title: There Are No Differences in Short- to Mid-term Survivorship Among Total Hip-bearing Surface Options: A Network Meta-analysis.
abstract: BACKGROUND
  Total hip arthroplasty (THA) is increasingly being performed in patients with long life expectancies and active lifestyles. Newer implant bearing surfaces, with superior wear characteristics, often are used in this cohort with the goal of improving longevity of the prosthesis, but comparisons across the numerous available bearing surfaces are limited, so the surgeon and patient may have difficulty deciding which implants to use.
  
  
  OBJECTIVE
  The purpose of this study was to answer the following question: Is there a short- to mid-term survivorship difference between common THA bearings used in patients younger than age 65 years?
  
  
  METHODS
  We conducted a systematic review to identify randomized clinical trials (RCTs) published after 2000 that reported survivorship of ceramic-on-ceramic (CoC), ceramic-on-highly crosslinked polyethylene (CoPxl), or metal-on-highly crosslinked polyethylene (MoPxl) bearings. To qualify for our review, RCTs had to have a minimum 2-year followup and study patients were required to have an average age younger than 65 years. Direct-comparison meta-analysis and network meta-analysis were performed to combine direct and indirect evidence.
  
  
  RESULTS
  Direct-comparison meta-analysis found no differences among the bearing surfaces in terms of the risk of revision; this approach demonstrated a risk ratio for revision of 0.65 (95% confidence interval [CI], 0.19-2.23; p = 0.50) between CoC and CoPxl and a risk ratio for revision of 0.40 (95% CI, 0.06-2.63; p = 0.34) between CoC and MoPxl. Network meta-analysis (with post hoc modification) likewise found no differences in survivorship across the three implant types, demonstrating the following probabilities of most effective implant with 95% credible intervals (CrI): CoC = 64.6% (0%-100%); CoPxl = 24.9% (0%-100%); and MoPxl = 9.9% (0%-100%). The CrIs ranged from 0% to 100% for all three bearing surfaces. Direct-comparison meta-analysis allowed for pooling of five RCTs, including 779 THAs, whereas network meta-analysis (before post hoc analysis) enabled pooling of 18 RCTs, including 2599 THAs.
  
  
  CONCLUSIONS
  Current published evidence does not support survivorship differences among commonly used bearing surfaces in patients younger than age 65 years undergoing THA at short- to mid-term followup. Long-term RCT data will be needed to determine if a survivorship benefit is realized in younger, more active patients over time.
  
  
  METHODS
  Level I, therapeutic study.
authors.affiliation: Mayo Medical School, Mayo Clinic, Rochester, MN, USA.
authors.forename: Cody C
authors.initials: CC
authors.lastname: Wyles
authors.forename: Jose H
authors.initials: JH
authors.lastname: Jimenez-Almonte
authors.forename: Mohammad H
authors.initials: MH
authors.lastname: Murad
authors.forename: German A
authors.initials: GA
authors.lastname: Norambuena-Morales
authors.forename: Miguel E
authors.initials: ME
authors.lastname: Cabanela
authors.forename: Rafael J
authors.initials: RJ
authors.lastname: Sierra
authors.forename: Robert T
authors.initials: RT
authors.lastname: Trousdale
mesh_terms: D000367:Age Factors; D019644:Arthroplasty, Replacement, Hip / Q000009:adverse effects / Q000295:instrumentation*; D001696:Biomechanical Phenomena; D002516:Ceramics / Q000737:chemistry; D016009:Chi-Square Distribution; D006621:Hip Joint / Q000503:physiopathology / Q000601:surgery*; D006622:Hip Prosthesis; D006801:Humans; D061825:Metal-on-Metal Joint Prostheses; D008670:Metals / Q000737:chemistry; D008875:Middle Aged; D016017:Odds Ratio; D020959:Polyethylene / Q000737:chemistry; D011474:Prosthesis Design; D011475:Prosthesis Failure; D016032:Randomized Controlled Trials as Topic; D020127:Recovery of Function; D012086:Reoperation; D012307:Risk Factors; D013499:Surface Properties; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D008670:Metals; D020959:Polyethylene