Abushal MH, Embaby OM, Mersal M, Badghish E, Elalfy M. Cemented vs uncemented femoral fixation in total hip arthroplasty: A systematic review and meta-analysis of periprosthetic fracture risk. World J Orthop 2026; 17(2): 115615 [DOI: 10.5312/wjo.v17.i2.115615]
Corresponding Author of This Article
Mohammed H Abushal, Assistant Professor, Department of Orthopedic Surgery, University of Tabuk, Duba Road, University City, Tabuk 71491, Saudi Arabia. mabushal@ut.edu.sa
Research Domain of This Article
Orthopedics
Article-Type of This Article
Systematic Reviews
Open-Access Policy of This Article
This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Feb 18, 2026 (publication date) through Feb 4, 2026
Times Cited of This Article
Times Cited (0)
Journal Information of This Article
Publication Name
World Journal of Orthopedics
ISSN
2218-5836
Publisher of This Article
Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA
Share the Article
Abushal MH, Embaby OM, Mersal M, Badghish E, Elalfy M. Cemented vs uncemented femoral fixation in total hip arthroplasty: A systematic review and meta-analysis of periprosthetic fracture risk. World J Orthop 2026; 17(2): 115615 [DOI: 10.5312/wjo.v17.i2.115615]
World J Orthop. Feb 18, 2026; 17(2): 115615 Published online Feb 18, 2026. doi: 10.5312/wjo.v17.i2.115615
Cemented vs uncemented femoral fixation in total hip arthroplasty: A systematic review and meta-analysis of periprosthetic fracture risk
Mohammed H Abushal, Osama M Embaby, Mahmoud Mersal, Emran Badghish, Mohamed Elalfy
Mohammed H Abushal, Department of Orthopedic Surgery, University of Tabuk, Tabuk 71491, Saudi Arabia
Osama M Embaby, Department of Orthopedic Surgery, Sandwell and West Birmingham Hospitals NHS Trust, Birmingham B66 2QT, United Kingdom
Mahmoud Mersal, Department of Orthopedic Surgery, University Hospital of Birmingham Foundation Trust, Birmingham B9 5SS, United Kingdom
Emran Badghish, Department of Surgery, College of Medicine, University of Bisha, Bisha 67714, Saudi Arabia
Mohamed Elalfy, Department of Orthopedic Surgery, Mansoura University, Mansoura 35516, Egypt
Co-first authors: Mohammed H Abushal and Osama M Embaby.
Author contributions: Abushal MH and Embaby OM designed the study concept and methodology they contributed equally to this article, they are the co-first authors of this manuscript; Abushal MH, Embaby OM, and Mersal M conducted the clinical investigation and data collection; Embaby OM and Mersal M performed data curation; drafted original manuscript; Abushal MH, Embaby OM, Mersal M, Badghish E, and Elalfy M subsequently reviewed and edited; and all authors have read and approved the final version of the manuscript.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
Open Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Mohammed H Abushal, Assistant Professor, Department of Orthopedic Surgery, University of Tabuk, Duba Road, University City, Tabuk 71491, Saudi Arabia. mabushal@ut.edu.sa
Received: October 21, 2025 Revised: November 4, 2025 Accepted: December 16, 2025 Published online: February 18, 2026 Processing time: 106 Days and 11.9 Hours
Abstract
BACKGROUND
Periprosthetic femoral fractures (PFFs) represent a devastating complication following primary total hip arthroplasty (THA), associated with significant morbidity, mortality, and healthcare costs. The choice of femoral fixation method - cemented vs uncemented - may influence the risk of postoperative periprosthetic fracture. While uncemented stems have gained popularity due to perceived advantages in younger patients and bone preservation, emerging evidence suggests potential differences in fracture risk between fixation methods, particularly in elderly and osteoporotic populations.
AIM
To conduct a systematic review and meta-analysis comparing the risk of PFFs between cemented and uncemented femoral fixation in primary THA.
METHODS
Following the PRISMA 2020 guidelines, we performed a comprehensive search of PubMed, EMBASE, and the Cochrane Library databases up to October 2025. We included comparative studies reporting periprosthetic fracture rates following primary THA with cemented vs uncemented femoral fixation. The primary outcome was the incidence of PFFs. Data were pooled using a random-effects model. Risk of bias was assessed using the Cochrane RoB 2.0 tool for randomized controlled trials and the Methodological Index for Non-Randomized Studies for observational studies. Publication bias was evaluated using funnel plot analysis and Egger’s test.
RESULTS
A total of 27 studies were included in the qualitative synthesis, of which three comparative studies, encompassing 2650 patients (772 cemented, 1878 uncemented), provided extractable data for quantitative meta-analysis of periprosthetic fracture incidence. The pooled analysis demonstrated a trend towards a lower risk of periprosthetic fractures in the cemented group compared to the uncemented group (risk ratio = 0.46; 95% confidence interval: 0.14-1.49; P = 0.19); however, this finding was not statistically significant. Substantial heterogeneity was observed among the included studies (I2 = 93.1%, P < 0.001). Funnel plot analysis was limited by the small number of studies but did not suggest significant publication bias.
CONCLUSION
This meta-analysis suggests that cemented femoral fixation in primary THA may be associated with a lower risk of PFFs compared to uncemented fixation, although this finding did not reach statistical significance and was based on limited, heterogeneous data. The choice of fixation method should be individualized based on patient age, bone quality, activity level, and surgeon experience. Cemented fixation may be particularly advantageous in elderly patients and those with poor bone stock. Further high-quality randomized controlled trials with adequate follow-up are needed to provide definitive evidence.
Core Tip: This article evaluated the effect of cemented vs uncemented femoral fixation in primary total hip arthroplasty on the risk of periprosthetic femoral fracture. Twenty-seven studies were reviewed, and three provided comparative data for quantitative analysis. The findings showed a non-significant trend toward fewer periprosthetic femoral fractures with cemented fixation but high heterogeneity among studies. These results highlight the need for individualized fixation choice in total hip arthroplasty and underscore the importance of high-quality prospective research to clarify optimal fixation strategies.
