Cemented versus cementless hemiarthroplasty for a displaced fracture of the femoral neck: a critical review of recent evidence

Displaced femoral neck fractures are commonly managed with hemiarthroplasty, yet there is an ongoing debate in literature regarding cemented versus cementless fixation. This review synthesizes evidence from recent randomized controlled trials, meta-analyses, registry-based studies, and cost-effectiveness analyses. Across study types, cemented fixation consistently reduces implant-related complications, particularly periprosthetic fractures, at the expense of slightly longer operative time. Mortality outcomes are largely comparable. Randomized trials generally show no significant differences, with some evidence of improved one-year survival after cemented fixation. Registry data, however, indicate a modest increase in very early postoperative mortality among frail patients treated with a cemented stem, likely related to bone cement implantation syndrome. Functional outcomes and quality of life are marginally better with cemented stems in the early postoperative period, though differences diminish over time. Registry data uniformly show higher reoperation rates with cementless fixation. Cost-effectiveness analyses across healthcare systems identify cemented hemiarthroplasty as dominant, with lower costs and greater quality-adjusted life years. Current guidelines, including those from NICE and the AAOS, recommend cemented fixation. Nevertheless, substantial regional variation persists, with cementless stems still widely used in some countries. Overall, the evidence strongly supports cemented hemiarthroplasty as the preferred strategy for most older adults, while cementless fixation may be considered for highly comorbid patients at greatest risk from cement implantation. Future priorities include maintaining surgical expertise in cementing techniques, promoting global guideline adherence, and refining the identification of frail patient subgroups who may benefit from alternative strategies such as cementless implants or even nonoperative management.