiarthroplasty
INTRODUCTION Hip hemiarthroplasty is superior to internal fixation for displaced femoral neck fractures, enabling earlier mobility, less reoperations, and better functional outcome at one year.1,2 Nonetheless, the choice of implants and cementation methods remains controversial.3–5 Cementless implants are more suitable for younger patients with good bone stock quality. Cementing the femoral stem does not necessarily improve outcome.6–10 Cementless arthroplasties are associated with mid-thigh pain and a higher risk of periprosthetic fractures, whereas cemented arthroplasties are associated with a higher risk of cardiac and respiratory complications secondary to the toxic effect of cement or pulmonary embolisation of bone marrow contents and methylmethacrylate particles.11–16 This study compared cemented versus cementless bipolar
Address correspondence and reprint requests to: Dr Zhaowen Dennis Ng, Department of Orthopaedic Surgery, National University of Singapore, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074. Email: [email protected]
Vol. 22 No. 2, August 2014
Cemented versus cementless hemiarthroplasty for femoral neck fractures 187
hemiarthroplasty in terms of operating time, blood loss, pain, functional outcome, morbidity, and mortality. MATERIALS AND METHODS Medical records of 207 patients aged ≥60 years who underwent bipolar hemiarthroplasty for displaced femoral neck fracture using a cemented (n=96) or cementless (n=111) prosthesis between January 2005 and December 2009 were reviewed. The patients were ambulatory prior to the fracture. Patients with a pre-existing hip abnormality requiring total hip replacement or a pathological fracture secondary to malignant disease were excluded. Patient age, gender, number of associated comorbidities, and prefracture ambulatory status were retrieved. General health status was defined
by the number of major comorbidities including diabetes mellitus, congestive heart failure, cardiac arrhythmias, ischaemic heart disease, previous cerebrovascular accident, renal disease, Parkinson’s disease, hypertension, chronic obstructive pulmonary disease, and the need for ongoing anticoagulation.17,18 Ambulatory status was classified as (1) non-ambulant or wheelchair bound, (2) ambulant with assistance, (3) ambulant with walking aids, and (4) independent. Postoperative pain was assessed using the visual analogue scale (VAS) from 0 to 10. Postoperative complications were recorded. The 2 groups were compared using the 2-tailed Fisher’s exact test for dichotomous variables and each subcategory of ambulatory status, whereas t test was used for continuous variables such as pain scores, blood loss, operating time, and length of hospital stay. A p value of 2 Prefracture ambulatory status (no. of patients) Non-ambulant Ambulant with assistance Ambulant with walking aids Independent Mean±SD operating time (minutes) Mean±SD intra-operative blood loss (ml) Mean±SD postoperative blood loss (ml) Mean±SD length of stay (days) Complication (no. of patients) Intra-operative fracture Dislocation Deep vein thrombosis Pulmonary embolism Wound infection Pneumonia Urinary tract infection Pressure sores Perioperative myocardial infarction leading to death Postoperative myocardial infarction not leading to death Respiratory failure Postoperative periprosthetic fracture At the 2-year follow-up* Mean (range) visual analogue scale score for thigh pain Ambulatory status (no. of patients) Non-ambulant Ambulant with assistance Ambulant with walking aids Independent * 19 patients were lost to follow-up and 24 had died
Bipolar hemiarthroplasty
p Value
Cemented (n=96)
Cementless (n=111)
73 (60–91) 75 (78)
72 (60–87) 86 (77)
0.55 0.26
72 24
81 30
0.67 0.59
0 5 26 65 95±18 371±154 215±117 7.1±2.1
0 4 32 75 81±18 290±147 231±121 7.4±2.0
0.87 0.68 0.76 0.017 0.024 0.47 0.75
0 0 3 0 2 1 2 3 1 2 1 0 (n=75) 0.9 (0–3)
1 0 4 0 3 2 4 2 1 1 0 1 (n=89) 2.7 (0–5)
0.67 0.75 0.57 0.44 0.48 0.57 0.44 0.67 0.67
3 17 26 29
7 19 29 34
0.21 0.79 0.64 0.47
0.023
Journal of Orthopaedic Surgery
188 ZD Ng et al.
RESULTS The cemented and cementless groups did not differ significantly in terms of patient age, gender, number of major comorbidities, and prefracture ambulatory status (Table). The cemented group had significantly longer operating time (95±18 vs. 81±18 minutes, p=0.017, t test) and greater intra-operative blood loss (371±154 vs. 290±147 ml, p=0.024, t test) than the cementless group, but the difference was not significant in terms of the need for blood transfusion and postoperative blood loss (closed suction drains). The length of hospital stay, functional outcome in terms of postoperative ambulatory status, and postoperative complications were similar in both groups. There was one intra-operative fracture during insertion of the implant in the cementless group. There were 3 deaths within 72 hours of operation: one died of acute myocardial infarction in each group, and one died of respiratory failure in the cemented group. One patient in the cementless group required revision surgery for a periprosthetic fracture sustained 6 months postoperatively following a fall. The one-year mortality was similar between the cemented and cementless groups (11/96 [11.5%] vs. 13/111 [11.7%]). After a mean follow-up period of 2.4 (range, 2–4.2) years, 75 patients in the cemented and 89 patients in the cementless groups were available for review. Postoperative thigh pain was significantly higher in the cementless group (p=0.023). 19 patients were lost to follow-up and 24 patients had died after a mean of 1.4 years. According to telephone interviews with family members, the operated hips were minimally symptomatic at the time of death. DISCUSSION Operating time and blood loss have been reported to be significantly greater in patients with cemented
hemiarthroplasty, but these are not associated with increased mortality or morbidity, whereas thigh pain is reported to be significantly greater in patients with cementless hemiarthroplasty.6,10 70% of patients with cementless hemiarthroplasty suffer from disabling thigh pain.19 Residual pain is higher in those treated with cementless implants.20,21 Regaining mobility at postoperative one year is reported to be better after cemented arthroplasty (p=0.005),20 although the rates of postoperative complications and early mortality are similar between the 2 groups,6 as is the Harris Hip Score (functional outcome) at one year.12 Cementation is associated with increased risks of cardiac arrhythmias and respiratory complications caused by embolism of marrow content forced into the circulation or the toxic effect of the cement. An increased risk of severe embolic events and impaired pulmonary function was reported during cemented total hip arthroplasty.22 However, cementless implants are associated with complications such as thigh pain, stress shielding, and a higher risk of periprosthetic fracture.8,13 In elderly patients, bone quality is generally poor; this can lead to poor bony ingrowth and inability to achieve a congruent fit, both of which preclude an initial rigid fixation that is important for cementless implants.23 CONCLUSION Cementless hemiarthroplasty is preferred over cemented hemiarthroplasty because of reduced operating time and intra-operative blood loss. It was associated with increased postoperative thigh pain, but functional outcomes, complications, and mortality were similar between the 2 groups. DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Frihagen F, Nordsletten L, Madsen JE. Hemiarthroplasty or internal fixation for intracapsular displaced femoral neck fractures: randomised controlled trial. BMJ 2007;335:1251–4. 2. Parker MJ, Gurusamy K. Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev 2006;4:CD001708. 3. Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial. J Bone Joint Surg Am 2006;88:2583–9. 4. Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P 3rd, Obremskey W, Koval KJ, et al. Internal fixation compared
Vol. 22 No. 2, August 2014
Cemented versus cementless hemiarthroplasty for femoral neck fractures 189
with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am 2003;85:1673–81. 5. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am 2006;88:249–60. 6. Emery RJ, Broughton NS, Desai K, Bulstrode CJ, Thomas TL. Bipolar hemiarthroplasty for subcapital fracture of the femoral neck. A prospective randomised trial of cemented Thompson and uncemented Moore stems. J Bone Joint Surg Br 1991;73:322–4. 7. Foster AP, Thompson NW, Wong J, Charlwood AP. Periprosthetic femoral fractures—a comparison between cemented and uncemented hemiarthroplasties. Injury 2005;36:424–9. 8. Khan RJ, MacDowell A, Crossman P, Datta A, Jallali N, Arch BN, Keene GS. Cemented or uncemented hemiarthroplasty for displaced intracapsular femoral neck fractures. Int Orthop 2002;26:229–32. 9. Lennox IA, McLauchlan J. Comparing the mortality and morbidity of cemented and uncemented hemiarthroplasties. Injury 1993;24:185–6. 10. Lo WH, Chen WM, Huang CK, Chen TH, Chiu FY, Chen CM. Bateman bipolar hemiarthroplasty for displaced intracapsular femoral neck fractures. Uncemented versus cemented. Clin Orthop Relat Res 1994;302:75–82. 11. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet 2007;370:1508–19. 12. Figved W, Opland V, Frihagen F, Jervidalo T, Madsen JE, Nordsletten L. Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures. Clin Orthop Relat Res 2009;467:2426–35. 13. Khan R, MacDowell A, Crossman P, Keene GS. Cemented or uncemented hemiarthroplasty for displaced intracapsular fractures of the hip—a systematic review. Injury 2002;33:13–7. 14. Fallon KM, Fuller JG, Morley-Forster P. Fat embolization and fatal cardiac arrest during hip arthroplasty with methylmethacrylate. Can J Anaesth 2001;48:626–9. 15. Ries MD, Lynch F, Rauscher LA, Richman J, Mick C, Gomez M. Pulmonary function during and after total hip replacement. Findings in patients who have insertion of a femoral component with and without cement. J Bone Joint Surg Am 1993;75:581–7. 16. Skyrme AD, Jeer PJ, Berry J, Lewis SG, Compson JP. Intravenous polymethyl methacrylate after cemented hemiarthroplasty of the hip. J Arthroplasty 2001;16:521–3. 17. Davidson TI, Bodey WN. Factors influencing survival following fractures of the upper end of the femur. Injury 1986;17:12– 4. 18. Sherk HH, Snape WJ, Loprete FL. Internal fixation versus nontreatment of hip fractures in senile patients. Clin Orthop Relat Res 1979;141:196–8. 19. Dorr LD, Glousman R, Hoy AL, Vanis R, Chandler R. Treatment of femoral neck fractures with total hip replacement versus cemented and noncemented hemiarthroplasty. J Arthroplasty 1986;1:21–8. 20. Parker MJ, Gurusamy KS, Azegami S. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 2010;6:CD001706. 21. Faraj AA, Branfoot T. Cemented versus uncemented Thompson’s prostheses: a functional outcome study. Injury 1999;30:671– 5. 22. Pitto RP, Koessler M, Kuehle JW. Comparison of fixation of the femoral component without cement and fixation with use of a bone-vacuum cementing technique for the prevention of fat embolism during total hip arthroplasty. A prospective, randomized clinical trial. J Bone Joint Surg Am 1999;81:831–43. 23. LaPorte DM, Mont MA, Hungerford DS. Proximally porous-coated ingrowth prostheses: limits of use. Orthopedics 1999;22:1154–62.
Cemented versus cementless hemiarthroplasty for femoral neck fractures in the elderly Zhaowen Dennis Ng, Lingaraj Krishna
Department of Orthopaedic Surgery, National University of Singapore, National University Hospital, Singapore
and mortality were similar between the 2 groups. ABSTRACT Purpose. To compare cemented versus cementless bipolar hemiarthroplasty in terms of operating time, blood loss, pain, functional outcome, morbidity, and mortality. Methods. Medical records of 207 patients aged ≥60 years who underwent bipolar hemiarthroplasty for displaced femoral neck fracture using a cemented (n=96) or cementless (n=111) prosthesis were reviewed. Postoperative thigh pain, ambulatory status, and complications were assessed. Results. The cemented group had significantly longer operating time (p=0.017) and greater intraoperative blood loss (p=0.024). Postoperative thigh pain was significantly higher in the cementless group (p=0.023). Conclusion. Cementless hemiarthroplasty is preferred over cemented hemiarthroplasty because of reduced operating time and intra-operative blood loss. It was associated with increased postoperative thigh pain, but functional outcomes, complications,
Key words: femoral neck fractures; hemiarthroplasty
INTRODUCTION Hip hemiarthroplasty is superior to internal fixation for displaced femoral neck fractures, enabling earlier mobility, less reoperations, and better functional outcome at one year.1,2 Nonetheless, the choice of implants and cementation methods remains controversial.3–5 Cementless implants are more suitable for younger patients with good bone stock quality. Cementing the femoral stem does not necessarily improve outcome.6–10 Cementless arthroplasties are associated with mid-thigh pain and a higher risk of periprosthetic fractures, whereas cemented arthroplasties are associated with a higher risk of cardiac and respiratory complications secondary to the toxic effect of cement or pulmonary embolisation of bone marrow contents and methylmethacrylate particles.11–16 This study compared cemented versus cementless bipolar
Address correspondence and reprint requests to: Dr Zhaowen Dennis Ng, Department of Orthopaedic Surgery, National University of Singapore, National University Hospital, 5 Lower Kent Ridge Road, Singapore, 119074. Email: [email protected]
Vol. 22 No. 2, August 2014
Cemented versus cementless hemiarthroplasty for femoral neck fractures 187
hemiarthroplasty in terms of operating time, blood loss, pain, functional outcome, morbidity, and mortality. MATERIALS AND METHODS Medical records of 207 patients aged ≥60 years who underwent bipolar hemiarthroplasty for displaced femoral neck fracture using a cemented (n=96) or cementless (n=111) prosthesis between January 2005 and December 2009 were reviewed. The patients were ambulatory prior to the fracture. Patients with a pre-existing hip abnormality requiring total hip replacement or a pathological fracture secondary to malignant disease were excluded. Patient age, gender, number of associated comorbidities, and prefracture ambulatory status were retrieved. General health status was defined
by the number of major comorbidities including diabetes mellitus, congestive heart failure, cardiac arrhythmias, ischaemic heart disease, previous cerebrovascular accident, renal disease, Parkinson’s disease, hypertension, chronic obstructive pulmonary disease, and the need for ongoing anticoagulation.17,18 Ambulatory status was classified as (1) non-ambulant or wheelchair bound, (2) ambulant with assistance, (3) ambulant with walking aids, and (4) independent. Postoperative pain was assessed using the visual analogue scale (VAS) from 0 to 10. Postoperative complications were recorded. The 2 groups were compared using the 2-tailed Fisher’s exact test for dichotomous variables and each subcategory of ambulatory status, whereas t test was used for continuous variables such as pain scores, blood loss, operating time, and length of hospital stay. A p value of 2 Prefracture ambulatory status (no. of patients) Non-ambulant Ambulant with assistance Ambulant with walking aids Independent Mean±SD operating time (minutes) Mean±SD intra-operative blood loss (ml) Mean±SD postoperative blood loss (ml) Mean±SD length of stay (days) Complication (no. of patients) Intra-operative fracture Dislocation Deep vein thrombosis Pulmonary embolism Wound infection Pneumonia Urinary tract infection Pressure sores Perioperative myocardial infarction leading to death Postoperative myocardial infarction not leading to death Respiratory failure Postoperative periprosthetic fracture At the 2-year follow-up* Mean (range) visual analogue scale score for thigh pain Ambulatory status (no. of patients) Non-ambulant Ambulant with assistance Ambulant with walking aids Independent * 19 patients were lost to follow-up and 24 had died
Bipolar hemiarthroplasty
p Value
Cemented (n=96)
Cementless (n=111)
73 (60–91) 75 (78)
72 (60–87) 86 (77)
0.55 0.26
72 24
81 30
0.67 0.59
0 5 26 65 95±18 371±154 215±117 7.1±2.1
0 4 32 75 81±18 290±147 231±121 7.4±2.0
0.87 0.68 0.76 0.017 0.024 0.47 0.75
0 0 3 0 2 1 2 3 1 2 1 0 (n=75) 0.9 (0–3)
1 0 4 0 3 2 4 2 1 1 0 1 (n=89) 2.7 (0–5)
0.67 0.75 0.57 0.44 0.48 0.57 0.44 0.67 0.67
3 17 26 29
7 19 29 34
0.21 0.79 0.64 0.47
0.023
Journal of Orthopaedic Surgery
188 ZD Ng et al.
RESULTS The cemented and cementless groups did not differ significantly in terms of patient age, gender, number of major comorbidities, and prefracture ambulatory status (Table). The cemented group had significantly longer operating time (95±18 vs. 81±18 minutes, p=0.017, t test) and greater intra-operative blood loss (371±154 vs. 290±147 ml, p=0.024, t test) than the cementless group, but the difference was not significant in terms of the need for blood transfusion and postoperative blood loss (closed suction drains). The length of hospital stay, functional outcome in terms of postoperative ambulatory status, and postoperative complications were similar in both groups. There was one intra-operative fracture during insertion of the implant in the cementless group. There were 3 deaths within 72 hours of operation: one died of acute myocardial infarction in each group, and one died of respiratory failure in the cemented group. One patient in the cementless group required revision surgery for a periprosthetic fracture sustained 6 months postoperatively following a fall. The one-year mortality was similar between the cemented and cementless groups (11/96 [11.5%] vs. 13/111 [11.7%]). After a mean follow-up period of 2.4 (range, 2–4.2) years, 75 patients in the cemented and 89 patients in the cementless groups were available for review. Postoperative thigh pain was significantly higher in the cementless group (p=0.023). 19 patients were lost to follow-up and 24 patients had died after a mean of 1.4 years. According to telephone interviews with family members, the operated hips were minimally symptomatic at the time of death. DISCUSSION Operating time and blood loss have been reported to be significantly greater in patients with cemented
hemiarthroplasty, but these are not associated with increased mortality or morbidity, whereas thigh pain is reported to be significantly greater in patients with cementless hemiarthroplasty.6,10 70% of patients with cementless hemiarthroplasty suffer from disabling thigh pain.19 Residual pain is higher in those treated with cementless implants.20,21 Regaining mobility at postoperative one year is reported to be better after cemented arthroplasty (p=0.005),20 although the rates of postoperative complications and early mortality are similar between the 2 groups,6 as is the Harris Hip Score (functional outcome) at one year.12 Cementation is associated with increased risks of cardiac arrhythmias and respiratory complications caused by embolism of marrow content forced into the circulation or the toxic effect of the cement. An increased risk of severe embolic events and impaired pulmonary function was reported during cemented total hip arthroplasty.22 However, cementless implants are associated with complications such as thigh pain, stress shielding, and a higher risk of periprosthetic fracture.8,13 In elderly patients, bone quality is generally poor; this can lead to poor bony ingrowth and inability to achieve a congruent fit, both of which preclude an initial rigid fixation that is important for cementless implants.23 CONCLUSION Cementless hemiarthroplasty is preferred over cemented hemiarthroplasty because of reduced operating time and intra-operative blood loss. It was associated with increased postoperative thigh pain, but functional outcomes, complications, and mortality were similar between the 2 groups. DISCLOSURE No conflicts of interest were declared by the authors.
REFERENCES 1. Frihagen F, Nordsletten L, Madsen JE. Hemiarthroplasty or internal fixation for intracapsular displaced femoral neck fractures: randomised controlled trial. BMJ 2007;335:1251–4. 2. Parker MJ, Gurusamy K. Internal fixation versus arthroplasty for intracapsular proximal femoral fractures in adults. Cochrane Database Syst Rev 2006;4:CD001708. 3. Baker RP, Squires B, Gargan MF, Bannister GC. Total hip arthroplasty and hemiarthroplasty in mobile, independent patients with a displaced intracapsular fracture of the femoral neck. A randomized, controlled trial. J Bone Joint Surg Am 2006;88:2583–9. 4. Bhandari M, Devereaux PJ, Swiontkowski MF, Tornetta P 3rd, Obremskey W, Koval KJ, et al. Internal fixation compared
Vol. 22 No. 2, August 2014
Cemented versus cementless hemiarthroplasty for femoral neck fractures 189
with arthroplasty for displaced fractures of the femoral neck. A meta-analysis. J Bone Joint Surg Am 2003;85:1673–81. 5. Keating JF, Grant A, Masson M, Scott NW, Forbes JF. Randomized comparison of reduction and fixation, bipolar hemiarthroplasty, and total hip arthroplasty. Treatment of displaced intracapsular hip fractures in healthy older patients. J Bone Joint Surg Am 2006;88:249–60. 6. Emery RJ, Broughton NS, Desai K, Bulstrode CJ, Thomas TL. Bipolar hemiarthroplasty for subcapital fracture of the femoral neck. A prospective randomised trial of cemented Thompson and uncemented Moore stems. J Bone Joint Surg Br 1991;73:322–4. 7. Foster AP, Thompson NW, Wong J, Charlwood AP. Periprosthetic femoral fractures—a comparison between cemented and uncemented hemiarthroplasties. Injury 2005;36:424–9. 8. Khan RJ, MacDowell A, Crossman P, Datta A, Jallali N, Arch BN, Keene GS. Cemented or uncemented hemiarthroplasty for displaced intracapsular femoral neck fractures. Int Orthop 2002;26:229–32. 9. Lennox IA, McLauchlan J. Comparing the mortality and morbidity of cemented and uncemented hemiarthroplasties. Injury 1993;24:185–6. 10. Lo WH, Chen WM, Huang CK, Chen TH, Chiu FY, Chen CM. Bateman bipolar hemiarthroplasty for displaced intracapsular femoral neck fractures. Uncemented versus cemented. Clin Orthop Relat Res 1994;302:75–82. 11. Learmonth ID, Young C, Rorabeck C. The operation of the century: total hip replacement. Lancet 2007;370:1508–19. 12. Figved W, Opland V, Frihagen F, Jervidalo T, Madsen JE, Nordsletten L. Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures. Clin Orthop Relat Res 2009;467:2426–35. 13. Khan R, MacDowell A, Crossman P, Keene GS. Cemented or uncemented hemiarthroplasty for displaced intracapsular fractures of the hip—a systematic review. Injury 2002;33:13–7. 14. Fallon KM, Fuller JG, Morley-Forster P. Fat embolization and fatal cardiac arrest during hip arthroplasty with methylmethacrylate. Can J Anaesth 2001;48:626–9. 15. Ries MD, Lynch F, Rauscher LA, Richman J, Mick C, Gomez M. Pulmonary function during and after total hip replacement. Findings in patients who have insertion of a femoral component with and without cement. J Bone Joint Surg Am 1993;75:581–7. 16. Skyrme AD, Jeer PJ, Berry J, Lewis SG, Compson JP. Intravenous polymethyl methacrylate after cemented hemiarthroplasty of the hip. J Arthroplasty 2001;16:521–3. 17. Davidson TI, Bodey WN. Factors influencing survival following fractures of the upper end of the femur. Injury 1986;17:12– 4. 18. Sherk HH, Snape WJ, Loprete FL. Internal fixation versus nontreatment of hip fractures in senile patients. Clin Orthop Relat Res 1979;141:196–8. 19. Dorr LD, Glousman R, Hoy AL, Vanis R, Chandler R. Treatment of femoral neck fractures with total hip replacement versus cemented and noncemented hemiarthroplasty. J Arthroplasty 1986;1:21–8. 20. Parker MJ, Gurusamy KS, Azegami S. Arthroplasties (with and without bone cement) for proximal femoral fractures in adults. Cochrane Database Syst Rev 2010;6:CD001706. 21. Faraj AA, Branfoot T. Cemented versus uncemented Thompson’s prostheses: a functional outcome study. Injury 1999;30:671– 5. 22. Pitto RP, Koessler M, Kuehle JW. Comparison of fixation of the femoral component without cement and fixation with use of a bone-vacuum cementing technique for the prevention of fat embolism during total hip arthroplasty. A prospective, randomized clinical trial. J Bone Joint Surg Am 1999;81:831–43. 23. LaPorte DM, Mont MA, Hungerford DS. Proximally porous-coated ingrowth prostheses: limits of use. Orthopedics 1999;22:1154–62.
