Choice of implant combinations in total hip replacement: systematic review and network meta-analysis
BMJ 2017; 359 doi: https://doi.org/10.1136/bmj.j4651 (Published 02 November 2017) Cite this as: BMJ 2017;359:j4651
- José A López-López, senior research associate1,
- Rachel L Humphriss, senior research associate1,
- Andrew D Beswick, research fellow2,
- Howard H Z Thom, research fellow1,
- Linda P Hunt, senior research fellow2,
- Amanda Burston, senior research associate2,
- Christopher G Fawsitt, senior research associate1,
- William Hollingworth, professor of health economics1,
- Julian P T Higgins, professor of evidence synthesis1,
- Nicky J Welton, professor of statistical and health economic modelling1,
- Ashley W Blom, professor of orthopaedic surgery2,
- Elsa M R Marques, research fellow2
- 1Department of Population Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- 2Musculoskeletal Research Unit, University of Bristol, Southmead Hospital, Learning and Research Building (Level 1), Bristol BS10 5NB, UK
- Correspondence to: E M R Marques e.marques{at}bristol.ac.uk
- Accepted 4 October 2017
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.
Footnotes
This article summarises findings from the Hip Implant Prosthesis Study (HIPS) study. We thank the HIPS steering group members: Keith Abrams (University of Leicester), Mark Wilkinson (University of Sheffield and National Joint Registry scientific committee), Mark Pennington (Kings College London), David Peacock (lay member), and Michael Nicholson (lay member) for methodological advice, and the Patient Experience Partnership in Research group (PEP-R) for patient views. We also thank Alison Richards for help in the development of the search strategy and Katie Warner for administrative support.
Copyright: This work is subject to Crown Copyright.
Contributors: EMRM, ADB, AWB, NJW, and WH conceived the project. RLH and ADB selected articles for inclusion, extracted data, and assessed risk of bias. RLH, ADB, JALL, EMRM, AWB, JPTH, WH, and NJW selected studies for inclusion. HHZT and JALL planned the statistical analyses with advice from NJW, JPTH, WH, and EMRM. JALL performed the network meta-analysis with advice from HHZT and CGF. AWB and LPH provided clinical expertise throughout, and AB and EMRM liaised with patient and surgeons for their involvement. EMRM, JALL, ADB, RLH, and AWB wrote the first draft of the paper and all authors revised it critically for important intellectual content. All authors have approved this version for publication. EMRM is the guarantor.
Funding: This article summarises independent research funded by the National Institute for Health Research’s (NIHR) research for patient benefit programme (PB-PG-0613-31032). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR, or the Department of Health. The funder had no role in the study design, data collection, data analysis, data interpretation, or writing of this article. All authors had full access to the data and had final responsibility for the decision to submit for publication.
Competing interests: All authors have completed the ICMJE uniform disclosure form at www.icmje.org/coi_disclosure.pdf and declare: no support from any organisation for the submitted work; no financial relationships with any organisations that might have an interest in the submitted work in the previous three years; no other relationships or activities that could appear to have influenced the submitted work.
Ethical approval: Not required.
Data sharing: No additional data available.
Transparency: The lead authors (EMRM, ADB, and JALL), affirm that the manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned and registered have been explained.
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