THR Fixation Method in Patients Less Than 65 Years Old

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

  1. Kiran M, et al. Cemented total hip replacement in patients under 55 years. Acta Orthop 2018. PubMed 29345170
  2. Are current rates of uncemented fixation in total hip arthroplasty supported by the literature? Hip Int 2024. PubMed 38700947
  3. Revisiting cemented femoral fixation in hip arthroplasty. J Bone Joint Surg Am 2022. PubMed 35298444
  4. Mean 16-year results of total hip arthroplasty with alumina ceramic femoral heads on highly crosslinked polyethylene. J Arthroplasty 2023. PubMed 37105332
  5. Eighteen-year follow-up of 2 alternative bearing surfaces used in total hip arthroplasty. J Arthroplasty 2020. PubMed 31672505
  6. 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.