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Editor’s Spotlight/Take 5: Has the Use of Fixation Techniques in THA Changed in This Decade? The Uncemented Paradox Revisited

2020; Lippincott Williams & Wilkins; Volume: 478; Issue: 4 Linguagem: Inglês

10.1097/corr.0000000000001181

1528-1132

Seth S. Leopold,

Knee injuries and reconstruction techniques

They say that history doesn’t repeat itself, but it often rhymes. So it goes, sort of, when it comes to registry data and implant fixation in THA. In this month’s Clinical Orthopaedics and Related Research®, an article called “Has the Use of Fixation Techniques in THA Changed in This Decade? The Uncemented Paradox Revisited” presents the second stanza of an important poem [1]. In at least some respects, it’s a happy song. It seems that the best-available evidence has influenced implant-fixation choices in some countries in ways that are likely to make THA a lifelong solution for thousands more patients every year than was the case even in the recent past [7]. Unfortunately, though, that evidence has not penetrated equally in all nations those authors surveyed. There is a legitimate question about which fixation approach better serves our very young patients, though good registry evidence favors cementless fixation in that group [3]. By contrast, the world’s registries consistently have found cemented stems to be the right choice for patients older than 75 years of age [1, 7], and some large registry studies have found that cemented stems are more durable in patients 10 [6] or even 20 years younger than that, particularly among women [2]. Seven years ago, CORR® published an article [7] that shared a disturbing finding: Despite registry data favoring cemented stem fixation, surgeons in all countries the authors surveyed (Australia, Canada, Denmark, England-Wales, New Zealand, Norway, and Sweden) increased their usage of uncemented fixation during the study period, which was 2006 to 2010. The authors found that the same was true even in patients older than 75 years of age, even though robust data even then favored cemented fixation in those patients. The authors called this the “uncemented paradox”: It’s one thing if surgeons in the United States question whether Norwegian registry data apply to them (though I, for one, believe they do). It’s quite another when Norwegian surgeons themselves act in disregard of clear answers derived from their own national register. This month, this same author group [1] share their findings here using an expanded pool of international registries from 2010 to 2017; their goal was to see whether, over time, surgeons have started to listen to a dataset that’s been shouting at us all along. As I suggested earlier, some surgeons—but not all—are. The authors of this study, led by Professor Anders Troelsen MD, PhD (Fig. 1), of Copenhagen University Hospital, found that although uncemented fixation is seeing greater use in Norway, Denmark, and Sweden, surgeons are moving more towards cemented implants in England-Wales, Australia, New Zealand, and Finland. There was some good news for patients older than 75 years of age: While surgeons in Denmark and Australia are using more cementless THAs in this vulnerable group, this unsupported practice has plateaued in Netherlands, Sweden, New Zealand, and England-Wales. And best of all, the usage of cementless THA in older patients has decreased a bit in Norway and it’s dropped dramatically in Finland. Sounds like the Finns have not just the cleanest air (and the original Santa Claus) [8] but also the most evidence-driven hip surgeons. Perhaps this is why they are the happiest people in the world. Then again, perhaps not.Anders Troelsen MD, PhDWhile not all surgeons perform hip replacements, all of us need to think about what it takes to get high-quality evidence into practice. In my experience, surgeons immersed in drawing data from the world’s high-quality registries have some of the best insights on this key question. Join me as I visit with one such surgeon, the senior author of “Has the Use of Fixation Techniques in THA Changed in This Decade? The Uncemented Paradox Revisited” [7], Professor Troelsen, in the Take 5 interview that follows. Take 5 Interview with Anders Troelsen, MD, PhD, senior author of “Has the Use of Fixation Techniques in THA Changed in This Decade? The Uncemented Paradox Revisited” Seth S. Leopold MD:Congratulations on another thought-provoking look at a very-resistant problem. Let’s start with the good news: What specific steps can you point to that were taken in the countries where cementless fixation decreased over the span of this study that might have accounted for the findings? Anders Troelsen MD, PhD: The role of the registries in this development is fundamental. The registries deliver “real-world” data on performance back to societies and surgeons. The fact that these data are collected in everyday practice makes them especially relevant for adjustments of practice patterns. If the data show that you, your department, or your region is underperforming, and you can identify a divergent practice pattern that accounts for the discrepancy, this motivates change. And following the change, it’s easy to follow one’s improvements prospectively in the registries. Dr. Leopold:What surprised you most in your study? Dr. Troelsen: Focusing on the positive side, I think that the “Finish example” is a great observation. Its inspiring that our colleagues there have been able to change their practice so dramatically. It is a huge step for evidence-based medicine in Finland. Talking with a Finish colleague about what happened in Finland, it appears that surgeons as a group made the decision to increase the use of cemented fixation based on contemporary evidence and an exceptionally high usage of uncemented fixation in Finland before the observed change. The registry served as a simple means of informing the usage of uncemented fixation to the surgeons. Dr. Leopold:The big question, of course, is what it will take to get surgeons to follow the evidence. What do you think needs to happen in the countries you studied where uncemented fixation is being used in the face of good data supporting cemented fixation? Dr. Troelsen: I believe that if surgeons and their societies can stay in charge of developing and supporting evidence-based orthopaedics it is by far the preferred approach. The alternative is that other stakeholders will demand (and take) action on our behalf, based on alternative interpretations of the data that don’t necessarily incorporate important, relevant clinical knowledge that only surgeons possess. I believe that national and arthroplasty subspecialty societies should take a leading role in defining good, evidence-based surgical behavior. Using and listening to the “real-world” data from the registries should be a cornerstone in this strategy, but as important is the correct clinical interpretation of the data, leading to clinically meaningful guidance to surgeons, with the aim of improving short- and long-term outcomes for patients. Let’s be honest: Surgeons do not like to be told what to do, in particular when we are told what is best for our patients. We need therefore to take ownership of this ourselves. Also, I see an important and changing role for the leading/expert surgeons in each country, as they should no longer suggest treatments that work well in their hands (these super-experts can make almost everything work), but rather they should suggest treatment strategies that will work well for the “average” surgeon. Please remember that the vast majorities of surgical procedures are not performed by high-volume subspecialists. Modifying the practices of practicing surgeons according to evidence-based strategies is one way we can find big improvements for our patients. Dr. Leopold:In round numbers, if all the countries in your study adopted the practice pattern now prevalent in Finland, how many patients might avoid needless revision? (I recognize this calls for a number of assumptions … I’m asking this just as a conversation-starter). Dr. Troelsen: I believe this question is very interesting and a potential facilitator in the quest to change practices towards using cemented fixation more frequently. Rather than speculating, I would suggest this should be studied prospectively or using data from the Finish registry. This would also capture the potential learning curve, which might be important as surgeons change practice towards more-frequent utilization of cemented fixation. Based on survivorship curves from many previous studies, I suspect that the benefits, in terms of fewer revisions, would be apparent within the first 2 years as the risk of stem revision for periprosthetic fracture is dramatically less after cemented fixation in the early follow-up [3]. Dr. Leopold:How do you think surgeons in the United States (or other countries that don’t have registry data in your study) should use the findings in your study? Dr. Troelsen: One of the fundamental strengths of registry data is that they show the outcome of everyday orthopaedic practice yielding so-called “real-world” data. Therefore, surgeons in the United States or countries without registries should use these findings to shape their practices realizing that their practices are as “everyday” and “real-world” as that of their colleagues in countries with registries reporting these data. You may argue that cultures and healthcare systems differ too much for some direct comparisons between registries, countries, and practices but choice of fixation and the outcome of this choice are fair to categorize as universal, high-level variables with high generalizability beyond individual nations’ registries. Very simply, a surgeon never taught how to cement a femoral stem should visit a colleague in a center with consistent high usage of cemented fixation and surgeons underutilizing cemented fixation in the elderly should change this practice as it is evidently the safe choice for the patients. Not being educated or not believing the real-world data can never be an excuse in this case.