What are the advantages and disadvantages of cemented versus uncemented (bone cement) total hip replacement (THR) procedures?

Cemented vs Uncemented Total Hip Replacement: Clinical Outcomes

Primary Recommendation for Hip Fracture Patients

For patients undergoing arthroplasty for femoral neck fractures, cemented femoral stems are strongly recommended based on superior outcomes and reduced complications. 1

Context-Specific Recommendations

Hip Fracture Setting (Strongest Evidence)

• Cemented femoral stems carry a strong AAOS recommendation for all hip fracture arthroplasty procedures, representing the highest level of guideline support 1
• This recommendation applies to both hemiarthroplasty and total hip arthroplasty performed for acute femoral neck fractures 1
• Long-term data through 10 years demonstrates cemented stems have significantly fewer complications in elderly fracture patients, with only 3 total complications versus 8 in the uncemented group 2
• The uncemented group experienced multiple periprosthetic fractures and dislocations requiring revision surgery in the first 4 years, while the cemented group had superior Harris Hip Scores (92-93 vs 81) 2

Elective Osteoarthritis Setting (More Nuanced)

For elective total hip replacement in osteoarthritis patients, both cemented and uncemented techniques demonstrate excellent 10-year survival rates >95%, though each carries distinct trade-offs:

Cemented THR Advantages:

• Lower revision rates (0.015 lower absolute probability at 8 years) 3
• Immediate weight-bearing capability with strong initial fixation 3
• Particularly beneficial in older patients with poor bone quality 1

Cemented THR Disadvantages:

• Small but significant increased early mortality risk (1.3-fold increased hazard in first 14 days, corresponding to 5 additional deaths per 10,000 procedures) 4
• Risk of bone cement implantation syndrome (BCIS) occurring in approximately 20% of cases, with severe cardiovascular events in ~1% 1, 5
• Higher risk in patients with: increasing age, male sex, significant cardiopulmonary disease, and diuretic use 1, 5

Uncemented THR Advantages:

• No early mortality spike in the first 14 days post-operatively 4
• Avoids BCIS risk entirely 4
• Lower infection revision rates (0.5% vs 0.7% for cemented) 6

Uncemented THR Disadvantages:

• Higher overall revision rates (hazard ratio 1.14) 3
• Higher revision rates for pain (0.7% vs 0.5% for cemented) 6
• Requires adequate bone quality for osseointegration 2
• Substantially higher early complication rates in elderly fracture patients 2

Critical Safety Considerations for Cemented Procedures

Bone Cement Implantation Syndrome (BCIS) Management

BCIS represents the primary acute risk of cemented arthroplasty, requiring specific preventive and management protocols:

Prevention Strategies:

• Ensure adequate hydration before and during anesthesia 1, 5
• Use pressurized lavage system to thoroughly clean femoral canal of fat and marrow 1, 5
• Insert cement retrograde with distal suction catheter on intramedullary plug 1, 5
• Avoid excessive manual pressurization in high-risk patients (elderly, male, cardiopulmonary disease, diuretic users) 1, 5
• Maintain systolic blood pressure within 20% of pre-induction values using vasopressors/fluids 1, 5

Immediate Management Protocol:

• Have vasopressors (metaraminol/adrenaline) drawn and ready before cement application 1, 5
• Invasive blood pressure monitoring for high-risk patients 1, 5
• Monitor for sudden drops in end-tidal CO2 indicating right heart failure 5
• Increase FiO2 to maintain oxygenation 5
• Establish clear surgeon-anesthetist communication before cement insertion 1, 5

BCIS Severity Grading:

• Grade 1 (~20% incidence): SpO2 <94% or >20% fall in systolic BP 5
• Grade 2 (~3% incidence): SpO2 <88% or >40% fall in systolic BP or loss of consciousness 5
• Grade 3 (~1% incidence): Cardiovascular collapse requiring CPR 5

Common Pitfalls to Avoid

• Using uncemented stems in elderly hip fracture patients: This increases periprosthetic fracture and dislocation risk substantially 2
• Failing to anticipate BCIS: Always prepare vasopressors before cement application, even in low-risk patients 1, 5
• Inadequate femoral canal preparation: Poor cleaning increases embolic load and BCIS severity 1, 5
• Ignoring the mortality reversal: While cemented THR has early mortality risk, this reverses by day 15 with subsequent survival benefit 4
• Applying elective THR data to fracture patients: The fracture population has distinctly different outcomes favoring cemented fixation 1, 2

Age-Related Considerations

Age does not significantly modify the relative performance between cemented and uncemented techniques in elective settings (p=0.24 for revision, p=0.30 for reoperation, p=0.58 for mortality interactions) 6, though absolute complication rates increase with age regardless of fixation method 1

Oncologic Population Exception

In oncologic patients undergoing hip arthroplasty for pathologic fractures, both cemented and uncemented techniques show equivalent outcomes with no significant differences in complications, mortality, blood loss, or functional scores 7. This represents the one population where surgeon discretion between techniques is truly equipoise 7.