Although several studies indicate excellent results for cementless implants, controversy persists regarding its use in elderly patients. We determined to evaluate the outcome on patients aged over 80 years who were treated with cementless total hip arthroplasty for primary osteoarthritis of the hip. We assessed the data of 162 consecutive total hip arthroplasties in octogenarian patients (mean age 83 years, range 80-96 years). A control group was created, consisting of 342 patients aged younger than 80 years (mean age 65 years, range 37-79 years). The median follow-up of the cohort was 128.4 months (range 6-211). Competing risk analyses revealed a cumulative implant survival of 98.1% at 5 and 10 years in the study group compared to 99.1% and 98.4% in the control group, taking system exchange as the end point. No differences in regard to system exchange could be detected between the groups. A significantly worsened complication-free survival rate was evident in the octogenarian group. Osteoporosis was the most powerful risk factor that proved to have a significant negative impact on development of complications. Uncemented total hip arthroplasty is a viable option for the elderly patient. In this population sector, an excellent rate of implant survival can be expected. However, a significant increase of total complications in the octogenarian group could be detected, and was mainly caused by an elevated number of early postoperative complications. Osteoporosis turned out to be a strong risk factor in regard to complication-free survival. Surgeons should therefore be aware of this.