Cemented femoral fixation: the North Atlantic divide

European nations, especially Scandinavian countries, have used cemented fixation since the introduction of total hip arthroplasty. In Sweden, with arguably the best national-level data on prostheses survivorship, >90% of all stems are fixated with cement. In sharp contrast, it is estimated that in the United States, >88% of all femoral stems use cementless technology. This represents a diametrically opposed difference in philosophical approach: the so-called North Atlantic Divide. The departure in North America from cemented femoral stems can be traced to the coinage of the phrase "cement disease," which implicated cement as a leading cause of osteolysis. This led to prolific innovation of uncemented technologies in North America, while European countries favored standardization enabled by the national arthroplasty registries. The term "cement disease" has been proven to be a misnomer, as supported by excellent outcomes from the Scandinavian registries, as well as excellent long-term outcomes for cemented stems in United States series, even in patients younger than 50 years. Like uncemented stems, there is variability in survivorship between femoral stems, and this appears to be related to specific design features. Despite the excellent long-term results, the use of cemented femoral components in Europe and Canada is decreasing in favor of uncemented stems. The reasons for this are not immediately obvious.