Long Stem Hemiarthroplasty

None of the included investigations in this clinical practice guideline directly compare short versus long stem hemiarthroplasty in this population. This limits the statement that can be made recommending one option over another. However, some evidence does exist demonstrating increased complication rates with the use of long stem cemented arthroplasty. Intraoperative hypotension and significant cardiopulmonary events including death have been documented in numerus studies (Herrenbruck 2002, Houdek 2017, Xing 2013), while other studies have demonstrated that long stem cemented implants are overall a relatively safe option if performed appropriately (Price 2013, Peterson 2017). The theoretical benefit of a long stem implant is to protect the majority of the femur from fracture in the setting of disease progression. However, some evidence does exist showing that reoperation rates in general are very low in this population and no different has been appreciated based on the length of the stem chosen (Xing 2013).

Benefits/Harms of Implementation

There may also be some additional cost involved with performing a long stem technique due to implant cost, operative time, and complication rates. Although both short stem and long stem options are at times acceptable and feasible, we believe that the potential risk involved with the long stem option is not warranted without obvious, symptomatic, concerning lesions more distal in the femur.

Future Research

Future direct comparisons of short and long stem options in a randomized trial would help to clarify the question. Additional studies investigating the use of short versus long stems in patients with distal disease in the femur would help to identify which patients would benefit from short versus long stem hemiarthroplasty procedures.