 SPECIALTY UPDATE
Cemented versus cementless
H. D. Veldman,
I. C. Heyligers,
B. Grimm,
T. A. E. J. Boymans
From Zuyderland
Medical Center,
Heerlen, The
Netherlands
 H. D. Veldman, BSc, Medical
student
 I. C. Heyligers, Prof. MD PhD,
Orthopaedic Surgeon
 B. Grimm, MEng PhD,
Research Director
 T. A. E. J. Boymans, MD,
Orthopaedic Surgeon
AHORSE Research Foundation,
Department of Orthopaedic
Surgery and Traumatology
Zuyderland Medical Center, H.
Dunantstraat 5, NL-6419 PC
Heerlen, The Netherlands.
Correspondence should be sent
to H. D. Veldman; email:
h.veldman@student.maastricht
university.nl
©2017 The British Editorial
Society of Bone & Joint
Surgery
doi:10.1302/0301-620X.99B4.
BJJ-2016-0758.R1 $2.00
Bone Joint J
2017;99-B:421–31.
Received 8 August 2016;
Accepted after revision 5
December 2016
VOL. 99-B, No. 4, APRIL 2017
hemiarthroplasty for a displaced fracture of
the femoral neck
A SYSTEMATIC REVIEW AND META-ANALYSIS OF CURRENT
GENERATION HIP STEMS
Aims
Our aim was to prepare a systematic review and meta-analysis to compare the outcomes of
cemented and cementless hemiarthroplasty of the hip, in elderly patients with a fracture of
the femoral neck, to investigate the mortality, complications, length of stay in hospital,
blood loss, operating time and functional results.
Materials and Methods
A systematic review and meta-analysis was conducted following the Preferred Reporting
Items for Systematic Reviews and Meta-Analyses guidelines on randomised controlled trials
(RCTs), studying current generation designs of stem only. The synthesis of results was done
of pooled data, with a fixed effects or random effects model, based on heterogeneity.
Results
A total of five RCTs including 950 patients (950 hips) were included. Cementless stems were
found to be associated with more complications compared with cemented stems (odds
ratio (OR) 1.61, 95% confidence interval (CI) 1.12 to 2.31, p = 0.01), especially implant-related
complications (OR 3.15, 95% CI 1.55 to 6.41, p = 0.002). The operating time was shorter for
cementless stems (weighted mean difference -9.96 mins, 95%CI -12.93 to -6.98, p < 0.001).
The data on functional outcomes could not be pooled. There was no statistically significant
difference for any other outcome between the two methods of fixation.
Conclusion
In hemiarthroplasty of the hip using current generation stems, cemented stems result in
fewer implant-related complications and similar mortality compared with cementless
stems.
Cite this article: Bone Joint J 2017;99-B:421–31.
Fractures of the hip account for 23.8% of all pain and fewer implant-related complica-
fractures in patients over the age of 75 years, tions.12,13,15 However, these reviews mainly
mostly as a consequence of trauma and osteo- included older studies which compared previ-
porosis.1 As the population ages, the incidence ous prostheses such as the Austin Moore and
of these fractures will increase.2-4 Cooper et al3 Thompson (Corin Group, Cirencester, United
projected a worldwide increase in fractures of Kingdom).12-15 These are now outdated and
the hip from 1.66 million in 1990 to 6.26 mil- rarely used16-20 and their inferior clinical
lion by 2050. A substantial proportion of these outcome16,21-24 may have affected the conclu-
are fractures of the femoral neck, which puts sions of these reviews. In Sweden, for example,
the femoral head at risk of osteonecrosis and as a proportion of all hemiarthroplasty
nonunion due to the tenuous blood supply.5 implants, the use of Austin Moore and Thomp-
Hemiarthroplasty of the hip is the routine son stems decreased from 18% in 2005 to
treatment for displaced fractures of the femo- 0.9% in 2009.18
ral neck.5,6 However, whether cemented or The aim of this systematic review and meta-
cementless fixation should be used remains analysis of randomised controlled trials
controversial.7-11 Many studies, systematic (RCTs) was to investigate whether either con-
reviews and meta-analyses have been temporary cemented or cementless hemiar-
published12-15 which suggest that cemented throplasty is more successful in elderly patients
hemiarthroplasty results in better function, less with a fracture of the femoral neck, with
421
422 H. D. VELDMAN, I. C. HEYLIGERS, B. GRIMM, T. A. E. J. BOYMANS
regards to mortality, function, complications, length of stay
in hospital, blood loss and operating time.
Materials and Methods
The report is structured according to the Preferred Report-
ing Items for Systematic Reviews and Meta-Analyses state-
ment.25 Two reviewers (HDV and TAEJB) independently
conducted a systematic search, in April 2016, of Pubmed
(1966 to 2016), EMBASE (1974 to 2016), the Web of Sci-
ence (1950 to 2016) and the Cochrane Central Register of
Controlled Trials (1948 to 2016). The search consisted of
terms relating to the condition (‘hip fracture’, ‘hip frac-
tures’, ‘fractured hip’, ‘proximal femur fracture’, ‘femoral
fracture’ or ‘fractured femur’), to treatment (‘hemiarthro-
plasty’ or ‘hemiprosthesis’) and to the method of fixation
(‘cemented’, ‘cementless’ or ‘uncemented’). The two
authors independently assessed the compliance of each arti-
cle with the inclusion criteria. Any disagreements were
solved by discussion.
Current generation (modern) stems were defined as hip
stems developed after 1985. Studies which investigated dis-
continued or unavailable stems were excluded, as were
those which considered Austin Moore or Thompson stems.
Studies were included if at least one of the outcomes of
interest was investigated: mortality, functional perfor-
mance, number and type of complications, length of stay,
blood loss and/or operating time. These outcomes were
chosen because they reflect clinical outcome and are ame-
nable quantitative outcome measures for meta-analysis.
Studies were only eligible for inclusion if a strict follow-up
period was defined (although we set no requirements as to
the length of follow-up), to ensure comparability between
studies. No further requirements were defined regarding
the surgical procedure or patient characteristics.
All relevant information was independently extracted
from the studies which were selected by two reviewers
(HDV and TAEJB). Where there was inconsistency in the
data, the study was discussed and critically appraised. Data
of interest were methodological data, patient characteris-
tics and outcome measures. Methodological data included
the number of centres which were involved in the recruit-
ment of the patients, the method of enrolment, the type of
stem and the principle of data analysis (‘intention-to-treat’
or ‘per protocol’). The characteristics of the patients
included the total number of patients and the number in
each group (cemented versus cementless), the mean age and
gender. Outcome measures were recorded, including their
number and the time of follow-up, and the number and
type of complications. The outcome measures ‘mortality’
and ‘functional outcomes’ were recorded according to the
time from surgery. The ‘number of complications’, ‘length
of stay’, ‘blood loss’ and ‘operating time’ were not bound to
a single point in time. Complications were classified as
implant-related, cardiovascular, local or general, and re-
operations for any reason. Implant-related complications
included intra- and post-operative periprosthetic fractures,
aseptic loosening and dislocation. Cardiovascular compli-
cations included intra-operative cardiac arrest, myocardial
infarction, cerebral infarction, pulmonary embolism, acute
arrhythmia and severe intra-operative hypotension. Local
complications included superficial or deep wound infec-
tion. General complications included pneumonia, urinary
tract infection, acute renal failure, gastric disease or decub-
itus ulcers.
The methodological quality of the studies which were
included, was assessed according to a modified version of
the ‘Cochrane Collaboration tool’ by two authors (HDV
and TAEJB).26 The risk of selection bias, detection bias,
attrition bias and reporting bias was examined for each
study. The possibility of other bias (e.g. confounding or co-
interventions) was also examined. Each of these aspects
was rated as ‘low risk', ‘unclear risk’ or ‘high risk' of bias.
Any disagreements on the rating were solved by discussion
and consultation with a third author (BG).
Statistical analysis. The outcomes of interest consisted of
dichotomous and continuous outcomes. Odds ratios (ORs)
were calculated for the dichotomous outcomes and a
weighted mean difference (WMD) was obtained for the
continuous outcomes. The 95% confidence intervals (CI)
were also acquired for each outcome. Heterogeneity
between results was measured by a chi-squared test and
subsequently quantified by I2. Synthesis of results was done
by pooling the data and a fixed effects model meta-analysis.
However, if the I2 indicated moderate or high heterogeneity
(i.e. I2 ≥ 50%), as defined by Higgins et al,27 data were
pooled according to the random-effects model. The level of
statistical significance was set at p < 0.05. All analyses were
performed in Revman Review Manager (Revman 5.3; The
Nordic Cochrane Centre, Cochrane Collaboration, Copen-
hagen, Denmark, 2014). In order to evaluate the possibility
of publication bias, Revman Review Manager was used to
create a funnel plot.
Results
The initial search, reasons for exclusion and final selection
of studies are shown in a flow diagram (Fig. 1). One study
was published twice with a different length of follow-
up.28,29 In order to derive the most recent and complete
information from their data, only the most recent study was
included.29 In total, five RCTs were included.29-33 They
were published between 2005 and 2014, and included 950
patients (950 hips) (Table I). The outcome measures and
lengths of follow-up differed between the studies (Table II).
The methodological quality varied greatly between the
studies (Figs 2 and 3). In two trials, randomisation was ade-
quately performed using a random number generator.29,33
A further two studies used a blinded block design but did
not describe how randomisation was performed,30,32 and
one study randomised patients based on the day of the
operation,31 which has a high risk of bias. In two studies,
allocation was performed by an opaque numbered
envelope which was opened in the operating theatre,29,33
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 CEMENTED VERSUS CEMENTLESS HEMIARTHROPLASTY FOR A DISPLACED FRACTURE OF THE FEMORAL NECK
Initial search (n = 354)
(pubmed (n =103), Embase (n = 50),
Cochrane (n = 50), Web of science (n =151)
Titles and abstracts
screened (n = 354)
Abstracts of potential
relevance (n = 140)
Full text articles
assessed for eligibility
(n = 73)
RCTs suitable for
inclusion (n = 6)
RCTs included in
quantitive synthesis
(n = 5)
Fig. 1
Flowchart of the selection of studies (RCT, randomised controlled
trial).
whilst three studies did not fully describe the allocation.30-32
Of the four RCTs which described functional outcomes,
three were considered to have a low risk of attrition bias
because of a small loss to follow-up, with equal distribution
between groups.29,30,33 The one RCT which did not
describe loss to follow-up or protocol violations had an
unclear risk of bias.31 Only one study described the use of a
national register to define death in their missing patients.30
In the other studies, it was unclear how the distinction was
made between missing patients and deaths.29,31-33 The
extremely low loss to follow-up in the study by Langslet et
al29 (2.2%) resulted in a low risk of bias. An unclear
risk30,32 or high risk31 of ‘other bias’ was allocated mainly
because of the possibility of confounding and/or co-
interventions in those trials.
Mortality. The studies defined peri-operative and early mor-
tality at different times (Table II). Mortality within the first
post-operative year ranged from the day of the operation to
six months post-operatively. None of the studies reported a
significant difference in mortality between the two groups
at any of these times. Data from the two studies which
VOL. 99-B, No. 4, APRIL 2017
423
Studies not investigating
the role of cementing in
hemiarthroplasty (n = 214)
Duplicates removed (n = 67)
67 articles removed
- Non-RCTs (n = 57)
- Conference paper (n = 1)
- Not available (n = 2)
- RCTs investigating
outdated Austin Moore
and/or Thompson stems
(n = 7)
One study was published
twice (a one-yr follow-up
and a five-yr follow-up),
the one-yr follow-up
was excluded (n = 1)
described mortality at one month post-operatively were
pooled.29,30 There was moderate heterogeneity between the
studies (I2 = 70%, p = 0.07), and analysis was performed
according to the random effects model. Pooling revealed no
significant difference between the groups in these two stud-
ies (OR 1.11, 95% CI 0.17 to 7.10, p = 0.92).
All five studies investigated mortality at one year post-
operatively.29-33 The mortality at this time ranged from
20.3%30 to 30.0%32 in the cementless group, and from
18.8%29 to 31.3%33 in the cemented groups. No study
found a significant difference in mortality after one year
between cemented and cementless hemiarthroplasty. After
pooling of the data no significant difference was found (OR
0.82, 95% CI 0.61 to 1.09, p = 0.17) (Fig. 4).
Mortality at two years post-operatively was described in
two studies.29,33 At this time, the mortality was 35.2%29
and 40.0%33 in the cementless group and 28.6%29 and
43.8%33 in the cemented group. Neither study found a sig-
nificant difference in mortality, and there was no significant
difference after pooling the data (OR 0.91, 95% CI 0.60 to
1.38, p = 0.65) (Fig. 4). There was no heterogeneity at one
424 H. D. VELDMAN, I. C. HEYLIGERS, B. GRIMM, T. A. E. J. BOYMANS

Table I. Details of the included randomised controlled trials (RCTs)

Gender
Age* (yrs)
Patients (n) (female) (%) Implant type ITT/PP
Study Enrolment
design period Total CLH CH Total CLH CH CLH CH CLH CH
Santini et al 200531 RCT, 1 Sept 2000 106 53 53 80.9 (?) 82.1 (7.6) 79.7 (8.6) 79.2 75.5 Bipolar stem Bipolar stem PP
center to Dec 2001 (Zimmer, (Zimmer)
Warsaw,
Indiana)
DeAngelis et al RCT, 1 Mar 2005 130 64 66 82.3 (55 to 100) 82.8 (7.6) 81.8 (9.0) 75.0 78.8 VerSys Beaded VerSys LD/Fx ITT
201230 center to May FullCoat (Zimmer)
2008 (Zimmer)
Taylor et al 201233 RCT, 1 May 2006 160 80 80 85.2 (70 to 99) 85.1 (6.6) 85.3 (7.0) 66.3 71.3 Zweymüller Exeter (Stryker, ITT
center to Nov Alloclassic Kalamazoo,
2008 (Zimmer) Michigan)
Talsnes et al 201332 RCT, 2 2005 to 334 172 162 84.1 (75 to ?) 84.0 (5.1) 84.3 (5.0) 78.5 72.4 Corail (Depuy, Titan (Depuy) PP
centers 2010 Warsaw,
Indiana)
Langslet et al 201429 RCT, 2 Sept 2004 220 108 112 83 (70 to ?) 83.0 (6.3) 83.4 (5.7) 74.0 78.0 Corail (Depuy) Spectron PP
centers to Aug (Smith &
2006 Nephew,
London, United
Kingdom)
*age is displayed as mean (range) for the total population and as mean (standard deviation) for each subgroup; where a value was not included in the
study a ‘?’ has been inserted
CLH, cementless hemiarthroplasty; CH, cemented hemiarthroplasty; ITT, intention-to-treat; PP, per protocol

Table II. Outcome measures and follow-up of the studies

Study outcomes Described complications Follow-up

Santini et al 200531 Complications, hospital length of stay, mortality, Decubitus score, gastric disease, iatrogenic 1 yr
operation time, VELCA functional scores femur fractures, MI, pneumonia, prosthesis
dislocation, pulmonary embolism, urinary
tract infection, wound infection
DeAngelis et al 201230 ADL, blood loss, complications, fatigue/level CVA, ICU stay, major haemorrhage, MI, In hospital, 30 days, 60 days,
of energy, mortality, operation time, physical pneumonia, pulmonary embolism, re- 1 yr
activity operation, wound infection
Taylor et al 201233 Blood loss, complications, hospital length of Cardiovascular complications, dislocation, 6 wks, 6 mths, 1 yr, 2 yrs
stay, mortality, operation time, Oxford Hip fractures, reoperation, respiratory/ urinary
Score, pain, quality of life, use of walking aids tract/ wound infection
Talsnes et al 201332 Blood loss, mortality, operation time None Operation day, 1 yr
Langslet et al 201429 Barthel index, blood loss, complications, Cardiac arrest, dislocation, fracture, MI, 7 days, 30 days, 90 days, 1 yr,
EQ-5D, Harris Hip Score, hospital length of pneumonia, pulmonary embolism, 2 yrs, 5 yrs
stay, mortality, operation time, pain, use of re-operation, thrombosis, wound infection
walking aids
ADL, activities of daily living; ICU, intensive care unit; MI, myocardial infarct; CVA, cerebrovascular accident; EQ-5D, Euroqol-5D; Qol, quality of life;
GI, gastro-intestinal; VELCA, Verona Elderly Care functional score

year follow-up (I2 = 0%, p = 0.45) and a small heterogene-
ity at two-year follow-up (I2 = 11%, p= 0.29).
Additionally, Langslet et al29 studied the rate of mortality
five years post-operatively, when there remained no signifi-
cant difference between the groups (Fig. 4).
Complications. Four studies described the number and type
of complications for each group.29-31,33 Only Taylor et al33
found a significant difference between the groups, noting
fewer complications in the cemented group when compared
with the cementless group (OR 2.54, 95% CI 1.34 to 4.83).
The total number of complications in the four studies
ranged from 20.3%30 to 55.0%33 in the cementless group
and from 17.9%29 to 32.5%33 in the cemented group. Pool-
ing revealed a significantly higher number of complications
in the cementless groups (OR 1.61, 95% CI 1.12 to 2.31,
p 0.01) (Fig. 5). There was small heterogeneity (I2 = 10%,
p = 0.34).
Implant-related complications. Implant-related complications
were described in three studies.29,31,33 Significantly more
implant-related complications occurred in the cementless
group (OR 3.15, 95% CI 1.55 to 6.41, p = 0.002) (Fig. 5).
There was small heterogeneity (I2 = 41%, p = 0.18).
Cardiovascular complications. Four studies described cardi-
ovascular complications.29-31,33 There was no significant
difference between the groups in any study, or after pooling
of the data (OR 0.54, 95% CI 0.24 to 1.20, p = 0.13)
(Fig. 5). There was no heterogeneity (I2 = 0%, p = 0.70).
Local complications. Four studies mentioned local compli-
cations.29-31,33 Pooling did not indicate a significant differ-
ence between groups (OR 0.71, 95% CI 0.27 to 1.86,

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 CEMENTED VERSUS CEMENTLESS HEMIARTHROPLASTY FOR A DISPLACED FRACTURE OF THE FEMORAL NECK 425

0.36 days, 95% CI -1.13 to 1.85, p = 0.63) (Fig. 6). There

Incomplete outcome data (attrition bias): operation and hospital outcomes

was no heterogeneity (I2 = 0%, p = 0.87).
Intra-operative blood loss. The mean intra-operative blood
loss ranged from 251 ml31 to 390 ml29 in the four studies
which described blood loss.29,30,32,33 There was no signifi-

Incomplete outcome data (attrition bias): functional outcomes

cant difference between the groups in two studies,30,33 the
other two recorded less blood loss in the cementless
group (WMD -90.00 mL, 95% CI -136.99 to -43.01 and
WMD -75.00 mL, 95% CI -119.52 to -30.48).29,32 Data

Incomplete outcome data (attrition bias): mortality

Blinding of outcome assessment (detection bias)
were pooled according to the random effects model because
Random sequence generation (selection bias)

of high heterogeneity (I2 = 82%, p < 0.001). There was no

significant difference in blood loss after pooling of the
Allocation concealment (selection bias)

data (WMD -36.19 ml, 95% CI -89.45 to 17.07, p = 0.18)

Selective reporting (reporting bias)

(Fig. 7).
Operating time. All five studies reported this; two found no
difference between the two groups.30,33 The other three
reported a longer operating time in the cemented
group.29,31,32 The pooled data also found a significantly
shorter duration of surgery in the cementless group (WMD
-9.96 minutes, 95% CI -12.93 to -6.98, p < 0.001) (Fig. 8).
Heterogeneity was low (I2 = 46%, p = 0.12).
Others bias

Functional outcomes. Four studies investigated these.29-31,33

However, the data could not be pooled as it was assessed
in different ways and at different times (Table II). The
individual studies reported comparable functional out-
DeAngelis 201230 ? ? + + + + + ?
comes for the cemented and cementless groups at all
Langslet 201429 + + + + + + + + follow-up times.29-31,33 However, Taylor et al33 reported
better functional results in the cemented group at six
Santini 200531 − ? ? ? ? ? + − weeks post-operatively, with regards to pain when flexing
the hip to 45° and the Oxford Hip Score.34 At six months
Talsnes 201332 ? ? ? + ? + ? post-operatively, the timed up and go (TUG) test35 was
lower in the cemented groups, representing a better out-
Taylor 201233 + + + + + ? + + come.33 Langslet et al,29 however, found a higher Harris
Hip Score36 and therefore a better functional outcome in
Fig. 2
the cementless group at five years post-operatively. There
Assessment of the risk of bias in the studies; ‘+’ low risk of bias, ‘?’ were no significant differences between the cemented and
unclear risk of bias, ‘-’ high risk of bias.29-33
cementless group for all other functional measurements
and follow-up times (Table II).
Risk of bias across studies. Since the outcome measures
‘mortality’ and ‘operating time’ were recorded in all the
p = 0.49) (Fig. 5). There was no heterogeneity (I2 = 0%, studies, funnel plots of these data were obtained. The fun-
p = 0.61). nel plots are asymmetrical. However, because of the limited
General complications. The same four studies described number of included studies, it remains questionable if this is
general complications.29-31,33 There was no significant dif- the result of publication bias.
ference between the groups in any study or after pooling of Current versus previous generation of stems. In order to
the data (OR 1.09, 95% CI 0.62 to 1.91, p = 0.76) (Fig. 5). examine whether the analyses of outcomes in exclusively
There was no heterogeneity (I2 = 0%, p = 0.74). current hip stems leads to different conclusions than analy-
Number of re-operations. This was described in three stud- ses of exclusively previous stems, further analyses were per-
ies.29-31 There was no significant difference between groups formed. The four most recently published systematic
within any study or after pooling of data (OR 1.24, 95% CI reviews and meta-analyses12-15 were searched for studies
0.53 to 2.88, p = 0.62) (Fig. 5). There was no heterogeneity investigating exclusively previous stems such as the
(I2 = 0%, p = 0.62). Thompson and Austin Moore. Seven studies were
Length of hospital stay. This was described by three stud- identified37-43 and checked for the same outcome measures
ies.29,31,33 The mean length ranged from 7.829 to 27.233 as investigated in the analyses of current stems. Unfortu-
days. There was no significant difference between the nately, one study was not accessible43 and one did not
groups in any study or after pooling of the data (WMD describe any of the outcomes of interest.41 The data from

VOL. 99-B, No. 4, APRIL 2017

426 H. D. VELDMAN, I. C. HEYLIGERS, B. GRIMM, T. A. E. J. BOYMANS

Random sequence generation (selection bias)

Allocation concealment (selection bias)
Blinding of outcome assessment (detection bias)
Incomplete outcome data (attrition bias): functional outcomes
Incomplete outcome data (attrition bias): operation and hospital outcomes
Incomplete outcome data (attrition bias): mortality
Selective reporting (reporting bias)
Others bias

0% 25% 50% 75% 100%

Low risk of bias Unclear risk of bias High risk of bias

Fig. 3

Summary of the assessment of the risk of bias.

Cemented Cementless Odds ratio Odds ratio

Study or subgroup Events Total Events Total Weight % M-H, Fixed, 95% CI Yr M-H,Fixed,95% CI
1.1.2 1-year mortality
Santini 2005 13 53 14 53 10.4 0.91 (0.38 to 2.17) 2005
Taylor 2012 25 80 23 80 15.6 1.13 (0.57 to 2.22) 2012
DeAngelis 2012 16 66 13 64 9.9 1.26 (0.55 to 2.88) 2012
Talsnes 2013 39 162 52 172 37.9 0.73 (0.45 to 1.19) 2013
Langslet 2014 21 112 32 108 26.2 0.55 (0.29 to 1.03) 2014
Subtotal (95% CI) 473 477 100 0.82 (0.61 to 1.09)
Total events 114 134
Heterogeneity: chi2 = 3.69, df = 4 (p = 0.45); I2 = 0%
Test for overall effect: Z = 1.38 (p = 0.17)
1.1.3 2-year mortality
Taylor 2012 35 80 32 80 39.4 1.17 (0.62 to 2.19) 2012
Langslet 2014 32 112 38 108 60.6 0.74 (0.42 to 1.30) 2014
Subtotal (95% CI) 192 188 100.0 0.91 (0.60 to 1.38)
Total events 67 70
Heterogeneity: chi2 = 1.13, df = 1 (p = 0.29); I2 = 11%
Test for overall effect: Z = 0.46 (p = 0.65)
1.1.4 5-year mortality
Langslet 2014 63 112 64 108 100.0 0.88 (0.52 to 1.51) 2014
Subtotal (95% CI) 112 108 100.0 0.88 (0.52 to 1.51)
Total events 63 64
Heterogeneity Not applicable
Test for overall effect: Z = 0.45 (p = 0.65)

0.2 0.5 1 2 5
Favours (cemented) Favours (cementless)
Fig. 4

Forest plot of mortality one, two and five years after cemented versus cementless hemiarthroplasty (CI, confidence interval; M-H, Mantel-Haenszel;
df, degrees of freedom).29-33

the remaining five studies37-40,42 were pooled as described
for the studies on current generation stems. A total of six
outcomes could be compared with our analyses of current
hip stems (Table III).
In the comparison of previous generation cemented ver-
sus cementless stems, only the shorter operating time in the
cementless groups was statistically significant. The mortal-
ity one year post-operatively, total number of complica-
tions, number of re-operations, length of stay and blood
loss did not differ between the groups.
Comparison of the results (ORs and WMDs) of previous
stems with those of current stems revealed similar trends.
The significantly higher number of complications in the
cementless group was only found in the current generation
of stems.
Discussion
The goal of this systematic review and meta-analysis was to
compare the results of current cemented and cementless
hemiarthroplasty of the hip.

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 CEMENTED VERSUS CEMENTLESS HEMIARTHROPLASTY FOR A DISPLACED FRACTURE OF THE FEMORAL NECK 427

Cementless Cemented Odds ratio Odds ratio

Study or subgroup Events Total Events Total Weight % M-H, Fixed, 95% CI Yr M-H,Fixed,95% CI
5.1.5 Total number of complicatlons
Santini 2005 22 53 16 53 20.3 1.64 (0.74 to 3.66) 2005
DeAngelis 2012 13 64 12 66 20.4 1.15 (0.48 to 2.75) 2012
Taylor 2012 44 80 26 80 25.4 2.54 (1.34 to 4.83) 2012
Langslet 2014 22 108 20 112 33.9 1.18 (0.60 to 2.31) 2014
Subtotal (95% CI) 305 311 100.0 1.61 (1.12 to 2.31)
Total events 101 74
Heterogeneity: chi2 = 3.34, df = 3 (p = 0.34); I2 = 10%
Test for overall effect: Z = 2.58 (p = 0.01)
5.1.6 Number of implant related complications
Santini 2005 2 53 1 53 10.2 2.04 (0.18 to 23.19) 2005
Taylor 2012 18 80 3 80 24.6 7.45 (2.10 to 26.46) 2012
Langslet 2014 11 108 7 112 65.3 1.70 (0.63 to 4.56) 2014
Subtotal (95% CI) 241 245 100.0 3.15 (1.55 to 6.41)
Total events 31 11
Heterogeneity: chi2 = 3.39, df = 2 (p = 0.18); I2 = 41%
Test for overall effect: Z = 3.16 (p = 0.002)
5.1.7 Number of cardiovascular complications
Santini 2005 2 53 4 53 22.5 0.48 (0.08 to 2.74) 2005
DeAngelis 2012 1 64 2 66 11.3 0.51 (0.04 to 5.74) 2012
Taylor 2012 6 80 7 80 37.8 0.85 (0.27 to 2.64) 2012
Langslet 2014 1 108 5 112 28.4 0.20 (0.02 to 1.74) 2014
Subtotal (95% CI) 305 311 100.0 0.54 (0.24 to 1.20)
Total events
Heterogeneity: chi2 = 1.42, df = 3 (p = 0.70); I2 = 0%
Test for overall effect: Z = 1.51 (p = 0.13)
5.1.8 Number of local complications
Santini 2005 0 53 1 53 14.7 0.33 (0.01, to 8.21) 2005
DeAngelis 2012 1 64 1 66 9.6 1.03 (0.06 to 16.85) 2012
Taylor 2012 5 80 4 80 37.1 1.27 (0.33 to 4.90) 2012
Langslet 2014 1 108 4 112 38.5 0.25 (0.03 to 2.29) 2014
Subtotal (95% CI) 305 311 100.0 0.71 (0.27 to 1.86)
Total events
Heterogeneity: chi2 = 1.83, df = 3 (p = 0.61); I2 = 0%
Test for overall effect: Z = 0.69 (p = 0.49)
5.1.9 Number of general complications
Santini 2005 17 53 15 53 43.1 1.20 (0.52 to 2.75) 2005
DeAngelis 2012 1 64 3 66 12.3 0.33 (0.03 to 3.29) 2012
Taylor 2012 11 80 10 80 36.5 1.12 (0.45 to 2.80) 2012
Langslet 2014 3 108 2 112 8.1 1.57 (0.26 to 9.59) 2014
Subtotal (95% CI) 305 311 100.0 1.09 (0.62 to 1.91)
Total events 32 30
Heterogeneity: chi2 = 1.24, df = 3 (p = 0.74); I2 = 0%
Test for overall effect: Z = 0.31 (p = 0.76)
5.1.10 Number of reoperations
Taylor 2012 4 80 2 80 19.5 2.05 (0.37 to 11.54) 2012
DeAngelis 2012 0 64 1 66 15.1 0.34 (0.01 to 8.46) 2012
Langslet 2014 8 108 7 112 65.4 1.20 (0.42 to 3.43) 2014
Subtotal (95% CI) 252 258 100.0 1.24 (0.53 to 2.88)
Total events 12 10
Heterogeneity: chi2 = 0.96, df = 3 (p = 0.62); I2 = 0%
Test for overall effect: Z = 0.49 (p = 0.62)

0.02 0.1 1 10 50
Favours (cementless) Favours (cemented)
Fig. 5

Forest plot of complications after cemented versus cementless hemiarthroplasty (CI, confidence interval; M-H, Mantel-Haenszel; df, degrees of
freedom).29-33

Many previously performed studies included stems of a
previous generation, or those which are now unavailable or
have been discontinued. This problem is extensively
described in the literature.12,15,19,29,31,33,44-46 However, this
is the first systematic review which only includes RCTs
involving current generation stems. Previous systematic
reviews are largely based on data from Austin Moore and
Thompson stems; six of eight studies in the review by Luo
et al,13 four of seven in the review by Li et al,12 seven of 12
in the review by Ning et al14and five of seven in the review
by Parker et al.15
The systematic review of Luo et al13 found no significant
difference in the mortality or the number of complications
and re-operations but found that patients with a cemented

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428 H. D. VELDMAN, I. C. HEYLIGERS, B. GRIMM, T. A. E. J. BOYMANS

Cementless Cemented Mean difference Mean difference

Study or subgroup Mean SD Total Mean SD Total Weight % IV, Fixed, 95% CI Year IV, Fixed, 95% CI
Santini 2005 17.46 6.29 53 17.23 9.1 53 25.0 0.23 (-2.75 to 3.21) 2005
Taylor 2012 26.5 14.26 80 27.2 14.6 80 11.1 -0.70 (-5.17 to 3.77) 2012
Langslet 2014 8.4 9.02 108 7.8 4.11 112 63.9 0.60 (-1.26 to 2.46) 2014

Total (95% CI) 241 245 100.0 0.36 (-1.13 to 1.85)

Heterogeneity: chi2 = 0.29, df = 2 (p = 0.87); I2 = 0%
Test for overall effect: Z = 0.48 (p = 0.63) -4 -2 0 2 4
Favours (cementless) Favours (cemented)

Fig. 6

Forest plot of the length of stay after cemented versus cementless hemiarthroplasty (SD, standard deviation; CI, confidence interval; IV, inverse-
variance method; df, degrees of freedom).29,31,33

Cementless Cemented Mean difference Mean difference

Study or subgroup Mean SD Total Mean SD Total Weight % IV, Random, 95% CI Year IV, Random, 95% CI
DeAngelis 2012 279 177 64 257 30.8 66 25.2 22.00 (-22 to 66.00) 2012
Taylor 2012 251 156.8 80 254 130.8 80 25.1 -3.00 (-47.74 to,41.74) 2012
Talsnes 2013 260 163 172 335 242 162 25.1 -75.00 (-119.52 to -30.48) 2013
Langslet 2014 300 171.9 108 390 183.7 112 24.6 -90.00 (-136.99 to -43.01) 2014

Total (95% CI) 424 420 100.0 -36.19 (-89.45 to 17.07)

2 2 2
Heterogeneity: Tau = 2424.75; chi = 16.77, df = 3 (p = 0.0008); I = 82%
Test for overall effect: Z = 1.33 (p = 0.18) -200 -100 0 100 200
Favours (cementless) Favours (cemented)

Fig. 7

Forest plot of the blood loss after cementedversus cementless hemiarthroplasty (SD, standard deviation; CI, confidence interval; IV, inverse-variance
method; df, degrees of freedom).29,30,32,33

Cementless Cemented Mean difference Mean difference

Study or subgroup Mean SD Total Mean SD TotalWeight % IV, Fixed, 95% CI Year IV, Fixed, 95% CI
Santini 2005 56.98 55 53 75 22.43 53 3.5 18.02 (-34.01 to -2.03)2005
Taylor 2012 74.7 18.8 80 79.3 17.2 80 28.4 -4.60 (-10.18 to 0.98) 2012
DeAngelis 2012 103.6 32 64 108.2 30.8 66 7.6 -4.60 (-15.40 to 6.20) 2012
Talsnes 2013 71 22 172 84 30 162 27.5-13.00 (-18.67 to -7.23) 2013
Langslet 2014 70.2 19.3 108 82.6 19.8 112 33.1 -12.40 (-17.57 to -7.23) 2014
Total (95% CI) 477 473 100.0 -9.96 (-12.93 to-6.98)
Heterogeneity: chi2= 7.42, df = 4 (p = 0.12); I2 = 46% -20 -10 0 10 20
Test for overall effect: Z = 6.56 (p < 0.00001) Favours (cementless) Favours (cemented)
Fig. 8

Forest plot of the blood loss after cementedversus cementless hemiarthroplasty (SD, standard deviation; CI, confidence interval; IV, inverse-variance
method; df, degrees of freedom).29-33

stem had better functional results and less pain.13 Li et al12
included two more recent RCTs30,33 but did not include the
three studies by Faraj and Branfoot,37 Harper47 and Santini
et al.31 However, they also concluded that cemented stems
achieve better function of the hip, less pain and fewer
implant-related complications compared with cementless
stems.12 The risk of mortality, re-operation or cardiovascu-
lar, cerebrovascular, local or general complications, were
identical in both groups. The most recent systematic review
was conducted by Ning et al14 in 2014. Based on two stud-
ies, they concluded that there was no significant difference
between cementless and cemented stems. The most recent
Cochrane review, from 2010, was conducted by Parker et
al.15 They concluded that there was reasonable evidence
that there was less pain and more mobility when a
cemented stem was used. They also stated that these differ-
ences may not exist with cementless hydroxyapatite-coated
stems, emphasising the relevance of the current review of
modern stems.
Synthesis of results. The rates of mortality at one month
and one, two and five years post-operatively were equal in
both groups, indicating that the use of cement has no detri-
mental effect on the short- and mid-term mortality.
We found that cementless stems were associated with a
higher total number of complications when compared with
cemented stems. There were also more implant-related
complications, such as periprosthetic fractures, aseptic
loosening and dislocation. This is in agreement with previ-
ously published observational studies involving current
generation stems.8,46,48 Also, a recently published RCT49
comparing cemented and cementless fixation in patients
who were treated with a hemiarthroplasty or total hip
arthroplasty (THA) after a displaced fracture of the femoral
neck, found a higher number of periprosthetic fractures in

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 CEMENTED VERSUS CEMENTLESS HEMIARTHROPLASTY FOR A DISPLACED FRACTURE OF THE FEMORAL NECK 429

Table III. Results of analyses on cemented versus cementless hemiarthroplasty in exclusively current generation stems and in exclusively previous
generation stems

Current generation stems (present

report) Analysed (n) Previous generation stems Analysed (n)
Patients Patients
OR/WMD Favours 95% CI Studies CLH:CH OR/WMD Favours 95% CI Studies CLH:CH
Mortality 1-yr 0.82 CH 0.61 to 1.09 5 134:114 0.93 CH 0.67 to 1.30 5 390:347
post-operatively
Total number of 1.61* CH 1.12 to 2.31 4 305:311 1.14† CH 0.41 to 3.15 2 226:227
complications
Total number of 1.24 CH 0.53 to 2.88 3 252:258 1.64 CH 0.77 to 3.51 2 278:223
re-operations
Length of hospital 0.36 CH -1.13 to 1.85 3 241:245 1.95 CH -0.16 to 4.07 3 292:304
stay (days)
Intra-operative -36.19† CLH -8.45 to 17.07 4 424:420 -49.00 CLH -120.10 to 22.10 1 26:27
blood loss (ml)
Duration of surgery -9.96* CLH -12.93 to -6.98 5 477:473 -6.97* CLH -9.49 to -4.45 2 226:227
(mins)
*OR or WMD considered statistically significant (p < 0.05)
†Data pooled according the random effects model due to moderate heterogeneity (I2 ≥ 50%)
OR, odds ratio (for dichotomous outcomes); WMD, weighted mean difference (for continuous outcomes); CI, confidence interval; CLH, cementless
hemiarthroplasty; CH, cemented hemiarthroplasty

patients with a cementless stem. The number of re-
operations for any reason did not differ between the
groups. The incidence of local and general complications
was also equal in the two groups. Interestingly, the number
of cardiovascular complications did not differ between the
groups in contradistinction to the widely held view that
there is an association between cement and cardiovascular
complications known as the ‘bone cement implantation
syndrome’.50 This was also described by Li et al.12
The length of stay in hospital was equal in both groups,
suggesting that both groups start mobilisation within the
same time period. The blood loss was comparable between
the groups. The mean operating time was nine minutes
shorter for cementless stems, which was statistically signif-
icant (p < 0.001). This will be partly due to the time for the
polymerisation of the cement. The shorter operating time in
this group may have some economic and organisational
benefits, but should not be overrated. The longer anaes-
thetic time in the cemented group results in higher costs.51
There are some studies on revision hip surgery52 and total
knee arthroplasty53 that have investigated the correlation
between operating time and the rate of complications; how-
ever, no such data are available for hemiarthroplasty.
The data about the functional outcomes could not be
pooled as different functional scores and follow-up times
were recorded in the studies. The effect of using cement
with a hemiarthroplasty on the functional results thus
remains unclear.
The most likely explanation for an increased rate of com-
plications when using contemporary cementless stems
could be the improvement due to improved cement, the
design of the stem and/or the surgical techniques for a
cemented procedure.
Limitations. This meta-analysis has limitations. First, there
were only five RCTs, describing 950 patients (950 hips),
which is low considering the high incidence of fracture of
the femoral neck. This led to asymmetrical funnel plots
which are barely useable in the assessment of publication
bias in the studies.
We acknowledge that our strict inclusion criteria is at the
expense of statistical power, which is not necessarily high in
meta-analyses.54,55 Nevertheless, pooling of the data
revealed statistically significant evidence regarding compli-
cations that were not identified in three RCTs.29-31 In addi-
tion, a significant difference was revealed regarding the
operating time, which was not found by half of the studies
describing this parameter.30,33 This suggests that the meta-
analysis achieved sufficient power to detect significant dif-
ferences.
Post hoc power analyses were conducted, which revealed
that the achieved power differed among the analyses (range
5.3% to 100.0%), with three of the 12 analyses achieving a
statistical power of ≥ 80%. The analyses that were ade-
quately powered were for the operating time, blood loss
and implant related complications (100%, 92.2% and
90.9%, respectively). The achieved power in the analysis of
the total number of complications was 72.8%. The sub-
analyses within the total number of complications regard-
ing cardiovascular, local, general complications and the
number of re-operations were underpowered (32%,
10.3%, 5.3% and 7.1%, respectively). The statistical
power of the analyses of mortality after one, two and five
years was also low (28.9%, 12.4% and 6.6%, respectively).
Finally, the length of stay in hospital achieved a statistical
power of only 6.5%. In conclusion, not all analyses in the
current study were adequately powered. This, however, is
not uncommon in meta-analyses in general.54,55 Turner et
al54 studied the role of underpowered studies in Cochrane
reviews (n = 1991), including 14 886 meta-analyses. They
concluded that the proportion of Cochrane meta-analyses

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430 H. D. VELDMAN, I. C. HEYLIGERS, B. GRIMM, T. A. E. J. BOYMANS
with a power of ≥ 80%, to detect a relative reduction of risk
of 30% which had been published was 22%; 12% were
powered between 50% and 80%, and 66% were under-
powered. Therefore, the risk of any meta-analysis being
underpowered should be kept in mind when interpreting
results.54
It should be noticed that the ORs and WMDs are accom-
panied with relatively wide 95% CIs. Thus, equal, higher or
lower risks are established, but the exact size of detected
differences remains difficult to determine. Additionally, the
individual studies carry a substantial risk of bias in their
methodology. It is not known how and to what extent these
risks of bias influence our findings.
Some outcome specific limitations have to be acknowl-
edged. Due to differences in follow-up times between stud-
ies, not all data about every follow-up time could be
pooled. Mortality was therefore only analysed at one
month and one, two and five years post-operatively; the
five-year mortality being only described in one study.29 The
difference in follow-up times and the different functional
outcomes made it impossible to pool these data. Therefore,
the overall effect of cementing the hemiarthroplasty on the
functional outcome remains unclear. In order to provide
more insight into the functional outcomes after cemented
versus cementless hemiarthroplasty, future RCTs should
record validated functional outcomes at standardised times
post-operatively.
Finally, the total number of complications was based on
the complications which were reported in the studies. Pos-
sible differences in the definition of a complication in the
studies may affect our results. Differences in the length of
follow-up might influence the number of complications
reported in each study. The rates of complications which
typically occur in the mid- or long-term, such as aseptic
loosening, may therefore differ between studies. Also, other
factors might influence the occurrence of specific
complications. For example, in THA it is described that
design and location of fixation of the cementless stem in the
patients’ specific proximal femur morphology influences
the osteointegration. In case of failing to achieve osteointe-
gration, it might be necessary to perform revision sur-
gery.56,57 The type of cementless stem used therefore, might
play a role in the number of implant-related complications
or re-operations. Furthermore, the features of the cement
used for fixating the implant may affect the outcome. For
example, a recent study by Sprowson et al58 showed a sig-
nificantly lower rate of surgical site infection after fixating
the implant with dual-antibiotic impregnated cement, when
compared with standard low dose single antiobiotic loaded
bone cement.
Our study is the first meta-analysis comparing cemented
and cementless hemiarthroplasty based on RCTs investigat-
ing exclusively current generation stems. Our analysis sug-
gests that cementless stems have a 61% higher number of
complications, in particular implant-related complications
such as periprosthetic fractures, which are almost three-
times more common. The number of re-operations and car-
diovascular, local and general complications did not differ
between the groups. The use of cement was not associated
with a detrimental effect on mortality five years post-oper-
atively. There were no differences in the length of stay in
hospital and the blood loss. The operating time was signif-
icantly shorter in the cementless group. Due to differences
in follow-up times and measurement tools in the studies, no
conclusions can be made about the functional outcomes
after treatment with a hemiarthroplasty based on this meta-
analysis.
In conclusion, although cemented hemiarthroplasty
seems to be a safer option than cementless hemiarthro-
plasty, there remains a need for a methodologically sound,
large multicentre RCT comparing modern cemented and
cementless hemiarthroplasty stems in the the medium- and
long-term, not only focusing on mortality and complica-
tions but also on patient reported outcome measures.
Take home message:
- This is the first meta-analysis comparing cemented and
cementless hemiarthroplasty based on RCTs, investigating
exclusively current generation hip stems.
- In hemiarthroplasty of the hip, current generation cemented stems seem
to be a safer option resulting in fewer implant-related complications and
similar mortality compared with current generation cementless stems.
- Although the duration of surgery in cementless hemiarthroplasty is
shorter, the use of cemented fixation in hemiarthroplasty after a femoral
neck fracture is thus recommended in current practice.
Author contributions:
H. D. Veldman: Study idea, Study design, Data collection, Data analysis, Writing
the paper.
B. Grimm: Study design, Data analysis, Writing the paper.
I. C. Heyligers: Study design, Writing the paper.
T. A. E. J. Boymans: Study idea, Study design, Data collection, Data analysis,
Writing the paper.
No benefits in any form have been received or will be received from a commer-
cial party related directly or indirectly to the subject of this article.
This article was primary edited by E. Moulder and first proof edited by J. Scott.
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