Definition
Choice between cemented, cementless, hybrid and reverse hybrid fixation in the patient under 65. Highest activity demands, longest expected implant lifetime, greatest likelihood of revision within the patient’s lifetime.
- Cementless – uncemented cup and stem; biological fixation
- Cemented – both components fixed with PMMA
- Hybrid – cementless cup, cemented stem
- Reverse hybrid – cemented cup, cementless stem
Epidemiology
- Practice has shifted to cementless fixation in younger patients in most registries, including Australia.
- The shift has run ahead of comparative evidence of superiority.
- Recent reviews question whether current rates of uncemented fixation are supported by the literature.
The Acetabulum
- Cementless hemispherical cup with highly crosslinked polyethylene – excellent long-term survivorship in the young.
- Cemented all-polyethylene cups perform well in the elderly; historically higher loosening rates in young and active patients.
- Cementless shell allows supplementary screw fixation in dysplastic or deficient bone, and modular exchange at revision.
- Little genuine controversy at the socket.
The Femur
- Cementless stem – reliable osseointegration in good bone; avoids cement mantle failure. Principal risk is intraoperative and early periprosthetic fracture, strongly age and bone-quality dependent, uncommon under 65 with normal bone.
- Cemented stem – longest track record; excellent survivorship in the young with a proven design and modern cementing technique; markedly lower periprosthetic fracture rate. Series in patients under 55 report good survivorship beyond 20 years.
- Registry data continue to favour cemented femoral fixation in the elderly and in poor bone. Below 65 with good bone the difference in revision rate is small.
- Surgeon familiarity and the individual femoral anatomy matter more than the general principle.
Factors That Change the Decision
- Bone quality rather than chronological age – Dorr C bone, inflammatory arthropathy, long-term corticosteroid, renal osteodystrophy, prior radiotherapy all favour cement
- Abnormal femoral anatomy – dysplasia with narrow canal and excessive anteversion, previous osteotomy, malunion. Cemented or modular stem allows version to be set independently of the canal.
- Metabolic bone disease, osteopetrosis – cement avoids reliance on ingrowth
- Diagnosis – AVN, post-traumatic arthritis and juvenile inflammatory arthritis behave differently from primary OA
- Revision planning – a well-fixed cementless stem is harder to extract; a cement mantle in a young femur also complicates later revision
Bearing Surface
- At least as important as fixation in this age group.
- Highly crosslinked polyethylene with a ceramic head is the current default; wear an order of magnitude lower than conventional polyethylene. Series at mean 16 years report very low osteolysis and wear-related revision.
- Ceramic-on-ceramic – excellent wear characteristics; squeaking and fracture risk.
- Metal-on-metal and large-head metal-on-metal designs abandoned.
- Larger heads improve stability; balance against liner thickness in a small cup.
Summary
- Cementless cup, highly crosslinked polyethylene, ceramic head for essentially all patients in this group
- Femoral fixation guided by bone quality and anatomy rather than age alone
- Cementless stem reasonable in good bone; cemented stem safer in poor bone or abnormal anatomy
- Use an implant with registry-documented performance in this age group
- Counsel explicitly on the likelihood of revision within the patient’s lifetime, and on activity, which influences wear more than fixation does
References
- Kiran M, et al. Cemented total hip replacement in patients under 55 years. Acta Orthop 2018. PubMed 29345170
- Are current rates of uncemented fixation in total hip arthroplasty supported by the literature? Hip Int 2024. PubMed 38700947
- Revisiting cemented femoral fixation in hip arthroplasty. J Bone Joint Surg Am 2022. PubMed 35298444
- Mean 16-year results of total hip arthroplasty with alumina ceramic femoral heads on highly crosslinked polyethylene. J Arthroplasty 2023. PubMed 37105332
- Eighteen-year follow-up of 2 alternative bearing surfaces used in total hip arthroplasty. J Arthroplasty 2020. PubMed 31672505
- Primary total hip arthroplasty in patients 20 years old and younger. J Bone Joint Surg Am 2020. PubMed 31977814
Reviewed by Professor Phong Tran, Head of Orthopaedic Surgery, Western Health. Last updated 10 October 2026.