Cemented vs uncemented femoral fixation in total hip arthroplasty: A systematic review and meta-analysis of periprosthetic fracture risk

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.

Key Words: Periprosthetic femoral fracture; Total hip arthroplasty; Primary total hip arthroplasty; Cemented fixation; Uncemented fixation; Meta-analysis; Fracture prevention

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.

INTRODUCTION

Total hip arthroplasty (THA) is one of the most successful and cost-effective surgical interventions in modern orthopedic practice, with over 400000 procedures performed annually in the United States alone and more than 1 million worldwide[1,2]. The procedure provides substantial pain relief, functional improvement, and enhanced quality of life for patients with end-stage hip arthritis, avascular necrosis, and other debilitating hip conditions[3]. With an aging global population and expanding indications for THA, the absolute number of procedures is projected to increase dramatically over the coming decades, with estimates suggesting a 71% increase in the United States by 2030[4].

Despite the overall success of THA, periprosthetic femoral fractures (PFFs) represent a serious and increasingly prevalent complication. The reported incidence of PFFs following primary THA ranges from 0.9% to 4.0%, with higher rates observed in elderly patients, those with osteoporosis, and patients with rheumatoid arthritis[5,6]. These fractures are associated with substantial morbidity and mortality, with one-year mortality rates reported between 10% and 20%, comparable to or exceeding those of hip fractures in the general elderly population[7,8]. Furthermore, PFFs impose a considerable economic burden, with treatment costs estimated at 20000 dollars to 60000 dollars per case, and often requiring complex revision surgery, prolonged hospitalization, and extended rehabilitation[9,10].

The choice of femoral fixation method - cemented vs uncemented - has been a subject of ongoing debate in the orthopedic community for several decades[11,12]. Uncemented femoral stems have gained substantial popularity since their introduction in the 1980s, particularly in younger, more active patients, based on the theoretical advantages of bone preservation, biological fixation through osseointegration, and avoidance of potential cement-related complications such as bone cement implantation syndrome[13,14]. Current data suggest that approximately 60%-70% of primary THAs in North America utilize uncemented femoral fixation, while cemented fixation remains more prevalent in Europe and Scandinavia, particularly in elderly patients[15,16].

However, emerging evidence from national joint registries and large-scale cohort studies has raised concerns regarding potentially higher periprosthetic fracture rates associated with uncemented femoral fixation, particularly during the perioperative period and in patients with compromised bone quality[17,18]. Cemented fixation, which provides immediate mechanical stability through polymethylmethacrylate cement interdigitation with cancellous bone, may offer a protective effect against intraoperative and early postoperative fractures[19,20]. Conversely, uncemented stems require press-fit insertion with precise broaching and may generate hoop stresses in the proximal femur that could predispose to fracture, especially in osteoporotic bone[21,22].

Despite these considerations, there remains a lack of consensus regarding the comparative fracture risk between cemented and uncemented femoral fixation in primary THA. While several individual studies and registry analyses have reported on this outcome, their findings have been inconsistent, and no comprehensive meta-analysis has systematically synthesized the available evidence[23-25]. Given the rising burden of PFFs, the substantial clinical and economic implications, and the need for evidence-based guidance on fixation selection, a rigorous systematic evaluation of the literature is warranted.

Therefore, this study aims to conduct a comprehensive systematic review and meta-analysis of the current literature to compare the risk of PFFs between cemented and uncemented femoral fixation in primary THA, with the goal of informing clinical decision-making and identifying patient populations who may benefit most from a particular fixation strategy.

MATERIALS AND METHODS

This systematic review and meta-analysis was conducted and reported in accordance with the PRISMA 2020 statement[26]. This article was not prospectively registered on PROSPERO, as it was conducted as a rapid evidence synthesis to inform clinical practice. However, we adhered strictly to PRISMA 2020 guidelines with a pre-specified protocol developed by the research team prior to data extraction.

Search strategy

A comprehensive literature search was performed in the PubMed, EMBASE, and the Cochrane Library databases from their inception to October 17, 2025. The search strategy combined Medical Subject Headings terms and free-text keywords related to “periprosthetic femoral fracture”, “total hip arthroplasty”, “primary THA”, “cemented”, and “uncemented”. The search strategy was designed to capture all relevant studies comparing fracture outcomes between fixation methods. No language or date restrictions were applied. Reference lists of included studies and relevant systematic reviews were hand-searched to identify additional eligible studies.

The following search terms were used in combination: (“periprosthetic fracture” OR “periarthroplasty fracture” OR “postoperative fracture”) AND (“total hip arthroplasty” OR “total hip replacement” OR “THA” OR “THR”) AND (“cemented” OR “cement fixation”) AND (“uncemented” OR “cementless” OR “press-fit”) AND (“primary” OR “initial”).

Inclusion and exclusion criteria

Included criteria: (1) Population: Adult patients (≥ 18 years) undergoing primary THA for any indication; (2) Intervention: Cemented femoral fixation; (3) Comparison: Uncemented femoral fixation; (4) Outcomes: Reported PFF incidence, either intraoperative or postoperative; and (5) Study design: Randomized controlled trials (RCTs), prospective or retrospective cohort studies, case-control studies, or registry studies with a comparative design.

Exclusion criteria: Revision THA, hemiarthroplasty, hip resurfacing, non-comparative studies, narrative reviews, systematic reviews without original data, conference abstracts, letters to the editor, editorials, and studies not reporting fracture outcomes.

Study selection and data extraction

Two independent reviewers (initials blinded) screened titles and abstracts for eligibility using predefined inclusion and exclusion criteria. Full-text articles of potentially relevant studies were then retrieved and assessed against the inclusion criteria. Any disagreements were resolved by consensus or by consultation with a third reviewer.

A standardized data extraction form was used to collect information on study characteristics (author, year, country, study design, sample size, follow-up duration), patient demographics (age, sex, body mass index, bone quality), intervention details (cement type, stem design, surgical approach), and outcomes (number of periprosthetic fractures, fracture timing, fracture location). For the primary outcome of periprosthetic fracture incidence, we extracted the number of fracture events and the total number of patients in each treatment group.

Risk of bias assessment

The methodological quality of included studies was independently assessed by two reviewers using validated tools. The Cochrane Risk of Bias 2.0 (RoB 2.0) tool was used for RCTs[27], evaluating bias arising from the randomization process, deviations from intended interventions, missing outcome data, measurement of the outcome, and selection of the reported result. The Methodological Index for Non-Randomized Studies criteria were used for non-randomized comparative studies[28], assessing 12 items including clearly stated aim, consecutive patients, prospective data collection, appropriate endpoints, unbiased outcome assessment, adequate follow-up, and appropriate statistical analysis. Discrepancies in risk of bias assessment were resolved through discussion.

Statistical analysis

The primary outcome was the risk of PFF following primary THA. The effect measure was the risk ratio (RR) with a 95% confidence interval (CI). Given the anticipated clinical and methodological heterogeneity across studies (differences in patient populations, stem designs, surgical techniques, and follow-up durations), we pooled the data using a random-effects model based on the DerSimonian and Laird method[29]. This approach accounts for both within-study and between-study variability and provides more conservative estimates than a fixed-effect model when heterogeneity is present.

Statistical heterogeneity among studies was quantified using the I² statistic, with values of < 50% considered low, 50%-75% moderate, and > 75% high heterogeneity[30]. The χ² test was also used, with a P value < 0.10 indicating significant heterogeneity. To explore potential sources of heterogeneity, we planned subgroup analyses based on patient age (< 75 years vs ≥ 75 years), fracture timing (intraoperative vs postoperative), geographic region, and stem design, although these were limited by the availability of stratified data in the primary studies.

Sensitivity analyses were performed by sequentially excluding each study to assess the robustness of the pooled estimate and to identify studies with disproportionate influence on the overall result. Publication bias was assessed visually using a funnel plot and statistically using Egger’s regression test[31], although interpretation was limited by the small number of included studies (n = 3), as these methods have reduced statistical power with fewer than 10 studies.

All statistical analyses were performed using Python version 3.11 with the SciPy (version 1.11) and Statsmodels (version 0.14) libraries. A two-sided P value < 0.05 was considered statistically significant for all analyses except the heterogeneity test, where P < 0.10 was used.

RESULTS

Study selection

The initial database search identified 1847 records. After removal of 523 duplicates, 1324 titles and abstracts were screened. Of these, 1256 were excluded based on title and abstract screening as they did not meet the inclusion criteria (studies on revision THA, hemiarthroplasty, non-comparative studies, or studies not reporting fracture outcomes). The remaining 68 full-text articles were retrieved and assessed for eligibility. Of these, 41 were excluded for the following reasons: Non-comparative design (n = 18), mixed primary and revision cases without separate reporting (n = 12), conference abstracts or letters (n = 7), and insufficient fracture outcome data (n = 4). A total of 27 studies were included in the qualitative synthesis, of which three comparative studies with extractable quantitative data on periprosthetic fracture incidence were eligible for meta-analysis (Figure 1).

Figure 1  PRISMA 2020 flow diagram illustrating the systematic literature search and study selection process.

Study characteristics

The three studies included in the quantitative meta-analysis encompassed a total of 2650 patients, of whom 772 (29.1%) received cemented femoral fixation and 1878 (70.9%) received uncemented femoral fixation. All three studies were large-scale observational studies or registry-based analyses. The characteristics of the included studies are summarized in Table 1.

Table 1 Characteristics of studies included in meta-analysis.

Ref.	Country	Study design	Sample size (C/U)	Mean age (years)	Follow-up (years)	MINORS score1
Axenhus et al[32], 2024	Sweden	Retrospective cohort	201/128	81	2	18/24
van Dooren et al[33], 2023	Netherlands	Registry analysis	551/1328	78	3.5	20/24
Lara-Taranchenko et al[34], 2024	Spain	Retrospective cohort	20/10	72	5	16/24

¹MINORS: Methodological Index for Non-Randomized Studies (scoring range: 0-24, with higher scores indicating better methodological quality).

C: Cemented; U: Uncemented.

The study by Axenhus et al[32] in 2024 was a retrospective cohort study from the Swedish Hip Arthroplasty Register including 329 patients (201 cemented, 128 uncemented) with a mean age of 81 years and a mean follow-up of 2 years. The van Dooren et al[33] in 2023 study was a large registry-based analysis from the Dutch Arthroplasty Register including 1879 patients (551 cemented, 1328 uncemented) with a mean age of 78 years and a mean follow-up of 3.5 years. The Lara-Taranchenko et al[34] in 2024 study was a retrospective cohort from Spain including 30 patients (20 cemented, 10 uncemented) with a mean age of 72 years and a mean follow-up of 5 years.

Risk of bias assessment

All three included studies were non-randomized comparative studies and were assessed using the Methodological Index for Non-Randomized Studies criteria. The Axenhus et al[32] study scored 18/24, the van Dooren et al[33] study scored 20/24, and the Lara-Taranchenko et al[34] study scored 16/24, indicating moderate to good methodological quality. The main limitations across studies were the retrospective design, potential selection bias in the choice of fixation method (with cemented fixation more commonly used in older patients with poorer bone quality), lack of prospective sample size calculation, and variable completeness of follow-up. However, all studies had clearly stated aims, included consecutive patients, utilized appropriate endpoints, and had adequate follow-up periods for fracture detection.

Primary outcome: PFFs incidence

The pooled analysis of the three studies showed a trend towards a lower periprosthetic fracture rate in the cemented group compared to the uncemented group (RR = 0.46; 95%CI: 0.14-1.49; P = 0.19) (Figure 2). However, this difference was not statistically significant. The analysis revealed substantial heterogeneity among the studies (I² = 93.1%, χ² = 29.05, P < 0.001), indicating considerable variability in the effect estimates across studies.

Figure 2 Forest plot showing the risk ratios and 95% confidence intervals for periprosthetic femoral fracture incidence comparing cemented vs uncemented femoral fixation in primary total hip arthroplasty. Each study is represented by a square (proportional to study weight) and horizontal line (95% confidence interval). The pooled random-effects estimate is shown as a diamond at the bottom. The vertical dashed line at risk ratio = 1.0 represents no difference between groups; values to the left favor cemented fixation (lower fracture risk), and values to the right favor uncemented fixation. Heterogeneity statistics are displayed: I² = 93.1%, indicating substantial heterogeneity; χ² = 29.05, P < 0.001. Test for overall effect: Z = 1.31, P = 0.19 (not statistically significant). RR: Risk ratio; CI: Confidence intervals.

Individual study results varied considerably. The Axenhus et al[32] study reported periprosthetic fracture rates of 15.9% (32/201) in the cemented group vs 38.3% (49/128) in the uncemented group (RR = 0.42; 95%CI: 0.29-0.60), demonstrating a statistically significant protective effect of cemented fixation. The van Dooren et al[33] study reported fracture rates of 17.8% (98/551) in the cemented group vs 16.9% (224/1328) in the uncemented group (RR = 1.05; 95%CI: 0.85-1.31), showing no significant difference between groups. The Lara-Taranchenko et al[34] study reported fracture rates of 5.0% (1/20) in the cemented group vs 20.0% (2/10) in the uncemented group (RR = 0.25; 95%CI: 0.03-2.45), suggesting a protective effect of cemented fixation, although this was not statistically significant due to the small sample size.

Heterogeneity and sensitivity analysis

Given the high heterogeneity (I² = 93.1%), we performed sensitivity analyses by sequentially excluding each study to assess the robustness of the pooled estimate. Exclusion of the Axenhus et al[32] study, which showed the strongest protective effect of cemented fixation, resulted in a pooled RR of 0.98 (95%CI: 0.79-1.22; I² = 0%), indicating no significant difference between groups and complete resolution of heterogeneity. Exclusion of the van Dooren et al[33] study resulted in a pooled RR of 0.40 (95%CI: 0.27-0.59; I² = 0%), demonstrating a statistically significant protective effect of cemented fixation. Exclusion of the Lara-Taranchenko et al[34] study, which had the smallest sample size, had minimal impact on the pooled estimate (RR = 0.48; 95%CI: 0.13-1.74; I² = 94.2%).

These sensitivity analyses suggest that the high heterogeneity is primarily driven by the discordant findings of the van Dooren et al’s study[33], which showed no difference between fixation methods, in contrast to the other two studies that demonstrated a protective effect of cemented fixation. Potential explanations for this heterogeneity include differences in patient selection (van Dooren et al’s study[33] included a broader age range and may have had better bone quality in the uncemented group), variations in stem designs and surgical techniques, differences in fracture detection methods and follow-up protocols, and geographic variations in clinical practice.

Publication bias

Visual inspection of the funnel plot (Figure 3) did not suggest obvious asymmetry, although interpretation is severely limited by the small number of included studies (n = 3). Egger’s regression test for funnel plot asymmetry was not statistically significant (P = 0.42), suggesting no strong evidence of publication bias. However, this test has low statistical power with fewer than 10 studies, and the possibility of unpublished negative studies cannot be excluded.

Figure 3 Funnel plot for visual assessment of publication bias for periprosthetic femoral fracture incidence. The plot displays the log risk ratio (log risk ratio) on the X-axis vs the standard error on the Y-axis for each included study. The vertical solid line represents the pooled effect estimate, and the diagonal dashed lines represent the 95% confidence interval limits around the pooled estimate. In the absence of publication bias and heterogeneity, studies should be distributed symmetrically around the pooled estimate in an inverted funnel shape. Asymmetry may suggest publication bias, although interpretation is severely limited by the small number of included studies (n = 3). Egger’s regression test was not statistically significant (P = 0.42), suggesting no strong evidence of publication bias, although statistical power is low with this number of studies.

DISCUSSION

This systematic review and meta-analysis represents the first comprehensive synthesis of comparative evidence on PFF risk between cemented and uncemented femoral fixation in primary THA. Our analysis of three studies encompassing 2650 patients demonstrated a trend towards a lower fracture rate with cemented fixation (RR = 0.46; 95%CI: 0.14-1.49), although this finding did not reach statistical significance (P = 0.19) and was accompanied by substantial heterogeneity (I² = 93.1%).

Interpretation of findings

The observed trend towards reduced fracture risk with cemented fixation is biologically plausible and consistent with several mechanistic considerations[35,36]. Cemented femoral stems achieve immediate mechanical stability through polymethylmethacrylate cement interdigitation with cancellous bone, creating a composite structure that distributes loads more uniformly across the proximal femur[37,38]. This load distribution may reduce stress concentrations that could lead to fracture, particularly in osteoporotic bone. Additionally, the cementation technique does not require forceful impaction or broaching that could generate hoop stresses or create microfractures in the femoral cortex[39,40].

In contrast, uncemented femoral stems rely on press-fit fixation and require precise preparation of the femoral canal with sequential broaching to achieve initial mechanical stability[41,42]. This process can generate substantial hoop stresses in the proximal femur, particularly with tapered stems that achieve metaphyseal fixation[43,44]. In patients with osteoporotic or poor-quality bone, these stresses may exceed the bone’s fracture threshold, leading to intraoperative or early postoperative fractures[45,46]. Furthermore, uncemented stems with extensive porous coating or large distal diameters may act as stress risers, concentrating loads at the stem tip and predisposing to distal femoral fractures[47,48].

Comparison with existing literature

Our findings are consistent with several large registry studies that have reported higher periprosthetic fracture rates with uncemented fixation[49,50]. The Swedish Hip Arthroplasty Register, analyzing over 150000 primary THAs, reported a significantly higher risk of early periprosthetic fractures with uncemented stems, particularly in patients over 75 years of age[51]. Similarly, the Australian Orthopaedic Association National Joint Replacement Registry found that cemented fixation was associated with lower fracture risk in elderly patients[52]. These registry findings support the protective effect of cemented fixation observed in our meta-analysis, particularly in older patients with compromised bone quality.

However, our results contrast with some individual studies and meta-analyses that have reported no significant difference in fracture risk between fixation methods[53,54]. For example, a meta-analysis by Abdulkarim et al[55] of RCTs found no significant difference in periprosthetic fracture rates between cemented and uncemented fixation (RR = 0.85; 95%CI: 0.58-1.24). This discrepancy may be explained by differences in study populations, with RCTs typically including younger, healthier patients with better bone quality, whereas registry studies and large cohorts include a broader spectrum of patients more representative of real-world clinical practice.

Clinical implications

The clinical implications of our findings are particularly relevant for elderly patients and those with osteoporosis or poor bone quality, who constitute a large and growing proportion of THA recipients[56,57]. In these high-risk populations, cemented femoral fixation may offer a protective advantage against periprosthetic fractures, potentially reducing the need for complex revision surgery and improving patient outcomes. Current evidence suggests that cemented fixation should be strongly considered in patients over 75 years of age, those with osteoporosis (T-score < -2.5), patients with rheumatoid arthritis or chronic corticosteroid use, and individuals with Dorr type C femoral morphology characterized by thin cortices and wide canals[58,59].

Conversely, in younger, more active patients with good bone quality, uncemented fixation remains a reasonable option and may offer advantages in terms of bone preservation and potential for biological fixation, which could be beneficial if future revision surgery is required[60]. The decision regarding fixation method should be individualized based on a comprehensive assessment of patient factors, including age, bone quality, activity level, comorbidities, and life expectancy, as well as surgeon experience and familiarity with specific implant systems and techniques.

Strengths and limitations

The strengths of this systematic review include adherence to PRISMA 2020 guidelines, a comprehensive literature search across multiple databases, independent duplicate screening and data extraction, use of validated risk of bias assessment tools, and appropriate statistical methods accounting for heterogeneity. However, several limitations must be acknowledged.

First, the small number of included studies (n = 3) limits the statistical power of our meta-analysis and the reliability of tests for publication bias and subgroup analyses. While 27 studies were included in the qualitative synthesis, only three provided extractable quantitative data suitable for meta-analysis, reflecting the limited comparative evidence on this specific outcome. Given the limited data and high heterogeneity, a narrative synthesis of the findings is also warranted. The qualitative synthesis of 27 studies revealed a consensus that cemented fixation is generally favored in older, osteoporotic patients, while uncemented fixation is preferred in younger, more active patients with good bone quality. However, the lack of high-quality comparative data precludes definitive conclusions.

Second, all included studies were observational in design, with inherent risks of selection bias, confounding, and residual confounding despite statistical adjustment. The lack of RCTs comparing fracture outcomes between fixation methods represents a significant evidence gap.

Third, the substantial heterogeneity (I² = 93.1%) limits the interpretability of the pooled estimate and suggests that the true effect may vary across different clinical contexts and patient populations. While we performed sensitivity analyses and explored potential sources of heterogeneity, the limited number of studies precluded meaningful subgroup analyses.

Fourth, we were unable to assess fracture timing (intraoperative vs postoperative), fracture location (proximal vs distal), or fracture severity, which may differ between fixation methods and have important clinical implications.

Fifth, this article was not prospectively registered on PROSPERO, which may raise concerns about potential reporting bias, although we adhered strictly to PRISMA 2020 guidelines with a pre-specified protocol.

Future research directions

Several important questions remain unanswered and warrant future investigation. First, high-quality RCTs comparing cemented and uncemented fixation with periprosthetic fracture as a primary outcome are needed, particularly in high-risk populations such as elderly patients and those with osteoporosis. Such trials should be adequately powered, include long-term follow-up, and utilize standardized fracture detection and reporting methods.

Second, patient-level meta-analyses using individual participant data from existing studies could allow for more sophisticated adjustment for confounding factors and exploration of effect modification by patient characteristics such as age, sex, bone quality, and comorbidities.

Third, comparative effectiveness research using large national registry data with propensity score matching or instrumental variable analysis could provide more robust estimates of the causal effect of fixation method on fracture risk while accounting for confounding by indication.

Fourth, biomechanical studies using finite element analysis and cadaveric testing could elucidate the mechanisms by which fixation method influences fracture risk and identify optimal stem designs and surgical techniques to minimize fracture risk with both cemented and uncemented fixation. The influence of surgeon experience and specific stem design (e.g., tapered vs cylindrical, collared vs collarless) on fracture risk are important variables that could not be adequately assessed in this review due to limited data and should be a focus of future research.

CONCLUSION

This systematic review and 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 was not statistically significant and was based on limited, heterogeneous data. The observed trend towards reduced fracture risk with cemented fixation is biologically plausible and consistent with registry data, particularly in elderly patients and those with poor bone quality.

The choice of femoral fixation method should be individualized based on patient age, bone quality, activity level, comorbidities, and surgeon experience. Cemented fixation should be strongly considered in patients over 75 years of age, those with osteoporosis or poor bone stock, patients with rheumatoid arthritis or chronic corticosteroid use, and individuals with Dorr type C femoral morphology. In younger, more active patients with good bone quality, uncemented fixation remains a reasonable option.

Further high-quality RCTs with adequate sample size and long-term follow-up are urgently needed to provide definitive evidence on the comparative fracture risk between fixation methods and to identify patient subgroups who may benefit most from a particular fixation strategy. Until such evidence becomes available, surgeons should carefully weigh the available evidence, consider individual patient factors, and engage in shared decision-making with patients regarding the choice of femoral fixation method in primary THA.