For years, a rigid dogma has permeated the orthopedic community: when performing a primary total hip arthroplasty (THA) on an elderly patient, especially a female patient with suspect bone quality, the femoral stem must be cemented. This belief is heavily bolstered by massive national joint registries, which frequently report that cementless fixation in the elderly is associated with higher rates of early periprosthetic fracture and costly revisions for aseptic loosening. Consequently, many surgeons instinctively reach for bone cement or, more recently, cementless stems featuring a prominent collar, believing these features are the only way to prevent catastrophic subsidence in aging bone.
However, the tide may be turning. Cementless fixation avoids the rare but devastating complications of bone cement implantation syndrome, which can trigger severe pulmonary and cardiovascular collapse. Furthermore, high-volume institutional data is beginning to aggressively challenge the registry-driven narrative, suggesting that the problem may not be the cementless stem itself, but rather how it is implanted.
