Cemented versus cementless cup fixation in fracture total hip arthroplasty: Analysis of revision and mortality rates from the German Arthroplasty Registry (EPRD)

Background: The management of femoral neck fractures (FNF) in elderly patients depends on comorbidities, pre-fracture mobility, any hip joint disease, and life expectancy, with treatment typically involving either hemiarthroplasty (HA) or total hip arthroplasty (THA). While cemented femoral stem fixation is standard, there is no clear consensus regarding cemented versus cementless cup fixation in THA. This study aimed to compare revision and mortality rates between THA, divided into cemented and cementless cup fixation, and HA, following FNF. Methods: Data from the German Arthroplasty Registry (EPRD) were analyzed, including all patients with fracture-related THA or HA and available follow-up. A total of 34,501 patients undergoing THA (27,757 cementless, 6,744 cemented cups) and 72,022 patients with HA were included. 5-year revision and mortality rates were compared. Results: The 5-year revision rate was the lowest in the HA group (4.1%), followed by cemented cup THA (5.0%), and cementless cup THA (6.8%; p < 0.001). Dislocation, infection, and periprosthetic fracture were the leading causes of revision. The 5-year mortality rate was the lowest in cementless cup THA patients (23%), 43% in cemented cup THA patients and highest in HA patients (54%). Cementless fixation was associated with a higher revision risk (HR 1.28, 95% CI 1.14-1.44), while HA was associated with increased mortality (HR 1.26, 95% CI 1.22-1.31). Conclusion: Cemented cup fixation in THA after FNF is associated with lower revision rates but higher mortality compared to cementless fixation. In patients with limited life expectancy, HA remains the preferred option.