Total hip replacement: A meta-analysis to evaluate survival of cemented, cementless and hybrid implants

Table 1 Characteristics of the included studies

Ref.	Age (years old)	Length of follow-up (years)	Diagnosis	Cementing technique (generation)	Comparison		Approach	Comments
Bjørgul et al[11]	65 to 66	14	Osteoarthritis (most)	3rd	Cemented (n = 120)	Hybrid (n = 120)	direct lateral
Chandran et al[12]	64.5 to 65.5	14	primary Osteoarthritis	2nd	Cemented (n = 97)	Cementless (n = 105)	anterolateral
Corten et al[13]	64 (mean)	19.5	primary Osteoarthritis	2nd	Cemented (n = 124)	Cementless (n = 126)	direct lateral
Kim et al[14]	43.4 to 46.8	18.4	Avascular necrosis (most)	3rd	Hybrid (n = 109)	Cementless (n = 110)	ND	May overlap with Kim et al[15]
McCombe et al[16]	67.3	6.5 to 8	Primary OA (most)	2nd	Cemented (n = 84)	Hybric (n = 78)	posterolateral
Berend et al[17]	67.1	6.8	Osteoarthritis (most)	ND	Cemented (n = 1908)	Cementless (n = 623)	anterolateral and posterior
Clohisy et al[18]	61 to 62	10 to 11	Osteoarthritis	2nd	Cemented (n = 45)	Hybrid (n = 45)	posterolateral
Emerson et al[8]	55 to 70	6.7 to 7.2	Osteoarthritis (most)	3rd	Hybrid (n = 113)	Cementless (n = 88)	anterolateral
Hartofilakidis et al[19]	39.6 to 45.4	12.4 to 15.4	Osteoarthrosis secondary to congenital hip disease (most)	2nd	Cemented (n = 59)	Hybric (n = 58)	lateral transtrochanteric
Kim et al[15]	64.6	17.3	Avascular necrosis	3rd	Hybrid (n = 50)	Cementless (n = 98)	ND	May overlap with et al[14]
Pospula et al[20]	46.7 to 53.7	3 to 5	Avascular necrosis (most)	ND	Cemented (n = 87)	Cementless (n = 95)	cemented posterolateral cementless transgluteal
Van Stralen et al[21]	69.5	2.5	Primary OA (most)		Cemented (n = 746)	Cementless (n = 138)	posterior
Thomason et al[22]	54	7.4	Rheumatoid arthritis	ND	Hybrid (n = 47)	Cementless (n = 51)	posterior
Zimmerman et al[7]	74.9	1	Osteoarthritis	ND	Hybrid (n = 85)	Cementless (n = 174)	anterolateral, posterior
Conroy et al[23]	Any	5	Osteoarthritis	ND	Cemented (n = 8945); hybrid (n = 20445);		ND
					Cementless (n = 28582)
Dale et al[24]	Any	0 to 20	Osteoarthritis (most)	ND	Cemented (n = 82996)	Cementless (n = 14348)	ND	May overlap with study of et al[16]
Engesaeter et al[25]	Any	0 to 16	Primary Osteoarthritis	ND	Cemented (n = 51016)	Cementless (n = 5259)	ND	May overlap with et al[15]
Eskelinen et al[26]	< 55	0 to 24	Rheumatoid arthritis	ND	Cemented (n = 821)	Cementless (n = 724)	ND
Hailer et al[27]	Any	15	Osteoarthritis (most)	ND	Cemented (n = 161460)	Cementless (n = 8593)	ND
Hooper et al[28]	Any	7	ND	ND	Cemented (n = 16005); hybrid (n = 15189)		ND
					Cementless (n = 10898)
Lucht et al[29]	Any	4		ND	Cemented (n = 11671); hybric (n = 4491)		ND
					Cementless (n = 2030)
Mäkelä et al[30]	> 55	15	Osteoarthritis	ND	Cemented (n = 9549)	Cementless (n = 10310)	ND
Mäkelä et al[31]	63 to 69 (> 55)	15	Rheumatoid arthritis	ND	Cemented (n = 3440)	Cementless (n = 579)	ND
Mäkelä et al[32]	< 55	15	Osteoarthritis	ND	Cemented (n = 2342)	Cementless (n = 1326)	ND
Malchau et al[33]	All	8	Osteoarthritis (most)	ND	Cemented (n = 178762)	Cementless (n = 6102)	ND
Pedersen et al[34]	Any	0 to 14	Osteoarthritis (most)	ND	Cemented (n = 34656); cementless (n = 25571)		ND
					Hybrid (n = 20539)
Roberts et al[35]	All	ND	ND	ND	Cemented (n = 92928)	Cementless (n = 69882)	ND

Table 2 Summary of finding comparing cemented and cementless total hip replacement

	Illustrative comparative risks7 (95%CI)		Relative effect	No of participants	Quality of the evidence	Comments
	Assumed risk	Corresponding risk	(95%CI)	(studies)	(GRADE)
	Cementless	Cemented
Revision of any component due to any reason - RCT Follow-up: 14 to 19.5 yr	Study population		RR 1.43 (1 to 2.04)	452 (2 studies)	++-- low1,2
	165 per 1000	235 per 1000 (165 to 336)
	Moderate
	156 per 1000	223 per 1000 (156 to 318)
Revision of any component due to any reason - Register or Cohort of register Follow-up: 0 to 24 yr	Study population		RR 0.46 (0.45 to 0.47)	518774 (10 studies)	+--- very low2,3,4
	99 per 1000	46 per 1000 (45 to 47)
	Moderate
	122 per 1000	56 per 1000 (55 to 57)
Revision of any component due to any reason - All types of study Follow-up: 0 to 24 yr	Study population		RR 0.47 (0.45 to 0.48)	521757 (13 studies)	+--- very low2,3,5
	99 per 1000	46 per 1000 (44 to 47)
	Moderate
	106 per 1000	50 per 1000 (48 to 51)
Revision of any component due to aseptic loosening - RCT Follow-up: 14 to 19.5 yr	Study population		RR 2 (1.29 to 3.1)	452 (2 studies)	+++- moderate2
	104 per 1000	208 per 1000 (134 to 322)
	Moderate
	97 per 1000	194 per 1000 (125 to 301)
Revision of any component due to aseptic loosening - Register or Cohort of register Follow-up: 0 to 24 yr	Study population		RR 0.88 (0.83 to 0.94)	255779 (6 studies)	+--- very low2,3,4
	47 per 1000	41 per 1000 (39 to 44)
	Moderate
	48 per 1000	42 per 1000 (40 to 45)
Revision of any component due to aseptic loosening - All types of study Follow-up: 0 to 24 yr	Study population		RR 0.9 (0.84 to 0.95)	256231 (8 studies)	+--- very low2,3,5,6
	47 per 1000	43 per 1000 (40 to 45)
	Moderate
	48 per 1000	43 per 1000 (40 to 46)
Revision of any component due to infection - Register or Cohort of register Follow-up: 0 to 20 yr	Study population		RR 1.27 (1.04 to 1.55)	382433 (6 studies)	+--- very low2,4
	5 per 1000	6 per 1000 (5 to 7)
	Moderate
	4 per 1000	5 per 1000 (4 to 6)
Revision of any component due to infection - All types of study Follow-up: 0 to 20 yr	Study population		RR 1.29 (1.06 to 1.57)	382683 (7 studies)	+--- very low2,5
	5 per 1000	6 per 1000 (5 to 7)
	Moderate
	4 per 1000	5 per 1000 (4 to 6)
Dislocation of any component - Cohort Follow-up: 2.5 to 5 yr	Study population		RR 0.69 (0.29 to 1.67)	1066 (2 studies)	+--- very low1,2,3
	30 per 1000	21 per 1000 (9 to 50)
	Moderate
	30 per 1000	21 per 1000 (9 to 50)
Dislocation of any component - Register or Cohort of register Follow-up: 5 to 15 yr	Study population		RR 0.69 (0.59 to 0.8)	254786 (6 studies)	+--- very low3,4
	6 per 1000	4 per 1000 (4 to 5)
	Moderate
	13 per 1000	9 per 1000 (8 to 10)
Dislocation of any component - All types of study Follow-up: 2.5 to 15 yr	Study population		RR 0.69 (0.6 to 0.79)	255852 (8 studies)	+--- very low2,5
	6 per 1000	4 per 1000 (4 to 5)
	Moderate
	14 per 1000	10 per 1000 Ta(8 to 11)

CI: Confidence interval; RR: Risk ratio; GRADE Working Group grades of evidence; High quality: Further research is very unlikely to change our confidence in the estimate of effect; moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate; low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate; very low quality: We are very uncertain about the estimate.

¹95% confidence interval around the pooled or best estimate of effect includes both (1) no effect and (2) appreciable benefit or appreciable harm (> 25%);

²No explanation was provided;

³Unexplained heterogeneity;

⁴Indirect studies from registers;

⁵Overall result from all types of study;

⁶High heterogeneity, explained by meta-regression;

⁷The basis for the assumed risk (e.g., the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95%CI).

Table 3 Summary of finding table comparing cemented to hybrid total hip replacement

Outcomes	Illustrative comparative risks6 (95%CI)		Relative effect(95%CI)	No of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Hybrid	Cemented
Revision of any component due to any reason - RCT Follow-up: 6.5 to 14 yr	Study population		RR 0.73 (0.47 to 1.13)	402 (2 studies)	+--- very low1,2,3
	187 per 1000	136 per 1000 (88 to 211)
	Moderate
	177 per 1000	129 per 1000 (83 to 200)
Revision of any component due to any reason - Register or Cohort of register Follow-up: 4 to 7 yr	Study population		RR 0.82 (0.76 to 0.89)	76746 (3 studies)	+--- very low3,4
	30 per 1000	24 per 1000 (23 to 26)
	Moderate
	31 per 1000	25 per 1000 (24 to 28)
Revision of any component due to any reason - All types of study Follow-up: 4 to 15.4 yr	Study population		RR 0.82 (0.76 to 0.89)	77265 (6 studies)	+--- very low3,5
	31 per 1000	25 per 1000 (23 to 27)
	Moderate
	104 per 1000	85 per 1000 (79 to 93)
Revision of any component due to aseptic loosening - All types of study Follow-up: 6.5 to 15.4 yr	Study population		RR 2.65 (1.14 to 6.17)	519 (3 studies)	+--- very low3,5
	23 per 1000	62 per 1000 (27 to 145)
	Moderate
	0 per 1000	0 per 1000 (0 to 0)
Revision of any component due to infection - Register or Cohort of register Follow-up: 0 to 14 yr	Study population		Not estimable	86389 (2 studies)	+--- very low3,4
	7 per 1000	0 per 1000 (0 to 0)
	Moderate
Revision of any component due to infection - All types of study Follow-up: 0 to 14 yr	Study population		RR 0.98	86881	+---
	7 per 1000	7 per 1000 (5 to 10)	(0.7 to 1.38)	(5 studies)	very low1,2,3,5
	Moderate
	2 per 1000	2 per 1000 (1 to 3)
Dislocation of any component - Register of Cohort of register Follow-up: 5 to 7 yr	Study population		RR 0.68 (0.57 to 0.8)	60584 (2 studies)	+--- very low3,4
	11 per 1000	7 per 1000 (6 to 9)
	Moderate
	11 per 1000	7 per 1000 (6 to 9)
Dislocation of any component - All types of study Follow-up: 5 to 14 yr	Study population		RR 0.67 (0.57 to 0.79)	60824 (3 studies)	+--- very low3,5
	11 per 1000	7 per 1000 (6 to 9)
	Moderate
	14 per 1000	9 per 1000 (8 to 11)

CI: Confidence interval; RR: Risk ratio; GRADE Working Group grades of evidence; High quality: Further research is very unlikely to change our confidence in the estimate of effect; moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate; low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate; very low quality: We are very uncertain about the estimate.

¹95% confidence interval around the pooled or best estimate of effect includes both (1) no effect and (2) appreciable benefit or appreciable harm (> 25%);

²No explanation was provided;

³Unexplained heterogeneity;

⁴Indirect studies from registers;

⁵Overall result from all types of study;

⁶The basis for the assumed risk (e.g., the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95%CI).

Table 4 Summary of finding table comparing hybrid and cementless total hip replacement

Outcomes	Illustrative comparative risks7 (95%CI)		Relative effect(95%CI)	No of participants(studies)	Quality of the evidence(GRADE)	Comments
	Assumed risk	Corresponding risk
	Cementless	Hybrid
Revision of any component due to any reason - Cohort Follow-up: 1 to 17.3 yr	Study population		RR 1.03 (0.69 to 1.54)	706 (4 studies)	+--- very low1,2
	105 per 1000	108 per 1000 (72 to 161)
	Moderate
	106 per 1000	109 per 1000 (73 to 163)
Revision of any component due to any reason - Register or Cohort of register Follow-up: 4 to 7 yr	Study population		RR 0.69 (0.64 to 0.74)	81635 (3 studies)	+--- very low2,3,4
	33 per 1000	23 per 1000 (21 to 25)
	Moderate
	39 per 1000	27 per 1000 (25 to 29)
Revision of any component due to any reason - All types of study Follow-up: 1 to 18.4 yr	Study population		RR 0.7 (0.65 to 0.75)	82560 (8 studies)	+--- very low2,5,6
	34 per 1000	24 per 1000 (22 to 26)
	Moderate
	116 per 1000	81 per 1000 (75 to 87)
Revision of any component due to aseptic loosening - Cohort Follow-up: 6.7 to 17.3 yr	Study population		RR 0.84 (0.47 to 1.51)	447 (3 studies)	+--- very low1,2
	76 per 1000	64 per 1000 (36 to 115)
	Moderate
	20 per 1000	17 per 1000 (9 to 30)
Revision of any component due to aseptic loosening - All types of study Follow-up: 6.7 to 17.3 yr	Study population		RR 0.85 (0.49 to 1.5)	666 (4 studies)	+--- very low1,2,6
	58 per 1000	49 per 1000 (28 to 86)
	Moderate
	19 per 1000	16 per 1000 (9 to 28)
Revision of any component due to infection - Register or Cohort of register Follow-up: 0 to 14 yr	Study population		Not estimable	72197 (2 studies)	+--- very low2,4
	4 per 1000	0 per 1000 (0 to 0)
	Moderate
Revision of any component due to infection - All types of study Follow-up: 0 to 18.4 yr	Study population		RR 1.47 (0.93 to 2.34)	72863 (5 studies)	+--- very low1,2,6
	4 per 1000	6 per 1000 (4 to 10)
	Moderate
	0 per 1000	0 per 1000 (0 to 0)
Dislocation of any component - Register or Cohort of register Follow-up: 5 to 7 yr	Study population		RR 1.12 (0.97 to 1.3)	75114 (2 studies)	+--- very low1,2,4
	9 per 1000	10 per 1000 (9 to 11)
	Moderate
	10 per 1000	11 per 1000 (10 to 13)
Dislocation of any component - All types of study Follow-up: 5 to 18.4 yr	Study population		RR 1.13 (0.98 to 1.3)	75333 (3 studies)	+--- very low1,2,6
	9 per 1000	10 per 1000 (9 to 11)
	Moderate
	9 per 1000	10 per 1000 (9 to 12)

CI: Confidence interval; RR: Risk ratio; GRADE Working Group grades of evidence; High quality: Further research is very unlikely to change our confidence in the estimate of effect; moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate; low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate; very low quality: We are very uncertain about the estimate.

¹95% confidence interval around the pooled or best estimate of effect includes both (1) no effect and (2) appreciable benefit or appreciable harm (> 25%);

²No explanation was provided;

³Unexplained heterogeneity;

⁴Indirect studies from registers;

⁵Overall result from all types of study;

⁶High heterogeneity, explained by meta-regression;

⁷The basis for the assumed risk (e.g., the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95%CI).