Total hip arthroplasty (THA) is a cornerstone of geriatric medicine, yet the selection of optimal fixation strategies and surgical approaches remains a subject of intense clinical debate. As global demographics shift toward an aging population, the demand for THA is projected to rise exponentially, necessitating a thorough evaluation of perioperative outcomes and longterm survivorship. This review critically analyzes recent 2024–2025 evidence regarding the biomechanical stability and clinical efficacy of cemented versus cementless fixation in patients aged 70 years or older. Current literature suggests that while cementless technology dominates younger cohorts, cemented fixation provides superior initial rotational stability in the osteoporotic environment, significantly reducing the risk of intraoperative periprosthetic fractures. Furthermore, this report examines the impact of the Direct Anterior Approach (DAA) compared to the Posterior Approach (PA) within the framework of Enhanced Recovery After Surgery (ERAS), highlighting the DAA's benefits in minimizing softtissue trauma and reducing hospital length of stay. Finally, we synthesize modifiable and non-modifiable risk factors for periprosthetic joint infection (PJI) and fracture progression. Understanding these multifaceted factors is essential for tailoring personalized surgical interventions and improving functional recovery in the geriatric population.