Choice of implant combinations in total hip replacement: systematic review and network meta-analysis

Abstract

Objective To compare the survival of different implant combinations for primary total hip replacement (THR). Design Systematic review and network meta-analysis. Data sources Medline, Embase, The Cochrane Library, ClinicalTrials.gov, WHO International Clinical Trials Registry Platform, and the EU Clinical Trials Register. Review methods Published randomised controlled trials comparing different implant combinations. Implant combinations were defined by bearing surface materials (metal-on-polyethylene, ceramic-on-polyethylene, ceramic-on-ceramic, or metal-on-metal), head size (large ≥36 mm or small <36 mm), and fixation technique (cemented, uncemented, hybrid, or reverse hybrid). Our reference implant combination was metal-on-polyethylene (not highly cross linked), small head, and cemented. The primary outcome was revision surgery at 0-2 years and 2-10 years after primary THR. The secondary outcome was the Harris hip score reported by clinicians. Results 77 studies were included in the systematic review, and 15 studies (3177 hips) in the network meta-analysis for revision. There was no evidence that the risk of revision surgery was reduced by other implant combinations compared with the reference implant combination. Although estimates are imprecise, metal-on-metal, small head, cemented implants (hazard ratio 4.4, 95% credible interval 1.6 to 16.6) and resurfacing (12.1, 2.1 to 120.3) increase the risk of revision at 0-2 years after primary THR compared with the reference implant combination. Similar results were observed for the 2-10 years period. 31 studies (2888 patients) were included in the analysis of Harris hip score. No implant combination had a better score than the reference implant combination. Conclusions Newer implant combinations were not found to be better than the reference implant combination (metal-on-polyethylene (not highly cross linked), small head, cemented) in terms of risk of revision surgery or Harris hip score. Metal-on-metal, small head, cemented implants and resurfacing increased the risk of revision surgery compared with the reference implant combination. The results were consistent with observational evidence and were replicated in sensitivity analysis but were limited by poor reporting across studies. Systematic review registration PROSPERO CRD42015019435.

Current Preclinical Testing of New Hip Arthroplasty Technologies Does Not Reflect Real-World Loadings: Capturing Patient-Specific and Activity-Related Variation in Hip Contact Forces

“…The ever-improving survivorship of joint arthroplasties is evidence of the important continued innovation and improvement in implant design and surgical techniques, which has led to better implant fixation options, improved wear performance, and reduction in perioperative and postoperative complication rates [2,3]. The outcomes of novel implant design are not however always better than for existing implants [10,11]. Occasionally, innovation leads to unforeseen problems such as early implant failure, as exemplified by the DePuy articular surface replacement (ASR) hip implant, which failed because of higher than anticipated wear between the 2 metal bearing surfaces [12e14].…”

Knockdown of Long Non-coding RNA TUG1 Suppresses Osteoblast Apoptosis in Particle-induced Osteolysis by Up-regulating BMP-7

“…Recently, the mechanism of osteolysis has been reported by various studies. It has been reported that wear debris could induce aseptic loosing and osteolysis [13][14][15] . Thus, in the present study, the clinical patients of hip arthroplasty with or without aseptic loosing were enrolled for studying the mechanism of osteolysis.…”

How might the longer-than-expected lifetimes of hip and knee replacements affect clinical practice?

“…However, these constructs only account for 25% of THRs implanted in England and Wales in 2016 [7]. A recent network meta-analysis concluded that newer THR implant combinations were not superior to a reference implant combination (metal-on-polyethylene, small head, cemented), which may now be considered 'old technology' [12]. The same group have subsequently demonstrated the superior cost-effectiveness of this implant combination [13].…”