We’ve all been there: struggling with cement pressurization in a tight femoral canal, watching precious OR minutes tick away as we chase perfect fixation. Cementless implants promised a cleaner, faster alternative decades ago, but skepticism lingered. Early enthusiasm met with mixed outcomes, and cement remained the gold standard in many practices. Now, two decades on, the question resurfaces with renewed urgency: Is the cementless revolution finally here?
For years, the orthopaedic community accepted cement as the reliable workhorse for arthroplasty fixation. The narrative was simple-cement provides immediate stability, predictable outcomes, and a safety net against early loosening. Cementless implants, by contrast, were often relegated to younger, healthier patients with good bone stock. The “noise” was the fear of early micromotion, thigh pain, and the dreaded stress shielding. But the “signal” emerging from long-term data and evolving implant technology challenges this orthodoxy.
Let’s dissect the evidence and implications. First, implant design has matured. Porous coatings, trabecular metal, and 3D-printed surfaces now offer superior osteointegration. These advances reduce the risk of fibrous ingrowth and improve initial stability, which was the Achilles’ heel of early cementless stems. Surgeons are no longer gambling on bone quality alone; the implant-bone interface is engineered to encourage biological fixation even in less-than-ideal bone.
Second, patient demographics and expectations have shifted. Our patients are living longer, more active lives. Cementless fixation offers the promise of durable, long-lasting implants that may reduce revision rates decades down the line. The literature increasingly supports this: registry data from Scandinavia and Australia show comparable or even superior survivorship for cementless hips at 15-20 years, especially in younger cohorts. The pendulum swings toward cementless not just for longevity but for functional outcomes-less thigh pain, better load transfer, and a more natural biomechanics.
Third, surgical technique and perioperative management have evolved. Navigation, robotics, and improved imaging help us achieve precise implant positioning, which is critical for cementless success. We’ve learned that initial press-fit matters immensely; subtle errors in sizing or alignment can doom a cementless implant. Cementless fixation demands a surgical mindset that embraces meticulous preparation and respect for bone biology. It’s not a “set it and forget it” approach.
What does this mean for our surgical fundamentals? We must rethink the dogma that cement equals safety and cementless equals risk. The art of arthroplasty now includes a nuanced decision-making process: patient factors, bone quality, implant design, and surgeon skill all intersect. Cementless fixation is no longer experimental; it’s a mainstream option that requires mastery. We must train residents and fellows to understand the biomechanics and biology underpinning both techniques, rather than defaulting to cement out of habit or convenience.
Our take is clear but measured. Cementless fixation is not a panacea, nor should it replace cement indiscriminately. Instead, it represents a paradigm shift grounded in two decades of innovation and data. We advocate for a tailored approach: embrace cementless implants when the biology and biomechanics align, but retain cement as a vital tool in the armamentarium. The revolution is here, but it’s not a coup-it’s an evolution.
For the learner hungry for surgical excellence, the takeaway is this: master both techniques, understand their indications deeply, and let evidence-not tradition-guide your choice. The cementless revolution demands intellectual rigor and surgical precision. It rewards those willing to challenge old assumptions and adapt to new realities. The future of arthroplasty fixation is not cementless versus cemented; it’s cementless and cemented, deployed with wisdom and skill.
