Hip Implants for Total Primary Hip Replacement

Health Technology Assessment Committee Recommendations¹

1. Ceramic on cross-linked polyethylene (ceramic-on-poly) hip implants are cost effective and similar in clinical effectiveness to metal on cross-linked polyethylene (metal-on-poly) hip implants and should be publicly provided.
2. Although cost-effective, ceramic-on-poly implants currently cost more in BC than metal-on-poly implants. It is reasonable to expect that increased volumes will result in a lower unit price, and only a modest drop in price is required to result in cost neutrality between the two over time.
3. Revision rates and the costs of revision surgeries be monitored in order to confirm the assumptions underlying the simulation model used in this analysis are correct and that the benefits of ceramic-on-poly implants are realised over time.
4. The literature be reviewed again in a few years to monitor any further evidence on the development of pseudotumours in patients with metal-on-poly implants.

Health Technology Assessment Committee Findings

1. The overall evidence shows no significant difference in safety and clinical effectiveness between ceramic-on-poly and metal-on-poly hip implants.
2. Both implants are considered cost-effective although there is a high degree of uncertainty around revision rates and cost estimates. As a result, the relative cost effectiveness of each implant is highly sensitive to the unit price.
3. Despite uncertainty regarding relative estimates between implant types, probability analysis points to ceramic-on-poly as likely to be the most cost-effective over time primarily due to a lower revision rate.
4. Revision surgeries are complicated and should be avoided. The trend in fewer revisions with ceramic-on-poly suggests this type of implant may be preferable for certain patients. Decisions on which implant is medically necessary will depend on multiple factors, including patient age and activity levels.
5. The net budget impact for THR surgeries over the next 20 years will be primarily driven by an increase in number of surgeries due to the aging population. Adoption of the ceramic-on-poly implant at current prices would add $15-$18 million to the total net budget impact over the 20 years.
6. No substantive costs, implementation issues or risks to adopting ceramic-on-poly were identified, and public provision of ceramic hip implants will eliminate any perceived inequity regarding this implant related to the ability to pay. Uncertainty regarding the relative effectiveness and cost-effectiveness of the various types of implants suggests that ongoing monitoring of revision rates and the cost of revision surgeries is required through ministry data, and/or the Canadian Joint Replacement Registry.
7. Research on the presence of pseudotumours in patients with metal-on-poly implants is very limited, and more research is required to assess the prevalence and potential health impacts of pseudotumours in metal-on-poly implants compared to ceramic alternatives.
8. Amongst the alternatives to the insured standard, ceramic-on-poly dominated ceramic-on-ceramic on the basis of cost-effectiveness, and scarce evidence was available to draw any robust conclusions regarding oxinium-on-poly.

The Health Technology Assessment Committee recommendations on Hip Implants for Total Primary Hip Replacement were accepted by a committee of senior health authority and ministry executives in January 2017. Please note health authorities determine how health technologies are implemented within their programs and services. Other relevant scientific findings may have been reported since the completion of the reference documents used to form the basis of the committee's recommendations. 

¹ Estimated budget impacts are taken from the health technology assessment produced by the Health Technology Assessment unit based at the Centre for Clinical Epidemiology and Evaluation.