Total hip replacement and resurfacing arthroplasty for end-stage arthritis of the hip
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Anja Desomer, Lorena San Miguel, Chris De Laet
The National Institute for Health and Care Excellence (NICE) performed an update in 2014 of two existing NICE technology appraisals on total hip replacement and resurfacing arthroplasty in patients with end-stage arthritis of the hip. Based on an update of the original systematic literature searches and a retrospective analysis of individual patient data from the National Joint Registry, NICE reformulated their original recommendation on the use of prostheses.
"Prostheses for total hip replacement and resurfacing arthroplasty are recommended as treatment options for people with end-stage arthritis of the hip only if the prostheses have rates (or projected rates) of revision of 5% or less at 10 years."
A 2014 NICE clinical guideline on the management of osteoarthritis in adults states that following non-surgical treatment, including exercise, physical therapy and analgesics, a joint replacement surgery could be considered if the patient has ongoing pain, joint stiffness, reduced function and a poor quality of life. This surgery may consist of a total replacement of the damaged hip (total hip replacement, THR) or a hip resurfacing arthroplasty.
THR consists in removing and replacing the patient’s femoral head and neck and acetabulum. Resurfacing arthroplasty preserves the neck of the patient’s femur, while the femoral head and acetabulum is not replaced but resurfaced with a cup.
Literature review and patient data analysis
The NICE review is an update of two technology appraisals on the effectiveness of THR and arthroplasty and focuses on the differences in revision rates between both surgical interventions in patients with end-stage arthritis. The original guidance on the selection of prostheses for primary total hip replacement recommended the use of prostheses with a maximum revision rate of 10% at 10 years. Meanwhile, guidance on the use of metal on metal (MoM) hip resurfacing arthroplasty recommended this intervention as an option for relatively active, younger people (below 65 years) with advanced hip disease who would otherwise receive a conventional primary THR.
The NICE Assessment Group conducted a systematic review of randomised controlled trials (RCTs), systematic reviews and registry studies on hip replacement. In addition to this, an analysis of individual patient data from the National Joint Registry (NJR) on all procedures performed in public and private practice from 2003 to 2012, was also performed. Sixteen RCTs and 8 systematic reviews were identified, but methodological weaknesses impeded the pooling of the results. The search for registry studies revealed 8 studies on arthroplasty and 22 on THR.
Results and conclusions
Evidence from the RCTs on the revision rates of arthroplasty and THR were inconclusive. Nevertheless, the systematic reviews, including data from both RCTs and observational studies, showed a higher revision rate after resurfacing arthroplasty compared to THR. This was further supported by three of the 4 registry studies. Finally, the results from retrospective data analysis of individual patient data, matched for age and sex, from the NJR were also in line with published registry studies: the revision rate for resurfacing arthroplasty over 9 years of follow-up was about 3 times higher than for all types of THR prostheses. In patients eligible for both resurfacing arthroplasty and THR (i.e. people younger than 65 years, and active), the predicted revision rates were:
- at 10 years: 17.2% for resurfacing arthroplasty versus 4.6% for THR
- at 20 years: 48.3% for resurfacing arthroplasty versus 12.9% for THR.
Some uncertainty remains regarding these differences in revision rates, as people who undergo resurfacing arthroplasty are more likely to be physically active, which could in turn contribute to an acceleration in the wear of a prosthesis.
In patients for whom resurfacing arthroplasty was not suitable, THR revision rates were similar or lower, depending on the material of the prostheses.
No clear conclusions could be drawn for the comparison of different types of THR.
Individual patient data also revealed that revision rates for resurfacing arthroplasty unadjusted for age were higher for women (18% at 9 years) than for men (7% at 9 years).
The cost-effectiveness evaluation showed that the most influential cost factor was the revision rate: the lower the revision rate, the more cost-effective a prosthesis becomes.
Based on these results, the NICE Assessment Group ‘considered that, because all of the categories of total hip replacement (THR) prostheses had a predicted revision rate of less than 5% at 10 years, the value reflecting the new standard should not be higher than 5%. It considered that, because the predicted revision rate of THR was less than 5% at 10 years in the population for whom both THR and resurfacing arthroplasty were suitable, the revision rate standard for resurfacing arthroplasty should be the same as that for THRs.’
Choice influencing factors
In addition to patient’s age, sex and activity level, other factors may influence the choice of the type of prosthesis, such as surgeon’s training and experience using different prostheses, his/her perception of which prosthesis performs best, and clinical data available for individual prostheses. The advantage of resurfacing arthroplasty would be to keep the patient’s bone mass and to preserve the native hip anatomy.
Situation in Belgium
According to the OECD Health data 2013, Belgium has one of the highest rates of hip replacement surgeries (236 per 100 000 population vs the average of 160 per 100 000 population in 32 OECD countries), exceeded only by Switzerland, Germany, Austria, Norway and Sweden.
In April 2009 a voluntary pilot registration system of hip and knee prostheses was set up (QERMID@Orthopride) and as of July 2014, registration of hip and knee prosthesis procedures became mandatory as a precondition for reimbursement, which should facilitate the analysis of the Belgian situation in the near future.
1. NICE. Total hip replacement and resurfacing arthroplasty for end-stage arthirtis of the hip In NICE technology appraisal guidance [TA 304]. National Institute for Health and Care Excellence (NICE) 2014; 1-63.
2. NICE. Guidance on the selection of prostheses for primary total hip replacement. In NICE technology appraisal guidance 2. National Institute for Health and Care Excellence (NICE) 2000; 1-3.
3. NICE. Guidance on the use of metal on metal hip resurfacing arthroplasty. In NICE technology appraisal guidance 44. National Institute for Health and Care Excellence (NICE) 2002; 1-3.
4. NICE. Osteoarthritis: care and management in adults. In NICE clinical guideline 177. National Institute for Health and Care Excellence (NICE) 2014; 1-37.
5. OECD. Health at a Glance 2013: OECD Indicators. In OECD Publishing. 2013.
(for the FR version: http://www.riziv.fgov.be/fr/professionnels/sante/fournisseurs-implants/q...)