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Safety assessment of short-stem THR, newer implant designs is at issue
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The serious discussion of small incisions for total hip replacement and their advantages began among orthopaedic surgeons, and in the media, in about 2006, when this method of placing hip components was introduced as one that minimized soft tissue damage and improved functional outcome. A few months later, younger patients who came to our clinic knew about the technique and asked that it be used on them.
We now know about the complications encountered when surgeons tried this new surgical approach that involved a shorter incision. We are also familiar with the later problems with metal-on-metal hip bearings developed to reduce dislocations, improve hip range of motion and help patients perform unrestricted activities soon after surgery. In fact, these implants were sometimes called the “sports hip” and the media helped promote their concepts more widely.
But still, we have not learned the needed lessons.
Short-stem adoption imminent
It concerns me that in the wake of these hip replacement “lessons,” we have not adopted a system of recognized and proven stepwise introduction of new implants and surgical techniques used before they are put into practice. Eventually there may be national or international restrictions on the implants and techniques we can use and this may be in response to the very cases I refer to.
Today, orthopaedic journals and congresses cover short-stem prostheses for use in total hip replacement (THR). The arguments for using them are they are bone-sparing and easier to revise, but their design concepts are new and, therefore, they should undergo a stepwise introduction. With many short-stem THR designs — each one different — this can also heighten the risk of possible problems since results with one implant cannot be applied to another. Thus we cannot quickly gather information about the safety of short-stem designs.
I am not sure we can wait another 5 years to 10 years for results with short-stem THR to appear in the implant registers before we introduce short-stem implants to the general orthopaedic practice. For me, the important question is whether you would want a standard stem with proven performance characteristics or a new non-cemented short-stem prosthesis that was used for only 1 year or 2 years when it comes time for your hip to be replaced.
Follow U.K. model
There are several THR implants that use proven concepts and have 90% to 95% 10-year survivorship data in the largest national registries. This means these implants function well in the average patient when implanted by the average hip replacement surgeon. Such implants should be used in 98% of all THR cases. This leaves the remaining 2% of prostheses to undergo stepwise development and introduction in the future, at selected clinics, by experienced hip surgeons. The United Kingdom developed the Orthopaedic Data Evaluation Panel (ODEP; www.odep.org.uk), which provides ongoing assessment of hip implants that benchmarks THR femoral stems and acetabular cups against guidance of the National Institute for Health and Care Excellence. This produces a rating for survivorship and data submission quality, by implant.
The work of ODEP shows the type of system I am in favor of already exists. I would like to see a similar system in place throughout Europe. Short-stem hips is a great place to start.
- For more information:
- Per Kjaersgaard-Andersen, MD, is Chief Medical Editor of Orthopaedics Today Europe. He can be reached at Orthopaedics Today Europe, 6900 Grove Road, Thorofare, NJ 08086, USA; email: orthopaedics@healio.com.
Disclosure: Kjaersgaard-Andersen has no relevant financial disclosures.