Beyond the cemented–cementless divide: Personalised fixation strategies in revision total hip arthroplasty

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Abstract

Background: As primary Total Hip Arthroplasty (THA) is increasingly performed in younger, more active patients, revision procedures have become more frequent and technically demanding. The choice between cementless and cemented femoral fixation in revision THA remains controversial, with each approach offering distinct biological and mechanical advantages. Objective: To synthesise current biological principles and clinical evidence comparing cemented and cementless femoral fixation in revision THA, with particular attention to complications, fixation strategies, and applicability in Lowand Middle-Income Countries (LMICs). Data source: A narrative review of contemporary orthopaedic literature, including national joint registry data, systematic reviews, and key clinical studies evaluating femoral fixation methods in revision THA. Data selection and extraction: Relevant studies were identified based on clinical relevance to revision THA, fixation method, patient age, bone quality, infection status, and reported outcomes. Data were qualitatively synthesised with emphasis on survivorship, complications, and functional outcomes. Results: Cementless stems provide biological durability through osseointegration, while cemented stems offer immediate mechanical stability and are particularly advantageous in osteoporotic bone or in infected cases when antibiotic-loaded cement is utilised. Registry data demonstrate a clear age-related shift, with cementless fixation predominating in patients younger than 75 years and cemented fixation remaining preferred in older patients. Long-term methods: survivorship is comparable between fixation methods; however, cementless stems are associated with higher risks of periprosthetic fracture and early subsidence. Functional outcomes are equivalent in most cohorts. Challenges specific to LMICs, including implant availability, cost constraints, and variable bone quality, influence fixation strategy selection. Conclusions: No single fixation strategy is universally superior in revision THA. Patient-specific selection guided by age, bone stock, and infection status remains paramount. Emerging advances in biologics, nanotechnology, additive manufacturing, and artificial intelligence hold promise for further refinement of fixation strategies and outcomes in revision hip arthroplasty.