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The NJR Report for Orthopaedic Fellowship Examination
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The NJR Report for Orthopaedic Fellowship Examination
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Segment:0 .
OK, so welcome to everyone who joined this evening, Wednesday FRC is teaching from the FARC splinter group tonight from the group, we have shown Arthur and myself, but the main presenter is Ramesh. He's taken on a huge task of summarizing the latest 14th report of the anger of 2017.
It's a large document over 200 pages, so it's kindly offered to present that it's a very important topic. It can come into adult pathology and also, as we saw last week, and the statistics could come as a funnel plot question in the statistics section. But it is also very important to understand the details of the Najjar because you could use that data to support your, your evidence and your answers in various questions and score higher marks.
So without undue delay, I'll leave it to Ramesh to start. Hi, guys. Hi so I think most of you are fresh following David's stock on the statistics from. I think you guys know more about kaplan-meier analysis than me, so I don't need to get into that, so that's sort of the way that serves to my job. Again, customary disclosure.
Basically, these are my views and my understanding of the document doesn't represent anybody else. All right, so this was back in 1972 this was a statement by John Connolly. It is one of his internal publications where he was the first of kind to talk about a central register to keep an eye on all the joint replacements and how they're being done by who and if they are being followed up regularly or not.
That was the first mention historically, just so you know, and this is a timeline of various registers, which have come up. The oldest is the Swedish registry goes all the way to 1975. And then the hip registry from Sweden and Romania in Wales, although it is, let's say, 2003, it was started as a steering group in 2002. They started collecting data only in 2003.
Right, so now what are the goals? So India has it's all, it's all on the website you can read through later. I'm not going to read all the lines mentioned on this slide, but essentially they're looking at real time monitoring of the data and basically to detect if there are any early failures. With the experience from 3M capital and metal on metal fiasco, they are now trying to catch early failures.
So that these patients don't undergo undue surgery and then having to have repeated revisions. The other thing they need to add the goal is to monitor the various different practices. It's a big country, obviously different surgeons having their own priorities and the way they do things. This is my way of doing things. So it gives us an opportunity to monitor the various different practices and easily identify an outlier compared to the rest of the country.
Another thing is end user awareness, basically putting the data out on an open platform gives an opportunity for the patients to look at the data and understand what they are getting into, and they can actually look up individual trust and individual consultant outcomes as well. So it's quite helpful for the patient groups. And this also gives them an opportunity to negotiate with the companies so that they can have cost effective supply chain and procurement of the implants.
And of course, it also post-sales feedback for the companies and all the users and the patients as well, right? So getting straight into hip replacement this particular slide. This could be a starting point to various things they can get into as straightforward statistics, all the more straightforward, but could lead into statistics.
It could lead into basic science section where they talk to you about metal profiles, crash profile of ceramics and various things. It could also take you into clinical problems. And how do you select an implant? So the summary of enger will help you in selecting the right, it will tell you the probability of survival of any implant, but it's higher or higher order thinking that will enable you to decide what is best for each patient.
Just because ceramic and poly has got the best outcome doesn't mean that you will do so for all patients. So this is just numbers and you can use this to facilitate patient care and things. So looking at the estimated total replacement it is, it has been a workhorse for surgeons for many years now and looking at the latest outcome is 13 years now for the Ngo that they have been publishing reports.
It's 4.25 for 13 years and looking at metal and metal, you know, it's really gone out of fashion now because of high failure rates and lots of other problems. Nearly 19% to 20 percent, depending on the age group and for others. Well, we're not sure whether they have put in a similar hybrid reverse hybrid where it has not been entered into the nail file, then the cost to the wood.
5% of failure rate over 13 years. This is a busy slide. And there's a lot of information in this, I think the main thing you need to concentrate on this particular column here and down to the bottom, which is the 13-year-old OK. And for the previous one was for cemented and this is for asymmetric and hybrid implies. If you look at cement and metal on poly, some reason the outcome is 5.9% probability of revision at 13 years, whereas in the cement metal it was just over 4% The other thing is metal and metal, if you're doing an ounce of winter, it's more than 20% ceramic and poly just quite good it's come down to.
Same as the cemented. And there was a fashion to use hot and hot bedding in the form of ceramic and metal. But I think that's gone into disrepute now, and there's no long term data on that. Obviously, it's been. It's not being used for a long time, for many citizens hybrid. If you look at the percentage wise, the use of hybrid replacements has increased over the last few years, although, and cemented hip replacement is still the highest number in terms of percentage of use in the country.
The hybrid is slowly picking up. Michael polley has got a fantastic standard 4.9% If you're doing metal on metal hybrids, which not many people do, it is 19% and the best thing, obviously, is ceramic on ceramic, which is less than 3 less than four percent, just 3 and 1/2. So these are the graphs you will you're all experts in this.
You have seen David's presentation. I don't need to explain what's involved in all this. But the main thing is used to look at the outcomes in less than 55 years. And that's the key thing, really, because this is the group where you will struggle to decide what is the best form of treatment for these patients, whether it is it, is it a joint preserving surgery or a joint replacement surgery or partial joint replacement surgery based on which joint you're dealing with?
So this is inclusive of metal and metal as well. This particular chart where you see that less than 55 years, the failure rate is pretty high. It goes up to 7% in 13 years. This particular gaffe is. I think important, I think this is the one we thought the metal on metal without the metal on metal, where it is less than 7.
And this is the one with the metal on metal hip replacements where you see that in females, the less than 15 for less than 50 five, the failure rate is pretty high. And there was a time. When they stop making metal on metal for size less than 44 or something like that, and that was the initial bit, and then it went into total disrepute and people stopped using it for female patients in way in that age group.
There are very few surgeons who still do metal and metal hip replacements, but in a correctly chosen patient, it does give good benefits over the standard hip replacements. So the all important head size, I'm sure most of you are aware of the Livermore study of where rates volumetric rates and leverage.
The main thing is this doesn't tell you whether you're using a standard polyethylene or an ultra high molecular quality, and there is no differentiation in the engine, which are other papers which which tell you that the high density, highly cross polyethylene axilo petrol engine doesn't differentiate between. So you'll have to take this data with a pinch of salt or as it is rather without reading too much into it.
So if you're looking at again, a busy slide, obviously that's how most of the graphs in and it's very difficult to try and break it down into anything simple. So let's look at 32 for that matter, 32 cemented. And that seems to be the place I work, at least sort of pretty standard size that is 32. And only 70. And that's the charge that you see that there is an initial sort of increased slope there, but then it's sort of study these studies itself for a period of time.
And if you're looking at 13 percent, it's just for 13 years is just over 4% But if looking at this population, whatever that color is. And then it keeps going up, and for 28 head, which is yellow in color again, it shows a steady sort of survival and for 13 years, it's again just short of 4% So it's pretty good. Again, you have to understand it is not a differentiation between the kind of polyethylene that is used.
It's just the size of the head and it's survival. So in cemented, it's slightly different, this particular green line is size four, 40 four, and we know that if you get into bigger head size more than 36 then or even 40, then you start getting higher volumetric wear and then it's not so commonly used. And that basically is not commonly used these days.
Looking at most common size. 28 and 32 28 is at orangish color just pretty steady there for that. For 13 years, you're just approaching five percent, slightly over 5% and for 36 30 two, which is purple in color. Again, it keeps going up and when it reaches more than 11 years, the survival just goes up, goes down a bit, which means the probability of revision goes up a bit more than 5% And metal and metal and cemented very busy slide, obviously various sizes, the biggest crisis, but I don't think we need to get into the details of these things because what I think most of the questions for metal and metal will be related to MHRA guidance and all the rest of it related to that rather than the injuries that's.
Ceramic and poly four cemented, we know that ceramic poly gives very good results for cement replacement. If you look at the size of the head. 30 six, which is green. Creating Kessler that again, not many people seems to be using it because it seems to be stopping there at 8 to nine years.
Looking at the 32, which is purple. What it would accomplish, and it's basically seems to be giving a steady sort of 2% or just two or 2% probability of revision at 13 years, which is quite good and 28 again has got a steady slope increasing. And as the years go by, there is a little bit more, although compared to the other liners, this seems to be giving the best result and most of us know about it anyway, said American folly for undocumented.
So three sizes 20 eight, 32 and 36 and 432. It's going up there. And if you're using a 28 ceramic ceramic claw palsy instrument, it seems to be steady increases in the rare rate. It's going up as the size increases. I think there are papers which show that up to 30 six, the ceramic on poly gives very good results. Beyond that, it seems to cause problems. Obviously, you can make the only so thin because it also depends on the size of the establishment of the makeup that you're putting in.
So ceramic on ceramic and cemented 28 head. You'll see that it is steadily increasing. And it goes up to nearly 5 and 1/2 to 6% for 13 years. So you do head. It's just short of four percent, which is pretty good, I think ceramic on ceramic for around some entities better than most of the others. Other liners that you use.
So unselected is still the most common, but hybrid is catching up. Sorry, to summarize, the cumulative probability for a revision of a total replacement is about 6.8% for cement and hip, with 4.3 and the best instrumented ceramic body, which is just short of 4% for a hybrid fixation. Although the overall percentage is more than cemented, the ceramic ceramic for hybrid is the best one 3.3% Find an unlimited sediment company is about 4.5 percent, that's basically about hip replacement.
From NPR looking at age and sex. If if the patient is female and less than 55. The risk is 13 for 5.13 0.5 percent, so this is a group you should think of, are you? Does the patient really need a hip replacement or do you want to be waiting for some more time? And incidentally, claw palsy, if you have to do it, gives the best result for these patients. It's about 3.8% at 10 years.
The male patient is slightly low and best interests in American politics, so I think if you're patient in the exam or in the discussion is 55 to 60 years, you'll have to think, what is the best bedding material that you're using and what is the size of head? If somebody is more than 75 and if they have a hip replacement after 70 five, it's very unlikely that they're going to need a revision in their lifetime. So that's the key thing.
If it is less than 55 60 eight, you have to think hard if you do the write operation for this patient. If somebody is more than 75 and they need a hip replacement and we're very unlikely to need revision in their lifetime, so that's a pretty good general rule that you can remember in your practice and for the exam. So same summary, resurfacing metal and metal 14% in 10 years.
That's a lot of risk of having revision stamp, metal and metal. Fortunately, not. I don't think anybody's doing it. But when they did it, it was 27% in 10 years, which is pretty high. And surprising got away for that long without having somebody looking into it.
The best performing metal and metal, and there are only two companies I think that make the best performing ones are 8% to 9% OK, so there is a trend to do hip replacements in a fraction of female patients if they meet a certain criteria. They seem to have similar revision rates, although people do worry about this application. But if due care and attention is given to the repair of the structures and the orientation of the combined size of the head, it has got similar rates.
But as we know, fraction of a femur in that age group is a significant injury and we do carry high mortality like any other patients or fracture, whether they hit me or totally replacement. So the most common indication is a loosening and pain. That's if you have a total replacement after the. The functioning of FEMA within the first year of the course of revision is usually dislocation or infection and fracture.
In the long run, it's usually loosening an infection. If you have to do a revision, the revision rates for 13 years is about 17 percent, which is quite significant. So going on to knee replacement. Again, more charts. I'm afraid this stock is going to be full of these, these kaplan-meier charts to simplify.
This is the data that have concluded, which is quite useful if they ask you why. What implants are you using and why are you using your implant? These are the most commonly used implants. I'm sure some people use others which are not very familiar with, but these are the common implants that is used, and this does not this particular on the right side. This percentage does not differentiate between whether you're doing a cruciate retaining or substituting or rotating platform, which is a general thing.
So the PFC will cause for many surgeons gives you the best results. It doesn't specify whether it is crucial substituting or retaining. It's just over 3% Zimmer next-gen is 4 and 1/2 scoppio Stryker due to the highest probability of revision at 13 years, which is 5.44. And triathlon Genesis Vanguard more or less in the same ballpark area.
And they are sort of showing promising results compared to the standard BFC that most people use. So the Communist communist is crucial to retaining its I think over 60% of the insurgency is crucial to retaining. Rest is obviously crucial, sacrificing bas status stabilizing plants. Again, under 55 is a very common problem, young, young arthritic knees.
So you have to decide what surgery you're doing, why you're doing, because if you end up doing a totally different risk operation is pretty high 12% much more than a standard knee replacement in a 70-year-old. Undocumented hybrid. Very limited people, I think only a 2% of the population use it. Unicorns are again another hot topic.
So the Oxford partially gives you about 15% risk of revision at 13 years. And a 1 which is the PFG, which is commonly used, gives the risk of revision in 13 years is 20% It's quite high. So these are although there is a lot of talk from the Oxford group about this. You still have to think, why you're doing a partial replacement as opposed to other joint preserving or a full token replacement.
OK for you, inequality, I think, as you see, under 55 goes up pretty high. More than 20. So again, busy slide. The reason why you have to do revision for four totally replacement. Most common is highlighted by the read is infection and aseptic loosening. And for yunicorn, it is persistent pain, aseptic loosening and other causes, which is usually progression of arthritis.
So in a nutshell, CR 60% is 99.8% Symbol is 1.1% of the total operations that is done symmetric totally 4.2 Unicorn 16 PFG 24.2 in 13 years. Aseptic loosening pain infection are the common reasons for revision and revision. It's similar to is about 16% So moving on to the shoulder, so I'm trying, I think we could be running out of time, so try and keep it as quick as possible.
The data is only limited is only four years, but there is enough papers on many, many of these journals, which gives you a 10 year results, even 12 12 years of total shoulder replacement, so it can be done for primarily elective procedure or trauma. Having out tuberosity or worse can be done for trauma, situation and total shoulder in elective situation for an intact calf. So less than 65 years in males, the revision is 7.6 percent, although this is only a four year data, and in females it's about 6.4% Moving on.
So in four years, if you have done a human lasting four years, there's a 5% risk of failure of it. And if you're doing a reversed total, it's about 4% in four years. So not just about what hip replacement, basically. And elbow, again, limited data few years, you're looking at either of a total elbow or replacements. And for two years, it's only about two or 3% of risk of corrosion.
An invitation for an ankle replacement, limited data six years unlimited is pretty common 88% and revision is 7. 77.7 at six years. OK, so what are the problems with Ngo data? We know it's not a randomized controlled study. You know, it's an observational study. It's just a collection of patients, which it has shown a lot of significant in statistical because they see numbers.
You can get statistical significance. But what we don't know is the clinically relevant. There is only an observational data, so you're not comparing like to you just pooling everybody together and writing a papers. What we don't know is it only shows association between with causal. It doesn't tell you that it is because of that, but it shows you that these are commonly occurring.
Coexisting problems is reporting bias because most of us are sometimes can be guilty of forgetting to write your Ngo form. We end up writing it anyway. Then there is selection bias. You know that you will give a settlement complete to younger patient or ceramic on ceramic to younger patient, as opposed to an older patient. You give it to a younger patient as opposed to oral patient.
So there is a selection bias as well, and there is lack of clear stratification. So you don't stratify or you don't basically consider how you arrived at the decision. You just look at the decision of the bearings and revision as an endpoint can be sometimes curious because you see so many of these patients who have problems with the joint replacement, but they don't want to consider the surgery because they have issues with medical issues, social issues.
So if you're looking at revision as an endpoint, then you are likely to get slightly mixed results, but it's still a big population of patients being studied. I think it is pretty good. So these are my references. The only other thing is to highlight this paper, I think, is in 2012. So this was one of the attempts to link the patient reported outcomes to engineer data.
And that's I think the way forward. It'll tell you and I'll tell you, not just the statistically significant things, but also clinically significant things. And this particular paper is about total versus replacement, although there's a lot of chatter about unicorn replacement. This puts things into perspective to some extent. It's just one paper.
I'm not saying this will tell you everything that you need to know, but it also basically tells you that there is no clinically significant difference and there is no. One of the arguments is that the unicorn patients get sort of better Oxford's gross scores compared to total replacement, but this study did not find that better. Oxford's growth in replacements.
OK, I think we breezed through quite a few of things. It's a huge document you just have to consider from your point of view, what are we going to use it for? You cannot read. You can read the whole thing when you have time, but I think you're essentially looking at the outcomes of your bearings in the hip replacement because that's the key thing, really.
That's what you will be quizzed on most. And of course, you need to understand the graph. I haven't included all clear graphs and this in funnel plots and things, but I think it just gets too much. I think maybe if there is a need, we can consider doing a separate stationary I'm not sure I would watch David's webinar. I'm not sure if it's covered all of those things in there. It was covered.
That was really amazing. I just wish there was such a presentation when I was preparing for my exam. You really managed to get a lot of data. The whole document is full of data. Yeah, I found it very difficult to summarize that data, but I like how you presented the tables and how at the end you summarized everything to recap and and that's really great.
And as you said, it is very important to remember those points, Ramesh highlighted. So you can back up your answers, particularly in a more tricky situation when the exam they ask you about a young patient, how are you going to inform them about the risk of revision? And then if you tell them in your data, tell us so and so you would, you will impress the examiner. So it's very interesting also to see that cemented total hip replacement is still the best performing implant implant in hip replacement, mental time and a lot of useful information there from our head sizes and various biomaterials use is really very useful.
So thank you. That was really the presentation and trying to keep it up if you don't only have a few seconds left. Sorry to interrupt you, but no, no, I appreciate that just showing that in the statistics. Thank you everyone, particularly Ramesh, to take you long time, many hours to summarize this and would be recorded. And everyone, I'm sure, will go through it in their very details to find the best answer for the exam.
We have 36 people attended today, which is amazing from all over the world, really. And this will be followed by this session, which one is kindly going to host and he will be joined by other mentors. I apologize. I have other commitments tonight, but I promise I will join and help with the future. But that's not good.
I know I'm slacking lately, but I really have to. OK, so OK. Thank you very much, guys. Good luck. And we will answer about someone. Ask about how we are going to be tested in such an issue. I will answer that following. We will rejoin for the hot seat. Thank you, guys.
Thank you. Thank you.
Segment:0 .
OK, so welcome to everyone who joined this evening, Wednesday FRC is teaching from the FARC splinter group tonight from the group, we have shown Arthur and myself, but the main presenter is Ramesh. He's taken on a huge task of summarizing the latest 14th report of the anger of 2017.
It's a large document over 200 pages, so it's kindly offered to present that it's a very important topic. It can come into adult pathology and also, as we saw last week, and the statistics could come as a funnel plot question in the statistics section. But it is also very important to understand the details of the Najjar because you could use that data to support your, your evidence and your answers in various questions and score higher marks.
So without undue delay, I'll leave it to Ramesh to start. Hi, guys. Hi so I think most of you are fresh following David's stock on the statistics from. I think you guys know more about kaplan-meier analysis than me, so I don't need to get into that, so that's sort of the way that serves to my job. Again, customary disclosure.
Basically, these are my views and my understanding of the document doesn't represent anybody else. All right, so this was back in 1972 this was a statement by John Connolly. It is one of his internal publications where he was the first of kind to talk about a central register to keep an eye on all the joint replacements and how they're being done by who and if they are being followed up regularly or not.
That was the first mention historically, just so you know, and this is a timeline of various registers, which have come up. The oldest is the Swedish registry goes all the way to 1975. And then the hip registry from Sweden and Romania in Wales, although it is, let's say, 2003, it was started as a steering group in 2002. They started collecting data only in 2003.
Right, so now what are the goals? So India has it's all, it's all on the website you can read through later. I'm not going to read all the lines mentioned on this slide, but essentially they're looking at real time monitoring of the data and basically to detect if there are any early failures. With the experience from 3M capital and metal on metal fiasco, they are now trying to catch early failures.
So that these patients don't undergo undue surgery and then having to have repeated revisions. The other thing they need to add the goal is to monitor the various different practices. It's a big country, obviously different surgeons having their own priorities and the way they do things. This is my way of doing things. So it gives us an opportunity to monitor the various different practices and easily identify an outlier compared to the rest of the country.
Another thing is end user awareness, basically putting the data out on an open platform gives an opportunity for the patients to look at the data and understand what they are getting into, and they can actually look up individual trust and individual consultant outcomes as well. So it's quite helpful for the patient groups. And this also gives them an opportunity to negotiate with the companies so that they can have cost effective supply chain and procurement of the implants.
And of course, it also post-sales feedback for the companies and all the users and the patients as well, right? So getting straight into hip replacement this particular slide. This could be a starting point to various things they can get into as straightforward statistics, all the more straightforward, but could lead into statistics.
It could lead into basic science section where they talk to you about metal profiles, crash profile of ceramics and various things. It could also take you into clinical problems. And how do you select an implant? So the summary of enger will help you in selecting the right, it will tell you the probability of survival of any implant, but it's higher or higher order thinking that will enable you to decide what is best for each patient.
Just because ceramic and poly has got the best outcome doesn't mean that you will do so for all patients. So this is just numbers and you can use this to facilitate patient care and things. So looking at the estimated total replacement it is, it has been a workhorse for surgeons for many years now and looking at the latest outcome is 13 years now for the Ngo that they have been publishing reports.
It's 4.25 for 13 years and looking at metal and metal, you know, it's really gone out of fashion now because of high failure rates and lots of other problems. Nearly 19% to 20 percent, depending on the age group and for others. Well, we're not sure whether they have put in a similar hybrid reverse hybrid where it has not been entered into the nail file, then the cost to the wood.
5% of failure rate over 13 years. This is a busy slide. And there's a lot of information in this, I think the main thing you need to concentrate on this particular column here and down to the bottom, which is the 13-year-old OK. And for the previous one was for cemented and this is for asymmetric and hybrid implies. If you look at cement and metal on poly, some reason the outcome is 5.9% probability of revision at 13 years, whereas in the cement metal it was just over 4% The other thing is metal and metal, if you're doing an ounce of winter, it's more than 20% ceramic and poly just quite good it's come down to.
Same as the cemented. And there was a fashion to use hot and hot bedding in the form of ceramic and metal. But I think that's gone into disrepute now, and there's no long term data on that. Obviously, it's been. It's not being used for a long time, for many citizens hybrid. If you look at the percentage wise, the use of hybrid replacements has increased over the last few years, although, and cemented hip replacement is still the highest number in terms of percentage of use in the country.
The hybrid is slowly picking up. Michael polley has got a fantastic standard 4.9% If you're doing metal on metal hybrids, which not many people do, it is 19% and the best thing, obviously, is ceramic on ceramic, which is less than 3 less than four percent, just 3 and 1/2. So these are the graphs you will you're all experts in this.
You have seen David's presentation. I don't need to explain what's involved in all this. But the main thing is used to look at the outcomes in less than 55 years. And that's the key thing, really, because this is the group where you will struggle to decide what is the best form of treatment for these patients, whether it is it, is it a joint preserving surgery or a joint replacement surgery or partial joint replacement surgery based on which joint you're dealing with?
So this is inclusive of metal and metal as well. This particular chart where you see that less than 55 years, the failure rate is pretty high. It goes up to 7% in 13 years. This particular gaffe is. I think important, I think this is the one we thought the metal on metal without the metal on metal, where it is less than 7.
And this is the one with the metal on metal hip replacements where you see that in females, the less than 15 for less than 50 five, the failure rate is pretty high. And there was a time. When they stop making metal on metal for size less than 44 or something like that, and that was the initial bit, and then it went into total disrepute and people stopped using it for female patients in way in that age group.
There are very few surgeons who still do metal and metal hip replacements, but in a correctly chosen patient, it does give good benefits over the standard hip replacements. So the all important head size, I'm sure most of you are aware of the Livermore study of where rates volumetric rates and leverage.
The main thing is this doesn't tell you whether you're using a standard polyethylene or an ultra high molecular quality, and there is no differentiation in the engine, which are other papers which which tell you that the high density, highly cross polyethylene axilo petrol engine doesn't differentiate between. So you'll have to take this data with a pinch of salt or as it is rather without reading too much into it.
So if you're looking at again, a busy slide, obviously that's how most of the graphs in and it's very difficult to try and break it down into anything simple. So let's look at 32 for that matter, 32 cemented. And that seems to be the place I work, at least sort of pretty standard size that is 32. And only 70. And that's the charge that you see that there is an initial sort of increased slope there, but then it's sort of study these studies itself for a period of time.
And if you're looking at 13 percent, it's just for 13 years is just over 4% But if looking at this population, whatever that color is. And then it keeps going up, and for 28 head, which is yellow in color again, it shows a steady sort of survival and for 13 years, it's again just short of 4% So it's pretty good. Again, you have to understand it is not a differentiation between the kind of polyethylene that is used.
It's just the size of the head and it's survival. So in cemented, it's slightly different, this particular green line is size four, 40 four, and we know that if you get into bigger head size more than 36 then or even 40, then you start getting higher volumetric wear and then it's not so commonly used. And that basically is not commonly used these days.
Looking at most common size. 28 and 32 28 is at orangish color just pretty steady there for that. For 13 years, you're just approaching five percent, slightly over 5% and for 36 30 two, which is purple in color. Again, it keeps going up and when it reaches more than 11 years, the survival just goes up, goes down a bit, which means the probability of revision goes up a bit more than 5% And metal and metal and cemented very busy slide, obviously various sizes, the biggest crisis, but I don't think we need to get into the details of these things because what I think most of the questions for metal and metal will be related to MHRA guidance and all the rest of it related to that rather than the injuries that's.
Ceramic and poly four cemented, we know that ceramic poly gives very good results for cement replacement. If you look at the size of the head. 30 six, which is green. Creating Kessler that again, not many people seems to be using it because it seems to be stopping there at 8 to nine years.
Looking at the 32, which is purple. What it would accomplish, and it's basically seems to be giving a steady sort of 2% or just two or 2% probability of revision at 13 years, which is quite good and 28 again has got a steady slope increasing. And as the years go by, there is a little bit more, although compared to the other liners, this seems to be giving the best result and most of us know about it anyway, said American folly for undocumented.
So three sizes 20 eight, 32 and 36 and 432. It's going up there. And if you're using a 28 ceramic ceramic claw palsy instrument, it seems to be steady increases in the rare rate. It's going up as the size increases. I think there are papers which show that up to 30 six, the ceramic on poly gives very good results. Beyond that, it seems to cause problems. Obviously, you can make the only so thin because it also depends on the size of the establishment of the makeup that you're putting in.
So ceramic on ceramic and cemented 28 head. You'll see that it is steadily increasing. And it goes up to nearly 5 and 1/2 to 6% for 13 years. So you do head. It's just short of four percent, which is pretty good, I think ceramic on ceramic for around some entities better than most of the others. Other liners that you use.
So unselected is still the most common, but hybrid is catching up. Sorry, to summarize, the cumulative probability for a revision of a total replacement is about 6.8% for cement and hip, with 4.3 and the best instrumented ceramic body, which is just short of 4% for a hybrid fixation. Although the overall percentage is more than cemented, the ceramic ceramic for hybrid is the best one 3.3% Find an unlimited sediment company is about 4.5 percent, that's basically about hip replacement.
From NPR looking at age and sex. If if the patient is female and less than 55. The risk is 13 for 5.13 0.5 percent, so this is a group you should think of, are you? Does the patient really need a hip replacement or do you want to be waiting for some more time? And incidentally, claw palsy, if you have to do it, gives the best result for these patients. It's about 3.8% at 10 years.
The male patient is slightly low and best interests in American politics, so I think if you're patient in the exam or in the discussion is 55 to 60 years, you'll have to think, what is the best bedding material that you're using and what is the size of head? If somebody is more than 75 and if they have a hip replacement after 70 five, it's very unlikely that they're going to need a revision in their lifetime. So that's the key thing.
If it is less than 55 60 eight, you have to think hard if you do the write operation for this patient. If somebody is more than 75 and they need a hip replacement and we're very unlikely to need revision in their lifetime, so that's a pretty good general rule that you can remember in your practice and for the exam. So same summary, resurfacing metal and metal 14% in 10 years.
That's a lot of risk of having revision stamp, metal and metal. Fortunately, not. I don't think anybody's doing it. But when they did it, it was 27% in 10 years, which is pretty high. And surprising got away for that long without having somebody looking into it.
The best performing metal and metal, and there are only two companies I think that make the best performing ones are 8% to 9% OK, so there is a trend to do hip replacements in a fraction of female patients if they meet a certain criteria. They seem to have similar revision rates, although people do worry about this application. But if due care and attention is given to the repair of the structures and the orientation of the combined size of the head, it has got similar rates.
But as we know, fraction of a femur in that age group is a significant injury and we do carry high mortality like any other patients or fracture, whether they hit me or totally replacement. So the most common indication is a loosening and pain. That's if you have a total replacement after the. The functioning of FEMA within the first year of the course of revision is usually dislocation or infection and fracture.
In the long run, it's usually loosening an infection. If you have to do a revision, the revision rates for 13 years is about 17 percent, which is quite significant. So going on to knee replacement. Again, more charts. I'm afraid this stock is going to be full of these, these kaplan-meier charts to simplify.
This is the data that have concluded, which is quite useful if they ask you why. What implants are you using and why are you using your implant? These are the most commonly used implants. I'm sure some people use others which are not very familiar with, but these are the common implants that is used, and this does not this particular on the right side. This percentage does not differentiate between whether you're doing a cruciate retaining or substituting or rotating platform, which is a general thing.
So the PFC will cause for many surgeons gives you the best results. It doesn't specify whether it is crucial substituting or retaining. It's just over 3% Zimmer next-gen is 4 and 1/2 scoppio Stryker due to the highest probability of revision at 13 years, which is 5.44. And triathlon Genesis Vanguard more or less in the same ballpark area.
And they are sort of showing promising results compared to the standard BFC that most people use. So the Communist communist is crucial to retaining its I think over 60% of the insurgency is crucial to retaining. Rest is obviously crucial, sacrificing bas status stabilizing plants. Again, under 55 is a very common problem, young, young arthritic knees.
So you have to decide what surgery you're doing, why you're doing, because if you end up doing a totally different risk operation is pretty high 12% much more than a standard knee replacement in a 70-year-old. Undocumented hybrid. Very limited people, I think only a 2% of the population use it. Unicorns are again another hot topic.
So the Oxford partially gives you about 15% risk of revision at 13 years. And a 1 which is the PFG, which is commonly used, gives the risk of revision in 13 years is 20% It's quite high. So these are although there is a lot of talk from the Oxford group about this. You still have to think, why you're doing a partial replacement as opposed to other joint preserving or a full token replacement.
OK for you, inequality, I think, as you see, under 55 goes up pretty high. More than 20. So again, busy slide. The reason why you have to do revision for four totally replacement. Most common is highlighted by the read is infection and aseptic loosening. And for yunicorn, it is persistent pain, aseptic loosening and other causes, which is usually progression of arthritis.
So in a nutshell, CR 60% is 99.8% Symbol is 1.1% of the total operations that is done symmetric totally 4.2 Unicorn 16 PFG 24.2 in 13 years. Aseptic loosening pain infection are the common reasons for revision and revision. It's similar to is about 16% So moving on to the shoulder, so I'm trying, I think we could be running out of time, so try and keep it as quick as possible.
The data is only limited is only four years, but there is enough papers on many, many of these journals, which gives you a 10 year results, even 12 12 years of total shoulder replacement, so it can be done for primarily elective procedure or trauma. Having out tuberosity or worse can be done for trauma, situation and total shoulder in elective situation for an intact calf. So less than 65 years in males, the revision is 7.6 percent, although this is only a four year data, and in females it's about 6.4% Moving on.
So in four years, if you have done a human lasting four years, there's a 5% risk of failure of it. And if you're doing a reversed total, it's about 4% in four years. So not just about what hip replacement, basically. And elbow, again, limited data few years, you're looking at either of a total elbow or replacements. And for two years, it's only about two or 3% of risk of corrosion.
An invitation for an ankle replacement, limited data six years unlimited is pretty common 88% and revision is 7. 77.7 at six years. OK, so what are the problems with Ngo data? We know it's not a randomized controlled study. You know, it's an observational study. It's just a collection of patients, which it has shown a lot of significant in statistical because they see numbers.
You can get statistical significance. But what we don't know is the clinically relevant. There is only an observational data, so you're not comparing like to you just pooling everybody together and writing a papers. What we don't know is it only shows association between with causal. It doesn't tell you that it is because of that, but it shows you that these are commonly occurring.
Coexisting problems is reporting bias because most of us are sometimes can be guilty of forgetting to write your Ngo form. We end up writing it anyway. Then there is selection bias. You know that you will give a settlement complete to younger patient or ceramic on ceramic to younger patient, as opposed to an older patient. You give it to a younger patient as opposed to oral patient.
So there is a selection bias as well, and there is lack of clear stratification. So you don't stratify or you don't basically consider how you arrived at the decision. You just look at the decision of the bearings and revision as an endpoint can be sometimes curious because you see so many of these patients who have problems with the joint replacement, but they don't want to consider the surgery because they have issues with medical issues, social issues.
So if you're looking at revision as an endpoint, then you are likely to get slightly mixed results, but it's still a big population of patients being studied. I think it is pretty good. So these are my references. The only other thing is to highlight this paper, I think, is in 2012. So this was one of the attempts to link the patient reported outcomes to engineer data.
And that's I think the way forward. It'll tell you and I'll tell you, not just the statistically significant things, but also clinically significant things. And this particular paper is about total versus replacement, although there's a lot of chatter about unicorn replacement. This puts things into perspective to some extent. It's just one paper.
I'm not saying this will tell you everything that you need to know, but it also basically tells you that there is no clinically significant difference and there is no. One of the arguments is that the unicorn patients get sort of better Oxford's gross scores compared to total replacement, but this study did not find that better. Oxford's growth in replacements.
OK, I think we breezed through quite a few of things. It's a huge document you just have to consider from your point of view, what are we going to use it for? You cannot read. You can read the whole thing when you have time, but I think you're essentially looking at the outcomes of your bearings in the hip replacement because that's the key thing, really.
That's what you will be quizzed on most. And of course, you need to understand the graph. I haven't included all clear graphs and this in funnel plots and things, but I think it just gets too much. I think maybe if there is a need, we can consider doing a separate stationary I'm not sure I would watch David's webinar. I'm not sure if it's covered all of those things in there. It was covered.
That was really amazing. I just wish there was such a presentation when I was preparing for my exam. You really managed to get a lot of data. The whole document is full of data. Yeah, I found it very difficult to summarize that data, but I like how you presented the tables and how at the end you summarized everything to recap and and that's really great.
And as you said, it is very important to remember those points, Ramesh highlighted. So you can back up your answers, particularly in a more tricky situation when the exam they ask you about a young patient, how are you going to inform them about the risk of revision? And then if you tell them in your data, tell us so and so you would, you will impress the examiner. So it's very interesting also to see that cemented total hip replacement is still the best performing implant implant in hip replacement, mental time and a lot of useful information there from our head sizes and various biomaterials use is really very useful.
So thank you. That was really the presentation and trying to keep it up if you don't only have a few seconds left. Sorry to interrupt you, but no, no, I appreciate that just showing that in the statistics. Thank you everyone, particularly Ramesh, to take you long time, many hours to summarize this and would be recorded. And everyone, I'm sure, will go through it in their very details to find the best answer for the exam.
We have 36 people attended today, which is amazing from all over the world, really. And this will be followed by this session, which one is kindly going to host and he will be joined by other mentors. I apologize. I have other commitments tonight, but I promise I will join and help with the future. But that's not good.
I know I'm slacking lately, but I really have to. OK, so OK. Thank you very much, guys. Good luck. And we will answer about someone. Ask about how we are going to be tested in such an issue. I will answer that following. We will rejoin for the hot seat. Thank you, guys.
Thank you. Thank you.
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