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Choice of implant combinations in total hip replacement: systematic review and network meta-analysis
José A López-López1, Rachel L Humphriss1, Andrew D Beswick2
1Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK.
Insights
Newer total hip replacement (THR) implant combinations do not improve revision surgery risk or patient outcomes compared to standard metal-on-polyethylene implants. Certain combinations, like metal-on-metal, increase revision risk, highlighting the need for careful implant selection.
Area of Science:
- Orthopedic Surgery
- Biomaterials Science
- Clinical Epidemiology
Background:
- Total hip replacement (THR) is a common procedure for hip osteoarthritis.
- Numerous implant combinations exist, differing in bearing surfaces, head size, and fixation.
- Evidence comparing the long-term survival and functional outcomes of these combinations is crucial.
Purpose of the Study:
- To systematically review and network meta-analyze the survival rates of different implant combinations used in primary total hip replacement.
- To compare revision surgery rates and functional outcomes (Harris hip score) across various implant configurations.
Main Methods:
- Systematic review and network meta-analysis of randomized controlled trials.
- Implant combinations defined by bearing material, head size, and fixation technique.
- Reference combination: metal-on-polyethylene (not highly cross-linked), small head, cemented fixation.
Main Results:
- No significant reduction in revision surgery risk was found for newer implant combinations compared to the reference.
- Metal-on-metal, small head, cemented implants and resurfacing showed an increased risk of revision surgery (0-10 years).
- No implant combination demonstrated a superior Harris hip score compared to the reference.
Conclusions:
- Current evidence does not support the superiority of newer implant combinations over the reference in terms of revision risk or functional outcomes.
- Specific combinations, including metal-on-metal and resurfacing, are associated with higher revision rates.
- Findings underscore the importance of established implant combinations and highlight potential risks with certain newer designs, though study reporting limitations exist.
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.
