What’s New in Hip Replacement: Level I and II Studies

Every month, JBJS publishes a Specialty Update—a review of the most pertinent and impactful studies published in the orthopaedic literature during the previous year in 13 subspecialties. Here is a summary of selected findings from Level I and II studies cited in the September 16, 2015 Specialty Update on hip replacement:

Transfusion and Blood Management

–Studies continue to demonstrate that tranexamic acid decreases the need for transfusion when used either intravenously or topically.

–The routine use of a drain following total hip replacement, even when used for reinfusion of shed blood, provides little to no benefit and does not decrease the risk of transfusion.¹

Preoperative Patient Teaching

–A Cochrane review concluded that preoperative teaching resulted in only modest improvements in quality of life, pain scores, anxiety, and function. Patients with depression, anxiety, and unrealistic expectations might receive the most benefit from these interventions.²

Surgical Approaches

–A meta-analysis demonstrated short-term superiority of the direct anterior approach over the posterior approach, but the authors concluded there was insufficient evidence of clear long-term superiority of either approach.³

–A study that reviewed the results of two academic surgeons who exclusively used either the direct anterior approach or a miniposterior approach found no systematic advantage to either approach in terms of surgical time, pain, or function. This suggests that factors other than surgical approach may be more important in influencing early recovery after hip replacement.⁴

Surgical Fixation

–A randomized trial comparing survivorship in four cemented femoral stem designs concluded that, in the presence of a collar, surface finish did not significantly affect survivorship or function. Between the two collarless groups, a polished surface conferred improved survivorship.⁵

–A multivariate registry-based meta-analysis found that, in patients who were 75 years or older, uncemented fixation had a significantly higher risk of revision than hybrid fixation.

Bearing Materials

— A multivariate registry-based meta-analysis concluded that use of ceramic implants with a smaller head size in cementless hip arthroplasty was associated with a higher risk of revision, compared with metal-on-highly cross-linked polyethylene and >28-mm ceramic-on-ceramic implants.

–A registry-based cohort study comparing revision rates in metal-on-conventional polyethylene bearings with metal-on-highly cross-linked polyethylene bearings found a rate over seven years of 5.4% for the conventional polyethylene bearing versus 2.8% for the highly cross-linked bearing.⁶

–A randomized study comparing metal-ion levels five years after metal-on-metal and metal-on-polyethylene hip replacements found significantly lower cobalt and chromium levels in the metal-on-polyethylene group.

–A multivariate meta-analysis comparing the risk of revision for metal-on-conventional and metal-on-highly cross-linked polyethylene implants in patients 45 to 64 year old did not find a difference between the two groups.

–A meta-analysis comparing ceramic-on-ceramic, ceramic-on-highly cross-linked polyethylene, and metal-on-highly cross-linked polyethylene found no differences in medium-term survivorship.⁷

References

1. Thomassen BJ,  den Hollander PH,  Kaptijn HH,  Nelissen RG, Pilot P. Autologous wound drains have no effect on allogeneic blood transfusions in primary total hip and knee replacement: a three-arm randomised trial. Bone Joint J. 2014 Jun;96-B(6):765-71.
2. McDonald S, Page MJ, Beringer K, Wasiak J, Sprowson A. Preoperative education for hip or knee replacement. Cochrane Database Syst Rev.2014;5:CD003526. Epub 2014 May 13.
3. Higgins BT, Barlow DR, Heagerty NE, Lin TJ. Anterior vs. posterior approach for total hip arthroplasty, a systematic review and meta-analysis. J Arthroplasty. 2015Mar;30(3):419-34. Epub 2014 Oct 22.
4. Poehling-Monaghan KL, Kamath AF, Taunton MJ, Pagnano MW. Direct anterior versus miniposterior THA with the same advanced perioperative protocols: surprising early clinical results. Clin Orthop Relat Res. 2015 Feb;473(2):623-31.
5. Hutt J, Hazlerigg A, Aneel A, Epie G, Dabis H, Twyman R, Cobb A. The effect of a collar and surface finish on cemented femoral stems: a prospective randomised trial of four stem designs. Int Orthop. 2014 Jun;38(6):1131-7. Epub 2014 Jan 29.
6. Paxton EW, Inacio MC, Namba RS, Love R, Kurtz SM. Metal-on-conventional polyethylene total hip arthroplasty bearing surfaces have a higher risk of revision than metal-on-highly crosslinked polyethylene: results from a US registry. Clin Orthop Relat Res. 2015 Mar;473(3):1011-21.
7. Wyles CC, Jimenez-Almonte JH, Murad MH, Norambuena-Morales GA, Cabanela ME, Sierra RJ, Trousdale RT.There are no differences in short- to mid-term survivorship among total hip-bearing surface options: a network meta-analysis. Clin Orthop Relat Res. 2015 Jun;473(6):2031-41. Epub 2014 Dec 17.