Cause-Specific Stem Revision Risk in Primary Total Hip Arthroplasty Using Cemented vs Cementless Femoral Stem Fixation in a US Cohort

We sought to evaluate the cause-specific revision risk following hybrid (cemented stem mated to a cementless acetabular implant) vs cementless total hip arthroplasty (THA) in a US cohort.Primary elective THA for osteoarthritis was identified using Kaiser Permanente's Total Joint Replacement Registry (2001-2018). Multivariable Cox regression was used to evaluate cause-specific revision, including aseptic loosening, infection, instability, and periprosthetic fracture (PPF), for hybrid vs cementless THA. Analysis was stratified by age (<65, 65-74, and ≥75 years) and gender.The study cohort comprised 88,830 THAs, including 4539 (5.1%) hybrid THAs. In stratified analysis, hybrid THA had a higher revision risk for loosening in females in all 3 age subgroups. A lower risk of revision for PPF was observed following hybrid THA in females aged ≥75 years. For females ≥75 years, cementless THA had an excess PPF risk of 0.9% while hybrid THA had an excess loosening risk of 0.2%, translating to a theoretical prevention of 10 PPF revisions but a price of 3 loosening revisions per 1000 hybrid THAs. No difference in revision risk was observed in males.We observed differences in cause-specific revision risks by method of stem fixation which depended upon patient age and gender. Although the trend toward all cementless fixation continue, there may be a role for hybrid fixation in females ≥75 years to mitigate risk for revision due to PPF at the potential cost of a slight increase in longer term aseptic loosening.Level III.