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?

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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)

  • Design characteristics (=Brand)

    • e.g. ASR


‘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?

Patient:

Age

Sex

BMI

Type of arthritis

General health

Function

Expectations

Surgeon:

Skills

Experience

Training

Evidence

Personal beliefs

Trust policy

Incentives


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

  • 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

  • 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

  • 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 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

  • 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

  • Revision

  • (Death)

  • Dislocation

  • Infection

  • Medical complications

  • Satisfaction

  • Functional outcome scores

Hospital Episode Statistics (HES)

PROMs

(EuroQoL & OHS)


Risk of revision after THR


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


Male


Female


Latest analyses

  • Adjusted multivariable competing risks models

  • Age group specific

  • ASA <3

  • OA pts only

  • MoM THR separate


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)


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


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?


Australian NJR figures


Trends in New Zealand


Other registry data


Australian Registry

171,000 patients, 6% cemented


Under 55 years

No significant differences


55-64 years

Hybrid significantly LOWER revision rate compared with cemented & uncemented


65-74 years

Cemented significantly HIGHER revision rate compared with uncemented & hybrid


Over 75 years

Uncemented significantly HIGHER revision rate compared with cemented


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

  • 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

  • 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

  • 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?

  • Good evidence

  • Low failure rates

  • Meets NICE guidelines

  • Cheaper

    • Initially

    • Overall revision costs


Why avoid cement?

  • Longer surgical time

  • Technically more demanding

  • Restricts cup to poly only

  • Revision more difficult???

  • (Industry pressure)


Summary

Age

55

I

60

I

65

I

70

I

75

I

Uncemented

Hybrid

Cemented


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?


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

  • Indepth NJR statistical analyses

    • Regression analsyis

    • Propensity score matching

  • PROMs data

    • Satisfaction

    • Functional differences


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


Thank you.


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