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

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 (I 2 = 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.