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Article

Trends in Hip Arthroplasty Cementation: Insights from an Italian Registry of 142,113 Patients

by
Loris Perticarini
1,*,†,
Luca Andriollo
1,2,3,†,
Roberta Righini
1,2,
Rudy Sangaletti
1 and
Francesco Benazzo
1,4,*
1
Sezione di Chirurgia Protesica ad Indirizzo Robotico—Unità di Traumatologia dello Sport, Ortopedia e Traumatologia, Fondazione Poliambulanza, 25124 Brescia, Italy
2
Ortopedia e Traumatologia, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
3
Artificial Intelligence Center, Alma Mater Europaea University, 1010 Vienna, Austria
4
Scienze Biomediche, IUSS Istituto Universitario di Studi Superiori, 27100 Pavia, Italy
*
Authors to whom correspondence should be addressed.
†
These authors contributed equally to this work.
Prosthesis 2024, 6(6), 1329-1339; https://doi.org/10.3390/prosthesis6060096
Submission received: 23 September 2024 / Revised: 22 October 2024 / Accepted: 31 October 2024 / Published: 5 November 2024
(This article belongs to the Special Issue State of Art in Hip, Knee and Shoulder Replacement (Volume 2))
Browse Figure
Versions Notes

Abstract

:
Introduction: The use of cementation in total hip arthroplasty (THA) has evolved over the years, with a notable shift toward cementless and hybrid techniques. The aim of this study is to evaluate data from an Italian registry on the type of fixation used in THA implants and their corresponding survival rates in a large patient cohort with long-term follow-up, and to compare these data with the most recent literature. Methods: From January 2000 to December 2020, a total of 137,256 primary THA procedures were performed, of which 10.4% were fixed with stem cementation. There were 4857 revision implants, of which 11.4% were implanted with stem cementation. Results: The trend showing a significant shift toward cementless fixation methods is particularly pronounced in younger patients, with cementless implants comprising 99.5% of procedures in patients under 40 years of age. As patient age increases, the use of cemented or hybrid fixation methods becomes more common. This trend aligns with existing literature, in which cementation is often preferred for elderly patients due to concerns about bone quality and the potential for better immediate fixation provided by cemented stems. At 10 years, the implant that showed the highest survival rate was the fully cemented implant, with a rate of 94.8%. This study also reports the causes of failure based on the different fixation techniques. Conclusions: The development of standardized guidelines that consider patient-specific factors such as age, bone quality, and comorbidities in the choice of fixation type could help reduce variability in practice and improve overall outcomes in hip arthroplasty.

1. Introduction

Total hip arthroplasty (THA) is a widely performed procedure that alleviates pain and improves function in patients with severe hip conditions such as osteoarthritis, rheumatoid arthritis, and avascular necrosis [1]. Advances in implant design and surgical techniques have improved outcomes, with femoral stem fixation playing a crucial role. Fixation methods include cemented, cementless, and hybrid techniques, with the choice influenced by factors such as patient age, bone quality, and surgeon preference [2].
Cemented THA, which uses polymethylmethacrylate (PMMA) for immediate stability, is particularly effective in older patients with poor bone quality, with survival rates exceeding 90% at 10 years [3]. In contrast, cementless THA, which is favored for younger, more active patients, relies on bone ingrowth and offers outcomes comparable to cemented THA when osseointegration is achieved [4]. Hybrid THA, combining cemented femoral stems with cementless acetabular components, also shows excellent long-term results, particularly in patients over 65 [5].
Despite the success of THA, implant failure remains a concern, with aseptic loosening being the leading cause of revision, accounting for 30–40% of cases. Periprosthetic fractures are more commonly associated with cementless techniques and infection contributes to 10–15% of revisions [6,7,8]. Antibiotic-loaded bone cement (ALBC) represents a significant advancement in reducing infection, especially in high-risk patients, though concerns remain about antibiotic resistance and its impact on osseointegration [9,10,11].
The aim of this study is to evaluate data from an Italian registry on the type of fixation used in THA implants and their corresponding survival rates in a large patient cohort with long-term follow-up, and to compare these data with the most recent literature. The focus will primarily be on the femoral stem, but data on the acetabular component will also be presented.

2. Materials and Methods

This study retrospectively examines all THAs implanted in the Emilia Romagna (ER) region of Northern Italy, which has a population of approximately 4.461 million. Data were sourced from the Registro dell’Impiantologia Protesica Ortopedica (RIPO), a regional joint register established in 2000 that tracks all hip, knee, and shoulder replacements conducted within the ER region. The region is serviced by 69 active orthopedic units, both public and private, all of which consented to data collection. The register, a member of the International Society of Arthroplasty Registries, reported a data accuracy rate of 97.2% in 2017.
Italian Social Security numbers were utilized to identify residents who underwent surgery outside the area, and the register also tracks any revisions performed outside ER. Descriptive analyses were conducted on all cases reported to RIPO, while survival analyses were exclusively performed on cases involving patients residing in the ER region. This decision was made to eliminate bias associated with the inability to track non-resident patients. Therefore, all survival analyses presented in this report consider primary implants performed in ER on resident patients and revisions on the same patients, wherever performed.
All patients who underwent THAs from 1 January 2000 to 31 December 2020 were included in the study, covering both primary implants and revisions. Specifically, the data reported include the number of arthroplasty procedures performed, classified by the type of surgery and fixation method. Additionally, for both primary THAs and revisions, the percentage of procedures by type of component fixation is detailed, along with their distribution over the years, and categorized by patient age at the time of the surgery.
An analysis of the survival of primary THAs was then carried out, evaluating the different types of fixation, and the various causes of failure were assessed. Additionally, the data on the different types of cemented stems that have been used were also reported. Finally, data on the cement used were reported, particularly regarding whether antibiotics were involved. Failures were recorded up to 31 December 2020.

Statistical Analysis

Continuous variables were presented using the arithmetic mean and standard deviation (SD), while categorical variables were reported using frequency distributions and percentages. Survival analysis was conducted using the Kaplan–Meier method, which included different endpoints along with their respective 95% confidence intervals. Kaplan–Meier survival analysis utilized the revision of at least one component as the endpoint, with survival times for unrevised implants recorded until the last observation date (31 December 2020, or the date of death). The Log-Rank Test was employed to compare survival rates across different groups. Additionally, the Cox multiple regression model was used for survival data analysis, and the proportionality of hazards assumption was verified using the Schoenfeld residuals method. The statistical analyses were carried out using the R software, specifically the 2023 release by the R Core Team, titled “R: A Language and Environment for Statistical Computing”, published by the R Foundation for Statistical Computing in Vienna, Austria.

3. Results

From 1 January 2000 to 31 December 2020, a total of 137,256 primary THA procedures were performed. In 10.4% of the implants (or 14,291), the stem was cemented. There were 4857 revision implants, of which 11.4% involved stem cementation. Table 1 provides the overall data on the number of primary and revision THAs, categorized by the method of fixation.
The analysis of the percentages of fixation types in primary THA procedures highlights how trends have changed over the years. Table 2 presents the data for the years 2000, 2010, and 2020. Notably, between 2000 and 2010, there was a progressive increase in cementless implants, accompanied by a decrease in cemented and hybrid implants. From 2011 to 2020, the percentage of cementless primary THAs consistently remained above 95%.
The analysis of the percentages of fixation types in primary THA procedures over the entire period from 2000 to 2020, based on age group distribution, shows that fully cementless implants are more commonly used in younger patients, with the <40 years age group having cementless implants in 99.5% of cases. As age increases, the percentage of cementless implants gradually decreases, representing 75.5% in the oldest age group (≥80 years). Conversely, all types of implants with a cemented component, whether fully cemented or hybrid, become progressively more common as age increases. The complete data are presented in Table 3.
The registry also reports data on the percentage distribution of primary THAs based on the type of fixation and divided by age groups for the individual years 2000 and 2020. In 2020, cemented prostheses accounted for 0% of implants in patients under 80 years old, making up only 0.3% in patients aged ≥80 years. Hybrid implants with a cemented stem and cementless cup also saw a significant decrease in patients over 60, who were the most represented group. Specifically, for example, the 60–69 age group decreased from 26.2% hybrid implants in 2000 to 2.0% in 2020 and the 70–79 age group went from 34.1% hybrid implants in 2000 to 5.1% in 2020.
Cementless implants, however, saw a marked increase. Indeed, the 70–79 age group increased from 44.3% in 2000 to 94.8% in 2020 and the ≥80 years age group went from 26.3% in 2000 to 88.5% in 2020.
The analysis of the percentages of fixation types in revision hip arthroplasty over the entire period from 2000 to 2020, based on age group distribution, also shows that fully cementless implants are more commonly used in younger patients, comprising 93.3% of implants in patients under 40 years and 59.9% in patients aged 80 years or older. The use of cemented implants increases progressively with age. For patients over 80 years old, fully cemented implants account for 11.7%, hybrid implants for 13.4%, and reverse hybrid implants for 15.0% [Table 4].
Reverse hybrids, comprising a cemented cup and cementless stem, were the least used type of implant in primary THAs. However, in revision hip arthroplasty, they represent the second most commonly used implant type across all age groups, reaching the highest percentages in the 70–79 age group (14.1%) and in those aged 80 years or older (15%).
Table 5 presents the data on the average follow-up of implants, the number of failures for different types of implants, and the survival analysis at 5 and 10 years for primary THAs based on the type of fixation. At 5 years, the type of implant with the highest survival rate is the hybrid implant, with a cemented stem, achieving a survival rate of 97.2% [95% CI; 96.8, 97.6]. At 10 years, the implant that shows the highest survival rate is the fully cemented implant, with a survival rate of 94.8% [95% CI; 94.0, 95.5].
In Figure 1, a survival data analysis graph is presented using the Cox multiple regression model. Additionally, the implants at risk of survival are shown at various years post-implantation.
Table 6 presents the causes of failures in cemented implants. The most frequent causes are aseptic cup loosening (30%), global aseptic loosening (18.3%), and dislocation (13.1%). Aseptic stem loosening accounts for 9.4% of the failures.
Table 7 presents the causes of failures in hybrid implants, which have a cemented stem and a cementless cup. The most frequent causes are aseptic stem loosening (28.8%), dislocation (17.7%), and periprosthetic fracture (12.2%).
The primary causes of failure in fully cementless implants are periprosthetic fractures, accounting for 16.3% of failures, followed by aseptic stem loosening (14.9%) and aseptic cup loosening (13.9%).
In reverse hybrid implants, which have a cemented cup and a cementless stem, the main cause of failure is aseptic cup loosening, which is responsible for 31.7% of failures, followed by dislocation (15%) and periprosthetic fractures (13.3%).
Regarding the use of the cemented stem, the registry contains data on the most commonly used stems over the past 20 years. From 2000 to 2014, the most commonly used cemented stem was the EXETER V40 Stryker Howmedica, representing 10.8% of the total. This was followed by the APTA Adler-Ortho (9.2%), the BASIS Smith and Nephew (8.0%), the LUBINUS SP2 Link (2.5%), and the MS 30 Zimmer (1.5%). Between 2015 and 2017, the EXETER V40 Stryker Howmedica continued to dominate, with its prevalence increasing to 21.7%. The POLARSTEM CEM Endoplus became the second most popular choice, used in 12.9% of cases. The KORUS Bioimpianti followed at 4.0%, while the HYDRA Adler-Ortho was used in 4.8% of cases and the BASIS Smith and Nephew was used in 5.3% of cases. From 2018 to 2020, the VERSYS HERITAGE Zimmer emerged as the most used stem, making up 28.3% of implants. The EXETER V40 Stryker Howmedica remained widely used at 14.2%, followed by the POLARSTEM CEM Endoplus with 6.6%, the KORUS Bioimpianti at 6.3%, and the APTA Adler-Ortho, also with 6.3%.
This shows evolving trends in cemented stem usage over the years, with some consistent choices like the EXETER V40, and the rise in the use of other stems like the VERSYS HERITAGE Zimmer in more recent years.
The choice to use antibiotic-loaded cement is made in 14.7% of primary prostheses. The most commonly used non-antibiotic cement was Surgical Simplex P–Howmedica, applied in 34.3% of primary THAs, followed by Cemex System–Tecres (10.2%). The most commonly used antibiotic-loaded cement was Antibiotic Simplex–Howmedica, which was used in 6% of implants.

4. Discussion

The main findings highlighted in this study are that, over time, the use of cementless implants has increased, particularly among younger patients. By 2020, cementless THA accounted for more than 95% of all procedures. In contrast, implants with cemented components, including cemented, hybrid, and reverse hybrid types, became increasingly common among patients aged 80 years and older.
Femoral stem cementation in hip arthroplasty has been a topic of considerable debate over the years. Data from the Italian Registry, which includes 142,113 patients who underwent THA between 2000 and 2020, provide a comprehensive overview of the trends in femoral stem fixation methods over two decades in Italy. During this period, the majority (93%) of primary THAs were performed without cementation, reflecting a significant shift towards cementless fixation methods [12]. This trend is particularly pronounced in younger patients, with cementless implants comprising 99.5% of procedures in patients under 40 years of age. As patient age increases, the use of cemented or hybrid fixation methods becomes more common, with 24.5% of patients aged 80 years or older receiving either cemented or hybrid implants. This trend aligns with existing literature showing that cementation is often preferred for elderly patients due to concerns about bone quality and the potential for better immediate fixation provided by cemented stems [13,14].
The design and cementation techniques of THA implants, particularly the Exeter stem (Stryker Orthopaedics, Mahwah, NJ, USA), have a significant impact on outcomes. Introduced in the 1970s, the Exeter stem’s double-tapered, polished design allows controlled subsidence within the cement mantle, improving long-term stability and reducing stress at the bone–cement interface [2,15]. Unlike other rigidly fixed stems, the Exeter stem’s dynamic load transfer reduces the risk of implant loosening [16]. The cement-on-cement technique used in revision surgeries preserves bone and shortens the operation time [17]. Studies report survival rates of over 95% at 10 years and 85% at 20 years, with the Exeter Universal stem showing a 20-year survival rate of 85.4%, where periprosthetic fractures were the main cause of revision, rather than aseptic loosening [18,19,20,21]. These features make the Exeter stem a benchmark in THA, especially for elderly patients or those in need of revision [20].
However, the data in our study, compared with data from the existing and available literature, highlight a clear preference for cementless fixation in younger patients, likely due to the superior bone quality in this demographic, which relies on biological fixation through osseointegration. The progression towards cementless fixation also aligns with broader trends observed in other national registries, which show that cementless THA has become increasingly dominant over time [22]. However, the continued use of hybrid methods in older patients underscores the importance of immediate fixation and stability, particularly in patients with poorer bone quality [23,24].
Patient age is a crucial factor in the choice of fixation method in THA. As data from the Italian Registry demonstrate, in line with previous research, there is a clear age-related pattern in the selection of cemented versus cementless implants [25]. In patients under 40 years of age, nearly all implants (99.5%) are cementless, reflecting the suitability of these patients for biological fixation due to their generally higher bone density and regenerative capacity. In contrast, older patients, particularly those over 80 years of age, more frequently receive cemented or hybrid implants, with 24.5% of procedures in this age group involving some form of cementation. Additionally, as Hammed et al. declare, cemented femoral component fixation in THA is associated with a lower risk of early revision and peri-prosthetic fractures [26]. In a review by Mancino et al. involving 2167 hips with a mean follow-up of 14.8 ± 4.1 years, evidence shows that the Exeter cemented stem demonstrates exceptional long-term reliability, with a revision rate of just 3.8%. Moreover, it has very low revision rates for aseptic loosening (0.22%) and periprosthetic fracture (0.6%) [16].
The complication rates, such as implant failure and revisions, associated with different fixation methods in THA are critical considerations for both surgeons and patients. According to data from the Italian Registry, cemented, hybrid, and cementless implants each present unique challenges and complications, despite the excellent outcomes associated with THA that continue to burden the healthcare system [27].
Cemented implants, though less frequently used in recent years, show a high survival rate, particularly in older patients [17]. In our study, the 10-year survival rate of fully cemented implants is 94.8%, which is slightly higher than that achieved by other methods. However, according to Moore et al., complications such as aseptic cup loosening (30%), global aseptic loosening (18.3%), and dislocation (13.1%) are notable causes of failure [28]. The use of cemented implants is also associated with an increased risk of fat embolism syndrome during surgery, although this risk is generally low and manageable with appropriate surgical techniques [29].
In our data, hybrid implants, particularly those with a cemented stem and a cementless cup, have shown the highest 5-year survival rate at 97.2%. However, they also present a unique set of complications. The most common causes of failure in hybrid implants include aseptic stem loosening (28.8%), dislocation (17.7%), and periprosthetic fractures (12.2%). Even though osteosynthesis is the gold standard in most proximal femur fractures, as reported in various studies, revision and prosthetic treatment are the most suitable approaches after this type of fracture [30,31]. Using a long-stem cemented prosthesis for revision enables early, pain-free weight-bearing without hindering the healing process of femoral fractures in elderly patients with limited mobility and poor balance, and it offers a lower rate of dislocation and stem loosening [32,33,34].
Cementless implants, now the predominant choice in primary THA for younger patients, have a survival rate of 94.4% that is competitive with cemented and hybrid methods, though slightly lower at the 10-year mark. The primary complications associated with cementless implants include aseptic stem loosening (14.9%), aseptic cup loosening (13.9%), and periprosthetic fractures (16.3%). Although our study highlights a statistically significant disparity in the percentage of periprosthetic fractures between cemented and uncemented THA, this discrepancy is not observed in the Dutch register, which indicates no difference in the risk of re-revisions [35]. Contrary to what Morgan et al. stated, the rate of periprosthetic fractures is rising, especially in uncemented THA, leading to an increase in patient mortality and morbidity [36]. Despite these risks, the shift towards cementless implants reflects the desire to avoid cement-related complications and the potential for better long-term outcomes in appropriate candidates [29].
The use of ALBC in THA has proven effective in reducing the risk of postoperative infections, as supported by the literature [10,37]. In the Italian Registry, ALBC was used in 14.7% of primary THA cases, aligning with studies that highlight its role in preventing periprosthetic joint infections [11,38,39]. However, despite its effectiveness, the routine use of ALBC remains controversial due to concerns about antibiotic resistance, allergic reactions, and cost [40]. The registry data suggest that selective use of ALBC, rather than routine application, may offer a balanced approach to managing infection risk while minimizing the associated drawbacks [41].
Despite excellent survival rates, reduced risk of periprosthetic fractures, and their effective use in individuals with poor bone quality, the limitations of choosing cementation include increased surgical time and the potential for complications that may intimidate the surgeon.
Indeed, during the cementation of the femoral stem in THA, particularly in elderly patients with pre-existing cardiovascular conditions, Bone Cement Implantation Syndrome (BCIS) may occur. This syndrome is characterized by hypoxia, hypotension, cardiac arrhythmias, and, in severe cases, cardiac arrest. It has an incidence ranging from 0.6% to 1.7% and a reported mortality rate of up to 0.11% in severe cases [42]. This has led to a more cautious approach to the use of cement in THA, particularly in high-risk patients.
Additionally, the benefits observed with cementless systems stem from the reduced operating time and lower costs associated with ancillary products required by cementing systems, as well as decreased expenses related to operating room personnel [43,44]. This could justify their increasingly widespread use.
Finally, innovations in materials over the last few decades may have played a role in the choice of cementless implants, with primary stability being achievable through the use of porous metals such as Trabecular Titanium [45,46]. Even the most modern stem designs have demonstrated excellent long-term survival, ensuring reliable primary stability at the time of implantation [47].
While the data from the Italian Registry provide valuable insights into the practice of femoral stem cementation in hip arthroplasty, several limitations must be acknowledged. First, the data collected rely on accurate and consistent reporting from multiple centers, which may introduce reporting bias. Additionally, the registry does not capture detailed information on patients’ functional outcomes, quality of life, or the surgeon’s experience, which are crucial factors in the success of hip arthroplasty.
Another limitation is the lack of granular data on the type of cement and the specific techniques used during cementation. Variations in cementation techniques, such as the use of pressurization and the timing of stem insertion, can significantly impact outcomes but were not analyzed in this study. Furthermore, while our study provides a large sample size, it is limited to a single country, which may affect the generalizability of the findings to other populations with different healthcare systems.

5. Conclusions

The decision to use cemented or uncemented implants in hip arthroplasty remains complex and multifactorial, influenced by patient age, bone quality, comorbidities, and the surgeon’s preference. The findings from the Italian Registry underscore the ongoing evolution in the use of cementation in THA. Over the past two decades, there has been a clear shift towards cementless implants, particularly in younger patients, driven by the desire to leverage biological fixation for long-term durability. However, cemented and hybrid methods remain important options, particularly for older patients with compromised bone quality, offering reliable fixation and reducing the risk of early complications.
Despite the valuable insights provided by the registry, further research is needed to address the limitations of observational data and to explore patient-centered outcomes. Prospective studies with longer follow-up periods, including detailed assessments of functional outcomes and quality of life, will be crucial in guiding future clinical practice and optimizing the results of hip arthroplasty. Additionally, the development of standardized guidelines that consider patient-specific factors such as age, bone quality, and comorbidities could help reduce variability in practice and improve overall outcomes in hip arthroplasty.

Author Contributions

Conceptualization, L.A., L.P. and F.B.; methodology, L.A. and L.P.; data curation, L.A. and R.R.; writing—original draft preparation, L.A. and R.R.; writing—review and editing, R.S., L.P. and F.B. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

This study was conducted in accordance with the Declaration of Helsinki. Ethical approval was not required for this study, since the data were obtained from an Italian registry that collects patient data across the region as part of its standard procedures. Furthermore, all data were anonymized and analyzed in a way that safeguards patient privacy.

Informed Consent Statement

Not applicable.

Data Availability Statement

The data that support the findings of this study are available from the corresponding author upon reasonable request. Some data are publicly available at RIPO (http://ripo.cineca.it/authzssl/index.htm), accessed on 1 September 2024.

Conflicts of Interest

The authors declare no conflicts of interest.

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Prosthesis 06 00096 g001
Figure 1. Survival data analysis (hybrid: cemented stem and cementless cup; reverse hybrid: cemented cup and cementless stem). Adapted with permission. This report is licensed under CC BY-NC-ND 4.0.
Figure 1. Survival data analysis (hybrid: cemented stem and cementless cup; reverse hybrid: cemented cup and cementless stem). Adapted with permission. This report is licensed under CC BY-NC-ND 4.0.
Prosthesis 06 00096 g001
Table 1. Data on the number of primary and revision total hip arthroplasties based on the method of fixation (hybrid: cemented stem and cementless cup; reverse hybrid: cemented cup and cementless stem).
Table 1. Data on the number of primary and revision total hip arthroplasties based on the method of fixation (hybrid: cemented stem and cementless cup; reverse hybrid: cemented cup and cementless stem).
Method of
Fixation		Conventional Primary THAs%Revisions%
Cementless122,20889.0364578.8
Hybrid96117.03897.5
Cemented46803.42353.9
Reverse hybrid7570.65889.8
Total 1137,2561004857100
1 The data were not reported in 356 primary THAs and in 27 revision THA.
Table 2. Percentage distribution of primary total hip arthroplasty based on the type of fixation in the years 2000, 2010, and 2020 (hybrid: cemented stem and cementless cup; reverse hybrid: cemented cup and cementless stem).
Table 2. Percentage distribution of primary total hip arthroplasty based on the type of fixation in the years 2000, 2010, and 2020 (hybrid: cemented stem and cementless cup; reverse hybrid: cemented cup and cementless stem).
Year of
Surgery		CementedCementlessHybridReverse
Hybrid
200015.261.822.11.0
20101.294.14.10.6
20200.295.34.30.2
Table 3. Percentage distribution of primary total hip arthroplasty based on the type of fixation and divided by age groups for the period 2000–2020 (hybrid: cemented stem and cementless cup; reverse hybrid: cemented cup and cementless stem).
Table 3. Percentage distribution of primary total hip arthroplasty based on the type of fixation and divided by age groups for the period 2000–2020 (hybrid: cemented stem and cementless cup; reverse hybrid: cemented cup and cementless stem).
Age GroupsCementedCementlessHybridReverse
Hybrid
<400.099.50.20.3
40–490.299.40.30.1
50–590.298.51.20.1
60–690.794.54.60.2
70–793.686.010.00.4
≥8010.175.513.41.0
Table 4. Percentage distribution of revision hip arthroplasty based on the type of fixation and divided by age groups, for the period 2000–2020 (hybrid: cemented stem and cementless cup; reverse hybrid: cemented cup and cementless stem).
Table 4. Percentage distribution of revision hip arthroplasty based on the type of fixation and divided by age groups, for the period 2000–2020 (hybrid: cemented stem and cementless cup; reverse hybrid: cemented cup and cementless stem).
Age GroupsCementedCementlessHybridReverse
Hybrid
<401.193.32.23.3
40–492.590.03.54.0
50–591.887.93.47.0
60–692.779.86.311.2
70–794.572.78.814.1
≥8011.759.913.415.0
Table 5. Percentage survival of primary total hip arthroplasty based on the method of fixation (hybrid: cemented stem and cementless cup; reverse hybrid: cemented cup and cementless stem; CI: confidence interval).
Table 5. Percentage survival of primary total hip arthroplasty based on the method of fixation (hybrid: cemented stem and cementless cup; reverse hybrid: cemented cup and cementless stem; CI: confidence interval).
Method of FixationAverage
Follow-Up (Years)		NumberNumber of Failures% Survival [95% CI] at 5 YearsAt Risk at 5 Years% Survival [95% CI] at 10 YearsAt Risk at 10 Years
Hybrid9.8748345297.2
[96.8, 97.6]		557394.6
[94.1, 95.2]		3641
Cemented9.1416821396.9
[96.3, 97.4]		306594.8
[94.0, 95.5]		1786
Cementless7.585,876412496.8
[96.7, 96.9]		52,68594.4
[94.2, 94.6]		26,511
Reverse hybrid7.26066092.5
[90.3, 94.8]		35387.6
[84.4, 90.9]		182
Table 6. Causes of failure in cemented primary total hip arthroplasty.
Table 6. Causes of failure in cemented primary total hip arthroplasty.
Cause of FailureFailed/Total%% of Cause of
Failure
Aseptic cup
loosening		64/41681.530.0
Global aseptic
loosening		39/41680.918.3
Dislocation28/41680.713.1
Aseptic stem
loosening		20/41680.59.4
Septic loosening20/41680.59.4
Periprosthetic
fracture		18/41680.48.5
Lack of data17/41680.48.0
Primary instability4/41680.11.9
Prosthesis
breakage		2/41680.00.9
Other1/41680.00.5
Total213/41685.1100
Table 7. Causes of failure in hybrid implants (cemented stem and cementless cup).
Table 7. Causes of failure in hybrid implants (cemented stem and cementless cup).
Cause of FailureFailed/Total%% of Cause of
Failure
Aseptic stem
loosening		130/74831.728.8
Dislocation80/74831.117.7
Periprosthetic
fracture		55/74830.712.2
Global aseptic
loosening		51/74830.711.3
Aseptic cup
loosening		38/74830.58.4
Septic loosening34/74830.57.5
Lack of data2874830.46.2
Polyethylene wear16/74830.23.5
Other7/74830.11.5
Prosthesis
breakage		7/74830.11.5
Ossifications3/74830.00.7
Primary instability2/74830.00.4
Pain without
loosening		1/74830.00.2
Total452/74836.0100
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MDPI and ACS Style

Perticarini, L.; Andriollo, L.; Righini, R.; Sangaletti, R.; Benazzo, F. Trends in Hip Arthroplasty Cementation: Insights from an Italian Registry of 142,113 Patients. Prosthesis 2024, 6, 1329-1339. https://doi.org/10.3390/prosthesis6060096

AMA Style

Perticarini L, Andriollo L, Righini R, Sangaletti R, Benazzo F. Trends in Hip Arthroplasty Cementation: Insights from an Italian Registry of 142,113 Patients. Prosthesis. 2024; 6(6):1329-1339. https://doi.org/10.3390/prosthesis6060096

Chicago/Turabian Style

Perticarini, Loris, Luca Andriollo, Roberta Righini, Rudy Sangaletti, and Francesco Benazzo. 2024. "Trends in Hip Arthroplasty Cementation: Insights from an Italian Registry of 142,113 Patients" Prosthesis 6, no. 6: 1329-1339. https://doi.org/10.3390/prosthesis6060096

APA Style

Perticarini, L., Andriollo, L., Righini, R., Sangaletti, R., & Benazzo, F. (2024). Trends in Hip Arthroplasty Cementation: Insights from an Italian Registry of 142,113 Patients. Prosthesis, 6(6), 1329-1339. https://doi.org/10.3390/prosthesis6060096

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