Perioperative Outcomes of Cemented vs Cementless Total Hip Arthroplasty: A National Inpatient Sample Study of 81,668 Elective Procedures

Background: Cemented and cementless fixation techniques in total hip arthroplasty (THA) each present distinct biomechanical properties and perioperative risk profiles. While cementless fixation has gained increasing popularity, large-scale nationally representative comparisons of perioperative outcomes between cemented and cementless elective THA remain limited. This study aimed to compare complication rates, healthcare utilization, and temporal trends between cemented and cementless elective THA using the National Inpatient Sample. Methods: A retrospective cohort study was conducted using the National Inpatient Sample database from 2016 to 2021. Adult patients undergoing elective primary total hip arthroplasty were identified using ICD-10-PCS codes and categorized into cemented and cementless fixation groups. Patient demographics, comorbidities, indications, postoperative complications, length of stay, hospital charges, and in-hospital mortality were compared. Multivariate logistic regression analysis was performed to evaluate the independent association between fixation type and postoperative complications while adjusting for demographic, clinical, and hospital-level variables. Results: A total of 81,668 elective THAs were identified, including 40,290 cemented (49.33%) and 41,378 cementless (50.67%) procedures. Cemented THA was associated with a shorter length of stay (2.09 ± 1.88 vs. 2.26 ± 2.47 days, p < 0.001) and lower total hospital charges ($65,584.53 ± 48,797.21 vs. $72,186.84 ± 49,860.20, p < 0.001). Unadjusted analyses demonstrated higher rates of acute kidney injury and sepsis in the cementless group. After multivariate adjustment, cemented fixation was associated with lower odds of acute kidney injury (OR 0.87, 95% CI 0.79–0.96, p = 0.004). However, cemented THA was associated with higher odds of postoperative delirium (OR 1.20, 95% CI 1.02–1.42, p = 0.030), blood transfusion (OR 1.27, 95% CI 1.17–1.37, p < 0.001), and periprosthetic fracture (OR 1.32, 95% CI 1.02–1.71, p = 0.035). Rates of myocardial infarction, pneumonia, venous thromboembolism, urinary tract infection, and in-hospital mortality were similar between groups. Temporal analysis demonstrated comparable utilization trends, with a decline in elective procedures during 2020–2021. Conclusions: In this nationwide analysis, cemented total hip arthroplasty was associated with lower risk of acute kidney injury, shorter length of stay, and lower hospital charges, but higher odds of postoperative delirium, blood transfusion, and periprosthetic fracture compared with cementless fixation. These findings highlight distinct perioperative risk profiles between fixation strategies and may assist surgeons in individualized decision-making for elective total hip arthroplasty.