What Is the Risk of Revision Surgery in Hydroxyapatite-coated Femoral Hip Stems? Findings From a Large National Registry
Authors: Inacio Maria C. , Lorimer Michelle , Davidson David C. , De Steiger Richard N. , Lewis Peter L. , Graves Stephen E. 
Published: October 2018

Abstract

Background
Despite wide adoption of hydroxyapatite (HA)-coated femoral stems in THA, no studies have found differences in the risk of revision surgery with its use or investigated the interaction of different prosthesis designs with stem coating.

Questions/purposes
The purpose of this study was to evaluate the risk of revision in THAs with HA-coated stems compared with non-HA-coated. To achieve this purpose, we asked: (1) What is the difference in risk of revision of THAs with HA-coated femoral stems compared with non-HA-coated using an aggregate analysis? (2) What is the difference in risk of revision of THAs with HA-coated femoral stems compared with non-HA-coated for five prosthesis types that used the same femoral and acetabular component combination but where the femoral stem had both a HA and non-HA coating option?

Methods
The Australian Orthopaedic Association National Joint Replacement Registry analyzed cementless primary THA registered between September 1, 1999, and December 31, 2014. Of the 147,645 cases that fit our selection criteria, 81.1% (N = 119,673) had HA-coated stems. Overall (that is, all procedures with any prostheses in the registry) and five prosthesis designs where both an HA-coated stem and non-HA-coated stem exist (Zimmer’s VerSys®/Trilogy® [N = 3924], Biomet’s Mallory-Head®/Mallory-Head [N = 2538], Smith & Nephew’s SL-Plus/EP Fit-Plus [N = 2028], Biomet’s Taperloc®/Exceed [N = 1668], and Biomet’s Taperloc/Mallory-Head [N = 1240]) were evaluated. Revision surgery was the outcome of interest. Survival analyses were conducted and hazard ratios (HRs) were adjusted for age, sex, bearing surface, femoral head size, and acetabular component HA coating.

Results
In the overall cohort, HA stems had a lower any-cause revision risk after 6 months (HR, 0.83; 95% confidence interval [CI], 0.72-0.95; p = 0.007). However, the risk of revision varied when we evaluated the effect of HA on revision for specific prothesis combinations that had both HA and non-HA options for the femoral stem. VerSys/Trilogy, Mallory-Head/Mallory-Head, Taperloc/Exceed, and Taperloc/Mallory-Head did not have a lower risk of any-cause revision with HA-coated stems compared with non-HA-coated. Only the SL-Plus/EP Fit-Plus subgroup showed a lower risk of revision for loosening (HR, 0.17; 95% CI, 0.06-0.44 between 0 and 7 years; p < 0.001) with HA- compared with non-HA-coated stems, but this was observed after an early (< 6 months) higher risk of revision for any reason (HR, 2.88; 95% CI, 1.15-7.21; p = 0.024).

Conclusions
Overall, HA coating of femoral stems was found to be associated with a 17% lower risk of revision for any reason. However, the lower risk of revision associated with HA was not consistent for all prosthesis designs where both HA- and non-HA-coated femoral stem versions were available. Some HA-coated stems have higher revision rates compared with their non-HA-coated versions. Our findings suggest that the effect of HA coating on revision risk varies depending on prosthesis design.

Level of Evidence
Level II, therapeutic study.