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Is there a difference in perioperative mortality between cemented and uncemented implants in hip fracture surgery?
1Department of Trauma and Orthopaedics, Ysbyty Gwynedd Hospital, Penrhosgarnedd Road, Bangor LL57 2LW, Wales, UK. munierh@doctors.org.uk
Insights
Cemented implants in hip fracture surgery are linked to a higher risk of perioperative death (PoD) compared to uncemented options. This increased mortality risk, particularly in patients with cardiovascular conditions, warrants careful consideration during surgical planning.
Area of Science:
- Orthopedic Surgery
- Trauma Surgery
- Patient Safety
Background:
- Cemented implants are common for proximal femoral fractures but raise concerns about hemodynamic effects.
- A National Patient Safety Agency alert highlighted risks associated with cement use in hip fracture surgery.
- This study investigates perioperative mortality differences between cemented and uncemented implants.
Purpose of the Study:
- To compare the incidence and pattern of 48-hour perioperative mortality.
- To evaluate the safety of cemented versus uncemented implants in hip fracture patients.
- To identify factors influencing mortality risk in hip fracture surgery.
Main Methods:
- Retrospective review of hospital records for patients who died within 48 hours post-hip fracture surgery (Jan 2005-Apr 2010).
- Data collected included demographics, fracture type, implant type, comorbidities, surgeon/anesthetist seniority, hemodynamic status, and cause of death.
- Analysis focused on comparing perioperative death rates between cemented and uncemented implant groups.
Main Results:
- Overall perioperative death rate was 1% (15/1402).
- Eight of 15 deaths (2.54%) followed cemented hemiarthroplasty, versus zero deaths with uncemented Austin-Moore hemiarthroplasty.
- Mortality risk was higher in patients with cardiovascular comorbidities and was not dependent on surgeon seniority.
Conclusions:
- Cemented implant insertion is associated with a significantly higher risk of perioperative death after hip fracture surgery.
- Pre-existing cardiovascular morbidity exacerbates mortality risk with cemented implants.
- The findings underscore the need for caution when using cemented implants in this patient population.
Introduction:
Although cemented implants have proven beneficial over uncemented implants for treatment of displaced sub-capital proximal femoral fractures, there are concerns regarding the haemodynamic consequence of using cemented implants in hip fracture patients. National Patient Safety Agency recently issued an alert regarding the use of cement in hip fracture surgery. We compared the incidence and pattern of 48 h perioperative mortality between patients receiving cemented and uncemented implants after hip fracture surgery.
Methods:
Using data prospectively recorded in hospital care records, we retrospectively reviewed the case records of all patients who died in hospital following hip fracture surgery between January 2005 and April 2010. We recorded demographic variables, type of fracture, implant used, medical co-morbidity, seniority of operating surgeon and anaesthetist, perioperative haemodynamic status, time and cause of death.
Results:
We identified 15 cases of perioperative death (PoD) over a 64-month period. PoD was 1% (15/1402). Eight of 15 deaths occurred following cemented hemiarthroplasty insertion. There were four cases of intra-operative death, two of them were following cemented hemiarthroplasty insertion. PoD following cemented hemiarthroplasty was 2.54% (8/314) and nil (0/168) following uncemented Austin-Moore hemiarthroplasty. Operations were performed by both trainees (six) and consultants (two). Both trainees (five) and consultants (three) anaesthetised the patients. None of the patients belonged to American Society of Anesthesiologists (ASA) I or II (ASA III 5 and IV 3). All patients had significant cardiovascular or pulmonary co-morbidity. Apart from the cases of immediate haemodynamic collapse and death, cemented implant insertion was followed by intra-operative haemodynamic instability in 2/15 and perioperative instability in 3/15 patients. Post-mortem was performed in 3/8 patients: 2/3 demonstrated pulmonary embolism (PE), 1/3 bronchopneumonia. Of the rest, 3/5 had suspected myocardial infarction (MI).
Conclusion:
There was 1% risk of perioperative death after hip fracture surgery. Risk of perioperative death was significantly higher following cemented implant insertion. Mortality risk was exacerbated in patients with pre-existing cardiovascular morbidity and was independent of the seniority of the surgeon or the anaesthetist.