Overview of Randomized Controlled Trials in Primary Total Hip Arthroplasty (34,020 Patients): What Have We Learnt?

Abstract

Aim: To provide an overview of randomized controlled trials (RCTs) in primary total hip arthroplasty summarizing the available high-quality evidence. Materials and Methods: Following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA), we searched the Cochrane Central Register of Controlled Trials (2020, Issue 1), Ovid MEDLINE, and Embase. We excluded nonrandomized trials, trials on neck of femur fractures or revision surgery, systematic reviews, and meta-analyses. Trials that met our inclusion criteria were assessed using a binary outcome measure of whether they reported statistically significant findings. These were then classified according to the intervention groups (surgical approach, fixation, and component design use, among others). Results: Three hundred twelve RCTs met the inclusion criteria and were included. The total number of patients in those 312 RCTs was 34,020. Sixty-one RCTs (19.5%) reported significant differences between the intervention and the control groups. The trials were grouped into surgical approach 72, fixation 7, cement 16, femoral stem 46, head sizes 5, cup design 18, polyethylene 25, bearing surfaces 30, metal-on-metal 30, resurfacing 20, navigation 15, robotics 3, surgical technique 12, and closure/drains/postoperative care 13 RCTs. Discussion: The evidence reviewed indicates that for the vast majority of patients, a standard conventional total hip arthroplasty with a surgical approach familiar to the surgeon using standard well-established components and highly cross-linked polyethylene leads to satisfactory clinical outcomes. This evidence also offers arthroplasty surgeons the flexibility to use the standard and cost-effective techniques and achieve comparable outcomes.

Short versus conventional straight stem in uncemented total hip arthroplasty: functional outcomes up to 5 years and survival up to 12 years: secondary results of a randomized controlled trial

“…No significant differences were observed between the groups at 5 years after THA, for either the primary or secondary outcomes. This is similar to our 2-year results [ 9 ] and to the vast majority of randomized trials in the primary THA population [ 25 ]. We used a rather conservative threshold for clinical relevance for the primary outcome: a difference of 10% [ 7 , 26 ].…”

Should patient age thresholds dictate fixation strategy in total hip arthroplasty?

“…Randomized controlled trials have not consistently shown one technique to be superior to another. 10,11 Some long-term follow-up studies have favoured cementless fixation, 12 and long-term excellent results with cementless stems have been reported, 13 even in elderly patients. 14 International joint arthroplasty registries generally report improved survivorship with cemented stem fixation, 8,15 particularly in elderly patients, while improved survivorship using cementless fixation has been reported in younger patients.…”

Three orthopaedic operations, over 1,000 randomized controlled trials, in over 100,000 patients

“…The evidence available from high-quality RCTs indicates that for the vast majority of patients, a standard conventional THA with a surgical approach familiar to the surgeon, using standard well-established components and XLPE, leads to satisfactory clinical outcomes. 15 …”