Cementless total hip arthroplasty for primary osteoarthritis in patients aged 55 years and older

Figures & data

Table 1.  Demographic data of the implants analyzed

THR Brands	No.	Mean follow-up	Mean age	Women	(%) No. of hospitals	Period of implantation
Anatomic Mesh/HG-II	604	11.1	63	56	24	1989–1997
PCA Std/PCA Pegged	508	11.6	63	55	23	1985–1995
Bi-Metric/PFU	2,687	8.8	63	49	53	1986–2001
Bi-Metric/Mallory	637	8.7	67	60	11	1989–2000
Bi-Metric/Vision	2,055	3.4	65	48	47	1998–2005
ABG I/ABG I	565	9.1	65	55	25	1992–1997
ABG I/ABG II	1,765	5.9	66	51	36	1996–2003
ABG II/ABG II	1,489	2.5	67	55	31	2000–2005
Cemented reference	9,549	8.8	72	66	62	1980–2005
Together	19,859	7.6	68	59	77	1980–2005

HG-II: Harris-Galante II; PCA Std: porous-coated Anatomic Standard; PFU: Press-Fit Universal; ABG: Anatomique Benoist Girard.

Table 2.  Material, surface, design features, and manufacturer of the implants. For abbreviations, see Table 1

THR Brands	Material	Surface	Special design features	Manufacturer
Stems
Bi-Metric	Titanium alloy	Proximally porous-coated	Straight, collarless	Biomet
Anatomic Mesh	Titanium alloy	Proximally porous-coated	Anatomic	Zimmer
ABG I	Titanium alloy	Proximally grit-blasted and HA-coated	Anatomic	Stryker Howmedica
ABG II	Titanium alloy	Proximally grit-blasted and HA-coated	Anatomic	Stryker Howmedica
PCA Standard	CoCr alloy	Proximally porous-coated	Anatomic	Stryker Howmedica
Exeter Universal	Stainless steel	Polished	Straight, collarless, cemented	Stryker Howmedica
Müller Straight	CoCr alloy	Matt	Straight, small collar, fluted macrostructure	Zimmer
Lubinus SP II	CoCr alloy	Matt	Anatomic, collar, modular	Link
Cups
ABG I	Titanium alloy	Grit-blasted and HA-coated	Hemispherical, open screw-holes	Stryker Howmedica
ABG II	Titanium alloy	Grit-blasted and HA-coated	Hemispherical, screw-holes plugged	Stryker Howmedica
Biomet Mallory	Titanium alloy	Porous-coated	Hemispherical, open screw-holes, fins	Biomet
Biomet Universal	Titanium alloy	Porous-coated	Hemispherical, open screw-holes	Biomet
Biomet Vision	Titanium alloy	Porous-coated	Hemispherical, screw-holes plugged	Biomet
Harris-Galante II	Titanium alloy	Porous-coated	Hemispherical, open screw-holes	Zimmer
PCA Pegged	Cobalt-chromium	Porous-coated	Hemispherical, open screw-holes	Stryker Howmedica
Exeter All-poly	Polyethylene	–	Cemented	Stryker Howmedica
Müller Std	Polyethylene	–	Cemented	Zimmer
Lubinus IP	Polyethylene	–	Groove design	Link

Table 3.  Reasons for revision of the 8 most common cementless brands and the cemented reference designs. Percentage in parentheses. For prosthesis types, see Table 1

A	B	C	D	E	F	G	H	I	J	K	L
Anatomic Mesh/HG-II	604	17 (15)	23 (20)	17 (15)	0 (0)	4 (4)	7 (6)	4 (4)	2 (2)	39 (35)	113
PCA Std/PCA Pegged	508	19 (14)	81 (60)	19 (14)	2 (2)	1 (1)	2 (2)	0 (0)	1 (1)	10 (7)	135
Bi-Metric/PFU	2,687	26 (8)	67 (19)	10 (3)	9 (3)	57 (17)	14 (4)	16 (5)	15 (4)	131 (38)	345
Bi-Metric/Mallory	637	5 (8)	11 (17)	3 (5)	1 (2)	12 (19)	3 (5)	5 (8)	3 (5)	21 (33)	64
Bi-Metric/Vision	2,055	11 (16)	1 (1)	6 (9)	8 (12)	28 (41)	5 (7)	0 (0)	4 (6)	6 (9)	69
ABG I/ABG I	565	10 (9)	27 (26)	3 (3)	1 (1)	6 (6)	3 (3)	3 (3)	6 (6)	47 (44)	106
ABG I/ABG II	1,765	1 (2)	6 (10)	2 (3)	5 (8)	13 (21)	10 (16)	1 (2)	10 (16)	15 (24)	63
ABG II/ABG II	1,489	2 (4)	1 (2)	3 (6)	3 (6)	10 (20)	7 (14)	4 (8)	19 (37)	2 (4)	51
Cemented reference	9,549	227 (28)	142 (18)	253 (32)	38 (5)	73 (9)	20 (3)	5 (1)	24 (3)	16 (2)	798
Together	19,859	318 (18)	359 (21)	316 (18)	67 (4)	204 (12)	71 (4)	38 (2)	84 (5)	287 (17)	1,744

A THR brand

B No. of primary operations

C Aseptic loosening (cup + stem)

D Aseptic loosening (cup)

E Aseptic loosening (stem)

F Infection

G Dislocation

H Malposition

I Fracture of the prosthesis

J Periprosthetic fracture

K Any other reason

L Together

Figure 1.  Cox-adjusted survival curves for 19,859 stems and 19,859 cups in patients aged 55 years or older with stem designs (panel A) or cup designs (panel B) as the strata factors. The endpoint was defined as stem (A) or cup (B) revision due to aseptic loosening. Adjustment was made for age and sex. For an explanation of abbreviations, see Table 4.

Table 4.  Survival of cementless stems and the cemented reference group. Endpoint was defined as revision due to aseptic loosening of the stem. 7-, 10-, and 15-year survival rates were obtained from the Kaplan-Meier analysis. For prosthesis types, see Table 1

A	B	C	D	E	F	G	H	I	J	K	L
All (≥ 55 years)
	Anatomic Mesh	604	11.1	532	98 (97–99)	444	96 (94–98)	91	92 (89–95)	0.53 (0.37–0.76)	0.001
	FU ≤ 7 years									0.38 (0.21–0.71)	0.002
	FU > 7 years									0.64 (0.40–1.00)	0.05
	PCA Std	508	11.6	430	98 (96–99)	351	95 (92–97)	146	89 (86–93)	0.62 (0.44–0.88)	0.007
	FU ≤ 7 years									0.49 (0.27–0.89)	0.02
	FU > 7 years									0.68 (0.44–1.05)	0.08
	Bi-Metric	5,379	6.8	2,698	99 (99–99)	1,463	99 (98–99)	154	96 (94–98)	0.20 (0.15–0.27)	< 0.001
	FU ≤ 7 years									0.18 (0.12–0.26)	< 0.001
	FU > 7 years									0.24 (0.16–0.37)	< 0.001
	ABG I	2,330	6.7	1,152	100 (99–100)	342	98 (97–99)	0	–	0.15 (0.09–0.25)	< 0.001
	FU ≤ 7 years									0.08 (0.04–0.18)	< 0.001
	FU > 7 years									0.40 (0.20–0.80)	0.009
	ABG II	1,489	2.5	0	–	0	–	0	–	0.31(0.13–0.76)	0.01
	FU ≤ 7 years									0.31 (0.13–0.76)	0.01
	FU > 7 years									–	–
	Cemented	9,549	8.8	6,231	97 (96–97)	4,442	95 (94–95)	1,115	91 (90–92)	1.0 (reference)	–
	FU ≤ 7 years									1.0 (reference)	–
	FU > 7 years									1.0 (reference)	–
	Total	19,859

A Age group

B Brand of stem

C Number of operations

D Mean follow-up (in years)

E At risk (7-year)

F % 7-year survival (95% CI)

G At risk (10-year)

H % 10-year survival (95% CI)

I At risk (15-year)

J % 15-year survival (95% CI)

K Adjusted RR ^a for revision (95% CI)

L p-value

^a RR: risk ratio from the Cox regression analysis (other stem brands compared to the cemented reference stems, with adjustment made for age and sex)

Table 5.  Survival of cementless cups and the cemented reference group. Endpoint was defined as revision due to aseptic loosening of the cup. 7-, 10-, and 15-year survival rates were obtained from the Kaplan-Meier analysis. For abbreviations, see Table 4

A	B	C	D	E	F	G	H	I	J	K	L
All (≥ 55 years)
	HG-II	604	11.1	531	99 (98–100)	445	97 (95–98)	92	88 (84–92)	0.75 (0.53–1.05)	0.09
	FU ≤ 7 years									0.50 (0.24–1.03)	0.0
	FU > 7 years									0.82 (0.56–1.22)	0.3
	PCA Pegged	508	11.6	432	94 (92–96)	353	86 (83–89)	148	75 (70–80)	1.91 (1.49–2.44)	< 0.001
	FU ≤ 7 years									2.21 (1.44–3.38)	< 0.001
	FU > 7 years									1.70 (1.26–2.30)	< 0.001
	PFU	2,687	8.8	2,035	98 (97–99)	1,192	97 (96–98)	145	91 (87–94)	0.54 (0.42–0.70)	< 0.001
	FU ≤ 7 years									0.68 (0.47–0.99)	0.04
	FU > 7 years									0.45 (0.32–0.64)	< 0.001
	Mallory	637	8.8	517	99 (98–100)	275	96 (94–98)	10	–	0.52 (0.31–0.86)	0.01
	FU ≤ 7 years									0.35 (0.14–0.85)	0.02
	FU > 7 years									0.68 (0.37–1.26)	0.2
	Vision	2,055	3.4	152	99 (98–100)	0	–	0	–	0.49 (0.27–0.89)	0.019
	FU ≤ 7 years									0.51 (0.27–0.97)	0.04
	FU > 7 years									3.39 (0.47–24.8)	0.2
	ABG I	565	9.1	454	98 (96–99)	330	93 (90–95)	0	–	1.17 (0.83–1.66)	0.4
	FU ≤ 7 years									0.81 (0.43–1.52)	0.5
	FU > 7 years									1.46 (0.96–2.24)	0.08
	ABG II	3,254	4.3	700	99 (99–100)	14	–	0	–	0.20 (0.11–0.38)	< 0.001
	FU ≤ 7 years									0.22 (0.11–0.43)	< 0.001
	FU > 7 years									0.19 (0.03–1.37)	0.1
	Cemented	9,549	8.8	6,221	98 (98–98)	4,441	96 (96–97)	1,113	92 (91–93)	1.0 (reference)	–
	FU ≤ 7 years									1.0 (reference)	–
	FU > 7 years									1.0 (reference)	–
	Total	19,859

Figure 2.  Cox-adjusted survival curves for 19,859 total hip replacements in patients aged 55 years or older with total hip replacement design as the strata factor. The endpoint was defined as revision of the stem and/or the cup due to aseptic loosening (panel A) or as revision for any reason (B). Adjustment was made for age and sex. For an explanation of abbreviations, see Table 4.

Table 6.  Survival of cementless total hip replacements and the cemented reference group. Endpoint was defined as revision due to aseptic loosening of the cup and/or the stem. 7-, 10-, and 15-year survival rates were obtained from the Kaplan-Meier analysis. For abbreviations, see Table 4

A	B	C	D	E	F	G	H	I	J	K	L
All ≥ 55 years)
	Anatomic Mesh/HG-II	604	11.1	532	97 (96–98)	445	94 (92–96)	92	85 (80–89)	0.68 (0.51–0.90)	0.006
	FU ≤ 7 years									0.52 (0.32–0.86)	0.01
	FU > 7 years									0.75 (0.53–1.06)	0.1
	PCA Std/PCA Pegged	508	11.6	433	92 (90–95)	354	83 (80–87)	148	71 (66–76)	1.48 (1.19–1.83)	< 0.001
	FU ≤ 7 years									1.37 (0.96–1.96)	0.09
	FU > 7 years									1.46 (1.11–1.92)	0.006
	Bi-Metric/PFU	2,687	8.8	2,035	98 (97–98)	1,192	96 (96–97)	145	90 (87–93)	0.37 (0.29–0.46)	< 0.001
	FU ≤ 7 years									0.39 (0.29–0.54)	< 0.001
	FU > 7 years									0.34 (0.25–0.47)	< 0.001
	Bi-Metric/Mallory	637	8.8	517	99 (98–100)	275	96 (94–98)	10	–	0.36 (0.23–0.58)	< 0.001
	FU ≤ 7 years									0.27 (0.13–0.55)	< 0.001
	FU > 7 years									0.48 (0.26–0.88)	0.02
	Bi-Metric/Vision	2,055	3.4	152	99 (98–99)	0	–	0	–	0.37 (0.23–0.60)	< 0.001
	FU ≤ 7 years									0.37 (0.23–0.62)	< 0.001
	FU > 7 years									2.53 (0.35–18.4)	0.4
	ABG I/ABG I	565	9.1	455	97 (96–99)	330	92 (90–95)	0	–	0.75 (0.54–1.04)	0.09
	FU ≤ 7 years									0.51 (0.29–0.87)	0.01
	FU > 7 years									1.03 (0.68–1.55)	0.9
	ABG I/ABG II	1,765	5.9	700	99 (99–100)	14	–	0	–	0.12 (0.06–0.22)	< 0.001
	FU ≤ 7 years									0.12 (0.06–0.24)	< 0.001
	FU > 7 years									0.13 (0.02–0.93)	0.04
	ABG II/ABG II	1,489	2.5	0	–	0	–	0	–	0.33 (0.15–0.74)	0.007
	FU ≤ 7 years									0.34 (0.15–0.76)	0.009
	FU > 7 years									–	–
	Cemented	9,549	8.8	6,234	96 (96–96)	4,447	93 (93–94)	1,116	88 (87–89)	1.0 (reference)	–
	FU ≤ 7 years									1.0 (reference)	–
	FU > 7 years									1.0 (reference)	–
	Total	19,859

Table 7.  Survival of cementless total hip replacements and the cemented reference group. Endpoint was defined as revision of the cup and/or the stem for any reason. 7-, 10-, and 15-year survival rates were obtained from the Kaplan-Meier analysis. For an explanation of abbreviations, see Table 4

A	B	C	D	E	F	G	H	I	J	K	L
55–64
Anatomic Mesh/HG-II		385	11.2	343	94 (92–97)	296	89 (86–92)	57	70 (64–76)	1.18 (0.91–1.54)	0.2
PCA Std/PCA Pegged		347	12.2	303	91 (88–94)	262	82 (78–86)	119	66 (61–72)	1.32 (1.03–1.69)	0.03
Bi-Metric/PFU		1,863	9.1	1,488	93 (92–94)	872	86 (85–88)	102	66 (61–72)	1.18 (0.97–1.44)	0.09
Bi-Metric/Mallory		266	9.0	224	95 (92–97)	119	83 (77–88)	8	72 (61–82)	1.27 (0.90–1.80)	0.2
Bi-Metric/Vision		1,080	3.8	96	95 (93–97)	0	–	0	–	1.05 (0.72–1.54)	0.8
ABG I/ABG I		280	9.4	239	90 (87–94)	174	74 (69–80)	0	–	2.13 (1.62–2.81)	< 0.001
ABG I/ABG II		746	6.0	309	95 (93–97)	6	–	0	–	0.90 (0.62–1.31)	0.6
ABG II/ABG II		610	2.4	0	–	0	–	0	–	1.54 (0.93–2.53)	0.0
Cemented		1,204	9.5	837	92 (91–94)	616	89 (87–91)	210	76 (72–79)	1.0 (reference)	–
Subtotal		6,781
65–74
Anatomic Mesh/HG-II		186	11.3	165	94 (90–97)	133	90 (86–95)	34	77 (67–87)	1.05 (0.70–1.56)	0.8
PCA Std/PCA Pegged		133	11.0	112	91 (86–96)	85	81 (74–88)	30	70 (61–80)	1.78 (1.23–2.58)	0.002
Bi-Metric/PFU		740	8.5	525	94 (92–96)	320	90 (87–93)	45	85 (81–89)	0.89 (0.68–1.16)	0.4
Bi-Metric/Mallory		274	8.8	223	95 (92–98)	119	91 (87–95)	2	–	0.88 (0.57–1.34)	0.5
Bi-Metric/Vision		850	3.1	51	94 (90–97)	0	–	0	–	1.10 (0.74–1.63)	0.6
ABG I/ABG I		238	9.0	187	91 (87–95)	142	86 (81–91)	0	–	1.34 (0.93–1.92)	0.1
ABG I/ABG II		789	5.9	311	98 (96–99)	8	–	0	–	0.48 (0.31–0.75)	0.001
ABG II/ABG II		647	2.4	0	–	0	–	0	–	1.62 (1.05–2.51)	0.03
Cemented		4,964	9.3	3,446	94 (93–95)	2,635	90 (89–91)	722	85 (83–87)	1.0 (reference)	–
Subtotal 8,821
>75
Anatomic Mesh/HG-II		33	8.9	25	90 (80–100)	17	–	2	–	1.69 (0.54–5.32)	0.4
PCA Std/PCA Pegged		28	7.6	18	–	8	–	1	–	2.44 (0.78–7.66)	0.1
Bi-Metric/PFU		84	5.6	31	93 (86–99)	14	–	1	–	1.60 (0.65–3.90)	0.3
Bi-Metric/Mallory		97	8.1	73	98 (95–100)	39	1	–		0.45 (0.11–1.80)	0.3
Bi-Metric/Vision		125	2.8	6	–	0	–	0	–	2.09 (0.92–4.77)	0.08
ABG I/ABG I		47	8.0	33	100 (100–100)	21	100 (100–100)	0	–	–	–
ABG I/ABG II		230	5.6	82	97 (94–99)	1	–	0	–	0.70 (0.31–1.60)	0.4
ABG II/ABG II		232	2.6	0	–	0	–	0	–	1.69 (0.85–3.35)	0.1
Cemented		3,381	7.6	1,954	96 (95–97)	1,198	95 (94–96)	186	94 (92–95)	1.0 (reference)	–
Subtotal		4,257
All (≥ 55 years)
Anatomic Mesh/HG-II		604	11.1	532	94 (92–96)	446	89 (87–92)	93	72 (67–78)	1.19 (0.97–1.47)	0.1
FU ≤ 7 years										0.91 (0.64–1.29)	0.6
FU > 7 years										1.32 (1.01–1.72)	0.04
PCA Std/PCA Pegged		508	11.6	433	91 (89–94)	354 82 (79–86)	149	67 (62–72)	1.51 (1.24–1.83)	< 0.001
FU ≤ 7 years										1.26 (0.91–1.75)	0.2
FU > 7 years										1.52 (1.18–1.95)	0.001
Bi-Metric/PFU		2,687	8.8	2,044	93 (92–94)	1,205	87 (86–89)	147	71 (67–75)	1.10 (0.95–1.27)	0.2
FU ≤ 7 years										0.98 (0.80–1.20)	0.8
FU > 7 years										1.18 (0.96–1.46)	0.1
Bi-Metric/Mallory		637	8.8	519	95 (93–97)	277	89 (85–92)	10	–	1.05 (0.81–1.36)	0.7
FU ≤ 7 years										0.76 (0.52–1.12)	0.2
FU > 7 years										1.43 (1.00–2.05)	0.05
Bi-Metric/Vision		2,055	3.4	153	95 (93–96)	0	–	0	–	0.99 (0.76–1.29)	0.9
FU ≤ 7 years										0.98 (0.75–1.29)	0.9
FU > 7 years										2.75 (0.38–19.9)	0.3
ABG I/ABG I		565	9.1	458	91 (89–94)	336	81 (77–84)	0	–	1.74 (1.41–2.15)	< 0.001
FU ≤ 7 years										1.27 (0.92–1.74)	0.1
FU > 7 years										2.30 (1.73–3.06)	< 0.001
ABG I/ABG II		1,765	5.9	701	96 (95–97)	14	–	0	–	0.66 (0.51–0.86)	0.002
FU ≤ 7 years										0.63 (0.48–0.84)	0.001
FU > 7 years										0.69 (0.28–1.69)	0.4
ABG II/ABG II		1,489	2.5	0	–	0	–	0	–	1.52 (1.13–2.05)	0.006
FU ≤ 7 years										1.46 (1.08–1.97)	0.01
FU > 7 years										–	–
Cemented		9,549	8.8	6,237	94 (94–95)	4,449	91 (91–92)	1,117	86 (84–87)	1.0 (reference)	–
FU ≤ 7 years										1.0 (reference)	–
FU > 7 years										1.0 (reference)	–
Total		19,859