Introduction

Total hip arthroplasty (THA) is a widely performed surgical procedure aimed at alleviating pain and restoring function in patients with severe hip joint pathologies, such as osteoarthritis (OA), rheumatoid arthritis (RA), and avascular necrosis (AVN) (Niemeläinen et al., 2020; You et al., 2022; Mencia et al., 2021). Hip OA alone represents a significant global burden, ranking among the leading causes of disability worldwide (Woolf & Pfleger, 2003). The procedure involves replacing the damaged hip joint with a prosthetic implant, and the method of fixation, cemented or uncemented, plays a crucial role in the long-term success of the surgery (Fabi & Levine, 2012).

Cemented fixation utilizes polymethylmethacrylate (PMMA) bone cement to anchor the implant components to the bone, providing immediate mechanical stability. This method has been traditionally favored for older patients with poor bone quality, as it allows for early weight-bearing and theoretically reduces the risk of postoperative complications related to implant instability (Palan et al., 2016; Vijapura et al., 2018). Studies have consistently shown that cemented THA can offer excellent long-term clinical outcomes, particularly in elderly populations, with a reduced incidence of certain complications such as periprosthetic fractures and lower early revision rates (Hailer et al., 2010; Mäkelä et al., 2014; National Joint Registry, 2022). For instance, a systematic review by Hailer et al. (2012) reported superior implant survival for cemented femoral stems in patients over 75 years (Abdulkarim et al., 2013). The technique of cementation, including vacuum mixing and retrograde filling, has been refined to optimize cement mantle quality and reduce potential complications like cement implantation syndrome (Aboushelib et al., 2008; Davis et al., 2003).

Uncemented fixation, on the other hand, relies on biological bone ingrowth into a porous-coated implant surface for long-term stability (Synder et al., 2012).

This method is often preferred for younger, more active patients with good bone quality, as it avoids potential complications associated with bone cement, such as the aforementioned cement implantation syndrome and certain systemic effects (Brown et al., 2002; Emara et al., 2021). However, uncemented THA may be associated with a higher risk of early postoperative complications, including periprosthetic fractures and persistent thigh pain (Zhu et al., 2015; Carlson et al., 2016). While uncemented fixation aims for biological integration, some studies indicate a greater initial risk of complications such as aseptic loosening or stress shielding in the short to medium term compared to well-performed cemented constructs, particularly in less ideal bone stock (Herberts & Malchau, 2000; Khanuja et al., 2011).

The choice between cemented and uncemented fixation methods remains a topic of ongoing debate among orthopedic surgeons (D'Ambrosi et al., 2016). While some studies and national joint registries suggest that cemented THA offers better outcomes in terms of implant survivorship and lower complication rates in older patients (National Joint Registry, 2022; Chen et al., 2021), others advocate for uncemented fixation in specific patient populations, emphasizing its potential for more durable long-term fixation in younger, high-demand individuals (Learmonth et al., 2007). For instance, a systematic review concluded that cemented fixation demonstrated overall better long-term survivorship than cementless fixation in primary hip replacement (Zwartelé et al., 2012). However, a meta-analysis by Morshed et al. (2007) found comparable long-term results between cemented and uncemented total hip arthroplasties regarding revision rates when patient selection was optimized (Morshed et al., 2007). The evolving designs of uncemented implants and improved surgical techniques continue to influence these outcomes (Synder et al., 2012; Kim et al., 2016).

In the context of Bangladesh, where the population is diverse in terms of age, activity levels, and bone quality, understanding the comparative outcomes of cemented versus uncemented THA is essential for optimizing patient care. However, there is a paucity of local data addressing this issue, highlighting the need for studies that evaluate the perioperative and postoperative outcomes associated with each fixation method in the Bangladeshi population.

This study aims to compare the perioperative data and postoperative complications between cemented and uncemented THA in a Bangladeshi cohort. By analyzing variables such as surgery duration, blood loss, hospital stay, and the incidence of complications like infection, dislocation, periprosthetic fracture, and aseptic loosening, this research seeks to provide evidence-based recommendations for the selection of fixation methods in THA tailored to the Bangladeshi context.

Materials and Methods

Study Design

This prospective, comparative observational study was conducted in the Department of Orthopaedic Surgery at Bangabandhu Sheikh Mujib Medical University Hospital, Dhaka, Bangladesh. The study spanned a 12-month period, from January to December 2023. Ethical clearance was obtained from the Institutional Review Board prior to initiation, and the research adhered strictly to the ethical principles outlined in the Declaration of Helsinki. Written informed consent was secured from each participant prior to enrollment in the study.

Patient Selection, study parameters

A total of 60 elderly patients aged 65 years and above, all diagnosed with radiographically confirmed primary hip osteoarthritis (OA), were recruited for elective total hip arthroplasty (THA). Based on the type of implant fixation determined by the surgical team, patients were divided into two equal groups. Group A (n = 30) underwent cemented THA using polymethylmethacrylate (PMMA) prostheses, while Group B (n = 30) received uncemented prostheses with porous-coated surfaces to facilitate biological integration. Inclusion criteria for participation included age 65 years or older, a confirmed diagnosis of primary hip OA, medical fitness for surgery under spinal or general anesthesia, and a willingness to adhere to the prescribed follow-up schedule. Patients were excluded if they had secondary osteoarthritis due to trauma, infection, avascular necrosis, or inflammatory arthropathy, a history of prior surgery on the affected hip, severe systemic comorbidities that contraindicated surgery, or cognitive impairments that limited their ability to provide informed consent.

All surgeries were performed by senior orthopedic surgeons using a standardized posterior surgical approach. For the cemented group, modern third-generation cementation techniques were employed, including pulsed lavage, vacuum mixing, and retrograde filling to ensure optimal implant fixation. In contrast, the uncemented group received implants with hydroxyapatite or porous titanium coatings designed to promote osseointegration and long-term stability without the use of bone cement.

Postoperative care protocols were uniform for all patients and included the administration of intravenous prophylactic antibiotics for 48 hours and thromboprophylaxis using low molecular weight heparin. Pain management was achieved through a multimodal analgesic regimen. All patients were mobilized beginning on the first postoperative day with the assistance of a structured physiotherapy program, and follow-up evaluations were conducted at 6 weeks, 3 months, and 6 months post-surgery. Functional recovery efforts were supported by a dedicated rehabilitation team.

The study evaluated both primary and secondary outcomes. Primary outcomes included functional assessment via the Harris Hip Score (HHS) at baseline and six months postoperatively, as well as the incidence of complications such as surgical site infections, joint dislocation, periprosthetic fractures, and aseptic loosening. Secondary outcomes encompassed intraoperative metrics including surgery duration (minutes), estimated blood loss (milliliters), length of hospital stay (days), and changes in hip joint range of motion (ROM), specifically flexion, abduction, and external rotation, measured using a standard goniometer.

Statistical Analysis

All data were analyzed using IBM SPSS Statistics for Windows, Version 25.0 (IBM Corp., Armonk, NY, USA). Continuous variables were presented as means with standard deviations and compared using independent sample t-tests. Categorical data were analyzed using chi-square or Fisher’s exact tests as appropriate. Statistical significance was defined as a p-value less than 0.05.

Results

The study enrolled 60 patients, equally divided between the cemented prosthesis group (Group A) and the uncemented prosthesis group (Group B). Baseline demographic characteristics were statistically comparable between groups, indicating a well-matched cohort (Table 1). The mean age was 70.5?±?4.2 years in Group A and 69.8?±?3.9 years in Group B (p?=?0.45). Gender distribution was similar, with males comprising 53.3% of Group A and 60% of Group B (p?=?0.61). The mean Body Mass Index (BMI) was also comparable—25.1?±?3.2?kg/m² in Group A and 24.7?±?3.0?kg/m² in Group B (p?=?0.58)—suggesting homogeneity in preoperative health status and eliminating baseline disparity as a potential confounder (Table 1).

Functional outcomes were assessed using the Harris Hip Score (HHS) both preoperatively and at six months postoperatively (Table 2). Preoperative HHS scores were not significantly different between the two groups (45.2?±?5.1 in Group A vs. 44.8?±?5.4 in Group B; p?=?0.72). However, by the six-month follow-up, Group A showed a significantly higher mean HHS (88.6?±?6.3) compared to Group B (85.2?±?7.1; p?=?0.03), indicating superior early functional recovery among patients who received cemented implants (Table 2, Figure 1).

Evaluation of joint range of motion (ROM) revealed improvements in all parameters following surgery, with notable differences favoring the cemented group (Table 3). Postoperative hip flexion improved to 110.5° in Group A from a preoperative mean of 60.1°, compared to an improvement from 59.5° to 105.4° in Group B. This difference in flexion was statistically significant (p?=?0.04). Similarly, total ROM was higher in Group A (199.0°) than in Group B (188.2°), with a significant p-value of 0.03. Although abduction and external rotation also improved more in Group A, those differences did not reach statistical significance (p?=?0.08 and p?=?0.09, respectively), suggesting a trend toward better overall functional mobility in the cemented group (Table 3).

Comparison of perioperative parameters revealed no significant differences in operative or recovery-related variables (Table 4). Mean surgery duration was 90?±?10 minutes for Group A and 85?±?12 minutes for Group B (p?=?0.12). Mean intraoperative blood loss was slightly higher in Group A (300?±?50 ml) than in Group B (280?±?45 ml), but this difference was not statistically significant (p?=?0.09). Likewise, mean hospital stay was 5.2?±?1.1 days in Group A and 4.8?±?1.3 days in Group B (p?=?0.15), further confirming comparable surgical burden and recovery trajectories between the groups (Table 4).

Postoperative complications were infrequent in both groups but slightly more common in the uncemented group (Table 5). Group A experienced two complications—one superficial infection and one dislocation (6.7%). In contrast, Group B had three complications—two periprosthetic fractures and one case of aseptic loosening (10%). Despite these differences, the overall incidence of complications remained low and did not reach statistical significance (Table 5).

Discussion

The study's short follow-up period and small sample size highlight the need for further research, including long-term comparative trials and cost-effectiveness analyses, to comprehensively assess the durability, revision rates, and patient satisfaction of each technique. Despite these limitations, the study strengthens existing global evidence supporting the use of cemented prostheses in elderly populations. Additionally, it provides valuable data from a South Asian context, contributing to a broader understanding of treatment outcomes in this demographic. Further studies with larger samples and extended follow-up periods are essential to confirm these findings and refine clinical practices.

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