Clin Orthop Relat Res (2018) 00:1-10

DOI 10.1097/01.blo.0000533621.57561.a4

Clinical Research

Is Cemented or Cementless Femoral Stem Fixation More Durable

in Patients Older Than 75 Years of Age? A Comparison of the
Best-performing Stems
Michael Tanzer MD, FRCSC, Stephen E. Graves MBBS, DPhil, FRACS, FAOrthA, Andrea Peng MMed,
Andrew J. Shimmin MBBS, FRACS, FAOrthA

Received: 12 April 2017 / Accepted: 13 March 2018 / Published online: 0, xxxx

Copyright © 2018 by the Association of Bone and Joint Surgeons

Abstract
Background There is ongoing debate concerning the best
method of femoral fixation in older patients receiving pri-
mary THA. Clinical studies have shown high survivorship
for cemented and cementless femoral stems. Arthroplasty
registry studies, however, have universally shown that
cementless stems are associated with a higher rate of
revision in this patient population. It is unclear if the
difference in revision rate is a reflection of the range of
implants being used for these procedures rather than the
mode of fixation.
Questions/purposes (1) Is the risk of revision higher in
patients older than 75 years of age who receive one of the
three cementless stems with the highest overall survivor-
ship in the registry than in those of that age who received
one of the three best-performing cemented stems? If so, is
there a difference in risk of early revision versus late
revision, defined as revision within 1 month after index
surgery? (2) Are there any diagnoses (such as osteoar-
thritis [OA] or femoral neck hip fracture) in which the
three best-performing cementless stems had better

Each author certifies that he or she, or a member of his or her immediate family, has no funding or commercial associations (eg,
consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with
the submitted article.
Clinical Orthopaedics and Related Research® neither advocates nor endorses the use of any treatment, drug, or device. Readers are
encouraged to always seek additional information, including FDA-approval status, of any drug or device prior to clinical use.
The Australian Orthopaedic Association Joint Replacement Registry approved the human protocol for this investigation, and each author
certifies that all investigations were conducted in conformity with ethical principles of research.
This work was performed at the Australian Orthopaedic Association Joint Replacement Registry (Adelaide, South Australia) and the Jo Miller
Lab (McGill University, Montreal, Canada).

M. Tanzer, Division of Orthopaedic Surgery, McGill University, Montreal, Canada

S. E. Graves, Australian Orthopaedic Association National Joint Replacement Registry, Adelaide, South Australia

A. Peng, South Australian Health and Medical Research Institute, Adelaide, Australia

A. J. Shimmin, Department of Surgery, Monash Medical Centre, Faculty of Medicine, Nursing and Health Sciences, Clayton, Victoria, Australia;
and Melbourne Orthopaedic Group, Victoria, Australia

M. Tanzer (✉), Division of Orthopaedic Surgery, McGill University, 1650 Cedar Avenue, Montreal, Quebec, H3X 4A4, Canada, email: michael.
tanzer@mcgill.ca

All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with
the publication and can be viewed on request.

Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
 2 Tanzer et al.
survivorship than one of the three best-performing
cementless stems? (3) Do these findings change when
evaluated by patient sex?
Methods The Australian Orthopaedic Association
National Joint Replacement Registry data were used to
identify the best three cemented and the best three
cementless femoral stems. The criteria for selection were
the lowest 10-year revision rate and use in > 1000 proce-
dures in this age group of patients regardless of primary
diagnosis. The outcome measure was time to first revision
using Kaplan-Meier estimates of survivorship. Compar-
isons were made for THAs done for any reason and then
specifically for OA and femoral neck fracture separately.
Results Overall, the cumulative percent revision in the
first 3 months postoperatively was lower among those
treated with one of the three best-performing cemented
stems than those treated with one of the three best-
performing cementless stems (hazard ratio [HR] for best
three cementless versus best three cemented = 3.47 [95%
confidence interval {CI}, 1.60-7.53], p = 0.001). Early
revision was 9.14 times more common in the best three
cementless stems than in the best three cemented stems
(95% CI, 5.54-15.06, p = 0.001). Likewise, among
patients with OA and femoral neck fracture, the cumu-
lative percent revision was consistently higher at
1 month postoperatively among those treated with one of
the three best-performing cementless stems than those
treated with one of the three best-performing cementless
stems (OA: HR for best three cementless versus best
three cemented = 8.82 [95% CI, 5.08-15.31], p < 0.001;
hip fracture: HR for best 3 cementless versus best three
cemented = 27.78 [95% CI, 1.39-143.3], p < 0.001).
Overall, the cumulative percent revision was lower in the
three best cemented stem group than the three best
cementless stem group for both males and females at
1 month postoperatively (male: HR = 0.42 [95% CI,
0.20-0.92], p = 0.030; female: HR = 0.06 [95% CI,
0.03-0.10], p < 0.001) and for females at 3 months
postoperatively (HR = 0.15 [95% CI, 0.06-0.33], p <
0.001), after which there was no difference.
Conclusions Cementless femoral stem fixation in patients
75 years or older is associated with a higher early rate of
revision, even when only the best-performing prostheses
used in patients in this age group were compared. Based on
this review of registry data, it would seem important to
ensure the proper training of contemporary cementing
techniques for the next generation of arthroplasty surgeons
so they are able to use this option when required. However,
the absence of a difference in the two groups undergoing
THA after 3 months suggests that there can be a role for
cementless implants in selected cases, depending on the
surgeon’s expertise and the quality and shape of the
proximal femoral bone.
Level of Evidence Level III, therapeutic study.
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics and Related Research®
Introduction
Cementless femoral components were introduced in an
effort to avert the high rates of loosening and osteolysis
reported with cemented femoral components using early
cementing techniques [10]. However, cementless femoral
components did not eliminate either of these complications
and improvements in cementing techniques have resulted
in significantly longer survivorship of cemented implants
[11-13]. As a result, the decade of the 1980s was consid-
ered by many hip surgeons to be the decade of cement
versus cementless THA [7]. Since then, the implant designs
and fixation strategies have varied widely between coun-
tries. Recent reports consistently show lower revision rates
for cemented stems [5, 6, 15, 17]. Despite these well-
documented and publicized results, cementless fixation use
for the oldest age group has continued to increase in many
countries [9, 24].
The recent Australian Orthopaedic Association National
Joint Replacement Registry (AOANJRR) annual report
indicated that in patients 75 years or older, cementless stem
fixation had a higher rate of revision compared with
cemented stem fixation and that this difference varied with
time [3]. However, these data represented pooling of 167
cementless and 89 cemented stems. Thus, it is possible that
the poorer results seen with cementless stems may simply
represent the number, volume, and performance of the in-
dividual stems used rather than the mode of fixation [1].
These differences in stem performance cast doubt on the
reason why the AOANJRR and other registry results show
that patients older than 75 years with cemented stems have
a lower risk of revision [5, 6, 15, 17, 24].
We therefore explored the AOANJRR data to discern
which stems provided the best long-term results, defined as
the lowest cumulative percent revision at 10 years. We aimed
to answer the following questions: (1) Is the risk of revision
higher in patients older than 75 years of age who receive one
of the three cementless stems with the highest overall
survivorship in the registry than in those of that age who
received one of the three best-performing cemented stems? If
so, is there a difference in risk of early revision versus late
revision, defined as revision within 1 month after index
surgery? (2) Are there any diagnoses (such as osteoarthritis
[OA] or femoral neck hip fracture) in which the three best-
performing cementless stems had better survivorship than
one of the three best-performing cementless stems? (3) Do
these findings change when evaluated by patient sex?
Patients and Methods
At our request, the AOANJRR approved and performed an
analysis comparing the best three cemented femoral stems
 Volume 00, Number 00
with the best three cementless femoral stems in patients 75
years or older undergoing primary THA. For purposes of
this study, we defined the “best three” as the three cemented
and cementless femoral stems in which each was used in >
1000 procedures and with the lowest cumulative percent
revision (CPR) at 10 years, regardless of primary
diagnosis. All procedures were performed between Sep-
tember 1, 1999, and December 31, 2015. Only THAs with
crosslinked polyethylene were included in this study to
ensure uniformity of bearing surface between groups and
essentially excluding osteolysis as a reason for revision. Of
the 214,800 primary THAs with polyethylene in the reg-
istry during this time period, 174,409 had crosslinked
polyethylene and their CPR rate at 15 years is 5.6% [3].
The registry includes > 98% of joint replacement pro-
cedures undertaken in Australia [3]. On initial submission
of forms from participating hospitals, the registry’s capture
rate is 95.9%. After verification against health department
data, checking of unmatched data, and subsequent retrieval
of unreported procedures, the registry is able to obtain an
almost complete data set relating to hip replacement in
Australia.
The AOANJRR identified 89 different cemented fem-
oral stems used during the study period. The three stems in
common use with the lowest risk of revision at 10 years
were the polished, tapered MS-30® stem (Zimmer-Biomet,
Warsaw, IN, USA), the composite I beam Omnifit® stem
(Stryker, Mahwah, NJ, USA), and the polished, tapered
Exeter V40TM (Stryker) stem. The cumulative revision rate
of these three femoral stems ranged from 4% to 5% at 10
years. These cemented stems were used in 31,635 cases and
represent 56% of all the surgeries with a cemented stem
during this time. There were 167 cementless femoral stems
used and the three best were the proximally porous-coated,
double wedge SynergyTM stem (Smith & Nephew, Lon-
don, UK), the proximally hydroxyapatite-coated, tapered
round Secur-FitTM stem (Stryker), and the tapered rectan-
gular SL-PlusTM (Smith & Nephew). The cumulative re-
vision rate of these three stems ranged from 4.5% to 6.1%
at 10 years. They were used in 5023 cases (14%). The
primary diagnosis was OA in 31,150 cases with 26,627
(86%) being in the cemented group and 4523 (14%) in the
cementless group. In patients whose primary diagnosis was
OA, 65% were female in the best three cemented femoral
stem group and 54% were female in the best three
cementless femoral stem group. THAs were performed for
a femoral neck fracture in 3337 cases with the majority
being cemented (92%). One of the three best cementless
stems was used in 74 of the 819 THAs in men and 206 of
the 2518 THAs in females with a femoral neck fracture.
The CPR of the combined results of the three best-
performing prostheses for each fixation type was calculated
using the Kaplan-Meier estimates of survivorship. Isolated
acetabular revisions were excluded from the analysis. The
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
THA Mode of Fixation in Older Patients 3
95% confidence interval (CI) was calculated using point-
wise Greenwood estimates. The CPR analysis was de-
termined for all diagnoses, for primary OA, and for femoral
neck fracture. Hazard ratios (HRs) from Cox proportional
hazard models, adjusted for age and sex, were used to
compare the combined rate of revision of the best three
femoral stems in the corresponding group. HRs were de-
termined for the first month postoperatively and over the
entire followup period. All statistical tests were two-tailed
at the 5% level of significance. A secondary analysis was
done to evaluate the CPR of primary total conventional hip
replacement in patients 75 years or older by femoral stem
fixation and sex.
Results
In aggregate, among patients older than 75 years of age, the
CPR in the first 3 months postoperatively was lower among
those treated with one of the three best-performing
cemented stems than those treated with one of the three
best-performing cementless stems (HR for best three
cementless versus best three cemented = 3.47 [95% CI,
1.60-7.53], p = 0.001; Fig. 1). Early revision was 9.14
times more common in the best three cementless stems than
in the best three cemented stems (95% CI, 5.54-15.06,
p = 0.001). In the entire cohort (Fig. 2), revision surgery for
fracture and loosening in the best three cementless stems
was at least double that for the best three cemented stems
(Table 1). There was no difference in the CPR between the
two stem fixation groups at any time after 3 months up to
the final followup at 13 years (cemented CPR = 2.2%,
cementless CPR = 3.7%, HR = 1.08 [95% CI, 0.80-1.46],
p = 0.615).
Likewise, among patients with OA (Fig. 3) and femoral
neck fracture (Fig. 4) who were older than 75 years of age,
the CPR was consistently higher at 1 month post-
operatively among those treated with one of the three best-
performing cementless stems than those treated with one of
the three best-performing cementless stems (OA: HR for
best three cementless versus best three cemented = 8.82
[95% CI, 5.08-15.31], p < 0.001; hip fracture: HR for best
three cementless versus best three cemented = 27.78 [95%
CI, 1.39-143.3], p < 0.001). This difference was main-
tained for the first 3 months in the patients with OA (HR for
best three cementless versus best three cemented = 3.31
[95% CI, 1.39-7.90], p < 0.006), but not in patients un-
dergoing THA for a fracture of the femoral neck. The
higher early CPR rate with the cementless stems in OA
(Fig. 5) was the result of the higher revisions for fracture
and loosening (Table 2), whereas fracture, loosening, and
dislocation resulted in a higher CPR in femoral neck
fractures treated with THA (Table 3). There was no
 4 Tanzer et al. Clinical Orthopaedics and Related Research®

Fig. 1 A graph depicting the CPR of primary THAs in patients 75 years or older is shown by
femoral stem fixation for all diagnoses. Parentheses indicate 95% CIs.

difference in the CPR between the two stem fixation groups
used to treat OA or a femoral neck fracture at final followup
(OA at 13 years: cemented CPR = 2.0%, cementless CPR =
3.7%, HR = 1.13 [95% CI, 0.82-1.57], p = 0.450; hip
fracture at 8 years: cemented CPR = 2.8%, cementless CPR
= 4.8%, HR = 1.35 [95% CI, 0.57-3.19], p = 0.498).
Overall, the CPR was lower in the three best cemented
stem group than the three best cementless stem group for
both males and females at 1 month postoperatively (male:
HR = 0.42 [95% CI, 0.20-0.92], p = 0.030; female: HR =
0.06 [95% CI, 0.03-0.10], p < 0.001) and for females at 3
months postoperatively (HR = 0.15 [95% CI, 0.06-0.33],
p < 0.001) after which there was no difference in the CPR
(Fig. 6). For a THA with one of the best three cementless
stems, males had a lower CPR than females at all time
periods (HR at 13 years = 1.78 [95% CI, 1.10-2.88], p =
0.019; male CPR = 2.8, female CPR = 4.3). However, the
CPR for a THA with one of the best three cemented stems
was lower in females than in males at all time periods (HR
at 13 years = 2.09 [95% CI, 1.66-2.62], p < 0.001; male
CPR = 2.9, female CPR = 1.8). Comparable findings
were noted in those patients who underwent THA for the
diagnosis of OA (Fig. 7).
Discussion
Registry data have consistently found lower revision rates
for cemented stems than cementless stems in patients older
than 75 years of age undergoing primary THA [24].
However, it is clear that not all implants are of equal re-
liability. As a result, the registry data reflect a combination
of both well- and poor-performing implants, in which the
volume and number of poor-performing implants can sig-
nificantly skew the outcomes. In this registry study of
patients older than 75 years of age undergoing primary
THA, we compared the three best-performing cemented

Fig. 2 A-B Graphs depicting the cumulative incidence revision diagnosis of primary THA in
patients 75 years or older by femoral stem fixation for all diagnoses are shown for the best
three (A) cemented and (B) cementless stems.

Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
 Volume 00, Number 00 THA Mode of Fixation in Older Patients 5

Table 1. Reason for revision: revision diagnosis of primary total conventional hip replacement in patients aged $ 75 years by
femoral stem fixation (all diagnoses)
Best 3 cemented femoral stems Best 3 cementless femoral stems
Percent primaries Percent Percent primaries Percent
Revision diagnosis Number revised revisions Number revised revisions
Fracture 162 0.5 53.8 62 1.2 62.6
Infection 51 0.2 16.9 7 0.1 7.1
Loosening/lysis 43 0.1 14.3 21 0.4 21.2
Prosthesis dislocation 32 0.1 10.6 7 0.1 7.1
Implant breakage stem 5 0.0 1.7 1 0.0 1.0
Metal-related pathology 2 0.0 0.7
Implant breakage acetabular 1 0.0 0.3
Incorrect sizing 1 0.0 0.3
Instability 1 0.0 0.3
Leg length discrepancy 1 0.0 0.3
Malposition 1 0.0 0.3
Pain 1 0.0 0.3 1 0.0 1.0
Number of revisions 301 1.0 100.0 99 2.0 100.0
Number of primaries 31,635 5023
Percent primaries revised: this shows the proportional contribution of each revision diagnosis as a percentage of the total number
of primary procedures; this percentage can be used to approximate the risk of being revised for that diagnosis; differing
percentages between groups, with the same distribution of followup, may identify problems of concern; percent revisions: the
number of revisions for each diagnosis is expressed as a percentage of the total number of revisions; his shows the distribution of
reasons for revision within a group but cannot be used as a comparison between groups.

and cementless femoral stems in the AOANJRR. This
approach allowed us to eliminate the potential confounding
effect of a large number of stems with poor performance
and focus primarily on the effect of the mode of femoral
stem fixation on revision rates. Using this methodology, we
found that overall, the CPR was lower among those treated
with one of the three best-performing cemented stems than
those treated with one of the three best-performing
cementless stems for only the first 3 months post-
operatively, after which there was no difference in the
CPR. In patients with a diagnosis of a femoral neck
fracture, the lower CPR was seen in the first month and in
OA, it was seen in the first 3 months, independent of the
patient’s sex.
This study has several limitations. First, the endpoint is
revision and therefore does not include other postoperative

Fig. 3 A graph depicting the CPR of primary THA in patients aged $ 75 years with OA by
femoral stem fixation. Parentheses indicate 95% CIs.

Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
 6 Tanzer et al. Clinical Orthopaedics and Related Research®

Fig. 4 A graph depicting the CPR of primary THA in patients aged $ 75 years by femoral
stem fixation for a primary diagnosis of femoral neck fracture. Parentheses indicate 95% CIs.

problems including radiographically loose prostheses that
have not been revised. This may have its greatest effect in
the cementless group for femoral neck fracture, where frail,
elderly, and sick patients may not be medically well
enough to have revision surgery for a loose cementless
femoral stem. It is not possible to estimate the effect that
this may have had on the overall data. Second, the data are
not controlled for patient, surgeon, and hospital factors that
are known to affect revision rates after THA [11, 21, 25].
However, registry data are reflective of the general health
care of the country because it includes population-level
data from a large number of patients, from surgeons with all
levels of experience, and with practically no exclusions.
Third, the AOANJRR reports loosening and fracture rates
for THA, which includes the femoral and the acetabular
components. However, in this study, we were able to ex-
clude all revisions related solely to the acetabulum. Ideally,
the cementless and cemented femoral stems would be
matched with the same cementless cup. This was not done
in this study so that the number of patients would not be
severely limited. By eliminating all revisions related di-
rectly to the acetabular component, this limitation has been
minimized. Finally, these registry data provide a national
overview of the risk of revision by mode of fixation in
patients 75 years or older, but it may not be a valid measure
of revision rates that can be obtained in expert single
centers.
Recently, Troelsen et al. [24] analyzed the annual
reports of hip arthroplasty registries and have questioned
the paradox of the increasing use of cementless femoral
components in older patients in light of their inferior reg-
istry results compared with cemented components. In all
four of the registries that provided age-stratified risk esti-
mates of revision when comparing THA with different
fixation techniques (Australia, Denmark, England-Wales,
and New Zealand), cemented fixation resulted in statisti-
cally significantly lower revision rates than uncemented
fixation in the oldest age groups (> 75 years; except

Fig. 5 A-B Graphs depicting the cumulative incidence revision diagnosis of primary THA in
patients 75 years or older by femoral stem fixation with a diagnosis of OA are shown for the
best three (A) cemented and (B) cementless stems.

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 Volume 00, Number 00 THA Mode of Fixation in Older Patients 7

Table 2. Reason for revision: revision diagnosis of primary total conventional hip replacement in patients aged $ 75 years by
femoral stem fixation (primary diagnosis osteoarthritis)
Best 3 cemented femoral stems Best 3 cementless femoral stems
Percent primaries Percent Percent primaries Percent
Revision diagnosis Number revised revisions Number revised revisions
Fracture 127 0.5 52.7 56 1.2 65.9
Infection 44 0.2 18.3 6 0.1 7.1
Loosening/lysis 34 0.1 14.1 18 0.4 21.2
Prosthesis dislocation 26 0.1 10.8 3 0.1 3.5
Implant breakage stem 5 0.0 2.1 1 0.0 1.2
Metal-related pathology 2 0.0 0.8
Implant breakage acetabular 1 0.0 0.4
Incorrect sizing 1 0.0 0.4
Pain 1 0.0 0.4 1 0.0 1.2
Number of revisions 241 0.9 100.0 85 1.9 100.0
Number of primaries 26,626 4523
Percent primaries revised: this shows the proportional contribution of each revision diagnosis as a percentage of the total number
of primary procedures; this percentage can be used to approximate the risk of being revised for that diagnosis; differing
percentages between groups, with the same distribution of followup, may identify problems of concern; percent revisions: the
number of revisions for each diagnosis is expressed as a percentage of the total number of revisions; this shows the distribution of
reasons for revision within a group but cannot be used as a comparison between groups.

England-Wales, > 65 years). However, raw data from the
registries cannot be assessed, thereby preventing supple-
mental analysis, to clarify any confounders that may
have led to their findings. In particular, the registries do
not follow specific implant designs to observe their
performance individually. By comparing the three best-
performing cementless stems with the three best-
performing cemented stems, we eliminated the potential
influence of implant design. In this study, cemented stems
had a lower risk of revision than cementless stems only in
the first 3 months postoperatively and then demonstrated
no difference in the CPR up to 13 years after the primary
THA. These early revisions were mainly attributable to the
risk of having revision for fracture or loosening being at
least double that in the cementless group compared with the
cemented group. Therefore, by selecting cementless and
cemented implants with similar 10-year survivorship, this
AOANJRR study contradicts the previous registry analysis
by Troelsen and demonstrates that after an early increased
failure rate of cementless implants, the long-term

Table 3. Reason for revision: revision diagnosis of primary total conventional hip replacement in patients aged $ 75 years by
femoral stem fixation (primary diagnosis femoral neck fracture)
Best 3 cemented femoral stems Best 3 cementless femoral stems
Percent primaries Percent Percent primaries Percent
Revision diagnosis Number revised revisions Number revised revisions
Fracture 27 0.9 65.9 4 1.4 36.4
Loosening/lysis 6 0.2 14.6 3 1.1 27.3
Infection 4 0.1 9.8
Prosthesis dislocation 3 0.1 7.3 4 1.4 36.4
Instability 1 0.0 2.4
Number of revisions 41 1.3 100.0 11 3.9 100.0
Number of primaries 3057 280
Percent primaries revised: this shows the proportional contribution of each revision diagnosis as a percentage of the total number
of primary procedures; this percentage can be used to approximate the risk of being revised for that diagnosis; differing
percentages between groups, with the same distribution of followup, may identify problems of concern; percent revisions: the
number of revisions for each diagnosis is expressed as a percentage of the total number of revisions; this shows the distribution of
reasons for revision within a group but cannot be used as a comparison between groups.

Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
 8 Tanzer et al.
Fig. 6 A graph depicting the CPR of primary THA in patients aged $ 75 years by femoral
stem fixation and sex for all diagnoses. Parentheses indicate 95% CIs.
cumulative revision rate of cementless stems is no different
than that of cemented stems in patients older than 75 years
of age.
In femoral neck fractures, the CPR was consistently
higher at 1 month postoperatively among those treated with
one of the three best-performing cementless stems than
those treated with one of the three best-performing
cementless stems. The early failures in the cementless
group were mainly a result of the increase in the revision
rate for fracture, loosening, and dislocation compared with
the cemented group. This is not unexpected because hip
fractures are osteoporotic fractures and older age is a sur-
rogate for proximal femoral bone quality and morphologic
features. Osteoporotic bones are very brittle and much
more susceptible to intraoperative fracture than normal
bone, although biomechanical studies have shown a pro-
tective effect of cement in terms of load to failure in oste-
oporotic bones [16, 23]. Proximally coated cementless
stems place increased stresses on the proximal femur and
increase the risk of fracture. Therefore, it is not surprising
that in the older patients investigated in our study, the
fracture rate resulting in early revision in the cementless
group was at least double that seen in the cemented group
for femoral neck fracture. However, the absence of a dif-
ference in the two groups in this study undergoing THA for
all diagnoses after 3 months suggests that there can be
a role for cementless implants in selected cases, depending
on the surgeon’s expertise and the quality and shape of the
proximal femoral bone. Nonetheless, in patients with se-
vere proximal femoral osteoporosis, the surgeon who is
unfamiliar with the nuances of a particular cementless stem
probably is better off using cemented fixation to achieve
stem stability and to reduce the risk of fracture and
loosening.
This study demonstrated that sex did influence the CPR
of cementless stems. Specifically, males with a THA had
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics and Related Research®
a lower CPR than females at all time periods. This corre-
lates with the anatomic changes that occur in each sex with
age. The shape and bone mass of the osteoporotic proximal
femur is different than that of the nonosteoporotic femur
and these changes are age- and sex-specific [22]. In males,
there are substantial changes in the femoral neck, but there
is no change in shaft cortical thickness or medullary width
with age [19, 20]. In females, there is no change in the
metaphyseal width, but there is thinning of the diaphyseal
cortices and expansion of the canal resulting in a decrease
in the canal flare index [8]. A Dorr Type C stovepipe femur
is consistent with severe osteoporosis, and this shape
makes it more difficult to obtain cementless stem fixation.
A radiostereometric analysis study that evaluated patients
with severe osteoporosis undergoing cementless hip re-
placement found that the cementless stems had a higher
subsidence of the stem during the first 3 months after sur-
gery [2]. Aro et al. [2] concluded that a low bone mineral
density, changes in intraosseous dimensions of the proxi-
mal femur, and aging adversely affected initial stability and
delayed osseointegration of cementless stems in females.
Like their study, the registry data in our study indicate that
during the early postoperative period, there is a high rate of
loosening with cementless stems in patients 75 years or
older. We found the revision rate for loosening in the
cementless group was four times that of the cemented
group during the first 3 months postoperatively in patients
with all diagnoses and during the first month in patients
with a femoral neck fracture, respectively.
Although the majority of femoral stems used in some
parts of the world are cementless and their use throughout
the world continues to increase [9, 24], it is apparent from
this study that surgeons performing arthroplasties need to
be able to cement a femoral stem to achieve the highest
possible survivorship in patients 75 years or older [4, 18].
The results of cemented femoral stems are technique-
 Volume 00, Number 00 THA Mode of Fixation in Older Patients 9

Fig. 7 A graph depicting the CPR of primary THA in patients aged $ 75 years by femoral
stem fixation and sex for OA. Parentheses indicate 95% CIs.

dependent and a constellation of surgical techniques can
help surgeons consistently provide a high-quality cement
mantle around a femoral stem [7]. We believe that as the
use of cementless femoral implants has increased, it has
resulted in decreased training of residents or registrars in
proper cementing techniques. Based on this review of
registry data and our knowledge of the morphologic fea-
tures and biomechanical properties of older bone, it would
seem important to ensure the proper training of contem-
porary cementing techniques for the next generation of
arthroplasty surgeons so they are able to use this option
when required. Cementless femoral stem fixation in older
patients has a higher earlier rate of revision when only the
best-performing prostheses in this age group are compared.
Implant choice alone is not responsible for these findings
and clearly indicates that the mode of fixation has a sub-
stantial effect on the rate of revision in this age group.
However, the absence of a difference in the two groups
undergoing THA after 3 months suggests that there can be
a role for cementless implants in selected cases, depending
on the surgeon’s expertise and the quality and shape of the
proximal femoral bone.
References
1. Anand R, Graves SE, de Steiger RN, Davidson DC, Ryan P, Miller
LN, Cashman K. What is the benefit of introducing new hip and
knee prostheses? J Bone Joint Surg Am. 2011;93(Suppl 3):51–54.
2. Aro HT, Alm JJ, Moritz N, Makinen TJ, Lankinen P. Low BMD
affects initial stability and delays stem osseointegration in
cementless total hip arthroplasty in women: a 2-year RSA study
of 39 patients. Acta Orthop. 2012;83:107–114.
3. Australian Orthopaedic Association National Joint Replacement
Registry. Hip, Knee & Shoulder Arthroplasty Annual Report
2016. Available at: https://aoanjrr.sahmri.com/en/annual-
reports-2016. Accessed February 12, 2018.

Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
 10 Tanzer et al.
4. Ballard TW, Callaghan JJ, Sullivan PM, Johnston RC. The
results of improved cementing techniques for total hip arthro-
plasty in patients less than fifty years old. A ten-year follow-up
study. J Bone Joint Surg Am. 1994;76:959–964.
5. Corbett KL, Losina E, Nti AA, Prokopetz JJ, Katz JN.
Population-based rates of revision of primary total hip arthro-
plasty: a systematic review. PloS One. 2010;5:e13520.
6. Hailer NP, Garellick G, Karrholm J. Uncemented and cemented
primary total hip arthroplasty in the Swedish Hip Arthroplasty
Register. Acta Orthop. 2010;81:34–41.
7. Harris WH. Hybrid total hip replacement: rationale and in-
termediate clinical results. Review. Clin Orthop Relat Res. 1996;
333:155–164.
8. Hartman CW, Gilbert BJ, Paprosky WG. Gender issues in total
hip arthroplasty: length, offset, and osteoporosis. Semin Arthro-
plasty. 2009;20:62–65.
9. Huo MH, Dumont GD, Knight JR, Mont MA. What’s new in total
hip arthroplasty. J Bone Joint Surg Am. 2011;93:1944–1950.
10. Jones LC, Hungerford DS. Cement disease. Clin Orthop Relat
Res. 1987;225:192–206.
11. Losina E, Barrett J, Mahomed NN, Baron JA, Katz JN. Early
failures of total hip replacement: effect of surgeon volume.
Arthritis Rheum. 2004;50:1338–1343.
12. Malcolm AJ. Pathology of cemented low-friction arthroplasties
in autopsy specimens. In: J Older, ed. Implant Bone Interface.
New York, NY, USA: Springer; 1990:77–82.
13. Maloney WJ, Harris WH. Comparison of a hybrid with an
uncemented total hip replacement. A retrospective matched-pair
study. J Bone Joint Surg Am. 1990;72:1349–1352.
14. Maloney WJ, Jasty M, Burke DW, O’Connor DO, Zalenski EB,
Bragdon C, Harris WH. Biomechanical and histologic in-
vestigation of cemented total hip arthroplasties. A study of
autopsy-retrieved femurs after in vivo cycling. Clin Orthop Relat
Res. 1989:249:129–140.
15. McMinn DJ, Snell KI, Daniel J, Treacy RB, Pynsent PB, Riley
RD. Mortality and implant revision rates of hip arthroplasty in
patients with osteoarthritis: registry based cohort study.
BMJ.2012; 344:e3319.
Copyright Ó 2018 by the Association of Bone and Joint Surgeons. Unauthorized reproduction of this article is prohibited.
Clinical Orthopaedics and Related Research®
16. Mears SC. Management of severe osteoporosis in primary total
hip arthroplasty. Current Translational Geriatrics and Experi-
mental Gerontology Reports. 2013;2:99–104.
17. Morshed S, Bozic KJ, Ries MD, Malchau H, Colford JM Jr.
Comparison of cemented and uncemented fixation in total hip
replacement: a meta-analysis. Acta Orthop. 2007;78:315–326.
18. Mulroy RD Jr, Harris WH. The effect of improved cementing
techniques on component loosening in total hip replacement. An
11-year radiographic review. J Bone Joint Surg Br. 1990;72:
757–760.
19. Noble PC, Box GG, Kamaric E, Fink MJ, Alexander JW, Tullos
HS. The effect of aging on the shape of the proximal femur. Clin
Orthop Relat Res. 1995;316:31–44.
20. Peacock M, Liu G, Carey M, Ambrosius W, Turner CH, Hui S,
Johnston CC Jr. Bone mass and structure at the hip in men and
women over the age of 60 years. Osteoporos Int. 1998;8:
231–239.
21. Schurman DJ, Bloch DA, Segal MR, Tanner CM. Conventional
cemented total hip arthroplasty. Assessment of clinical factors
associated with revision for mechanical failure. Clin Orthop
Relat Res. 1989;240:173–180.
22. Stas VA, Templeton JE, Paprosky WG. Implications of female
sex/osteoporosis on femoral implant selection and restoration of
biomechanics of the hip. In: AH Glassman, PF Lachiewicz, M
Tanzer, eds. Orthopaedic Knowledge Update 4. Hip and Knee
Reconstruction. 4th ed. Rosemont, IL, USA: AAOS; 2011:
219–232.
23. Thomsen MN, Jakubowitz E, Seeger JB, Lee C, Kretzer JP,
Clarius M. Fracture load for periprosthetic femoral fractures in
cemented versus uncemented hip stems: an experimental in vitro
study. Orthopedics. 2008;31:653.
24. Troelsen A, Malchau E, Sillesen N, Malchau H. A review of
current fixation use and registry outcomes in total hip arthro-
plasty: the uncemented paradox. Clin Orthop Relat Res. 2013;
471:2052–2059.
25. Young NL, Cheah D, Waddell JP, Wright JG. Patient charac-
teristics that affect the outcome of total hip arthroplasty: a review.
Can J Surg. 1998;41:188–195.