Should we cement all hip replacements
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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


Should we cement all hip replacements

‘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)


Risk of revision after thr

Risk of revision after THR


Should we cement all hip replacements

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


Should we cement all hip replacements

Male


Female

Female


Latest analyses

Latest analyses

  • Adjusted multivariable competing risks models

  • Age group specific

  • ASA <3

  • OA pts only

  • MoM THR separate


Should we cement all hip replacements

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)


Should we cement all hip replacements

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


Should we cement all hip replacements

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


Is implant use evidence based

Is implant use evidence-based?


Australian njr figures

Australian NJR figures


Trends in new zealand

Trends in New Zealand


Other registry data

Other registry data


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)


Should we cement all hips

Should we cement all hips?


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


Acknowledgements andy sprowson mike reed andy port prof gregg national joint registry

AcknowledgementsAndy Sprowson, Mike Reed, Andy Port, Prof Gregg, National Joint Registry


Thank you

Thank you.


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