Orthopedic Reviews 2013 volume 5 e8 Cemented versus uncemented fixation in total hip replacement a systematic review and meta analysis of randomized controlled trials Ali Abdulkarim Prasad Ellanti Nicola Motterlini Tom Fahey John M O Byrne Department of Orthopaedics Cappagh National Orthopaedic Hospital Finglas Dublin Royal College of Surgeons Dublin Ireland Abstract The optimal method of fixation for primary total hip replacements THR particularly fixation with or without the use of cement is still controversial In a systematic review and metaanalysis of all randomized controlled trials comparing cemented versus uncemented THRS available in the published literature we found that there is no significant difference between cemented and uncemented THRs in terms of implant survival as measured by the revision rate Better short term clinical outcome particularly an improved pain score can be obtained with cemented fixation However the results are unclear for the long term clinical and functional outcome between the two groups No difference was evident in the mortality and the post operative complication rate On the other hand the radiographic findings were variable and do not seem to correlate with clinical findings as differences in the surgical technique and prosthesis design might be associated with the incidence of osteolysis We concluded in our review that cemented THR is similar if not superior to uncemented THR and provides better short term clinical outcomes Further research improved methodology and longer follow up are necessary to better define specific subgroups of patients in whom the relative benefits of cemented and uncemented implant fixation can be clearly demonstrated Introduction Total hip replacement THR is one of the most successful and cost effective of surgical procedures with the primary goals of pain relief and restoration of function Since THRs were introduced there has been steady improvement in the technology associated with it leading to better functional outcome and implant survivorship 1 The success of THRs and the increasing page 34 frequency of its use is largely due to the development of the cemented low friction arthroplasty with its high survival rate 2 3 However the outcomes of other cemented THR prostheses were poor with high and early loosening rate primarily due to the implant designs and cementing techniques in many cases The cement itself was considered a cause of loosening leading the term cement disease The uncemented THR was developed to avoid these problems however the early designs had similarly poor outcomes The development of circumferentially coated uncemented implants which allow bone to grow into or onto the prosthesis has led to an improved implant survival rate and supported their growing use despite higher costs 4 6 Published studies comparing cemented to uncemented THRs are rare The majority of these are retrospective non randomised comparisons 7 8 or comparison in the same patient with bilateral THRs 9 10 Various randomized controlled trials RCTs have been designed to compare the clinical and radiological outcomes of cemented versus uncemented fixation 11 12 Thus far no one study has been able to draw a decisive conclusion because of inherent limitations Furthermore there are no horizontal or longitudinal comparisons of the published RCTs in the literature Our study aims to determine whether the contemporary hip surgeons should abandon the proven dependability of cemented fixation for the emerging technology of cementless fixation Objectives This review aims to systematically evaluate all RCTs comparing cemented versus uncemented fixation of THRs with no restriction to the patients age Information sources A comprehensive search across multiple Databases was performed for studies published in English and other languages Databases included Medline BIOSYS Embase Web of Science CAB Health Cumulative Index to Nursing and Allied Health Literature Science Citation Index Current Contents and the Cochrane Library Issue 4 2010 The reference list of each study was reviewed to find additional relevant studies Experts in the field and manufacturers of implants were contacted to identify further studies The so called grey literature was identified using the Inside Database of the British Library the System for Information on Grey Literature in Europe and relevant abstract bands The studies not published because of negative results or other rea Orthopedic Reviews 2013 5 e8 Correspondence Ali Abdulkarim Department of Orthopaedics Cappagh National Orthopaedic Hospital Finglas Dublin 11 Ireland Tel 35 3863022807 E mail aliameir gmail com Key words cemented uncemented total hip arthroplasty meta analysis Contributions AA main authors PE coauthor NM statistical analysis TF methodological supervisor JMOB senior author Conflict of interests the authors declare no potential 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 Commons Attribution NonCommercial 3 0 License CC BYNC 3 0 Copyright A Abdulkarim et al 2013 Licensee PAGEPress Italy Orthopedic Reviews 2013 5 8 doi 10 4081 or 2013 e8 sons were identified from online trial registers UK National Research Register of ongoing health research information on clinical trials sponsored by the NIH and The International Register of Clinical Trials Registers Eligibility criteria Types of studies We included reports of only RCTs In the case of multiple publications of a trial we included the first published article Exceptions were made if a more recent publication corroborates the results of a longer follow up or examined a different outcome or both Types of participants Humans aged 18 years or older who underwent a primary THR were eligible Types of interventions and comparison The intervention of interest is the implantation of primary cemented THRs compared to primary uncemented THRs Types of outcome measures The primary outcome is failure of the primary procedure measured objectively by the revision rate due to aseptic loosening of either the cup or the stem Secondary outcomes included radiological signs of loosening or Review Table 1 Patients characteristics of in both groups Study ID Mean age Gender years male female P McCombe 2004 Laupacis 2002 S P GODSIFF 1992 H kan Str m 2006 Reigstad 1993 67 3 64 64 5 54 64 76 86 33 31 29 29 15 30 32 88 Wykman et al 1991 Onsten Carlsson
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