Mackenzie Kelly, Ryland P. Kagan, Isabella Zaniletti, Vishal Hegde, Ayushmita De, Adam A. Sassoon, Majd Marrache, Harpal S. Khanuja
5 min
As the number of total hip arthroplasties (THA) continues to rise, surgeons and researchers are evaluating the optimal femoral stem design and fixation method to minimize revision risks. While cemented fixation has historically been favored for its lower risk of periprosthetic femoral fracture, recent advancements in cementless technology—specifically collared metadiaphyseal-filling designs—have prompted a re-evaluation of which approach provides the best long-term outcomes for patients aged 65 and older.
Researchers conducted a retrospective analysis using data from the American Joint Replacement Registry (AJRR) linked with Centers for Medicare and Medicaid Services (CMS) claims. The study included 79,022 primary THA procedures performed between 2012 and 2021. The cohort was divided into two groups: 61,854 patients who received cementless collared metadiaphyseal-filling stems and 17,168 patients who received cemented femoral stems. To account for differences in patient demographics and comorbidities, the researchers used inverse-probability-of-treatment-weighting (IPTW) and Cox proportional hazard models to compare the risks of all-cause revision, periprosthetic femoral fracture, aseptic loosening, dislocation, and infection.
The study found that cementless collared metadiaphyseal-filling stems were associated with a lower risk of all-cause revision (HR 0.46) compared to cemented stems. Furthermore, these cementless stems showed a decreased risk of revision for aseptic loosening, dislocation, and infection. Notably, there was no statistically significant difference in the risk of periprosthetic femoral fracture between the two groups, challenging the conventional view that cemented stems are superior in preventing this specific complication.
These findings suggest that for patients aged 65 and older, the specific geometry of cementless collared metadiaphyseal-filling stems may offer a superior safety profile compared to cemented fixation. By providing the benefits of cementless fixation without an increased risk of periprosthetic fracture, this design may represent an optimal choice for this patient population. The results encourage further investigation into whether these cementless designs should be preferred to reduce the overall burden of revision surgery.
Sam: Exactly. The implant is locked into the bone's architecture by mechanical fit rather than by an adhesive medium. And that matters clinically because it removes the acute risks associated with cement delivery in older patients, particularly those with cardiovascular compromise. [[RP_SECTION:registry-study-limitations|Registry Study Limitations]]
Alex: I want to push back on the methodology, though. This is a registry study—observational by design. Even with inverse-probability-of-treatment weighting to balance age, BMI, and comorbidities, the selection bias problem seems significant. We don't know why a surgeon chose cement for any given case.
Sam: That is the most critical limitation, and the authors acknowledge it. The IPTW adjustment can balance the covariates that were recorded, but it cannot touch the ones that weren't. Bone quality metrics—Dorr classification, canal flare index—aren't captured in the registry. Neither is the surgeon's proficiency with each technique.
Alex: Which means the cemented group may have been selected precisely because those patients had anatomy or bone quality that made cementless fixation seem riskier. If that's the case, the cemented group was already at higher baseline risk before the implant was even chosen.
Sam: [slower, for clarity] That confound is essentially untestable with this dataset. And there's a related issue on the surgical technique side. If a surgeon is less practiced with press-fit stems, their cementless outcomes will be worse than the technique's ceiling. Conversely, if the cemented cases in this cohort tended to be longer, more complex procedures, that alone could explain the higher infection rates—without cement itself being the causal factor.
Alex: So the registry shows us outcomes, but it can't reconstruct the clinical reasoning that drove the implant choice. Strong signal, but the causal story is incomplete. [[RP_SECTION:clinical-implications-and-future|Clinical Implications and Future]]
Sam: That is the right framing. What the study does establish is that stem geometry—the collar and the metadiaphyseal fill—is a stronger determinant of survivorship than the fixation medium alone. That shifts the clinical conversation away from "cement versus cementless" as a binary and toward "which geometry provides the best biomechanical match for this patient's anatomy."
Alex: Which is a more useful question to be asking. And it suggests the next methodological step is integrating radiographic data into these registries—actual bone quality measurements, canal morphology, implant fit—so you can start to disentangle geometry from fixation medium from patient selection.
Sam: Agreed. Until that granularity exists, this is a compelling signal that warrants prospective, ideally randomized work in this age group. The findings are significant enough to take seriously, but they should read as a call for more targeted investigation rather than a practice-changing verdict. Thanks for listening to ResearchPod.