Is osteoporosis a contraindication for cementless total hip arthroplasty in younger patients? A matched cohort analysis of 71,578 patients

Sri Tummala; Aruni Areti; Adeeb Alomar; Angela Zhang; Dane K. Wukich; Senthil N. Sambandam

doi:10.1016/j.jor.2025.05.048

View/Download PDF

Buy Reprints

PDF

Translate this page into:

68 (); 185-190

doi:

10.1016/j.jor.2025.05.048

Is osteoporosis a contraindication for cementless total hip arthroplasty in younger patients? A matched cohort analysis of 71,578 patients

Sri Tummala^a,b,, Aruni Areti^c, Adeeb Alomar^d, Angela Zhang^d, Dane K. Wukich^a, Senthil N. Sambandam^a

a Department of Orthopaedic Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA

b Texas A&M College of Medicine, Dallas, TX, USA

c Baylor College of Medicine, Houston, TX, USA

d University of Texas Southwestern Medical School, Dallas, TX, USA

⁎Corresponding author: Sri Tummala. Sr1@tamu.edu

Received: 2025-5-13, Accepted: 2025-5-24, Published: 2025-5-26

Professor P K Surendran Memorial Education Foundation

Disclaimer:
This article was originally published by Reed Elsevier India Pvt. Ltd. and was migrated to Scientific Scholar after the change of Publisher.

Abstract

Cementless total hip arthroplasty (THA) is traditionally favored in younger patients given its established potential in promoting osseointegration and long-term stability. Osteoporosis, however, is typically seen as a relative contraindication, especially in older patients, due to concerns about poor bone quality affecting implant integration and increasing perioperative risks. It's unclear if these concerns apply to younger osteoporotic patients, as data in this subgroup are limited. This study aims to compare postoperative outcomes in osteoporotic vs. non-osteoporotic patients under 75 undergoing cementless THA, to assess the impact of osteoporosis and inform fixation strategies for surgeons.

A propensity score–matched analysis was conducted using the TriNetX database on 71,578 patients undergoing cementless primary THA, comparing those with and without osteoporosis. Primary outcomes included THA revision, periprosthetic fracture (PPF), aseptic loosening (ASL), mechanical complications, periprosthetic joint infection (PJI), and hospital readmissions at 90 days, 1 year, and 3 years. Three-year implant survivorship was evaluated using Kaplan–Meier analysis. Secondary outcomes covered common medical complications.

At 3 years, the osteoporotic group showed a significantly higher risk of PPF (1.6 fold; RR: 1.601; 95 % CI: 1.239–2.067; p < 0.05). Other primary outcomes and all secondary outcomes were comparable across cohorts at all time points. Kaplan–Meier analysis showed no significant difference in implant survivorship (HR: 1.060; p = 0.687).

In patients younger than 75, cementless THA resulted in comparable rates of both medical and implant-related complications at all follow-up intervals, except for an increased risk of PPF at 3 years. These findings suggest that osteoporosis may not be a strict contraindication for cementless fixation in younger patients, and with careful intraoperative assessment of bone quality and consideration of patient-specific factors, cementless THA remains a viable option for select young osteoporotic patients.

Level of Evidence: Thereapeutic Level III.

1 Introduction

Osteoporosis, defined by reduced bone mineral density and compromised bone microarchitecture, is a common comorbidity in patients undergoing THA, particularly those over the age of 50, a group comprising over 10.2 million individuals in the United States alone. ¹^,² While often associated with older adults, osteoporosis also affects a substantial number of non-geriatric patients under 75 years of age, highlighting its clinical relevance across a wider age range. ³ THA continues to be the gold standard treatment for end-stage hip osteoarthritis and osteoporosis, with annual procedural volumes projected to surpass 600,000 in the U.S. by 2030. ⁴^,⁵ As life expectancy rises and patients maintain active lifestyles later into life, orthopaedic surgeons are increasingly likely to encounter younger and more active candidates for THA who are also osteoporotic. This trend in patient demographics warrants the need to re-evaluate the effect of osteoporosis on postoperative implant and medical outcomes in this patient population.

Cementless THA is often favored in non-geriatric patients due to its proven potential for durable biologic fixation through osseointegration as well as recent advances in implant design. ^6–8 However, given that its efficacy hinges on adequate bone quality, this approach may not be viable in compromised osteoporotic bone that could impair initial stability and biologic ingrowth, which is essential for long-term success. ¹¹^,¹² While cementless techniques have been found to reduce long-term loosening in younger cohorts, ¹³ their reliability in osteoporotic bone remains contentious, ⁹^,¹⁰ with studies investigating various orthopaedic procedures highlighting diminished osseointegration and elevated risks of complications such as aseptic loosening (ASL) and periprosthetic fractures (PPF) in older osteoporotic patients. ¹⁴^,¹⁵ Hence, as an alternative, a cemented implant fixation method, which uses polymethylmethacrylate for mechanical interlock, has historically been the approach of choice for osteoporotic patients with compromised bone quality, offering immediate stability and reliable implant survivability. ¹³^,¹⁶ Nonetheless, cementless fixation still continues to dominate orthopaedic practice in the United States, accounting for 94 % of all primary THA procedures as of 2021. ⁹^,¹⁷^,¹⁸

Although younger osteoporotic patients have demonstrated elevated complication risks in other joint replacement procedures, ¹⁷^,^19–21 the specific impact of osteoporosis on THA outcomes in this age group remains poorly defined. Existing literature lacks adequate evidence to determine whether osteoporosis may need to be considered a contraindication for cementless fixation in patients under 75 years old, a knowledge gap that is increasingly relevant given the projected rise in THA demand among younger, osteoporotic individuals. To date, no studies have directly compared postoperative outcomes between osteoporotic and non-osteoporotic patients undergoing cementless THA. This study seeks to address that gap by evaluating medical and implant-related complications, as well as implant survivorship across multiple postoperative time points, to inform clinical decision-making in this evolving patient population.

2 Methods

2.1

2.1 Database

This study utilized the TriNetX Research Network (https://trinetx.com, Cambridge, MA, USA), one of the largest federated health data platforms, integrating electronic medical records from over 100 healthcare organizations (HCOs) across the United States, Canada, and Western Europe. The Research Network includes data from 100 HCOs and represents more than 150 million patient records. Additional patient-level insights were supplemented with claims data from over 100 commercial and government payers, including Medicare. ²²^,²³

2.2

2.2 Patient selection

We identified patients aged 75 years or younger who underwent cementless primary total hip arthroplasty (THA) between 2003and 2022, using the following CPT and ICD-10 procedural codes: 27130, 0SRB06A, 0SRB04A, 0SRB02A, 0SR904A, 0SR903A, 0SR901A, 0SR902A, 0SRB0JA, 0SR90JA, 0SR906A, 0SRB01A, and 0SRB03A. Patients were stratified into two cohorts based on diagnostic status within six months prior to surgery: those with an osteoporosis diagnosis and those without. Osteoporosis was defined using ICD-10 codes M80.0, M80, M81, and M81.8.

2.3

2.3 Outcome measures

The primary outcomes included rates of THA revision, periprosthetic joint infection (PPJI), PPF, ASL, and hospital readmissions at 90 days, 1 year, and 3 years postoperatively. Secondary outcomes assessed rates of blood transfusion, deep vein thrombosis (DVT), and pulmonary embolism (PE). Additionally, a Kaplan–Meier survival analysis was performed at the 3-year follow-up to evaluate long-term implant survivorship.

2.4

2.4 Statistical analysis

Risk ratios (RR) with corresponding 95 % confidence intervals were calculated for all outcomes to compare event rates between cohorts. Absolute risk differences were also reported. Statistical significance was determined using Fisher's exact test or Chi-square test for categorical variables and Student's t-test for continuous variables. A p-value <0.05 was considered statistically significant.

2.5

2.5 Propensity score matching and baseline characteristics

To reduce confounding, 1:1 propensity score matching was performed using a greedy nearest-neighbor algorithm without replacement. Matching covariates included age, sex, body mass index (categorized), essential hypertension, diabetes mellitus, tobacco and alcohol use, chronic ischemic heart disease, and chronic kidney disease (stage 3 and higher). These variables were selected based on preliminary regression analysis identifying them as potential confounders. The final matched cohorts each included 7837 patients. Balance between groups was confirmed using standardized mean differences, all of which were below 0.1. A complete summary of baseline characteristics before and after matching is provided in Table 1.

Table 1 Patient Demographic & Characteristics Before and After Propensity Matching.

Before Propensity Matching	Osteoporosis (8,248)	No-Osteoporosis (63,330)	p
Before Propensity Matching	N (Mean or %)	N (Mean or %)	p
Age at index in years	8226 (61.2 ± 8.6)	62,907 (55.8 ± 9.7)	<0.001
Sex
Men	1643 (20.0 %)	32,700 (52.0 %)	<0.001
Women	6359 (77.3 %)	28,774 (45.7 %)	<0.001
Diagnosis
Tobacco use	562 (6.8 %)	2016 (3.2 %)	<0.001
Chronic kidney disease (CKD)	1091 (13.3 %)	2216 (3.5 %)	<0.001
Primary hypertension	4825 (58.7 %)	22,502 (35.8 %)	<0.001
Chronic ischemic heart disease	1256 (15.3 %)	6403 (10.1 %)	<0.001
Diabetes mellitus	1630 (19.8 %)	6719 (10.7 %)	<0.001
Alcohol Use	604 (7.3 %)	2226 (3.5 %)	<0.001
BMI
At Most 18.5 kg/m²	745 (9.1 %)	1396 (2.2 %)	<0.001
18.5–25 kg/m²	3625 (44.1 %)	12,477 (19.8 %)	<0.001
25–30 kg/m²	3875 (47.1 %)	21,309 (33.9 %)	<0.001
30–35 kg/m²	2921 (35.5 %)	19,203 (30.5 %)	<0.001
35–40 kg/m²	1748 (21.2 %)	12,144 (19.3 %)	<0.001
At Least 40 kg/m²	1067 (13.0 %)	7246 (11.5 %)	<0.001
DM, diabetes mellitus; BMI, body mass index.

After Propensity Matching	Osteoporosis (7,837)	No-Osteoporosis (7,837)	p
After Propensity Matching	N (Mean or %)	N (Mean or %)	p
Age at index in years	7837 (61.0 ± 8.6)	7837 (60.8 ± 7.6)	0.196
Sex
Men	1626 (20.7 %)	1583 (20.2 %)	0.395
Women	5994 (76.5 %)	6010 (76.7 %)	0.763
Diagnosis
Tobacco use	481 (6.1 %)	492 (6.3 %)	0.716
Chronic kidney disease (CKD)	891 (11.4 %)	907 (11.6 %)	0.688
Primary hypertension	4470 (57.0 %)	4530 (57.8 %)	0.332
Chronic ischemic heart disease	1096 (14.0 %)	1065 (13.6 %)	0.473
Diabetes mellitus	1483 (18.9 %)	1545 (19.7 %)	0.210
Alcohol Use	524 (6.7 %)	536 (6.8 %)	0.703
BMI
At Most 18.5 kg/m²	573 (7.3 %)	603 (7.7 %)	0.363
18.5–25 kg/m²	3292 (42.0 %)	3254 (41.5 %)	0.538
25–30 kg/m²	3608 (46.0 %)	3551 (45.3 %)	0.361
30–35 kg/m²	2758 (35.2 %)	2746 (35.0 %)	0.841
35–40 kg/m²	1666 (21.3 %)	1707 (21.8 %)	0.426
At Least 40 kg/m²	1005 (12.8 %)	1031 (13.2 %)	0.537
DM, diabetes mellitus; BMI, body mass index.

2.6

2.6 Software used for statistical analysis, Validation, and data visualization

Data were compiled using the TriNetX Live platform, with statistical analysis and visualization conducted on R (R Software, Vienna, Austria) and Microsoft Excel (2024). All analytical procedures were independently reviewed by the co-authors and subsequently verified by the corresponding author (ST).

3 Results

3.1

3.1 Patient demographic data analysis

A total of 71,578 patients under 75 years of age who underwent cementless total hip arthroplasty (THA) were identified, including 8226 patients with osteoporosis (11.5 %) and 62,907 without osteoporosis (87.9 %). Before matching, the osteoporosis cohort was significantly older on average (61.2 ± 8.6 years) compared to the non-osteoporosis cohort (55.8 ± 9.7 years, p < 0.001). Women comprised the majority in the osteoporosis group (77.3 %) but were less prevalent in the non-osteoporosis cohort (45.7 %, p < 0.001).

Significant differences between cohorts before matching included the proportion of men (20.0 % osteoporotic vs. 52.0 % non-osteoporotic; p < 0.001), tobacco use (6.8 % vs. 3.2 %; p < 0.001), alcohol use (7.3 % vs. 3.5 %; p < 0.001), chronic kidney disease (13.3 % vs. 3.5 %; p < 0.001), primary hypertension (58.7 % vs. 35.8 %; p < 0.001), diabetes mellitus (19.8 % vs. 10.7 %; p < 0.001), and across all BMI categories (p < 0.001).

After propensity score matching, 7837 osteoporotic patients were 1:1 matched to 7837 non-osteoporotic patients, eliminating previously noted differences. Age became balanced (61.0 ± 8.6 years vs. 60.8 ± 7.6 years; p = 0.196), as did gender (76.5 % women vs. 76.7 % women; p = 0.763; 20.7 % men vs. 20.2 % men; p = 0.395) and all comorbidities, including tobacco use (6.1 % vs. 6.3 %; p = 0.716), alcohol use (6.7 % vs. 6.8 %; p = 0.703), chronic kidney disease (11.4 % vs. 11.6 %; p = 0.688), primary hypertension (57.0 % vs. 57.8 %; p = 0.332), diabetes mellitus (18.9 % vs. 19.7 %; p = 0.210), and BMI distribution (all p > 0.05). The matched cohort (15,674 patients total) was used for all subsequent analyses (Table 1).

3.2

3.2 Analysis of patient complications

3.2.1

3.2.1 Three-month follow-up

At three months following THA, there were no significant differences (p > 0.05) between the osteoporosis and non-osteoporosis cohorts in any primary outcomes, including revision rates, readmission, PJI, PPF, or ASL. Similarly, the secondary outcomes showed no significant differences (p > 0.05) between the two groups in the incidence of blood transfusion, DVT, or PE (Table 2).

Table 2 Table of risk ratios: 3-Month follow-up (Matched).

Measure	Osteoporosis (n)	No Osteoporosis (n)	Osteoporosis Proportion	No Osteoporosis Proportion	Risk Ratio	95 % CI	p
*Primary Outcomes*
Aseptic Loosening	12	10	0.16 %	0.13 %	1.221	(0.528, 2.824)	0.64
THA Revision	105	98	1.50 %	1.33 %	1.125	(0.856, 1.479)	0.40
Periprosthetic Fracture	61	56	0.81 %	0.72 %	1.121	(0.781, 1.609)	0.54
Periprosthetic Joint Infection	89	86	1.20 %	1.13 %	1.061	(0.790, 1.425)	0.69
Readmission	77	100	1.11 %	1.38 %	0.810	(0.603, 1.088)	0.16
*Secondary Outcomes*
Transfusion	194	216	2.74 %	2.90 %	0.945	(0.780, 1.144)	0.56
Deep Vein Thrombosis	51	51	0.69 %	0.67 %	1.032	(0.701, 1.520)	0.87
Pulmonary Embolism	26	16	0.35 %	0.21 %	1.662	(0.892, 3.095)	0.11

3.2.2

3.2.2 One-year follow-up

At one year following THA, no significant differences (p > 0.05) were observed between the osteoporosis and non-osteoporosis cohorts in either primary or secondary outcomes (Table 3).

Table 3 Table of risk ratios: 1-Year follow-up (Matched).

Measure	Osteoporosis (n)	No Osteoporosis (n)	Osteoporosis Proportion	No Osteoporosis Proportion	Risk Ratio	95 % CI	p
*Primary Outcomes*
Aseptic Loosening	25	20	0.33 %	0.26 %	1.268	(0.705, 2.280)	0.43
THA Revision	150	143	2.16 %	2.00 %	1.099	(0.876, 1.378)	0.42
Periprosthetic Fracture	93	74	1.25 %	0.97 %	1.291	(0.953, 1.749)	0.10
Periprosthetic Joint Infection	133	134	1.81 %	1.78 %	1.017	(0.802, 1.290)	0.89
Readmission	109	115	1.59 %	1.61 %	0.992	(0.765, 1.287)	0.95
*Secondary Outcomes*
Transfusion	235	232	3.36 %	3.16 %	1.062	(0.888, 1.269)	0.51
Deep Vein Thrombosis	85	80	1.17 %	1.06 %	1.096	(0.809, 1.485)	0.55
Pulmonary Embolism	50	35	0.67 %	0.46 %	1.462	(0.950, 2.249)	0.08

3.2.3

3.2.3 Three-year follow-up

At three years following THA, a significant difference in PPF rates was observed, with the osteoporotic cohort demonstrating a 1.6-fold increased risk of PPF compared to the non-osteoporotic group (Risk Ratio: 1.601; 95 % CI: 1.239–2.067; p < 0.05). No other primary outcomes showed significant differences between the two cohorts.

The three-year Kaplan–Meier survival analysis revealed no statistically significant difference in implant survivability between groups (p > 0.05) (Log-Rank test: χ² = 0.697, p = 0.404; HR = 1.107; 95 % CI: 0.799–1.535) (Fig. 1, Table 4). Similarly, no significant differences (p > 0.05) were found between the two groups in any of the secondary outcomes (Table 5).

Kaplan-Meier Analysis Curve for Implant Survival at 3 Years.

Table 4 Statistical comparison of implant survivability (Log-Rank and Hazard Ratio tests).

	Hazard Ratio	95 % CI	χ²	df	p-value
Log-Rank Test	-	-	0.163	1	0.687
Hazard Ratio and Proportionality	1.060	(0.799, 1.407)	0.159	1	0.690

Table 5 Table of risk ratios: 3-Year follow-up (Matched).

Measure	Osteoporosis (n)	No Osteoporosis (n)	Osteoporosis Proportion	No Osteoporosis Proportion	Risk Ratio	95 % CI	p
*Primary Outcomes*
Aseptic Loosening	50	34	0.66 %	0.44 %	1.491	(0.966, 2.303)	0.07
THA Revision	213	196	3.07 %	2.70 %	1.138	(0.940, 1.378)	0.18
Periprosthetic Fracture	148	95	1.98 %	1.24 %	1.601	(1.239, 2.067)	<0.05
Periprosthetic Joint Infection	189	177	2.57 %	2.35 %	1.094	(0.893, 1.339)	0.39
Readmission	153	159	2.24 %	2.22 %	1.007	(0.809, 1.254)	0.95
*Secondary Outcomes*
Transfusion	294	284	4.20 %	3.87 %	1.085	(0.925, 1.273)	0.32
Deep Vein Thrombosis	151	138	2.07 %	1.84 %	1.129	(0.898, 1.419)	0.30
Pulmonary Embolism	95	76	1.33 %	0.99 %	1.605	(0.947, 1.742)	0.11

4 Discussion

Cementless femoral fixation in primary THA has traditionally been approached with caution in osteoporotic patients, largely due to concerns about implant stability and complications such as PPF and ASL, as shown in studies primarily focused on geriatric populations. ²⁴^,²⁵ While these risks are well-documented in older patients, the reduced bone mineral density and compromised structural integrity seen in osteoporotic bone also raise concerns for younger patients with osteoporosis. This existing evidence has led some surgeons to consider cemented fixation even in non-geriatric patients, aligning with the treatment strategies commonly used in older individuals. However, the current body of literature lacks direct comparisons of postoperative medical and implant-related outcomes between younger osteoporotic and non-osteoporotic cohorts undergoing cementless THA. As a result, the validity of osteoporosis as a strict contraindication to cementless fixation in younger patients remains uncertain. This study offers insights into the comparative safety and efficacy of cementless fixation in a younger, osteoporotic population.

After propensity-score matching, our results revealed that only PPF demonstrated a significantly higher incidence in the osteoporotic cohort compared to the non-osteoporotic group at three-year follow-up (1.91 % vs. 1.23 %, p < 0.05). All other primary outcomes, including revision rates, ASL, readmission, and PJI, were comparable between cohorts across all time points. Importantly, implant survival was statistically equivalent between groups, suggesting that younger osteoporotic patients may still retain adequate biologic potential for osseointegration following cementless THA, despite compromised bone mineral density and structural integrity. Additionally, all measured secondary outcomes were similar between cohorts at every follow-up interval, further supporting the viability of cementless fixation in this population.

The observed increase in PPF risk aligns with the known pathophysiological mechanism of osteoporosis and is not unexpected given that reduced bone mineral density may predispose patients to fractures even from low-energy mechanisms such as falls. ²⁶ This association is further supported by prior registry data reporting PPF rates ranging from 0.03 % to 11.9 % in cementless THA,²⁷^,²⁸ although these findings primarily reflect outcomes in older populations. In contrast, our younger cohort, with a mean age of 61 years, exhibited PPF rates at the lower end of this spectrum (1.91 % vs. 1.23 %), which may be attributed to relatively preserved bone quality and greater regenerative potential in non-geriatric individuals. The delayed manifestation of increased PPF risk at 3 years, and not at 1 year, may partly be explained by the cumulative effect of age-related bone loss, microstructural deterioration, and increasing mechanical stress at the bone-implant interface over time. Additionally, in younger osteoporotic patients, initial postoperative bone quality may have been sufficient to support early implant stability, with fractures occurring later as bone density continued to decline or as the frequency of low-energy trauma events increased with aging and activity resumption. While osteoporosis inherently elevates fracture risk, our comparable results suggest that younger patients may partially offset this risk through less advanced bone deterioration and enhanced biologic capacity for osseointegration, both key factors in the success of cementless fixation.

The absence of significant differences in ASL and THA revision rates between cohorts stands in contrast to earlier biomechanical models and clinical studies, which suggested that osteoporotic bone predisposes patients to implant instability and failure. ²⁹^,³⁰ This discrepancy may be attributable, in part, to recent advancements in implant design. For example, tapered stems with porous coatings have been shown to reduce micromotion in osteoporotic bone, as demonstrated by Meneghini et al., ³¹ while hydroxyapatite-coated implants have exhibited strong osseous integration even in osteopenic environments, ⁸^,²¹ likely contributing to improved fixation durability. Additionally, differences in study methodology may also help explain the contrasting findings as many of these early studies did not particularly evaluate younger, non-geriatric osteoporotic patients, limiting their generalizability to our study's population. Taken together, methodological differences and implant innovations combined with the preserved post-operative healing capacity of younger patients could collectively explain why osteoporosis may not have alone predicted higher rates of implant failure in our study.

Systemic complication rates such as blood transfusion, DVT, and PE were also found to be comparable between the two cohorts, suggesting that osteoporosis may not independently increase perioperative medical risk in younger patients. While these outcomes were secondary to our primary focus, their consistency further reinforces the broader safety profile of cementless fixation in this population. However, given the scarcity of focused studies in this area, further investigation is warranted to validate these findings.

Given the comparable medical and implant-related outcomes observed in younger osteoporotic patients, these findings must be weighed against the potential risks associated with cemented fixation, which has traditionally been preferred in this population. Cemented techniques carry well-documented complications, most notably bone cement implantation syndrome (BCIS), a potentially life-threatening intraoperative event characterized by hypoxia, hypotension, and cardiovascular collapse, which is particularly concerning in physiologically active patients. ²⁹^,³² Additionally, the increased operative time required for cement preparation and pressurization may delay mobilization, elevate hospitalization costs, and hinder early recovery, factors especially impactful in a younger population with higher functional demands. ^29–32 Thus, our findings suggest that cementless fixation remains a viable and effective option in select cases when intraoperative stability is achievable, and bone quality is sufficient. Patients without severe cortical compromise or metabolic bone disease may avoid the added risks and logistical challenges associated with cemented fixation. ²⁶ Furthermore, tools such as CT-based bone density screening may also enhance preoperative planning and patient selection, ¹⁸ supporting a personalized, clinically nuanced approach to fixation strategy, rather than defaulting to cemented implants when not deemed as absolutely warranted based on surgical judgment.

4.1

4.1 Limitations

Our study has several limitations inherent to its retrospective design. Relying on electronic health record data introduces potential biases related to diagnostic coding inaccuracies, data entry errors, and incomplete clinical documentation. Additionally, the variation in institutional practices across the TriNetX network limits our ability to analyze surgeon-specific factors that may influence THA outcomes, such as technique or experience. Although the study provides strong short to midterm insights with up to three years of follow-up, it does not fully capture long-term implant survival, an important consideration for younger patients who may require revision procedures decades after the index operation. Despite these constraints, the use of propensity score matching, a validated method for reducing confounding, ³³ enhanced the internal validity of our findings. By balancing cohorts across key clinical variables, including age, sex, BMI, hypertension, diabetes mellitus, tobacco use, chronic ischemic heart disease, and chronic kidney disease, we minimized bias from measurable confounders and strengthened the reliability of our comparative analysis.

5 Conclusions

In this study, we found that cementless THA resulted in comparable rates of both medical and implant-related complications between patients with and without osteoporosis under the age of 75 at all follow-up intervals, except for an increased risk of PPF at 3 years in osteoporotic patients. These findings suggest that while cemented fixation certainly remains appropriate for patients with severe cortical compromise or metabolic bone disease, osteoporosis alone may not represent an absolute contraindication for cementless fixation in this younger population. With careful intraoperative assessment of bone quality and consideration of patient-specific factors, cementless THA appears to be a viable option for select young osteoporotic patients. This approach may help avoid the added risks, costs, and recovery delays associated with cemented techniques when not otherwise indicated. Further research is warranted to evaluate long-term outcomes and patient-reported metrics, which will help better define the role of cementless fixation in this population.

CRediT authorship contribution statement

Sri Tummala: Writing – original draft, Data curation, Formal analysis, Investigation, Conceptualization, Methodology, Validation, Writing – review & editing, Prepared Tables 1–5, Prepared Fig. 1. Aruni Areti: Writing – review & editing, Validation, Software. Adeeb Alomar: Writing – review & editing, Validation. Angela Zhang: Writing – review & editing, Validation. Dane K. Wukich: Writing – review & editing, Validation. Senthil N. Sambandam: Conceptualization, Methodology, Supervision, Project administration, Writing – review & editing, Validation, All authors have read and approved the final manuscript.

Ethical statements

Institutional Review Board Statement:

This study was exempt from IRB approval since the data were de-identified and publicly available.

Funding statement

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

References

Xu J.J., Magruder M.L., Lama G., Vakharia R.M., Tabbaa A., Wong J.C.H., . Osteoporosis may not Be an absolute contraindication for cementless total knee arthroplasty. J Arthroplast. 2025;40(4):905-909.
[Google Scholar]
Sarafrazi N., Wambogo E.A., Shepherd J.A., . Osteoporosis or Low Bone Mass in Older Adults: United States, 2017-2018. 2021;405:1-8.
[Google Scholar]
Onizuka N., Onizuka T., . Disparities in osteoporosis prevention and care: understanding gender, racial, and ethnic dynamics. Curr Rev Musculoskelet Med. 2024;17(9):365-372.
[Google Scholar]
Wang Z., Wishman M.D., Tutaworn T., Hentschel I.G., Levin J.E., Lane J.M., . Osteoporosis and cement usage in total hip arthroplasty. Eur J Orthop Surg Traumatol. 2024;34(3):1649-1655.
[Google Scholar]
Sloan M., Premkumar A., Sheth N.P., . Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg—Am. 2018;100:1455-1460.
[Google Scholar]
Atik O.Ş., Çankaya D., . To cement or not to cement, that is the question in elderly. Jt Dis Relat Surg. 2021;32(2):277-278.
[Google Scholar]
Wechter J., Comfort T.K., Tatman P., Mehle S., Gioe T.J., . Improved survival of uncemented versus cemented femoral stems in patients aged < 70 years in a community total joint registry. Clin Orthop Relat Res. 2013;471(11):3588-3595.
[Google Scholar]
Voigt J.D., Mosier M., . Hydroxyapatite (HA) coating appears to be of benefit for implant durability of tibial components in primary total knee arthroplasty. Acta Orthop. 2011;82:448e59.
[Google Scholar]
Hameed D., McCormick B.P., Sequeira S.B., et al . Cemented versus cementless femoral fixation for total hip arthroplasty following femoral neck fracture in patients aged 65 and older. J Arthroplast. 2024;39(7):1747-1751.
[Google Scholar]
Kamath A.F., Lee G.C., Sheth N.P., Nelson C.L., Garino J.P., Israelite C.L., . Prospective results of uncemented tantalum monoblock tibia in total knee arthroplasty: minimum 5-year follow-up in patients younger than 55 Years. J Arthroplast. 2011;26:1390e5.
[Google Scholar]
Atik O.Ş., Aslan A., Odluyurt M., . Are fragility fractures being treated properly? Jt Dis Relat Surg. 2020;31:403-404.
[Google Scholar]
Jämsen E., Eskelinen A., Peltola M., Mäkelä K., . High early failure rate after cementless hip replacement in the octogenarian. Clin Orthop Relat Res. 2014;472:2779-2789.
[Google Scholar]
Lindberg-Larsen M., Petersen P.B., Jørgensen C.C., Overgaard S., Kehlet H., . Lundbeck Foundation Center for Fast-track Hip and Knee Arthroplasty Collaborating Group. Postoperative 30-day complications after cemented/hybrid versus cementless total hip arthroplasty in osteoarthritis patients > 70 years. Acta Orthop. 2020;91:286e92.
[Google Scholar]
Moskal J.T., Capps S.G., Scanelli J.A., . Still no single gold standard for using cementless femoral stems routinely in total hip arthroplasty. Arthroplast Today. 2016;2:211e8.
[Google Scholar]
Wilson J.M., Smartt A.A., Abdel M.P., et al . Can selected use of cemented and uncemented femoral components in a broad population produce comparable results following primary total hip arthroplasty for osteoarthritis? J Arthroplast. 2023;38:S166e73.
[Google Scholar]
Ahn J., Man L.-X., Park S., Sodl J.F., Esterhai J.L., . Systematic review of cemented and uncemented hemiarthroplasty outcomes for femoral neck fractures. Clin Orthop Relat Res. 2008;466
[Google Scholar]
Kuyl E.V., Agarwal A.R., Patel P.K., et al . Osteoporotic patients undergoing total hip arthroplasty have a similar 5-year cumulative incidence rate of periprosthetic fracture regardless of cemented versus cementless femoral stem fixation. J Arthroplast. 2024;39(5):1285-1290.e1.
[Google Scholar]
Bukowski B.R., Sandhu K.P., Bernatz J.T., et al . CT required to perform roboticassisted total hip arthroplasty can identify previously undiagnosed osteoporosis and guide femoral fixation strategy. Bone Joint Lett J. 2023;105-B:254e60.
[Google Scholar]
Aro H.T., Alm J.J., Moritz N., M€ akinen T.J., Lankinen P., . Low BMD affects initial stability and delays stem osseointegration in cementless total hip arthroplasty in women: a 2-year RSA study of 39 patients. Acta Orthop. 2012;83:107e14.
[Google Scholar]
Hopman S.R., de Windt T.S., van Erp J.H.J., Bekkers J.E.J., de Gast A., . Uncemented total hip arthroplasty; increased risk of early periprosthetic fracture requiring revision surgery in elderly females. J Orthop. 2021;25:40e4.
[Google Scholar]
Apostu D., Lucaciu O., Berce C., Lucaciu D., Cosma D., . Current methods of preventing aseptic loosening and improving osseointegration of titanium implants in cementless total hip arthroplasty: a review. J Int Med Res. 2018;46:2104e19.
[Google Scholar]
Palchuk M.B., London J.W., Perez-Rey D., et al . A global federated real-world data and analytics platform for research. JAMIA Open. 2023;6
[Google Scholar]
Real world data—Linked.
[Google Scholar]
Okike K., Chan P.H., Prentice H.A., Paxton E.W., Burri R.A., . Association between uncemented vs cemented hemiarthroplasty and revision surgery among pa- tients with hip fracture. JAMA. 2020;323:1077.
[Google Scholar]
Luo X., He S., Li Z., Huang D., . Systematic review of cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures in older patients. Arch Orthop Trauma Surg. 2012;132:455e63.
[Google Scholar]
Yang C., Han X., Wang J., et al . Cemented versus uncemented femoral component total hip arthroplasty in elderly patients with primary osteoporosis: retrospective analysis with 5-year follow-up. J Int Med Res. 2019;47(4):1610-1619.
[Google Scholar]
Kelly M.P., Chan P.H., Prentice H.A., Paxton E.W., Hinman A.D., Khatod M., . Cause-specific stem revision risk in primary total hip arthroplasty using cemented vs cementless femoral stem fixation in a US cohort. J Arthroplast. 2022;37(1):89-96.e1.
[Google Scholar]
Talsnes O., Vinje T., Gjertsen J.E., et al . Perioperative mortality in hip fracture patients treated with cemented and uncemented hemiprosthesis: a register study of 11,210 patients. Int Orthop. 2013;37(6):1135-1140.
[Google Scholar]
Konan S., Abdel M.P., Haddad F.S., . Cemented versus uncemented hip implant fixation: should there be age thresholds? Bone Joint Res. 2020;8(12):604-607.
[Google Scholar]
Daher M., Mekhael E., El-Othmani M.M., . Total hip arthroplasty in patients with hip osteoporosis: a narrative review. Hip Pelvis. 2024;36(4):260-272.
[Google Scholar]
Meneghini R.M., Daluga A., Soliman M., . Mechanical stability of cementless tibial components in normal and osteoporotic bone. J Knee Surg. 2011;24:191e6.
[Google Scholar]
Kallala R., Anderson P., Morris S., Haddad F.S., . The cost analysis of cemented versus cementless total hip replacement operations on the NHS. Bone Joint Lett J. 2013;95-B(7):874-876.
[Google Scholar]
Kane L.T., Fang T., Galetta M.S., et al . Propensity score matching: a statistical method. Clin Spine Surg. 2020;33:120-122.
[Google Scholar]

Show Sections

[1] Xu J.J., Magruder M.L., Lama G., Vakharia R.M., Tabbaa A., Wong J.C.H., . Osteoporosis may not Be an absolute contraindication for cementless total knee arthroplasty. J Arthroplast. 2025;40(4):905-909.
[Google Scholar]

[2] Sarafrazi N., Wambogo E.A., Shepherd J.A., . Osteoporosis or Low Bone Mass in Older Adults: United States, 2017-2018. 2021;405:1-8.
[Google Scholar]

[3] Onizuka N., Onizuka T., . Disparities in osteoporosis prevention and care: understanding gender, racial, and ethnic dynamics. Curr Rev Musculoskelet Med. 2024;17(9):365-372.
[Google Scholar]

[4] Wang Z., Wishman M.D., Tutaworn T., Hentschel I.G., Levin J.E., Lane J.M., . Osteoporosis and cement usage in total hip arthroplasty. Eur J Orthop Surg Traumatol. 2024;34(3):1649-1655.
[Google Scholar]

[5] Sloan M., Premkumar A., Sheth N.P., . Projected volume of primary total joint arthroplasty in the U.S., 2014 to 2030. J Bone Joint Surg—Am. 2018;100:1455-1460.
[Google Scholar]

[6] Atik O.Ş., Çankaya D., . To cement or not to cement, that is the question in elderly. Jt Dis Relat Surg. 2021;32(2):277-278.
[Google Scholar]

[7] Wechter J., Comfort T.K., Tatman P., Mehle S., Gioe T.J., . Improved survival of uncemented versus cemented femoral stems in patients aged < 70 years in a community total joint registry. Clin Orthop Relat Res. 2013;471(11):3588-3595.
[Google Scholar]

[8] Voigt J.D., Mosier M., . Hydroxyapatite (HA) coating appears to be of benefit for implant durability of tibial components in primary total knee arthroplasty. Acta Orthop. 2011;82:448e59.
[Google Scholar]

[9] Hameed D., McCormick B.P., Sequeira S.B., et al . Cemented versus cementless femoral fixation for total hip arthroplasty following femoral neck fracture in patients aged 65 and older. J Arthroplast. 2024;39(7):1747-1751.
[Google Scholar]

[10] Kamath A.F., Lee G.C., Sheth N.P., Nelson C.L., Garino J.P., Israelite C.L., . Prospective results of uncemented tantalum monoblock tibia in total knee arthroplasty: minimum 5-year follow-up in patients younger than 55 Years. J Arthroplast. 2011;26:1390e5.
[Google Scholar]

[11] Atik O.Ş., Aslan A., Odluyurt M., . Are fragility fractures being treated properly? Jt Dis Relat Surg. 2020;31:403-404.
[Google Scholar]

[12] Jämsen E., Eskelinen A., Peltola M., Mäkelä K., . High early failure rate after cementless hip replacement in the octogenarian. Clin Orthop Relat Res. 2014;472:2779-2789.
[Google Scholar]

[13] Lindberg-Larsen M., Petersen P.B., Jørgensen C.C., Overgaard S., Kehlet H., . Lundbeck Foundation Center for Fast-track Hip and Knee Arthroplasty Collaborating Group. Postoperative 30-day complications after cemented/hybrid versus cementless total hip arthroplasty in osteoarthritis patients > 70 years. Acta Orthop. 2020;91:286e92.
[Google Scholar]

[14] Moskal J.T., Capps S.G., Scanelli J.A., . Still no single gold standard for using cementless femoral stems routinely in total hip arthroplasty. Arthroplast Today. 2016;2:211e8.
[Google Scholar]

[15] Wilson J.M., Smartt A.A., Abdel M.P., et al . Can selected use of cemented and uncemented femoral components in a broad population produce comparable results following primary total hip arthroplasty for osteoarthritis? J Arthroplast. 2023;38:S166e73.
[Google Scholar]

[16] Ahn J., Man L.-X., Park S., Sodl J.F., Esterhai J.L., . Systematic review of cemented and uncemented hemiarthroplasty outcomes for femoral neck fractures. Clin Orthop Relat Res. 2008;466
[Google Scholar]

[17] Kuyl E.V., Agarwal A.R., Patel P.K., et al . Osteoporotic patients undergoing total hip arthroplasty have a similar 5-year cumulative incidence rate of periprosthetic fracture regardless of cemented versus cementless femoral stem fixation. J Arthroplast. 2024;39(5):1285-1290.e1.
[Google Scholar]

[18] Bukowski B.R., Sandhu K.P., Bernatz J.T., et al . CT required to perform roboticassisted total hip arthroplasty can identify previously undiagnosed osteoporosis and guide femoral fixation strategy. Bone Joint Lett J. 2023;105-B:254e60.
[Google Scholar]

[19] Aro H.T., Alm J.J., Moritz N., M€ akinen T.J., Lankinen P., . Low BMD affects initial stability and delays stem osseointegration in cementless total hip arthroplasty in women: a 2-year RSA study of 39 patients. Acta Orthop. 2012;83:107e14.
[Google Scholar]

[20] Hopman S.R., de Windt T.S., van Erp J.H.J., Bekkers J.E.J., de Gast A., . Uncemented total hip arthroplasty; increased risk of early periprosthetic fracture requiring revision surgery in elderly females. J Orthop. 2021;25:40e4.
[Google Scholar]

[21] Apostu D., Lucaciu O., Berce C., Lucaciu D., Cosma D., . Current methods of preventing aseptic loosening and improving osseointegration of titanium implants in cementless total hip arthroplasty: a review. J Int Med Res. 2018;46:2104e19.
[Google Scholar]

[22] Palchuk M.B., London J.W., Perez-Rey D., et al . A global federated real-world data and analytics platform for research. JAMIA Open. 2023;6
[Google Scholar]

[23] Real world data—Linked.
[Google Scholar]

[24] Okike K., Chan P.H., Prentice H.A., Paxton E.W., Burri R.A., . Association between uncemented vs cemented hemiarthroplasty and revision surgery among pa- tients with hip fracture. JAMA. 2020;323:1077.
[Google Scholar]

[25] Luo X., He S., Li Z., Huang D., . Systematic review of cemented versus uncemented hemiarthroplasty for displaced femoral neck fractures in older patients. Arch Orthop Trauma Surg. 2012;132:455e63.
[Google Scholar]

[26] Yang C., Han X., Wang J., et al . Cemented versus uncemented femoral component total hip arthroplasty in elderly patients with primary osteoporosis: retrospective analysis with 5-year follow-up. J Int Med Res. 2019;47(4):1610-1619.
[Google Scholar]

[27] Kelly M.P., Chan P.H., Prentice H.A., Paxton E.W., Hinman A.D., Khatod M., . Cause-specific stem revision risk in primary total hip arthroplasty using cemented vs cementless femoral stem fixation in a US cohort. J Arthroplast. 2022;37(1):89-96.e1.
[Google Scholar]

[28] Talsnes O., Vinje T., Gjertsen J.E., et al . Perioperative mortality in hip fracture patients treated with cemented and uncemented hemiprosthesis: a register study of 11,210 patients. Int Orthop. 2013;37(6):1135-1140.
[Google Scholar]

[29] Konan S., Abdel M.P., Haddad F.S., . Cemented versus uncemented hip implant fixation: should there be age thresholds? Bone Joint Res. 2020;8(12):604-607.
[Google Scholar]

[30] Daher M., Mekhael E., El-Othmani M.M., . Total hip arthroplasty in patients with hip osteoporosis: a narrative review. Hip Pelvis. 2024;36(4):260-272.
[Google Scholar]

[31] Meneghini R.M., Daluga A., Soliman M., . Mechanical stability of cementless tibial components in normal and osteoporotic bone. J Knee Surg. 2011;24:191e6.
[Google Scholar]

[32] Kallala R., Anderson P., Morris S., Haddad F.S., . The cost analysis of cemented versus cementless total hip replacement operations on the NHS. Bone Joint Lett J. 2013;95-B(7):874-876.
[Google Scholar]

[33] Kane L.T., Fang T., Galetta M.S., et al . Propensity score matching: a statistical method. Clin Spine Surg. 2020;33:120-122.
[Google Scholar]

Is osteoporosis a contraindication for cementless total hip arthroplasty in younger patients? A matched cohort analysis of 71,578 patients

Abstract

Abstract

1 Introduction