Cemented vs uncemented hip hemiarthroplasty in medial femoral neck fractures in the elderly: the Association of Orthopaedic Traumatology of Italian Hospitals (OTODI) Multicenter Study| Lo Scalpello - Journal

Abstract

Background. The choice between cemented and uncemented hip hemiarthroplasty for medial femoral neck fractures in the elderly remains debated. While international guidelines often recommend cementation, modern uncemented designs offer potential advantages in operative efficiency.

Methods. This OTODI (Orthopaedic Traumatology of Italian Hospitals)-coordinated, prospective multicenter study analyzed 1,417 patients over 75 years of age across 150 Italian centers. Clinical trends, operative parameters, and mid-term outcomes (up to 12 months) were compared between cemented and uncemented fixation.

Results. Uncemented fixation was predominant (65.6%). The uncemented group showed significantly shorter mean operative times (62.0 vs. 72.8 minutes; p < 0.0001) and better initial functional scores (Barthel Index; p = 0.046). No significant differences were found in intraoperative complications, 12-month mortality, or long-term functional recovery.

Conclusions. In Italian clinical practice, modern uncemented hip hemiarthroplasty are frequently utilized and provide comparable safety and efficacy to cemented stems. These findings support the use of modern uncemented designs as a reliable alternative that reduces operative time without compromising mid-term outcomes.

Introduction

The management of medial femoral neck fractures in the elderly population is a critical challenge for modern healthcare systems, driven by an aging global population and the high prevalence of age-related comorbidities. These fractures are frequently the result of low-energy trauma, such as falls in domestic settings, and carry significant implications for patient mobility, independence, and mortality. For many patients over the age of 75, the surgical standard of care involves hip hemiarthroplasty to restore function and allow for rapid mobilization.

A central debate in orthopedic surgery concerns the method used to secure the femoral stem: using bone cement (cemented fixation) or relying on modern biological integration designs (uncemented fixation). Historically, international guidelines and data from Northern European registries have favored cemented prostheses, citing superior primary stability and a lower risk of early implant loosening ^1-3. However, the process of cementation is not without risks; it is associated with longer operative times and the potential for “bone cement implantation syndrome,” a rare but serious intraoperative complication particularly dangerous for patients with pre-existing cardiovascular conditions ^4,5.

Conversely, advancements in prosthetic technology – including the use of titanium, hydroxyapatite coatings, and porous surfaces – have made uncemented stems increasingly attractive ⁶. These modern designs offer simplified intraoperative handling and shorter surgical durations, which may reduce the overall physiological stress on fragile patients. Despite these advancements, there remains a lack of recent, large-scale prospective data reflecting current clinical trends within the Italian orthopedic landscape.

This study, coordinated by OTODI (Orthopaedic Traumatology of Italian Hospitals), was designed to address this gap. By analyzing a large multicenter cohort, we sought to define the current prevalence of cemented and uncemented techniques in Italy. The primary aim of this study was to compare the clinical outcomes, complications, and short- to mid-term mortality rates between cemented and uncemented hip hemiarthroplasty in patients over the age of 75.

Materials and methods

A prospective, multicenter, observational study was conducted under the coordination of OTODI (Orthopaedic Traumatology of Italian Hospitals). A total of 150 orthopedic centers across Italy were included, uniformly distributed throughout the country and selected according to the criterion of > 150 femoral fractures operated/year (source: Programma Nazionale Esiti 2023, data 2022). The enrollment period spanned from February 1 to April 30, 2025, including 1,500 consecutive patients aged over 75 years with a medial femoral neck fracture due to low-energy trauma. All patients were treated with a hip hemiarthroplasty using a standard femoral stem (straight or anatomical), with or without cementation. Exclusion criteria included pathological fractures, high-energy trauma, polytrauma, pre-fracture non-ambulatory status, and systemic diseases with altered bone metabolism.

Collected data included preoperative variables (age, sex, comorbidities, hematochemical parameters), intraoperative parameters (implant type, operative time, immediate complications), and postoperative outcomes (visual analogue scale (VAS), harris hip score (HHS), Barthel Index, transfusion requirement). Follow-up assessments were performed at 3, 6, 9, and 12 months. Statistical analysis was carried out using R Studio; continuous variables were expressed as mean ± standard deviation, and categorical variables as percentages. Differences between cemented and uncemented groups were analyzed using appropriate significance tests, with p < 0.05 considered statistically significant. Survival analysis was used to compare mortality within 12 months after surgery between the two-fixation group (cemented vs uncemented) using the Kaplan- Meier curve.

Results

A total of 1,417 patients were analyzed, with a mean age of 84.5 ± 6.5 years; females accounted for 69.8% of the sample and males for 30.2%. The fracture occurred in a domestic setting in 91.3% of cases. The most common comorbidities were cardiovascular (61.3%) and neurological (25.8%). Uncemented fixation was predominant (65.6%) compared to cemented (34.4%) (Fig. 1), and 77.2% of patients underwent surgery within 48 hours. The mean operative time was significantly shorter in the uncemented group (62.0 ± 20.9 minutes) compared with the cemented group (72.8 ± 24.9 minutes; p < 0.0001) (Fig. 2). No significant differences were observed in intraoperative complications (1.0% vs. 2.7%; p = 0.061), postoperative complications (12.5% vs. 11.2%; p = 0.522), or transfusion requirements (42.8% vs. 39.4%; p = 0.233). At discharge, pain (VAS) and functional outcome (HHS) were comparable between groups (p = 0.078 and p = 0.232, respectively), while the Barthel Index showed a significant difference favoring the uncemented group (p = 0.046). Longitudinal analysis (F (3,1710) = 190.78; p < 0.001) demonstrated a progressive improvement in functional independence up to 12 months, with no substantial differences between fixation techniques (Fig. 3). Mortality at 3, 6, and 12 months was 6.85%, 12.78%, and 16.10%, respectively, consistent with international data ^7-9. Survival analysis was performed to compare 12-month mortality between the cemented and uncemented fixation groups. Kaplan-Meier curves showed nearly overlapping survival probabilities throughout the follow-up period, with a slight, non-significant advantage for the uncemented group during intermediate phases. At 3 months, survival rates were comparable between cemented and uncemented patients (91.9% vs. 92.9%) and remained high at 6 months (83.2% vs. 86.6%). At 12 months, survival was estimated at 77.1% in the cemented group and 82.1% in the uncemented group. The log-rank test revealed no statistically significant difference between survival curves (χ² = 3.39; df = 1; p = 0.065).

Discussion

The findings of this large, prospective multicenter study confirm that, in elderly patients with medial femoral neck fractures treated with hip hemiarthroplasty, the choice between cemented and uncemented fixation results in comparable short- and mid-term clinical outcomes. This aligns with recent international evidence showing that both techniques provide similar mortality and functional results in the months following surgery. Large-scale studies and meta-analyses conducted in the past few years support this equivalence: a nationwide Japanese propensity-matched study found no significant difference in survival between cemented and uncemented implants in elderly patients with femoral neck fractures, while a prospective comparative investigation similarly demonstrated comparable 3-12-month functional recovery and mortality between fixation methods despite some intraoperative differences ^10,11.

Historically, cemented stems were considered the gold standard due to superior primary stability, lower residual pain, and reduced mechanical complications. Recent high-quality evidence continues to reinforce this perspective. A 2024 meta-analysis of randomized trials showed that cemented fixation was associated with lower 1-year mortality, as well as reduced risk of intra- and postoperative periprosthetic fractures and implant loosening. Similar conclusions were drawn in an overlapping systematic review, which highlighted that the most rigorous available evidence favors cemented stems in terms of avoiding prosthesis-related complications. Another updated systematic review of 24 randomized controlled trials demonstrated that cemented implants provide better early hip function, less pain, and lower complication rates, although at the cost of longer operative times. These findings remain consistent with the NICE recommendations favoring cemented fixation in elderly patients, although past guidelines relied largely on older implant designs no longer representative of current practice ^12-16.

However, modern uncemented stems have undergone significant technological advances – including improved porous coatings, enhanced press-fit geometry, and hydroxyapatite surfaces – that have narrowed the performance gap and changed clinical preferences. Consistent with our study, multiple investigations have shown that uncemented stems provide important intraoperative advantages, particularly significantly reduced operative time and lower overall surgical burden. A recent retrospective analysis reported that uncemented hemiarthroplasty reduces operative duration and overall procedural cost without compromising clinical outcomes or mortality at 30 days and 1 year. Another 2025 comparative study found that uncemented fixation was associated with shorter surgery duration and less blood loss, although cemented stems demonstrated modestly better early functional scores, with results converging by the 3-month mark ^17,18.

Taken together, contemporary evidence suggests a nuanced and evolving landscape: cemented fixation remains advantageous for minimizing implant-related complications and may offer slight early functional benefits, while modern uncemented stems reduce operative time and perioperative physiological stress without compromising medium-term clinical outcomes. For frail elderly patients, where operative duration may be a critical determinant of perioperative risk, the advantages of uncemented stems become particularly relevant. Conversely, individuals with osteoporotic bone or higher risk of periprosthetic fracture may still benefit from cemented fixation.

Our findings therefore support an individualized, patient-centered approach rather than rigid preference for one technique. When viewed in the context of recent high-quality international data, the results of this OTODI study reinforce that both cemented and uncemented modern stems are safe and effective, and that the optimal choice should integrate patient frailty, bone quality, anesthesiologic profile, and surgeon expertise. This balanced interpretation aligns with the growing consensus that modern uncemented designs represent a reliable alternative to cemented stems, providing meaningful intraoperative advantages without compromising medium-term functional results or survival.

Conclusions

In Italian clinical practice, uncemented hip hemiarthroplasty represent the most frequently adopted option for elderly patients with medial femoral neck fractures. Clinical differences compared with cemented fixation are generally modest, with shorter operative times and slightly faster functional recovery, while mid-term functional outcomes and mortality rates appear comparable. This large, prospective, multicenter study provides robust support for the effectiveness of uncemented stems of modern design. Further cost-effectiveness analyses and randomized controlled trials are warranted to consolidate the evidence base and guide the development of shared national guidelines.

Conflict of interest statement

The authors declare no financial, personal or any other nature conflict of interest.

Funding

No funding or sponsorship has been received for this manuscript.

Authors contributions

Each author participated in the data collection, analysis and writing of this article.

Ethical consideration

Patient data was retrospectively analyzed and did not change patient care. Ethical Committee approval was therefore deemed unnecessary.

History

Received: January 20, 2026

Accepted: May 15, 2026

Published online: June 12, 2026

Figures and tables

Figure 1.Type of implant shows preference for an uncemented femoral stem.

Figure 2.Duration of surgery is significantly less in the uncemented group.

Figure 3.Bartehl Index showed progressive improvement in functional independence up to 12 months, with no substantial differences between fixation techniques.

References

1. Kunj Kotak KK, Yash Patel YP. Cemented Versus Uncemented Hemiarthroplasty for Femoral Neck Fractures in Elderly Patients. International Journal of Medical and Pharmaceutical Research. 2026; 7(2):278-283. DOI
2. Langslet E, Frihagen F, Opland V. Cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures: 5-year followup of a randomized trial. Clin Orthop Relat Res. 2014; 472(4):1291-9. DOI
3. Fernandez MA, Achten J, Parsons N. Cemented or Uncemented Hemiarthroplasty for Intracapsular Hip Fracture. N Engl J Med. 2022; 386(6):521-530. DOI
4. Ekman E, Palomäki A, Laaksonen I. Early postoperative mortality similar between cemented and uncemented hip arthroplasty: a register study based on Finnish national data. Acta Orthop. 2019; 90(1):6-10. DOI
5. Yang Y, Meng X, Huang Y. Study of the cement implantation syndrome: A review. Medicine (Baltimore). 2024; 103(24):e38624. DOI
6. Sahoo D, Mishra SS, Mohanty A. Functional Outcome of Uncemented (Hydroxyapatite Coated) Bipolar Hemiarthroplasty in Fracture Neck of Femur in Elderly. Spartan Med Res J. 2026; 10(3):24-32. DOI
7. Berggren M, Stenvall M, Englund U. Co-morbidities, complications and causes of death among people with femoral neck fracture - a three-year follow-up study. BMC Geriatr. 2016; 16:120. DOI
8. Panula J, Pihlajamäki H, Mattila VM. Mortality and cause of death in hip fracture patients aged 65 or older: a population-based study. BMC Musculoskelet Disord. 2011; 12:105. DOI
9. Castronuovo E, Pezzotti P, Franzo A. Early and late mortality in elderly patients after hip fracture: a cohort study using administrative health databases in the Lazio region, Italy. BMC Geriatr. 2011; 11:37. DOI
10. Tanaka H, Tarasawa K, Mori Y. Nationwide Comparison of Cemented Versus Uncemented Hemiarthroplasty for Femoral Neck Fractures in the Elderly: A Propensity Score-Matched Analysis Using Japan’s Diagnosis Procedure Combination Database. J Arthroplasty. 2026; 41(7):2094-2100.e1. DOI
11. Suman A, Naynam S. Cemented vs Uncemented Hemiarthroplasty for Displaced Femoral Neck Fractures in Older Adults: Comparative Effectiveness Study. IJLBPR. 2025; 16(1):154-159. DOI
12. Feng Y, Wan J, Deng H. Effect of cemented vs uncemented on outcomes for hemiarthroplasty in the elderly: A meta-analysis of randomized clinical trials. Medicine (Baltimore). 2024; 103(37):e39562. DOI
13. Reddy AK, Scott JT, Norris GR. Cemented vs Uncemented hemiarthroplasties for femoral neck fractures: An overlapping systematic review and evidence appraisal. PLoS One. 2023; 18(2):e0281090. DOI
14. Hip fracture: management. National Institute for Health and Care Excellence (NICE): London; 2023. Publisher Full Text
15. Li L, Zhao X, Yang X. Cemented versus uncemented hemiarthroplasty for the management of femoral neck fractures in the elderly: a meta-analysis and systematic review. Arch Orthop Trauma Surg. 2021; 141(6):1043-1055. DOI
16. He Y, Tang X, Liao Y. The Comparison between Cemented and Uncemented Hemiarthroplasty in Patients with Femoral Neck Fractures: A Systematic Review and Meta-analysis of Randomized Controlled Trials. Orthop Surg. 2023; 15(7):1719-1729. DOI
17. Wignadasan W, Najefi A, Dewhurst M. Cemented Versus Uncemented Hemiarthroplasty for Displaced Intracapsular Neck of Femur Fractures in the Elderly: Outcomes and Costings. Indian J Orthop. 2024; 58(6):716-721. DOI
18. Ahmed W, Kashyap N, Kumar R. Evaluation of functional outcome between cemented and uncemented total hip replacement. Bioinformation. 2025; 21(11):4121-4127. DOI