Comparison of cemented and uncemented fixation in total hip replacement

Figures & data

Figure 1. Flow diagram showing details of the literature search, including articles excluded at each stage of the review.

Table 1.  Characteristics of the studies included (n = 20)

Study Authors, year	Location	Studydesign ^a	Follow-up(years)	Implant compared ^b
				Cemented	Cementless
Wykman et al. 1991	Sweden	RCT	4.2	Charnley LFA	HP-Garches
Reigstad et al. 1993	Norway	RCT	5	Landos Titane	Zweymuller Endler
Laupacis et al. 2002	Canada	RCT	6.3	Mallory-Head	Mallory-Head
Havelin et al. 2000	Norway	MCC	11	Multiple	Multiple
Lucht 2000	Denmark	MCC	3	Multiple	Multiple
Puolakka et al. 2000	Finland	MCC	10	Multiple	Multiple
Malchau et al. 2002	Sweden	MCC	10	Multiple	Multiple
Zimmerman et al. 2002	USA	MCC	1	Multiple	Mutiple
Krismer et al. 1991	Austria	SCC	6	RM cup	Müller cup
Freeman and Plante-Bordeneuve 1994	UK	SCC	7	NR	NR
Weidenhielm et al. 1995	USA	SCC	7	Exeter-CPT	PCA
D'Lima et al. 1998	USA	SCC	6	Harris Precoat	Harris-Galante Porous
Volkman et al. 1999				cup	Model Munchen
Emerson et al. 2002	USA	SCC	7.5	Mallory-Head Interloc titanium	Mallory-Head circumferential porous coat
Guerra et al. 2003	Italy	SCC	10	AnCA cemented	AnCA HA
Gaffey et al. 2004	USA	SCC	15	Charnley all-polyethylene	Harris Galante 1
Clohisy and Harris 2001	USA	MP	11	CAD/ Harris all-polyethylene cup	Precoat/Harris-Galante 1&2
Goetz et al. 1994	USA	MP	6	Harris Precoat	Harris-Galante
Kim et al. 2003	USA	BL	9.3	Elite	Profile
Knessl et al. 1989	Switzerland	BL	7	Muller/Enler	Zweymuller/Enler

^aRCT: randomized controlled trial; MCC: multicenter cohort study; SCC: single-center cohort study; MP: matched-pair cohort study; BL: bilaterally controlled cohort study.

^bIn the case of multicenter studies with multiple implant combinations tested, the reader is referred to the primary sources for a complete list; NR: not reported.

Table 2.  Comparisons of fixation strategies and comparative survivorship results

Failure Definition	Study (first author and year)	Sample size		Average age ^a		Difference in survivproportion (95% CI)
		Cemented	Cementless	Cemented	Cementless
Type A: either component or both
	Laupacis 2002	124	126	64	64	0.03 (−0.02–0.08)
	Wykman 1991	90	90	67.4	64.8	−0.04 (−0.11–0.03)
	Lucht 2000	NR ^b	NR	≤55	≤55	0.01 (−0.01–0.04)
	Lucht 2000	NR	NR	< 55	< 55	−0.01 (−0.03–0.00)
	Malchau 2002	76391	2744	NR	NR	−0.07 (−0.08–0.06)
	Puolakka 2001	4069	5519	NR	NR	−0.08 (−0.09–0.06)
	Reigstad 1993	60	60	65	64	−0.03 (−0.07–0.01)
	Malchau 2002	2588	1004	< 55	< 55	0.04 (−0.01–0.08)
	Knessl 1989	60	60	60	60	−0.02 (−0.10–0.07)
Type B: specific component survival
	D'Lima 1998	100	100	71	52	−0.01 (−0.04–0.02)
	Emerson 2002	102	78	70	55	0.12 (0.06–0.18)
	Freeman 1994	38	89	67	53	0.04 (−0.05–0.13)
1. Stem	Guerra 2003	599	608	NR	NR	−0.02 (−0.03–0.00)
	Laupacis 2002	124	126	64	64	0.07 (0.05–0.10)
	Havelin 2000	2849	5912	< 60	< 60	0.08 (0.06–0.09)
	Kim 2003	50	50	47.3	47.3	0.00 (−0.05–0.05)
	Goetz 1994	41	41	61	57	−0.06 (−0.14–0.01)
	Weidenhielm 1995	85	66	62.6	66.9	−0.12 (−0.19–0.04)
	Zimmerman 2002	174	85	72.4	75.3	0.07 (0.04–0.09)
2. Cup	Gaffey 2004	471	120	65.7 ^c	62.6	0.07 (0.05–0.09)
	Havelin 2000	2849	3341	<60	<60	−0.03 (−0.04–0.01)
	Krismer 1991	263	160	62.9	57.3	−0.06 (−0.11–0.01)
	Volkmann 1999	329	169	70	58	−0.04 (−0.07–0.01)
	Clohisy 2001	45	45	61	62	−0.02 (−0.09–0.05)

^aFor the purposes of meta-regression analysis, studies that only specified an age range (i.e. ≤55 or < 60, versus < 55 or < 60) were assumed to have mean ages of 50 for the younger group and 70 for the older group.

^bNR: not reported.

^cSample-weighted average of 15- and 25-year Charnley stem cohorts.

Table 3.  Results of meta-analysis

Studies	No. of comparisons	Pooled difference ^a in survivorshipproportion (95% CI) ^b	Hypothesis testfor subgroup difference^c
All studies	24	−0.005 (−0.031–0.022)	None
Registry/multi-institution-based studies	8	−0.002 (−0.046–0.042)	p = 0.5
Single institution-based	16	−0.006 (-0.040–0.027)
Randomized studies	4	0.016 (−0.054–0.086)	p = 0.3
Non-randomized studies	20	−0.009 (−0.037–0.020)
Failure type A	9	−0.018 (−0.052–0.016)	p = 0.2
Failure type B	15	0.003 (−0.031–0.036)

^aInverse variance weighted meta-analysis reporting random effects estimates given test of hetero-geneity p-value < 0.2 in all cases.

^bNegative numbers favor cemented fixation whereas positive numbers favor uncemented fixation.

^cZ-test for significant difference in summary estimate of survival difference, using standard normal distribution with 1 degree of freedom.

Figure 2. Forest plot of cemented vs. uncemented fixation survivorship difference for type A studies (where failure is defined as revision of either or both components). Shaded boxes represent study-specific estimates with area proportional to sample size and attached horizontal lines representing 95% CIs. The diamond at the bottom represents combined random effects estimate. Positive numbers (< 0) favor uncemented implant fixation and negative numbers (< 0) favor cemented implant fixation. The Danish registry reported on by Lucht et al. (2000) is entered twice because of stratification of results of patients into age groups of ≤ 55 years and < 55 years, but does not require adjustment of weights because the comparisons are independent.

Table 4.  Meta-analysis by selected subgroups (95% CI)

Failure definition	Studies	Subgroup definition	Number of comparisons	Pooled difference ^a in survivorship (95% CI) ^b	Hypothesis test for subg difference ^c
Type A: either component or both
Laupacis et al., Reigstad et al., Wykman et al.		Randomized studies	3	−0.010 (−0.076–0.057)	p = 0.4
Knessl et al., Lucht et al., Malchau et al., Puolakka et al.		Non-randomized studies	6	−0.021 (−0.061–0.019)
Lucht et al., Malchau et al.		Patients ≤55	2	0.031 (−0.008–0.069)	p = 0.004
Knessl et al., Laupacis et al., Reigstad el al., Lucht et al., Puolakka et al., Wykman et al., Malchau et al.		Age unrestricted	7	−0.038 (−0.069– −0.007)
Type B: specific component
D'Lima et al., Emerson et al., Freeman et al., Goetz et al., Guerra et al., Havelin et al., Kim et al., Laupacis et al., Weidenhielm et al., Zimmerman et al.		Stem only	10	0.013 (−0.032–0.059)	p = 0.2
Clohisy et al., Gaffey et al., Havelin et al., Krismer et al., Volkman et al.		Cup only	5	−0.018 (−0.073–0.038)
Krismer et al., Volkman et al.		Threaded or macro-ingrowth cup	2	−0.054 (−0.090– −0.018)
Clohisy et al., Gaffey et al.		Micro-ingrowth or ongrowth cup	2	0.031 (−0.056–0.12)
Emerson et al., Laupacis et al.		Titanium cemented stem	2	0.12 (0.051–0.19)
Goetz et al., Weidenhielm et al., D'Lima et al., Guerra et al., Kim et al.		Stainless steel or cobalt chrome	5	−0.051 (−0.098– −0.004)

^aInverse variance weighted meta-analysis reporting random effects estimates given test of heterogeneity p-value < 0.2 in all cases.

^bNegative numbers favor cemented fixation whereas positive numbers favor uncemented fixation.

^cTests for significant difference in summary estimate of survival difference, using standard normal distribution with 1 degree of freedom.

Figure 3. Forest plot of cemented vs. uncemented fixation survivorship difference for type B studies (where failure is defined as revision of a specific component—cup or stem). Shaded boxes represent study-specific estimates with area proportional to study size and attached horizontal lines representing 95% CIs. The diamond at the bottom represents combined random effects estimate. Positive numbers (< 0) favor uncemented implant fixation and negative numbers (< 0) favor cemented implant fixation.

Figure 4. Sensitivity analysis of pooled estimate of type B studies (where failure is defined as revision of a specific component—the cup) to omission of each individual study. Positive numbers (< 0) favor uncemented implant fixation and negative numbers (< 0) favor cemented implant fixation.

Figure 5. Scatter plot of study estimate of the difference in survival probability vs. year of publication with superimposed regression line. Y-axis values greater than zero favor uncemented fixation and the area of each circle is proportional to the sample size of the study. Slope = 1.4% per year (95% CI: 0.5–2.3)

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