Nearly 8,000 younger hip replacement patients across the UK will be randomly assigned to receive either cemented or uncemented implants in the world’s largest trial of its kind. The problem is that surgeons lack reliable evidence on which implant type works best for patients under 70. Current guidance is based on older patients, where cemented metal-on-polyethylene implants are the clear winner. For younger patients—who will need their implants to last decades—the data is too uncertain to guide practice. The NHS spends over £6 billion on primary hip replacements in the next decade, plus £900 million on revision surgeries when implants fail. If the trial succeeds, it will settle a long-running debate and could change orthopaedic practice worldwide. Surgeons would know definitively whether cheaper cemented implants (£500–800) perform as well as more expensive uncemented or hybrid options (up to £2,000) in younger patients. The results will be combined with routine data from the National Joint Registry to model long-term costs and outcomes, potentially saving the NHS hundreds of millions of pounds while improving patients’ quality of life and reducing the need for repeat surgery.
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Background: Total hip replacement (THR) is clinically and cost-effective for the treatment of osteoarthritis. More than 100,000 primary THRs were performed in the UK in 2019. Three quarters of THRs last 15-20 years; nearly 60% last 25 years. Implant failure often requires revision surgery which seriously affects patients function and quality-of-life. In the next decade, the NHS will spend over £6 billion on primary THRs, including £1.2 billion on implants, and £900 million on revision surgery. During THR surgery, different ways of fixing the implants to the bone can be used, and these are associated with different outcomes for the patients and costs for the NHS. Cemented implants (cup and stem components are fixed to the bone with cement) are the cheapest (£500-800); they have a long track-record of use worldwide and perform better regardless of hospital or surgeon expertise. Uncemented (stem and cup are press-fit to the bone) and hybrid implants (cemented stem and uncemented cup) can cost up to £2,000. Our NIHR-funded Hip Implant Prosthesis Study showed that cemented metal-on-polyethylene THRs are the most cost-effective option in men aged >75 and women >65 years. For younger patients, cemented implants also ranked higher, but the evidence is very uncertain and has not warranted a change in guidance. An NIHR signal and BMJ editorial called for new trial evidence, powered on revision surgery, for the younger primary THR patients. Aim: To establish which implants are best for patients <70 years of age receiving primary elective THR. Methods: We designed a programme of studies to inform a trial and advise on implementation of findings into practice to affect clinical change. WP1: National survey of hospitals and surgeons to understand current practice and provision of implants, and further work to understand and rank surgeons preferences and younger patients expectations of THR implants. WP2: Update our systematic review on outcomes for the different implant types and conduct reviews to understand risk factors and outcomes for younger and older THR patients. WP3: Analyse routine data to identify risk factors for outcomes in younger patients and produce long-term estimates to complement the trial results. WP4: RCT involving nearly 8,000 patients with embedded qualitative research to evaluate the long-term effectiveness and cost-effectiveness of hip implant types for younger patients, powered on 10-year revision risks with long-term follow-up through the National Joint Registry. WP5: Estimate the most cost-effective implant type for younger patients by extrapolating our RCT results to the longer-term using the trial patients' routine data and WP3 estimates. We are committed to include all patients in our research. Our Programme will be informed by collaboration with patients, including those from underserved groups, to make the research inclusive and representative of all. Outputs and impact: This Programme will include the world s largest randomised trial of hip implants, and the results have the potential to change orthopaedic practice worldwide. We will disseminate our findings widely and design an implementation strategy to best translate our findings into clinical practice and improve care for patients receiving THR.
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