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Failure rate of cemented and uncemented total hip replacements: register study of combined Nordic database of four nations

BMJ 2014; 348 doi: (Published 13 January 2014) Cite this as: BMJ 2014;348:f7592
  1. Keijo T Mäkelä, associate professor1,
  2. Markus Matilainen, statistician2,
  3. Pekka Pulkkinen, statistician3,
  4. Anne M Fenstad, statistician4,
  5. Leif Havelin, professor45,
  6. Lars Engesaeter, professor45,
  7. Ove Furnes, professor45,
  8. Alma B Pedersen, clinical associate professor6,
  9. Søren Overgaard, professor78,
  10. Johan Kärrholm, professor9,
  11. Henrik Malchau, professor910,
  12. Göran Garellick, associate professor11,
  13. Jonas Ranstam, professor12,
  14. Antti Eskelinen, associate professor13
  1. 1Department of Orthopaedics and Traumatology, Turku University Hospital, Rauhankatu 24 D 32, Turku, FI-20100, Finland
  2. 2Department of Biostatistics, Turku University, Finland
  3. 3Hjelt Institute, Helsinki University, Helsinki, Finland
  4. 4The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway
  5. 5Department of Clinical Medicine, University of Bergen, Bergen, Norway
  6. 6Competence Centre for Clinical Epidemiology and Biostatistics, North, Department of Clinical Epidemiology, Aarhus University Hospital
  7. 7Department of Orthopaedic Surgery, Traumatology and Clinical Institute, Odense University Hospital, Odense, Denmark
  8. 8Danish Hip Arthroplasty Register, Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark
  9. 9The Swedish Hip Arthroplasty Register, Department of Orthopaedics, Institute of Surgical Sciences, Sahlgrenska University Hospital, University of Gothenburg, Mölndal, Sweden
  10. 10Orthopaedic Department, Massachusetts General Hospital/ Harvard Medical School, Boston, Massachusetts, US
  11. 11The Swedish Hip Arthroplasty Register, Department of Orthopaedics, Institute of Surgical Sciences, Sahlgrenska University Hospital, University of Gothenburg, Mölndal, Sweden
  12. 12Swedish National Competence Center Musculoskeletal Disorders, Skåne University Hospital, Lund, Sweden
  13. 13The Coxa Hospital for Joint Replacement, Tampere, Finland
  1. Correspondence to: K T Mäkelä keijo.makela{at}


Objective To assess the failure rate of cemented, uncemented, hybrid, and reverse hybrid total hip replacements in patients aged 55 years or older.

Design Register study.

Setting Nordic Arthroplasty Register Association database (combined data from Sweden, Norway, Denmark, and Finland).

Participants 347 899 total hip replacements performed during 1995-2011.

Main outcome measures Probability of implant survival (Kaplan-Meier analysis) along with implant survival with revision for any reason as endpoint (Cox multiple regression) adjusted for age, sex, and diagnosis in age groups 55-64, 65-74, and 75 years or older.

Results The proportion of total hip replacements using uncemented implants increased rapidly towards the end of the study period. The 10 year survival of cemented implants in patients aged 65 to 74 and 75 or older (93.8%, 95% confidence interval 93.6% to 94.0% and 95.9%, 95.8% to 96.1%, respectively) was higher than that of uncemented (92.9%, 92.3% to 93.4% and 93.0%, 91.8% to 94.0%), hybrid (91.6%, 90.9% to 92.2% and 93.9%, 93.1% to 94.5%), and reverse hybrid (90.7%, 87.3% to 93.2% and 93.2%, 90.7% to 95.1%) implants. The survival of cemented (92.2%, 91.8% to 92.5%) and uncemented (91.8%, 91.3% to 92.2%) implants in patients aged 55 to 64 was similar. During the first six months the risk of revision with cemented implants was lower than with all other types of fixation in all age groups.

Conclusion The survival of cemented implants for total hip replacement was higher than that of uncemented implants in patients aged 65 years or older. The increased use of uncemented implants in this age group is not supported by these data. However, because our dataset includes only basic information common to all national registers there is potential for residual confounding.


  • Contributors: All authors were involved in the study design, analysis and interpretation of the data, and drafting and final approval of the manuscript. KTM is guarantor. All authors had full access to all of the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding: This study was funded by a research grant from Turku University Hospital and a grant from the Orion-Farmos Research Foundation. These are non-profit organisations and with no role in the study. The researchers are totally independent of the funders.

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare: JK has received grants outside the submitted work from Link Germany, Zimmer Europe, and Biomet; OF has received grants from Smith & Nephew, Norway, and Orthomedic, Norway, outside the submitted work; HM has received grants from Link Germany, Zimmer Europe and USA, Biomet Europe and USA, MAKO USA, and DePuy outside the submitted work; 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; and no other relationships or activities that could appear to have influenced the submitted work.

  • Ethical approval: This study was approved through each national registries own ethical process.

  • Data sharing: No additional data available.

  • Transparency: A statement that the lead author (the manuscript’s guarantor) affirms 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, if relevant, registered) have been explained.

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