Hip and knee replacements continue to be 2 of the top 3 most common surgical procedures in Canada, with more than 160,000 surgeries a year and estimated inpatient costs of more than $1.26 billion annually. These figures include revision surgeries (also known as repeat surgeries), which are more complex and costlier, have higher risks and require patients to stay in hospital longer than primary (first) surgeries.

Hip and knee replacements improve mobility and quality of life for patients and are among the procedures deemed priorities for wait time reductions.

Revision surgeries are costly to health care systems — a revision can cost more than twice as much as a first hip replacement. They also have negative impacts on patients (e.g., poorer outcomes, longer recovery times) and may increase wait times for people waiting for surgery.

The analysis, which has been published in the CJRR annual report since 2017 and shared with orthopedic surgeons across the country, showed that using cementless implants had a higher rate of revision within 5 years than using implants with cement (1 more revision per 100 surgeries).

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When we looked at the use of cemented fixation for arthroplasty in hip fracture patients across Canada, we found that the rates were quite low. Having Canadian data demonstrating a lower revision risk with this type of fixation informed our Choosing Wisely Canada recommendation and facilitated a change in surgical practice. — Dr. Eric Bohm, Past President, Canadian Arthroplasty Society

This data was also used to support a Choosing Wisely Canada recommendation released in 2021: “Don’t use cementless stem fixation when performing arthroplasty for fractured neck of femur in elderly patients.”

“Compared to cemented fixation, cementless fixation results in increased revision risk, increased risk of periprosthetic fracture and no reduction in mortality risk. There have been many studies on the outcomes of patients with femoral neck fractures. These studies and subsequent meta analysis in conjunction with international registry data has led to multiple guidelines recommending the use of cemented stems when performing arthroplasty. The use of cemented stems results in a lower risk of revision, lower risk of periprosthetic fracture, and no benefit in mortality risk. These findings are similar to Canadian data demonstrating an increased revision risk with cementless fixation that is independent of individual surgeon volume, and increased mortality with cementless fixation.”Reference 1

CJRR data is being used to monitor the use of these implants across the country, along with changes in practice as a result of the Choosing Wisely Canada recommendation.

The use of cemented implants after a hip fracture increased from 43% of replacements to 58% between 2017 and 2022. Based on this trend, CJRR data was used to project that in 5 years there will be an estimated 41 fewer revision surgeries a year across Canada due to the lower revision risk for cement use compared with no cement use.

With the average current cost to hospitals for each revision surgery at nearly $23,000 (not including out-of-hospital services such as rehabilitation costs), this projected reduction in revision surgeries will lead to health care system savings of approximately $950,000 and will mean that 68 Canadians may have a shorter wait time to get their hip replaced. These savings and benefits are for a single year — and health care systems across Canada will continue to see them for many years to come.

Advancements in hip replacements have led to a shift in practice in recent years. Monitoring these trends is crucial for understanding long-term outcomes for patients as well as cost implications for health systems. Therefore, understanding the factors that influence and contribute to revision surgeries by analyzing comparable pan-Canadian data can support clinical best practices, improve patient outcomes and health system cost savings, and ultimately result in earlier access to surgery for other patients waiting for a hip replacement.

• Joint replacement
• CJRR annual report: Hip and knee replacements in Canada — Series 
• Canadian Joint Replacement Registry (CJRR)
• Impact of early revisions of hip and knee replacements

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