A Review of Current Fixation Use and Registry Outcomes in Total Hip Arthroplasty: The Uncemented Paradox

Abstract

Background The majority (86%) of THAs performed in the United States are uncemented. This may increase the revision burden if uncemented fixation is associated with a higher risk of revision than other approaches. Question/purposes We sought to investigate trends for use of uncemented fixation and to analyze age-stratified risk of revision comparing cemented, hybrid, and uncemented fixation as reported by national hip arthroplasty registries. Methods Data were extracted from the annual reports of seven national hip arthroplasty registries; we included all national registries for which annual reports were available in English or a Scandinavian language, if the registry had a history of more than 5 years of data collection. Results Current use of uncemented fixation in primary THAs varies between 15% in Sweden and 82% in Canada.From 2006 to 2010 the registries of all countries reported overall increases in the use of uncemented fixation; Sweden reported the smallest absolute increase (from 10% to 15%), and Denmark reported the greatest absolute increase (from 47% to 68%). Looking only at the oldest age groups, use of uncemented fixation also was increasing during the period. In the oldest age group of each of the registries we surveyed (age older than 65 years for England-Wales; age older than 75 years in three registries), cemented fixation was associated with a lower risk of revision than was uncemented fixation. Conclusions Increasing use of uncemented fixation in THA is a worldwide phenomenon. This trend is paradoxic, given that registry data, which represent nationwide THA outcomes, suggest that cemented fixation in patients older than 75 years results in the lowest risk of revision. Level of Evidence Level II, systematic review.

Trends in hip replacements between 1999 and 2012 in Sweden

“…We believe one of the reasons for this change of fixation choice is the feedback received in the form of the annual reports as issued by the SHAR. The trend away from fully cemented implants toward uncemented implants is discussed in a research paper from the Nordic Arthroplasty Register Association (NARA) in the paper titled the uncemented paradox 27, 28. This change in practice has accelerated in recent years although cemented implants still constitute the majority overall.…”

Do Rerevision Rates Differ After First-time Revision of Primary THA With a Cemented and Cementless Femoral Component?

“…The Swedish hip registry shows increased use of highly crosslinked polyethylene (HXLPE) over time, from only a few percent in 2004 to approximately 50% of all primary THAs in 2010 [13]. Simultaneously more primary THAs were being performed using the cementless technique; Troelsen et al [27] showed cementless fixation use in Denmark to increase from 47% to 68% between 2006 and 2010. Because HXLPE has reduced wear compared with traditional polyethylene [5], it is plausible that increased use of HXLPE reduced bone defects in THA revised for aseptic loosening over time, thus being a potential confounder to our findings of less bone loss in revised cementless THAs.…”

“…Although the optimal component fixation method in primary THA is still debated, several studies have shown increased use of the cementless technique in most parts of the world [14,19,27]. The potential for biological fixation as well as extensive marketing and excellent outcomes in single-center studies of cementless femoral components may account for the increasing worldwide use of cementless fixation [16].…”

“…The potential for biological fixation as well as extensive marketing and excellent outcomes in single-center studies of cementless femoral components may account for the increasing worldwide use of cementless fixation [16]. Such increased use of cementless components might be considered paradoxical because some registry data suggest inferior survival of cementless THA [7,19,21,27].…”

Editorial: Large Database Studies—What They Can Do, What They Cannot Do, and Which Ones We Will Publish

“…We publish it frequently [10,11], and we have promoted it in Spotlight commentaries and interviews on these pages [13]. CORR 1 will publish selected proceedings from the most-recent meeting of the International Society of Arthroplasty Registries this summer, and we will cover the important role registries play in clinical research in an editorial in the coming months.…”