Comparative Study of Cemented versus Uncemented Total Hip Arthroplasty in Terms of Functional Outcome and Complications.

Total hip arthroplasty (THA) is one of the most successful orthopedic procedures for relieving pain, restoring mobility, and improving the quality of life in patients with end-stage hip disorders. Since its introduction, THA has undergone remarkable advancements in implant design, bearing surfaces, fixation techniques, and surgical approaches, resulting in improved implant longevity and patient satisfaction. The common indications for THA include primary osteoarthritis, avascular necrosis of the femoral head, rheumatoid arthritis, fracture neck of femur, post-traumatic arthritis, developmental dysplasia of the hip, and inflammatory joint diseases. With increasing life expectancy and growing demand for mobility among elderly as well as younger active individuals, the number of THA procedures performed worldwide has increased substantially.[1]

One of the most important decisions during THA is the choice between cemented and uncemented fixation of the prosthetic components. Cemented total hip arthroplasty utilizes polymethylmethacrylate (PMMA) bone cement to secure the femoral and acetabular components, providing immediate implant stability and allowing early weight bearing. Cemented implants have traditionally demonstrated excellent long-term survival, particularly among elderly patients with poor bone quality or osteoporosis. However, concerns regarding cement implantation syndrome, longer operative time, and difficulty during revision surgery have prompted the development and widespread adoption of uncemented implants.[2]

Uncemented total hip arthroplasty relies on biological fixation through osseointegration between the implant surface and host bone. Modern porous-coated and hydroxyapatite-coated implants encourage bone ingrowth, resulting in durable fixation without the use of cement. These implants are generally preferred in younger patients with good bone stock because of their potential for long-term biological stability and easier revision. Nevertheless, uncemented fixation may be associated with complications such as intraoperative femoral fractures, postoperative thigh pain, delayed weight bearing in selected patients, and early implant migration if adequate primary stability is not achieved.[3]

Several randomized controlled trials, observational studies, and joint registry analyses have compared cemented and uncemented THA regarding functional outcomes, implant survival, complication rates, and revision surgery. Although both fixation methods have demonstrated excellent clinical results, evidence suggests that patient age, bone quality, activity level, surgeon experience, and implant selection significantly influence postoperative outcomes. Functional assessment using validated scoring systems such as the Harris Hip Score (HHS), Oxford Hip Score, and WOMAC score has become the standard for evaluating postoperative recovery. Similarly, monitoring complications including periprosthetic fracture, aseptic loosening, prosthetic joint infection, dislocation, thromboembolic events, and revision surgery is essential for determining the long-term success of THA.[4]

Despite numerous published studies, the optimal fixation method remains a subject of ongoing debate, particularly in developing countries where patient demographics, bone quality, implant availability, and economic considerations may differ from Western populations. Therefore, comparative evaluation of cemented and uncemented THA in the local population is necessary to generate evidence that may assist surgeons in selecting the most appropriate fixation technique. The present study was undertaken to compare cemented and uncemented total hip arthroplasty with respect to functional outcomes and postoperative complications, thereby contributing to evidence-based clinical decision-making and improving patient care.[5]

AIM

To compare the functional outcomes and postoperative complications between cemented and uncemented total hip arthroplasty.

OBJECTIVES

1)      To compare the functional outcome of cemented and uncemented total hip arthroplasty using the Harris Hip Score.

2)      To compare the incidence of postoperative complications between cemented and uncemented total hip arthroplasty.

3)      To evaluate radiological outcomes and implant stability following cemented and uncemented total hip arthroplasty.

•                     Repeated measurements of functional scores, where applicable, were analyzed using repeated-measures ANOVA.

•                     Relative risk or odds ratio with 95% confidence intervals were calculated where appropriate.

•                     A p-value <0.05 was considered statistically significant.

Data Collection

Data were collected using a structured case record form designed specifically for the study. The following information was recorded:

•                     Demographic details (age, sex, BMI)

•                     Diagnosis and indication for THA

•                     Side of surgery

•                     Associated comorbidities

•                     Preoperative clinical findings

•                     Radiological findings

•                     Type of prosthesis (cemented or uncemented)

•                     Operative duration

•                     Intraoperative blood loss

•                     Length of hospital stay

•                     Time to mobilization

•                     Harris Hip Score (preoperative and postoperative follow-up)

•                     Radiological assessment of implant stability

•                     Early and late postoperative complications

•                     Requirement for revision surgery

•                     Final clinical and functional outcome.

while revision surgery was required in 4.3% and 2.9% of patients, respectively (p=1.000). Overall postoperative complications were observed in 31.4% of the cemented group and 24.3% of the uncemented group, with no statistically significant difference between the two groups (χ²=0.89, p=0.346).

Table 4: Radiological outcomes and implant stability following cemented and uncemented THA

*Statistically significant at p<0.05.

Table 4 compares the radiological outcomes and implant stability between cemented and uncemented THA. The mean cup inclination angle was comparable between the cemented and uncemented groups (42.7±5.4° vs. 41.9±4.9°; p=0.360). Neutral cup positioning was achieved in 81.4% of cemented THA patients and 87.1% of uncemented THA patients, with no significant difference (p=0.353). The mean stem alignment deviation was similar in both groups (1.8±1.2° vs. 1.5±1.1°; p=0.125). Radiolucent lines were observed in 11.4% of cemented THA patients and 5.7% of uncemented THA patients (p=0.366). Stem subsidence greater than 2 mm occurred more frequently in the uncemented group (12.9%) than in the cemented group (5.7%), although this difference was not statistically significant (p=0.243). The mean postoperative limb length discrepancy was comparable between the groups (6.3±3.1 mm vs. 5.7±2.8 mm; p=0.232). Stable implant fixation at follow-up was achieved in 90.0% of patients undergoing cemented THA and 87.1% of those undergoing uncemented THA, with no statistically significant difference (p=0.592). Evidence of successful osseointegration was observed in 90.0% of patients with uncemented implants, while this parameter was not applicable to the cemented fixation group.

Regarding complications, the present study showed no statistically significant difference in overall postoperative complications between cemented and uncemented THA. Superficial wound infection, deep infection, dislocation, DVT, limb length discrepancy, aseptic loosening, and revision surgery were comparable between groups. Periprosthetic fracture was numerically higher in the uncemented group, although not statistically significant. Similar findings were reported by Roitzsch et al. (2025)[7], who observed that fixation method influenced revision risk, particularly in fracture-related THA. Moore et al. (2024)[3] reported higher infection, aseptic loosening, and revision rates in cemented fixation in a large database study, while other registry-based studies have suggested that cemented fixation may reduce early periprosthetic fracture risk in elderly patients. Thus, complication patterns appear to depend on patient selection, age, bone quality, surgical technique, and implant design. The present finding of comparable overall complications supports the view that both cemented and uncemented THA are safe when used in appropriately selected patients.

Radiological outcomes in the present study were also comparable between the two groups. Cup inclination angle, neutral cup position, stem alignment deviation, radiolucent lines, stem subsidence, limb length discrepancy, and implant stability did not show statistically significant differences. Stable implant fixation was observed in 90.0% of cemented and 87.1% of uncemented THA cases. Evidence of osseointegration was present in 90.0% of uncemented implants. These findings are consistent with Abushal et al. (2025)[8] and Siddiqi et al. (2025)[9], who emphasized that cementless fixation depends on initial mechanical stability followed by biological osseointegration. Lim et al. (2025)[10] also noted that stem subsidence after cementless THA may be influenced by bone mineral density, femoral morphology, and canal fill ratio. In the present study, although stem subsidence was numerically higher in the uncemented group, the difference was not statistically significant, suggesting acceptable early implant stability.

provided excellent clinical and functional outcomes with acceptable complication rates. Patients undergoing uncemented THA showed significantly better early postoperative functional recovery, as evidenced by higher Harris Hip Scores at 6 weeks, 3 months, and 6 months, greater overall improvement in functional score, earlier achievement of independent ambulation, and lower postoperative pain scores. Conversely, cemented THA was more frequently performed in older patients and was associated with significantly longer operative time and hospital stay. Despite these differences, the incidence of postoperative complications, including infection, dislocation, deep vein thrombosis, aseptic loosening, revision surgery, and overall complication rate, was comparable between the two groups. Radiological assessment also demonstrated similar implant positioning, alignment, and stability, while satisfactory osseointegration was achieved in the majority of uncemented implants. Therefore, both fixation techniques are safe and effective options for primary total hip arthroplasty. The choice between cemented and uncemented fixation should be individualized according to patient age, bone quality, functional demand, implant characteristics, and surgeon expertise rather than relying on a single fixation strategy for all patients.

LIMITATIONS OF THE STUDY

1)      The sample size of 140 patients, although adequate for comparison, may not detect differences in rare complications.

2)       The follow-up duration was relatively short and did not permit assessment of long-term implant survival or late aseptic loosening.

3)       Implant selection and fixation method were influenced by surgeon preference and patient characteristics, introducing potential selection bias.

4)       Multiple implant designs and manufacturers were not analyzed separately, which may have influenced functional and radiological outcomes.

5)       Functional assessment was primarily based on the Harris Hip Score without inclusion of other patient-reported outcome measures.

6)      Bone mineral density and objective assessment of bone quality were not evaluated for all patients.

7)      The study did not include cost-effectiveness analysis or quality-of-life assessment.

8)      Long-term revision rates and implant survivorship could not be determined.

9)      Multicentre randomized studies with larger sample sizes and longer follow-up are required to validate these findings.

5.       Ahmed W, et al. Evaluation of functional outcome between cemented and cementless total hip replacement. Cureus. 2025.

6.       Marahatta SB, RC DR, KC KM, Sigdel A. Functional outcome of primary total hip arthroplasty using Harris Hip Score in arthritic hip. Europasian J Med Sci. 2020;2(2):4-10.

7.       Roitzsch C, et al. Cemented versus cementless cup fixation in total hip arthroplasty after femoral neck fracture. Arthroplasty. 2025.

8.       Abushal MH, et al. Cemented versus uncemented femoral fixation in total hip arthroplasty. World J Orthop. 2025.

9.       Siddiqi A, et al. Cementless femoral stems in primary total hip arthroplasty. J Orthop Exp Innov. 2025.

10.    Lim JY, et al. Factors affecting early implant subsidence after cementless total hip arthroplasty. Hip Pelvis. 2025;37:289-296.

11.    Evans JT, Evans JP, Walker RW, Blom AW, Whitehouse MR, Sayers A. How long does a hip replacement last? A systematic review and meta-analysis. Lancet. 2019;393(10172):647-654.

12.    Karachalios T, Komnos G, Koutalos A. Total hip arthroplasty: survival and outcomes. EFORT Open Rev. 2018;3(5):232-239.

13.    Darrith B, Courtney PM, Della Valle CJ. Outcomes of cemented versus cementless fixation in primary total hip arthroplasty. J Am Acad Orthop Surg. 2018;26(20):e430-e438.