Cementless total hip arthroplasty in rheumatoid arthritis: a systematic review of the literature

Abstract

BackgroundCompromised rheumatic bone is a potential risk factor for mechanical complications in cementless total hip arthroplasty (THA) in cases of rheumatoid arthritis (RA). Increased rates of intra-operative fractures, component migration and (early) aseptic loosening are to be expected. Despite this, cementless THA is performed in cases of RA.MethodsA literature search on cementless THA in RA was performed in EMBASE (1993–2011), Medline (1966–2011) and the Cochrane Library. A systematic review was conducted with a special emphasis on mechanical complications.ResultsTwenty-three case series and five studies of implant registries were included. Acetabular fractures and/or migration of the cup were reported in 9 out of 22 studies of the cup. Proximal femoral fractures and/or subsidence of the stem were reported in 14 out of 20 studies of the stem. Six studies compared failure rates of uncemented and cemented components due to aseptic loosening. The overall failure rate ratio (uncemented/cemented) for the cup was 0.6 (95% CI: 0.14–2.60) and for the stem 0.71 (95% CI: 0.06–8.55), both favoring uncemented fixation. The failure rates in case series without a control group were compared to the NICE criteria (failure rate/1). The overall failure rate for the cup was 0.97 (95% CI: 0.50–1.88) and for the stem 0.79 (95% CI: 0.44–1.41). Failure rates of aseptic loosening of higher than 1 (favoring cemented fixation) were reported in 6 out of 26 studies of the cup and in 2 out of 25 studies of the stem. In all these studies, the inferior implant designs were blamed, and not the type of fixation or the quality of the bone.ConclusionsDespite substantial rates of mechanical stem complications, no evidence was found to establish that cementless components perform less well than cemented components. The results justify the use of cementless THA in RA patients.

Has Total Hip Arthroplasty in Patients 30 Years or Younger Improved? A Systematic Review

“…The decrease in loosening may also be attributed to improvement in implant fixation techniques, because Group II is predominated by cementless implants. Cementless fixation has been associated with decreased rates of failure as a result of aseptic loosening in multiple studies [7,8,11,31,34], including a randomized controlled trial [7,8]; however, this has not necessarily been corroborated with registry data [15]. It is unclear whether the introduction of alternative bearing surfaces has contributed to this reduction in aseptic loosening, because most studies failed to report the type of bearing surface used.…”

Primary total hip arthroplasty: health related quality of life outcomes

“…Until recently, cement endoprosthesis was a first choice of many surgical practices worldwide, but it has been steadily replaced by uncemented implants, although there has not been unanimous evidence presented on which method has clear advantage, if any [20,25,26]. The choice of endoprosthetic fixation is generally based on the characteristics of each individual patient and on the personal experience of the surgeon; however, that choice is not always determined by strict medical reasons, but rather on the availability of certain type of endoprosthesis, regardless the agreement of the surgeon.…”

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“…Although there was initial apprehension on the use of cementless prostheses in rheumatoid arthritis patients due to a perceived high rate of mechanical failure in these patients, recent evidence suggests that there was no significant difference in the overall outcomes between cemented and cementless prostheses in rheumatoid patients 41 . Other workers have also recently shown very good medium term outcomes of cementless THAs in a cohort of patients with Paget's disease; with 84% of these patients having excellent outcomes after 79.4 months of follow-up 42 .…”