Cementless Stem for Femoral Neck Fractures in a Patient’s 10th Decade of Life: High Rate of Periprosthetic Fractures

BACKGROUND: Subsidence of cementless femoral stems in hemiarthroplasty (HA) and increased fracture rates are ongoing concerns of orthopedic surgeons when treating fractures in very old patients. Additionally, bone cement implantation syndrome may result in perioperative cardiac or pulmonary complications, especially in older patients, leading to morbidity and mortality. This study was performed to analyze possible subsidence and intraoperative fractures in a cohort of very old patients treated with cementless stems. METHODS: We retrospectively analyzed a consecutive cohort of patients aged ≥90 years with femoral neck fractures treated by uncemented HA and an anterior minimally invasive approach. Immediate full-weight bearing was allowed postoperatively. Pelvic radiographs were examined for subsidence immediately postoperatively and 6 weeks later. RESULTS: We treated 109 patients (74% women; mean age, 93 years; range, 90-102 years) by HA from January 2010 to March 2016. The 30-day mortality rate was 16%, and the morbidity rate was 47%. There were 11 (12%) intraoperative fractures: 8 (Vancouver B(2)) had to be addressed immediately during the primary operation, while 3 (1 Vancouver B(1) and 2 Vancouver A(G)) were treated conservatively. One periprosthetic femoral fracture (Vancouver B(1)) was documented during follow-up. In 17 patients, subsidence of >2.0 mm (median, 3.9 mm; range, 2.5-9.0 mm) was documented. CONCLUSION: Early subsidence was low in this very old cohort treated with an uncemented stem and not showing a periprosthetic fracture. The risk of intraoperative periprosthetic fractures was high. The use of uncemented implants in osteoporotic bone continues to be an intervention with high risk and should only be performed by experienced surgeons. LEVEL OF EVIDENCE: Level III, Therapeutic study.