Cemented versus uncemented stems in total hip arthroplasty: No independent effect on transfusion or complications despite reduced total blood loss

Abstract Purpose The impact of femoral stem fixation on perioperative blood loss and transfusion in total hip arthroplasty (THA) remains controversial. To compare cemented and uncemented stem fixation in elective primary THA regarding perioperative blood loss, transfusion requirements and postoperative complications. We hypothesized that stem fixation would not independently influence transfusion or complication risk after adjustment for patient‐related factors. Methods This retrospective cohort study analysed data from a institutional registry including THAs performed between 2016 and 2023. Patients were stratified according to femoral stem fixation (cemented vs. uncemented). Outcomes included intraoperative, total and hidden blood loss (HBL), allogeneic red blood cell transfusion and postoperative complications. Multivariable linear and logistic regression analyses assessed the independent effect of stem fixation, adjusting for age, sex, body mass index, American Society of Anesthesiologists (ASA) class, operative time and preoperative haemoglobin. Results A total of 648 patients were included (uncemented n = 548; cemented n = 100). Patients in the cemented group were older (79.8 ± 7.4 vs. 72.4 ± 9.1 years) and more frequently female (76.0% vs. 65.8%). Transfusion rates were higher in the cemented group. After multivariable adjustment, cemented fixation was independently associated with lower total blood loss (adjusted mean difference −146 mL; 95% confidence interval CI −271 to −21), whereas no independent associations were observed for intraoperative and HBL. Stem fixation was not independently associated with transfusion requirement (adjusted odds ratio OR 1.06; 95% CI 0.56–1.99) or postoperative complications (adjusted OR 0.64; 95% CI 0.21–1.98). Conclusion In elective primary THA, cemented femoral stem fixation is associated with a modest reduction in total blood loss but does not independently influence transfusion rates or postoperative complication risk. Clinically, these findings indicate that fixation should not be selected based on expectations of reduced transfusion risk. Instead, perioperative blood management should focus on patient‐related factors, particularly preoperative haemoglobin optimization. Level of Evidence Level III, retrospective comparative cohort study.