Updated final NICE guidance published today (26 February) recommends that people who need hip replacements should receive artificial joints that are more durable. The updated recommendations include a stricter benchmark for the quality of hip prostheses, proposing that the new joint should work well in at least 95% of hip replacements over 10 years, instead of the current 90%.
Hip replacements or resurfacing are often needed to improve mobility problems and severe discomfort caused by rheumatoid arthritis or osteoarthritis in the hip joint. Arthritis is a very common and painful condition - it affects more than 3 million people in the UK. Someone with arthritis can experience significant pain and stiffness which will limit everyday tasks such as walking, climbing stairs and performing household tasks. However, a successful hip replacement can completely relieve pain and disability associated with arthritis of the hip when exercise, physiotherapy or medicines no longer work. Around 60,000 operations to replace hips are carried out in the NHS in England and Wales each year with a further 25,000 carried out in independent hospitals.
Sometimes wear or other problems with the artificial joint mean that it has to be replaced. This replacement is called a ‘revision'. The updated guidance recommends using prostheses for total hip replacement and resurfacing arthroplasty as treatment options if only they have rates (or projected rates) of revision of 5% (1 in 20) or less at 10 years. Previous NICE guidance recommended a revision rate of 10% (1 in 10) after 10 years as a benchmark in the selection of artificial joints.
Commenting on the guidance, Professor Carole Longson, Director of the Centre for Health Technology Evaluation at NICE said: “This updated guidance is good news for people with arthritis of the hip who have already tried non-surgical treatments such as exercise, physical therapy or painkillers, and so may need a hip replacement. The new recommendation will help ensure they receive the best possible prosthesis which will work for a longer period of time than previously required, before it may need replacing.
“As more information has become available about how long artificial joints can last, we have recommended the use of prostheses with a proven lower revision rate. This means that a new joint should work well in at least 95% of hip replacements over 10 years, so a new joint may be needed in 5% or fewer instances over this period. Our previous guidance advised that prostheses should work well in at least 90% of replacements, so repeat surgery may have been needed in up to 10% of instances over 10 years. The stricter revision rate benchmark that we recommend in the updated guidance is good news for people with hip replacements or hips resurfacing - more people can expect their prostheses to continue working well over 10 years.”
Notes to Editors
Explanation of terms
1. In total hip replacement (THR) surgery, the acetabulum (hip socket) is replaced with either a single-piece cup made from 1 material (polyethylene, ceramic or metal) or a 2 piece (modular) cup made from a metal outer shell and a polyethylene, ceramic or metal liner. The head of the femur (thigh bone) is replaced with either a single-piece metal stem and head or a modular component consisting of a metal stem with a metal, ceramic or ceramicised metal head.
2. Hip resurfacing arthroplasty involves removing and replacing the surface of the femoral head with a hollow metal hemisphere, which fits into a metal cup fixed into the acetabulum. All resurfacing arthroplasty prostheses currently on the market are metal on metal (MoM) and are cemented into place. As with THR prostheses, resurfacing arthroplasty prostheses may also vary by femoral head size.
3. What type of hip replacement prostheses a patient receives depends on various factors, such as a patient's age and underlying hip physiology, as well as the surgeon's choice and experience of using a particular class of prosthesis.
About the guidance
4. The guidance will be available at TA304 from 00.01hrs, Weds 26 February. Embargoed copies of the guidance are available from the NICE press office on request.
5. The average list prices for THRs across the manufacturers were: £1557 for cemented polyethylene on metal; £3016 for cementless polyethylene on metal; £3869 for cementless ceramic on ceramic; £2650 for hybrid polyethylene on metal and £1996 for cemented polyethylene on ceramic. The average list price for resurfacing arthroplasty prostheses across the manufacturers was £2672.
6. Typically, the price of hip replacement prostheses depends on the volume ordered and locally negotiated discounts, so the prices paid by the NHS are routinely lower than the list prices listed above.
7. It's important to note that prostheses which do not meet the NICE guidance benchmark are not ‘banned'- NICE does not have the remit to do this. NICE guidance only focuses on recommending prostheses which fall within the new recommended benchmark. When NICE recommends a treatment ‘as an option', the NHS must make sure it is available within the period set out in the paragraph above. This means that, if a patient has end stage arthritis of the hip and the doctor responsible for their care thinks that total hip replacement or resurfacing arthroplasty is the right treatment, it should be available for use, in line with NICE's recommendations.
8. The Medicines and Healthcare Regulatory Agency (MHRA) monitors the safety of devices used in clinical practice. In June 2010, the MHRA issued an alert on all MoM hip replacement prostheses (both THR and resurfacing arthroplasty) after reports of soft tissue reactions that may be associated with pain. In June 2012, the MHRA released an updated alert noting that MoM prostheses (THR and resurfacing arthroplasty) may wear at an accelerated rate. The MHRA stated that people with MoM prostheses may develop soft tissue damage caused by wear debris from these prostheses. It advised annual monitoring of the hip using imaging and measurement of metal levels in the blood to determine whether a revision is needed in people with MoM hip replacement prostheses who have symptoms, or who have a certain type of MoM hip replacement, including stemmed MoM THRs with a larger femoral head (36 mm diameter or larger) or the recalled DePuy ASR hip replacements (THR and resurfacing arthroplasty).
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