Background <p>Periprosthetic femur fractures (PFF) are a significant complication associated with Total Hip Arthroplasty (THA) and Hemiarthroplasty (HA). There remains a gap in the literature regarding a consensus on which method of stem fixation yields higher rates of periprosthetic fractures—cemented or cementless. The aim of this study is to analyze the rates of comminution, stem loosening and requirements for full femoral component revision in periprosthetic femoral fractures when comparing cemented implants to cementless implants.</p> Methods <p>A retrospective cohort study of all femoral PFFs between 2007 and 2023 at a single academic institution was conducted. Subjects were grouped via stem fixation—cemented versus cementless. Presenting radiographs were examined to assess the fracture complexity and Vancouver Classification. Procedure type required was also analysed to assess the rates of revision versus ORIF amongst the groups. Revision arthroplasty for infection &amp; dislocation, as well as femoral stem fractures and intra-operative periprosthetic fractures were excluded. Statistical analysis was carried out using Stata13/IC for Mac (64-bit-Intel).</p> Results <p>Over the 17-year period, 216 femoral PFFs that underwent operative treatment were examined. The femoral stem fixation was cemented in 129 patients and cementless in 87 patients. Periprosthetic femur fractures in cemented femoral stems had significantly higher rates of comminuted fracture patterns (<i>p</i> &lt; 0.05), and stem loosening (Vancouver B2 and B3, <i>p</i> &lt; 0.05). There was a clinically significant association between stem fixation type and revision of the stem (10% higher rate of revision with cemented implants).</p> Conclusion <p>Cemented stems are significantly more likely than cementless stems to cause comminution and stem loosening in the context of periprosthetic femoral fractures. PFFs around cemented stems show a clinically significant higher rate of revision of the stem.</p>