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Should we cement all hip replacements?. Simon Jameson National Joint Registry Research Fellow Northern Deanery Registrar Teaching Programme. September 2011. Implant options. Fixation Cement / uncemented / hybrid Head size 22-58mm Bearing surface MoP, MoM, CoC, CoP, (CoM)

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should we cement all hip replacements

Should we cement all hip replacements?

Simon Jameson

National Joint Registry Research Fellow

Northern Deanery Registrar Teaching Programme

September 2011

implant options
Implant options
  • Fixation
    • Cement / uncemented / hybrid
  • Head size
    • 22-58mm
  • Bearing surface
    • MoP, MoM, CoC, CoP, (CoM)
  • Design characteristics (=Brand)
    • e.g. ASR
slide4

‘The FDA’s approval is based on a two-year, randomized clinical trial, which found no clinical difference between 194 patients who received the new ceramic-on-metal system and 196 patients in a control group who received a metal-on-metal hip implant….’

FDA, June 2011

which implant to use
Which implant to use?

Patient:

Age

Sex

BMI

Type of arthritis

General health

Function

Expectations

Surgeon:

Skills

Experience

Training

Evidence

Personal beliefs

Trust policy

Incentives

implant usage 2010
Implant usage 2010
  • 146 different brands of femoral stem
  • 123 different brands of cup
  • Exeter V40 - 63% cemented market
  • Contemporary cemented cup - 35%
  • Corail stem - 47% uncemented
  • Pinnacle cup system - 34%

National Joint Registry 8th Annual Report

nice recommendations
NICE recommendations
  • Revision rate of less than 10% at 10yrs
    • Or at least 3-yr revision data, consistent with the 10-yr benchmark
  • Cemented implants - ‘more evidence of the long-term viability’
  • ‘no cost-effective data… to support…more costly cementless and hybrid hip prostheses’

Technology Appraisal Guidance (TAG) No. 2 - ‘Guidance on the selection of prostheses for Primary Total Hip Replacements’ (NICE 2003)

orthopaedic device evaluation panel odep rating
Orthopaedic Device Evaluation Panel (ODEP) Rating
  • Longevity and quality of evidence
  • ODEP 10A (‘benchmark - <10% revision)
    • 84% of cemented stems
    • 74% of uncemented stems
    • 42% of cemented cups
    • 5% of uncemented cups
    • 51% resurfacing systems

10-year data

3-, 5- or 7-year data

Listed as pre-entry if less than 3 years data

national joint registries
National joint registries
  • Scandanavian registries in 1970s/80s
    • Sweden, Finland and Norway
  • Australian 1999
  • New Zealand 1999
  • Scottish Arthroplasty Registry 2000
  • England and Wales 2002
  • Canada
  • (US)
national joint registries1
National joint registries
  • Provide quality demographic data
  • Reduce revision rates and costs
    • AOA estimated $10million annual savings with a 1% reduction in revision*
  • Audit hopsitals and surgeons
  • Improve patient outcomes
    • Reduce morbidity and mortality, and improve function

Graves SE, Davidson D, et al. (2004). The Australian Orthopaedic Association National Joint Replacement Registry. Med J Aust 180(5 Suppl): S31-34.

njr for england wales
NJR for England & Wales
  • THR / TKR / TAR (TSR / TER)
  • >1 million procedures (largest NJR)
  • Now mandatory across the NHS and independent sector
  • Data collected via MDS
  • Complication data via HES linkage
  • Patient Reported Outcome Measures
outcome measures
Outcome measures
  • Revision
  • (Death)
  • Dislocation
  • Infection
  • Medical complications
  • Satisfaction
  • Functional outcome scores

Hospital Episode Statistics (HES)

PROMs

(EuroQoL & OHS)

slide16

For the entire England & Wales primary THR population:

‘Cemented THR has SIGNIFICANTLY LOWER REVISION RATE at 7yrs compared to uncemented and hybrid’

National Joint registry 8th Annual Report

latest analyses
Latest analyses
  • Adjusted multivariable competing risks models
  • Age group specific
  • ASA <3
  • OA pts only
  • MoM THR separate
slide21

In OA patients over 70 years:

CEMENTED THR has SIGNIFICANTLY LOWER REVISION RATES at 5yrs compared to uncemented & hybrids, in both males & females

(35% died by 10 years)

slide23

In OA patients aged 60-69 years:

UNCEMENTED THR has SIGNIFICANTLY HIGHER REVISION RATES at 5yrs compared to cemented in males & females

No difference between cemented & hybrid

slide25

In OA patients less than 60 years:

UNCEMENTED THR has SIGNIFICANTLY HIGHER REVISION RATES at 5yrs compared to cemented & hybrids in females

No difference between cemented, uncemented & hybrid in males

australian registry
Australian Registry

171,000 patients, 6% cemented

under 55 years
Under 55 years

No significant differences

55 64 years
55-64 years

Hybrid significantly LOWER revision rate compared with cemented & uncemented

65 74 years
65-74 years

Cemented significantly HIGHER revision rate compared with uncemented & hybrid

over 75 years
Over 75 years

Uncemented significantly HIGHER revision rate compared with cemented

new zealand registry
New Zealand Registry
  • 60,000 THRs (since 1999)
  • Cemented significantly LOWER risk
  • Revision risk stratified by age:
    • Cemented higher in <55yrs
    • Hybrid lower in 55-64yrs
    • Uncemented higher in 65-74
    • Cemented lower in >75
scandanavian registries
Scandanavian registries
  • Longest follow-up
  • Cemented 10yr survival 88% - 95%
  • Uncemented have a HIGHER revision risk across all 3 registries (80 - 85%)
  • Revision risk is higher in younger pts
    • Cemented implants were superior
problems with njr data
Problems with NJR data
  • Medium term
  • Currently revision only
    • Uncemented hips may allow greater function / cause less discomfort
  • Severity of disease not known prior to surgery
  • Lack of indepth analyses
cost implications
Cost implications
  • Tariff for revision = £8196
  • Revision rate at 7yrs 5.46% for uncemented versus 3.08% for cemented
  • 69,000 THRs in 2010 –
    • If all uncemented were cemented (43% - 29,670), there would be 2.38% (706) less revisions in 7 yrs, saving £5.8million
  • + initial lower cost of cemented hips
why do cemented
Why do cemented?
  • Good evidence
  • Low failure rates
  • Meets NICE guidelines
  • Cheaper
    • Initially
    • Overall revision costs
why avoid cement
Why avoid cement?
  • Longer surgical time
  • Technically more demanding
  • Restricts cup to poly only
  • Revision more difficult???
  • (Industry pressure)
summary
Summary

Age

55

I

60

I

65

I

70

I

75

I

Uncemented

Hybrid

Cemented

odep rating and 5yr failure
ODEP rating and 5yr failure
  • Cemented
    • Styker Exeter V40 – 10A
  • Hybrid
    • Styker Exeter V40 – 10A
    • Styker Trident – 5A
  • Uncemented
    • DePuy Corail stem – 10A
    • DePuy Pinnacle cup system – 7A

0.92% (0.78-1.08)

0.42% (0.24-0.73)

  • DePuy Elite Plus – 10A
  • Styker Contemporary cup – 5A

1.26% (0.99-1.59)

1.85% (1.63-2.10)

conclusion
Conclusion
  • Patients over 70ys
    • Cemented THR
  • Patients 60-70ys
    • Cemented THR
    • (Hybrid - option of ceramic bearing)
  • Patients under 60ys
    • Females – hybrid or cemented
    • More evidence required for males
future
Future
  • Indepth NJR statistical analyses
    • Regression analsyis
    • Propensity score matching
  • PROMs data
    • Satisfaction
    • Functional differences
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