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THA: Early migration of acetabular cups associated with late revision due to loosening
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March 2013
THA: Early migration of acetabular cups associated with late revision due to loosening
Study Type:Meta-analysis/Systematic Review
OE Level Evidence:2
Journal Level of Evidence:N/A
Early proximal migration of cups is associated with late revision in THA: a systematic review and meta-analysis of 26 RSA studies and 49 survivalstudies
Acta Orthop. 2012 Dec;83(6):583-91. doi: 10.3109/17453674.2012.745353. Epub 2012 Nov 5Did you know you're eligible to earn 0.5 CME credits for reading this report? Click Here
OE EXCLUSIVE
Dr. Pijls discussing the association between early migration of acetabular cups and late aseptic revision.
Synopsis
Two parallel systematic reviews and meta-analyses were performed to determine the affiliation between early migration of acetabular cups and late aseptic revision. One review covered the early migration data from radio-stereometric analysis (RSA) studies (26 studies involving 700 cups), and the other focused on revision rates for aseptic loosening from long-term survival studies (49 studies involving 38,013 cups). The results showed that there was a clinically significant association between early migration of acetabular cups and late revision due to loosening; cups with proximal migration of between 0.2 and 1.0 mm were considered to be at risk of having revision rates greater than 5% at 10 years. Furthermore, cups with proximal migration of more than 1.0mm were considered unacceptable, as all of them showed revision rates of more than 5% at 10 years
Publication Funding Details
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Funding:
Non-Industry funded
Sponsor:
Atlantic Canada Opportunities Agency
Conflicts:
Other
Were the search methods used to find evidence (original research) on the primary question or questions stated?
Was the search for evidence reasonably comprehensive?
Were the criteria used for deciding which studies to include in the overview reported?
Was the bias in the selection of studies avoided?
Were the criteria used for assessing the validity of the included studies reported?
Was the validity of all of the studies referred to in the text assessed with use of appropriate criteria (either in selecting the studies for inclusion or in analyzing the studies that were cited)?
Were the methods used to combine the findings of the relevant studies (to reach a conclusion) reported?
Were the findings of the relevant studies combined appropriately relative to the primary question that the overview addresses?
Were the conclusions made by the author or authors supported by the data and or analysis reported in the overview?
How would you rate the scientific quality of this evidence?
Yes = 1
Uncertain = 0.5
Not Relevant = 0
No = 0
The Reporting Criteria Assessment evaluates the transparency with which authors report the methodological and trial characteristics of the trial within the publication. The assessment is divided into five categories which are presented below.
4/4
Introduction
3/4
Accessing Data
3/4
Analysing Data
2/4
Results
3/4
Discussion
Detsky AS, Naylor CD, O'Rourke K, McGeer AJ, L'Abbé KA. J Clin Epidemiol. 1992;45:255-65
The Fragility Index is a tool that aids in the interpretation of significant findings, providing a measure of strength for a result. The Fragility Index represents the number of consecutive events that need to be added to a dichotomous outcome to make the finding no longer significant. A small number represents a weaker finding and a large number represents a stronger finding.
Why was this study needed now?
Each year, several hundred thousand total hip arthroplasties (THAs) are performed globally, and this number is expected to double within the next 2 decades. It is critical to monitor the safety and quality of THA to avoid harm and to minimize cost to the community. While it may take 10 years before the final stages of loosening become apparent on conventional radiographs, it is possible to detect loosening early preoperatively with radiostereometric analysis (RSA). Hence, this review hypothesized that early migration of the acetabular cup (measured through RSA) is associated with late revision for aseptic loosening.
What was the principal research question?
Does the early migration of the acetabular cup have a specific association with late revision for aseptic loosening?
Study Characteristics
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Data Source:
The following databases were searched up to 2009: PubMed, Embase, Web-of-Science, and the Cochrane library. Furthermore, a separate search was conducted in 9 leading orthopedic and biomechanical journals (Acta Orthop, Clin Orthop Relat Res, J Arthroplasty, J Bone Joint Surg (Am and Br), Knee Surg Sports Traumatol Arthrosc, J Orthop Res, J Biomech, and Clin Biomech). Lastly, Google Scholar was used.
Index Terms:
RSA studies = PubMed: ("Photogrammetry"[Mesh] OR "roentgen stereophotogrammetric analysis" OR rsa OR radiostereometr* OR stereophotogrammetr* OR "roentgen fluoroscopic") AND ("Joint Prosthesis"[Mesh] OR hip prosthesis OR knee prosthesis OR TKA OR THA OR THR OR TKR OR "joint replacement" OR Arthroplasty, Replacement[mesh] OR "total knee replacement" OR "total hip replacement").
Survival cohort studies = PubMed: ("Joint Prosthesis"[Mesh] OR hip prosthesis OR knee prosthesis OR TKA OR THA OR THR OR TKR OR "joint replacement" OR Arthroplasty, Replacement[mesh] OR "total knee replacement" OR "total hip replacement") AND ("Prosthesis Failure"[Mesh] OR "prosthetic loosening" OR "aseptic loosening" OR "implant loosening" OR "implant failure") AND ("survival analysis"[MeSH Terms] OR ("survival"[All Fields] AND "analysis"[All Fields]) OR "survival analysis"[All Fields] OR cohort studies[mesh] OR "follow up" OR "follow-up" OR experience OR outcome).
Study Selection:
Initial screening based on the title and abstract of RSA studies was performed to identify studies on patients treated with THA for osteoarthritis (OA), SA, or FF. In instances where the abstract information did not arise or where there was any doubt, studies remained eligible. Two reviewers independently evaluated the full text of eligible studies. The inclusion criteria for RSA studies were: 1) primary THA; and 2) minimal RSA follow-up of 1 year, measuring acetabular cup migration. Non-clinical studies (such as animal or phantom studies) were excluded.
Data Extraction:
Migration data was extracted in duplicate from the RSA studies by two reviewers independently. As the failure mechanism of acetabular cups involves rising proximal migration and inclination, the data extraction of RSA studies comprised proximal migration and inclination of the acetabular cup until the second postoperative year. Data concerning patient demographics and regional influences were also extracted to allow for confounder correction.
Data Synthesis:
In order to address the issue of extracting data from different studies, the review determined the degree of similarity of the population from RSA and survival study combinations. This was expressed by a match score, for age, sex, diagnosis, hospital type, and continent. The match score was constructed according to the results of a recent Delphi survey among an international group of 37 independent experts and can vary between 0 (poor) and 5 (excellent). A weighted regression model was used to assess the association between early migration and late aseptic revision, corrected for the influence of match score, RSA study quality, survival study quality, number of THAs in the RSA studies and number of THAs in the survival studies.
What were the important findings?
- Clear association was shown between 2-year proximal migration and the 10-year revision rate expressed as prosthesis survival; for every 1 mm increase in proximal migration (at 2 years), 10 % (95% CI: 5.5 – 14.2; p < 0.05) was added to the 10-year revision rate.
- A number of factors were found that may have influenced the association between the 2-year proximal migration and the 10-year revision rate; however, the association remained significant (P < 0.05) following adjustments for these potential confounding factors.
- No clear association was seen between proximal migration rate (i.e. 2-year proximal migration minus 1-year proximal migration) and the 10-year revision rate.
- Results indicated that accepting 5% revision at 10 years resulted in a threshold of 0.2 mm for acceptable proximal migration at 2 years and a threshold of 1.0 mm for unacceptable proximal migration at 2 years.
What should I remember most?
Clinically relevant associations between early proximal migration of acetabular cups (measured with RSA) and clinical failure (defined as revision surgery) was shown. Each mm of proximal migration increased the 10-year revision rate by an average of 10%, a rate that is more than double the standard revision rates of several national joint registries.
How will this affect the care of my patients?
There is a clinically relevant association between early migration of the acetabular component of a total hip arthroplasty and late revision for loosening. The proposed migration thresholds can be established in a phased, evidence-based introduction, as they allow early detection of high-risk THAs while exposing a small number of patients.
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