Femoral neck fractures: Cementless hemiarthroplasty is more common than cemented fixation but carries higher risks

According to a retrospective review of hemiarthroplasty treatment for femoral neck fracture, cementless fixation is used more often than cemented fixation. However, the cementless approach was associated with an 11-fold higher risk of complications than cemented fixation. These findings were presented at the AAOS 2025 Annual Meeting.

“Prior to this study, there was uncertainty about how popular cementless hemiarthroplasty was and what risks this fixation type posed, relative to cemented fixation. This study nicely elucidates those risks,” said lead author Robert A. Burnett, MD, joint reconstruction surgeon at Midwest Orthopaedics at Rush and an assistant professor at Rush University Medical Center in Chicago.

Dr. Burnett and colleagues conducted a retrospective analysis of data from a multicenter hip fracture database on patients who received hemiarthroplasty for femoral neck fracture from 2010 to 2019. The researchers compared patient demographics, surgical details, rate of revision due to periprosthetic fracture, surgical complications (dislocation, periprosthetic joint infection [PJI]), and mortality. The team used logistic regression analysis to compare risk of various complications, adjusting for age, sex, BMI, and comorbidity status.

During the study period, cementless fixation (n = 577, 58.6%) was more common than cemented fixation (n = 407, 41.4%). “We did not expect to find a high utilization of cementless hemiarthroplasty nationally, especially given the increased emphasis on cemented fixation in the fracture setting,” Dr. Burnett said. However, he noted that over the study period, a trend emerged indicating that use of cemented fixation was increasing.

Patients who received cementless hemiarthroplasty were younger (77.7 years vs. 81.8 years, P < .001). Surgical time was shorter with cementless fixation (90.5 ± 35.7 minutes vs. 105.0 ± 38.7 minutes, P < .001). Those who received cementless fixation were:

• Less likely to return to independent ambulation (8.2% vs. 19.2%, P < .001)
• Significantly more likely to need revision surgery for periprosthetic fracture (2.6% vs. 0.3%, P = .004; odds ratio [OR], 11.06; 95% confidence interval [CI], 1.43-85.38).
• More likely to experience a dislocation (6.1% vs. 2.7%, P = .014; OR, 2.29; 95% CI, 1.13-4.67)

“We suspect that the instability is explained by stem subsidence leading to decreased abductor tension and instability,” Dr. Burnett said. Table 1 details the complications associated with cementless hemiarthroplasty.

Rates of PJI were similar between groups (4% vs. 4.9%, P = .483). Cementless fixation had a lower rate of 90-day mortality (10.8% vs. 19.2%, P < .001). “This difference may be explained by higher age and comorbidity burden in the cemented hemiarthroplasty group,” Dr. Burnett added.

However, the difference in mortality rates dissipated at final follow-up (OR, 1.23), “suggesting that the higher complication rate associated with cementless fixation may lead to increased short- and mid-term mortality in patients.”

The authors encouraged orthopaedic surgeons to consider routine use of cemented fixation for femoral neck fractures to decrease the risk of future fracture and the need for further surgical intervention.

“There are many questions that have arisen after looking at this topic. We are curious if similar trends exist in femoral neck fracture patients treated with total hip arthroplasty. We would also like to look at risk factors, including age and comorbidity burden, for surgical complications in cementless fixation to determine if this strategy is appropriate in certain patient populations,” Dr. Burnett said.

Dr. Burnett’s coauthors of “Cementless hemiarthroplasty complication risk does not justify current utilization patterns” were Anne Josephine Hakim; Brenna Blackburn, PhD, MPH; Lucas Anderson, MD, FAAOS; Jeremy Gililland, MD, FAAOS; Patrick F. Bergin, MD, FAAOS; Antonia F. Chen, MD, MBA, FAAOS; Kyle Cichos, PhD; Brett D. Crist, MD, FAAOS; Graham John DeKeyser, MD; Michael Ewing, MD; Jeffrey Frandsen, MD; Elie S. Ghanem, MD, FAAOS; Charles Gusho, MD; Erik Nathan Hansen, MD, FAAOS; Eric Michael Jordan, BS; James A. Keeney, MD, FAAOS; Gerald McGwin, MS, PhD; Simon Mears, MD, FAAOS; Christopher Michael Melnic, MD, FAAOS; Michael O’Malley, MD, FAAOS; Jeffrey Benjamin Stambough, MD, FAAOS; and Benjamin M. Stronach, MD, FAAOS.

Keightley Amen, BA, ELS, is a freelance writer for AAOS Now.