Is there a difference in perioperative mortality between cemented and uncemented implants in hip fracture surgery?

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.