NICE 2002/ 34
Issued: 19 June 2002
PRESS RELEASE
NICE recommends the selective use of metal on metal hip resurfacing
The National Institute for Clinical Excellence has issued guidance recommending the selective use of a technique called metal on metal hip resurfacing, used to treat hip disease.Metal on metal (MoM) hip resurfacing involves replacing the diseased or damaged surfaces in the hip joint with metal surfaces. Less bone has to be removed for MoM resurfacing than to fit a conventional cup and ball artificial hip joint.
NICE recommends that MoM hip resurfacing be considered as an option for people with advanced hip disease who would otherwise receive a conventional primary THR and are likely to live longer than the device is likely to last. When considering a MoM hip resurfacing surgeons should bear in mind how active the individual is and that the current available clinical and cost effectiveness evidence on MoM hip resurfacing comes mainly from studies that have involved people less than 65 years of age.
Information on MoM resurfacing operations carried out should be collected as part of a UK national joint registry. The information collected will help the NHS to gather evidence on both the clinical effectiveness and cost effectiveness of MoM hip resurfacing.
The data from the national joint registry will allow researchers to find out how long MoM hip resurfacing devices last before they need to be replaced. Until more long- term evidence is available, NICE recommends that surgeons should choose a device for MoM resurfacing for which there is at least 3 years' evidence. This evidence should show that the device is likely to meet a target of less than 1 in 10 devices needing replacing over 10 years.
Andrew Dillon, Chief Executive of NICE, said, "This is a relatively new technique which has the potential to offer benefits for particular groups of patients. It isn't a replacement for conventional hip replacements and we need to know more about its long term durability and safety. This is one reason why we have recommended that its use is monitored, along with conventional devices, in a national joint registry." Ends
Notes for editors:
Hip disease and artificial hip joints
1. Artificial hip joints can be fitted to relieve the pain and disability associated with hip joint disease, including osteoarthritis and rheumatoid arthritis of the hip. In conventional total hip replacement operations (THRs), the hip joint is replaced with an artificial 'ball and cup' joint. The cup fits into the socket of the hip joint, and the ball replaces the head of the thigh bone. The cups are usually made of polythene (plastic), but sometimes they are made of metal or a ceramic material. The ball is usually made of metal
2. Approximately 50,000 first-time, or primary, THRs are performed in England and Wales each year.
3. THRs are generally successful operations, although sometimes wear or other problems with the artificial joint mean that it has to be replaced. This replacement is called a 'revision'. A revision to replace an existing artificial hip joint may be less successful than the first THR. Artificial hip joints are likely to wear out more quickly in people who are active.
Metal on metal hip resurfacing
4. Metal on metal hip resurfacing involves replacing the diseased or damaged surfaces in the hip joint (that is at the top of the thigh bone and inside the socket of the hip bone) with metal surfaces. Less bone has to be removed for MoM resurfacing than to fit a conventional cup and ball artificial hip joint.
5. Some surgeons think that MoM hip resurfacing devices are harder wearing than conventional THRs because they do not contain polythene, which can become worn down as the joint is used. If a MoM hip joint does stop working, a revision can be carried out to replace it with a conventional cup and ball THR device. It is thought that it may be easier to carry out a revision for an MoM device than for a conventional THR. However, there is concern that substances from the metal surfaces might be absorbed into the body, although at the moment there have been no reported cases of this happening.
NICE guidance
6. MoM hip resurfacing is recommended as an option for people with advanced hip disease who would otherwise receive a conventional primary THR and are likely to live longer than the device is likely to last.
When considering a MoM hip resurfacing surgeons should bear in mind:
7. Information on MoM resurfacing operations carried out should be collected as part of a UK national joint registry. The information collected will help the NHS to gather evidence on both the clinical effectiveness and cost effectiveness of MoM hip resurfacing- how active the individual is
- that the evidence resurfacing available at the moment for the clinical effectiveness and cost effectiveness of MoM hip comes mainly from studies that have involved people less than 65 years of age. ('Clinical effectiveness' means how well MoM hip resurfacing works, and 'cost effectiveness' mean how well it works in relation to how much it costs.).
8. The data from the national joint registry will allow researchers to find out how long MoM hip resurfacing devices last before they need to be replaced. Until more long-term evidence is available, NICE recommends that surgeons should choose a device for MoM resurfacing for which there is at least 3 years' evidence. This evidence should show that the device is likely to meet a target of less than 1 in 10 devices needing replacing over 10 years.
9. MoM hip resurfacing should be performed only by surgeons who have received training in the technique.
10. Surgeons should make sure that people considering having MoM hip resurfacing understand all the risks and benefits associated with it, and are aware that less is known about the safety and reliability of MoM devices than about conventional cup and ball THR devices.
11. When it is assumed that purchasing a more expensive MoM prosthesis (£1800 excluding VAT) is the only difference in the cost of performing MoM hip resurfacing compared with a conventional THR (prosthesis cost: £500 to £2000 excluding VAT) and that 4500 people each year will undergo MoM hip resurfacing instead of conventional THRs, the total budget impact is estimated to be between an increase of £5.9 million per annum (if MoM devices are used instead of conventional THRs costing £500) and a reduction of £0.9 million per annum (if MoM devices are used instead of conventional THRs costing £2000). However, as patients considered to be suitable for MoM hip resurfacing are more likely to have been considered for a THR approaching £2000, the budget impact is more likely to be at the lower end of this range.
Information on NICE
12. Copies of the full guidance and supporting documentation will be available on the NICE web site (www.nice.org.uk) from 10 am 6 June 2002.
13. Health professionals are expected to take the Institute's guidance fully into account when exercising their clinical judgement for individual patients. This guidance does not, however, override the individual responsibility of health professionals to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and/or guardian or carer.
14. The National Institute for Clinical Excellence (NICE) is a part of the NHS. Part of its work is technology appraisals. The Institute produces guidance for both the NHS and patients on medicines, medical equipment and clinical procedures based on evidence of clinical and cost effectiveness. Each appraisal takes an average 12 months to complete and involves the manufacturers of the technology, groups that represent patients/carers and healthcare professionals.
15. NICE was established to
Some of these guidance have been cost saving, others required investment to implement. The estimated cost of implementing are between £541 and £590 million.encourage faster uptake of clinically & cost effective new treatments,
promote more equitable access to treatments (new or existing) of proven clinical and cost effectiveness
promote the better use of resources in the NHS, by focussing resources on treatments which achieve most health gain in relation to the NHS/PSS resources expendedpromote the longer-term interest of the NHS in the development of innovative treatments for the future.To date NICE has issued 44 technology appraisal guidance, on 164 researchable topics.
13 have recommended routine use of the technology
27 have recommended selective use of the technology
4 have recommended research use only
17. NICE promotes clinical and cost effectiveness through its technology appraisals, clinical guidelines and audit tools. The Institute supports the work of those who make the complex treatment decisions - doctors, nurses, and other health professionals. The needs of the patient are central to NICE's work, and the Institute has forged strong links with patient groups and representatives.
18. Topics for the NICE work programme are selected by the Department of Health and the National Assembly for Wales. NICE advises the NHS on how these technologies can best be used. It is also responsible for the production of national clinical guidelines, promoting best practice throughout the NHS. To support and assess the implementation of such guidelines, audit tools are produced for use in the clinical setting.
