[page 34] [Orthopedic Reviews 2013; 5:e8]Cemented versus uncementedfixation in total hip replacement: a systematicreview and meta-analysis of randomized controlled trialsAli Abdulkarim, Prasad Ellanti, Nicola Motterlini, Tom Fahey, John M. O’ByrneDepartment of Orthopaedics, CappaghNational Orthopaedic Hospital, Finglas,Dublin; Royal College of Surgeons,Dublin, IrelandAbstractThe optimal method of fixation for primarytotal hip replacements (THR), particularly fixa-tion with or without the use of cement is stillcontroversial. In a systematic review and meta-analysis of all randomized controlled trials com-paring cemented versus uncemented THRSavailable in the published literature, we foundthat there is no significant difference betweencemented and uncemented THRs in terms ofimplant survival as measured by the revisionrate. Better short-term clinical outcome, partic-ularly an improved pain score can be obtainedwith cemented fixation. However, the resultsare unclear for the long-term clinical and func-tional outcome between the two groups. No dif-ference was evident in the mortality and thepost operative complication rate. On the otherhand, the radiographic findings were variableand do not seem to correlate with clinical find-ings as differences in the surgical techniqueand prosthesis design might be associated withthe incidence of osteolysis. We concluded inour review that cemented THR is similar if notsuperior to uncemented THR, and provides bet-ter short term clinical outcomes. Furtherresearch, improved methodology and longer fol-low up are necessary to better define specificsubgroups of patients in whom the relativebenefits of cemented and uncemented implantfixation can be clearly demonstrated.IntroductionTotal hip replacement (THR) is one of themost successful and cost-effective of surgicalprocedures with the primary goals of pain reliefand restoration of function. Since THRs wereintroduced, there has been steady improvementin the technology associated with it, leading tobetter functional outcome and implant survivor-ship.1The success of THRs and the increasingfrequency of its use is largely due to the devel-opment of the cemented low-friction arthroplas-ty with its high survival rate.2,3However, theoutcomes of other cemented THR prostheseswere poor with high and early loosening rate,primarily due to the implant designs andcementing techniques in many cases. Thecement itself was considered a cause of loosen-ing leading the term cement disease. The unce-mented THR was developed to avoid these prob-lems; however the early designs had similarlypoor outcomes. The development of circumfer-entially coated uncemented implants whichallow bone to grow into or onto the prosthesishas led to an improved implant survival rate andsupported their growing use, despite highercosts.4-6Published studies comparing cementedto uncemented THRs are rare. The majority ofthese are retrospective, non-randomised com-parisons,7,8 or comparison in the same patientwith bilateral THRs.9,10Various randomized con-trolled trials (RCTs) have been designed tocompare the clinical and radiological outcomesof cemented versus uncemented fixation.11,12Thus far no one study has been able to draw adecisive conclusion because of inherent limita-tions. Furthermore, there are no horizontal orlongitudinal comparisons of the published RCTsin the literature. Our study aims to determinewhether the contemporary hip surgeons shouldabandon the proven dependability of cementedfixation for the emerging technology of cement-less fixation.ObjectivesThis review aims to systematically evaluateall RCTs comparing cemented versus unce-mented fixation of THRs, with no restriction tothe patients age. Information sourcesA comprehensive search across multipleDatabases was performed for studies pub-lished in English and other languages.Databases included Medline, BIOSYS, Embase,Web of Science, CAB Health, Cumulative Indexto Nursing and Allied Health Literature,Science Citation Index/ Current Contents andthe Cochrane Library (Issue 4, 2010). The ref-erence list of each study was reviewed to findadditional relevant studies. Experts in the fieldand manufacturers of implants were contactedto identify further studies. The so called greyliterature was identified using the InsideDatabase of the British Library, the System forInformation on Grey Literature in Europe, andrelevant abstract bands. The studies not pub-lished because of negative results or other rea-sons were identified from online trial registers(UK National Research Register of ongoinghealth research, information on clinical trialssponsored by the NIH and The InternationalRegister of Clinical Trials Registers).Eligibility criteriaTypes of studies We included reports of only RCTs. In thecase of multiple publications of a trial, weincluded the first published article. Exceptionswere made if a more recent publication corrob-orates the results of a longer follow up orexamined a different outcome or both.Types of participantsHumans aged 18 years or older who under-went a primary THR were eligible. Types of interventions and compar-isonThe intervention of interest is the implanta-tion of primary cemented THRs compared toprimary uncemented THRs.Types of outcome measuresThe primary outcome is failure of the pri-mary procedure, measured objectively by therevision rate due to aseptic loosening of eitherthe cup or the stem. Secondary outcomesincluded radiological signs of loosening orOrthopedic Reviews 2013; volume 5:e8Correspondence: Ali Abdulkarim, Department ofOrthopaedics, Cappagh National OrthopaedicHospital, Finglas, Dublin 11, Ireland.Tel. +35.3863022807E-mail: [email protected] words: cemented, uncemented, total hiparthroplasty, meta analysis.Contributions: AA, main authors; PE, coauthor;NM, statistical analysis; TF, methodologicalsupervisor; JMOB, senior author.Conflict of interests: the authors declare nopotential conflict of interests.Received for publication: 10 October 2012.Revision received: 3 November 2012.Accepted for publication: 13 December 2012.This work is licensed under a Creative CommonsAttribution NonCommercial 3.0 License (CC BY-NC 3.0).©Copyright A. Abdulkarim et al., 2013Licensee PAGEPress, ItalyOrthopedic Reviews 2013;
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