Hawaii Permanente Medical Group, Kaiser Permanente, Honolulu.
Surgical Outcomes and Analysis Department, Kaiser Permanente, San Diego, California.
JAMA. 2020 Mar 17;323(11):1077-1084. doi: 10.1001/jama.2020.1067.
Consensus guidelines and systematic reviews have suggested that cemented fixation is more effective than uncemented fixation in hemiarthroplasty for displaced femoral neck fractures. Given that these recommendations are based on research performed outside the United States, it is uncertain whether these findings also reflect the US experience.
To compare the outcomes associated with cemented vs uncemented hemiarthroplasty in a large US integrated health care system.
DESIGN, SETTING, AND PARTICIPANTS: Retrospective cohort study of 12 491 patients aged 60 years and older who underwent hemiarthroplasty treatment of a hip fracture between 2009 and 2017 at 1 of the 36 hospitals owned by Kaiser Permanente, a large US health maintenance organization. Patients were followed up until membership termination, death, or the study end date of December 31, 2017.
Hemiarthroplasty (prosthetic replacement of the femoral head) fixation via bony growth into a porous-coated implant (uncemented) or with cement.
The primary outcome measure was aseptic revision, defined as any reoperation performed after the index procedure involving exchange of the existing implant for reasons other than infection. Secondary outcomes were mortality (in-hospital, postdischarge, and overall), 90-day medical complications, 90-day emergency department visits, and 90-day unplanned readmissions.
Among 12 491 patients in the study cohort who underwent hemiarthroplasty for hip fracture (median age, 83 years; 8660 women [69.3%]), 6042 (48.4%) had undergone uncemented fixation and 6449 (51.6%) had undergone cemented fixation, and the median length of follow-up was 3.8 years. In the multivariable regression analysis controlling for confounders, uncemented fixation was associated with a significantly higher risk of aseptic revision (cumulative incidence at 1 year after operation, 3.0% vs 1.3%; absolute difference, 1.7% [95% CI, 1.1%-2.2%]; hazard ratio [HR], 1.77 [95% CI, 1.43-2.19]; P < .001). Of the 6 prespecified secondary end points, none showed a statistically significant difference between groups, including in-hospital mortality (1.7% for uncemented fixation vs 2.0% for cemented fixation; HR, 0.94 [95% CI, 0.73-1.21]; P = .61) and overall mortality (cumulative incidence at 1 year after operation: 20.0% for uncemented fixation vs 22.8% for cemented fixation; HR, 0.95 [95% CI, 0.90-1.01]; P = .08).
Among patients with hip fracture treated with hemiarthroplasty in a large US integrated health care system, uncemented fixation, compared with cemented fixation, was associated with a statistically significantly higher risk of aseptic revision. These findings suggest that US surgeons should consider cemented fixation in the hemiarthroplasty treatment of displaced femoral neck fractures in the absence of contraindications.
共识指南和系统评价表明，在移位性股骨颈骨折的人工半髋关节置换术中，骨水泥固定比非骨水泥固定更有效。鉴于这些建议是基于美国以外的研究得出的，尚不确定这些发现是否也反映了美国的经验。
比较在美国一个大型综合医疗保健系统中，骨水泥固定与非骨水泥固定的人工半髋关节置换术的结果。
设计、地点和参与者：这是一项回顾性队列研究，纳入了 2009 年至 2017 年期间在 Kaiser Permanente 旗下的 36 家医院中的 1 家医院接受人工半髋关节置换术治疗髋部骨折的 12491 名 60 岁及以上的患者。患者随访至会员资格终止、死亡或 2017 年 12 月 31 日的研究截止日期。
半髋关节置换术（通过骨生长到多孔涂层植入物中进行的假体置换，即非骨水泥固定；或使用骨水泥固定）。
主要结局指标是无菌性翻修，定义为索引手术后任何因非感染原因而更换现有植入物的再手术。次要结局指标包括死亡率（住院期间、出院后和总死亡率）、90 天内的医疗并发症、90 天内的急诊就诊和 90 天内的非计划再入院。
在研究队列中，12491 名接受人工半髋关节置换术治疗髋部骨折的患者中（中位年龄为 83 岁，8660 名女性[69.3%]），6042 名（48.4%）接受了非骨水泥固定，6449 名（51.6%）接受了骨水泥固定，中位随访时间为 3.8 年。在多变量回归分析中，控制了混杂因素后，非骨水泥固定与更高的无菌性翻修风险显著相关（术后 1 年的累积发生率，3.0%比 1.3%；绝对差异，1.7%[95%CI，1.1%-2.2%]；风险比[HR]，1.77[95%CI，1.43-2.19]；P<0.001）。在 6 个预先指定的次要终点中，均未显示出组间有统计学意义的差异，包括住院期间死亡率（非骨水泥固定组为 1.7%，骨水泥固定组为 2.0%；HR，0.94[95%CI，0.73-1.21]；P=0.61）和总死亡率（术后 1 年的累积发生率：非骨水泥固定组为 20.0%，骨水泥固定组为 22.8%；HR，0.95[95%CI，0.90-1.01]；P=0.08）。
在接受大型美国综合医疗保健系统中人工半髋关节置换术治疗的髋部骨折患者中，与骨水泥固定相比，非骨水泥固定与无菌性翻修的风险显著增加相关。这些发现表明，在美国，如果没有禁忌证，外科医生在治疗移位性股骨颈骨折时应考虑骨水泥固定。
