There were almost 650,000 total hip replacement procedures performed in Europe in 2017, with the majority completed using cementless implants¹. This total number, which includes replacements utilizing cemented, cementless, and hybrid cemented device options, is projected to increase at a CAGR of 2 percent and will surpass 730,000 by 2024. However, the movement toward cementless implants seems to be slowing as other technologies become more prevalent.

Similar to the orthopedic market in the United States, cementless hip implants remain the most popular option for total hip replacement in the European region. However, the portion of the cementless hip market in the United States is considerably higher than in Europe. Moreover, while cementless hips will likely continue to cannibalize other cementation types in the United States, the European orthopedic community is expected to increasingly adopt hybrid implants that comprise both cemented and uncemented components. Between 2017 and 2024, hybrid hip implants are projected to exhibit the fastest growth in the total hip replacement market in Europe.


A Brief History of Hip Implants
Hip implants can be fixed to a patient’s existing bone with three fixation methods—with or without the use of bone cement, or as a combination of these two methods. Depending on the fixation type, total hip replacement implants can be divided into cemented, cementless, and hybrid devices. Orthopedic surgeons started to use cement in hip arthroplasty during the 1950s. Since then, with the development of cementation techniques and materials, three generations of cemented hip devices have been used. The fourth generation of cemented hip prostheses feature a high-pressure lavage and canal plug and are considered to be the gold standard in cemented arthroplasty worldwide.

With the introduction of cementless total hip implants in the 1980s, the cemented market has been gradually cannibalized by the cementless market. Cementless prosthesis components use biological fixation to ensure the implant holds to the patient’s bone. This is achieved by generating compression with the use of a slightly larger implant than the size of the bone-bed; therefore, cementless implants are also often referred to as “press-fit” devices. Hybrid devices combine different components—either a cemented stem with an uncemented cup or a cemented cup with an uncemented stem. The latter implant type is referred to as a reverse hybrid.

The latest generation of cementless hip implants features the use of additive manufacturing technology. In recent years, some orthopedic companies have announced the limited launch of hip replacement products produced using 3D printing. For example, in March 2016, Smith & Nephew introduced their REDAPT Acetabular Fully Porous Cup with CONCELOC Technology in the United States. While some market experts believe the development and increasing adoption of additive manufacturing will likely accelerate the shift from cemented to cementless implant component options worldwide, other members of the orthopedic community remain skeptical about this technology. The current availability and use of such implants across the globe, particularly in Europe, is limited.

Advantages and Disadvantages
The superiority of one fixation type over another has been argued by different experts in recent years, as different implant options are associated with a number of advantages and drawbacks. While all fixation methods, including cemented, cementless, and hybrid have been successfully used in hip arthroplasty over the years, their usage trends differ across the globe.

One of the significant benefits of cemented implant components is their lower cost compared to cementless options because of the added cost of the porous metal coatings necessary to achieve bone infiltration. As a result, hip replacements using cemented implants are generally the least expensive total hip arthroplasty option worldwide. Another advantage of cemented implants is their use in patients with poor bone structure or a lack of bone stock, which makes biological fixation difficult.

In terms of implant survival rates, both cementless and modern cemented implant options have been demonstrating good results. However, even after adjusting for patient age, surgeon skill, and the implantation term, cementless fixations tend to have slightly higher revision rates than the cemented method, as published in a February 2017 meta-analysis conducted by Phedy P. et al². The paper evaluated 27 previously conducted clinical studies, including randomized clinical trials cohorts and joint registers.

Many surgeons prefer to use cementless hip implants, as they believe press-fitted implants are more durable over the long-term. One of the main disadvantages of using bone cement relates to its possible degradation over time, which can lead to implant loosening. The cement can also cause inflammation of the soft tissue adjacent to the implant site. The use of cementless components in hip arthroplasty also allows for reduced total surgical time, which is desirable to surgeons and healthcare facilities, as minimizing operating room time reduces overall procedure costs.

Country-Specific Market Trends
The recent market study performed by iData Research analyzes market trends in 15 European countries, including Germany, United Kingdom, France, Italy, Spain, Portugal, Belgium, Netherlands, Luxembourg, Finland, Sweden, Norway, Denmark, Austria, and Switzerland. According to the study, European surgeons are gradually moving towards hybrid prostheses. However, the acceptance of different fixation methods varies throughout different regions in Europe.

For example, cemented hip implants are the most commonly implanted in the Nordic European countries, and the large joint replacement market in the United Kingdom is seeing a shift toward cemented hip implants, despite opposing trends elsewhere. Out of the 15 countries studied, the United Kingdom is the only country where the number of cemented hips implanted is expected to outnumber cementless hips implanted by 2024. In 2017, the National Joint Registry for England, Wales, Northern Ireland and the Isle of Man reported the lowest revision rates in the cemented hip implants group³. Studies like this appear to be a contributing factor to surgeons’ preference for cemented implants.

While the cementless method had taken over much of the cemented hip implant market in the past, reaching over 50 percent of procedures performed, that transition has appeared to stop. Cementless and cemented implants will remain the significant methods between 2017 and 2024, but are seeing minimal growth and will become less important as European orthopedic surgeons realize the potential of hybrid methods.

References
¹ European Market Report Suite for Large Joint Reconstruction Devices 2018 – MedSuite, iData Research
² Phedy P., et al. (2017). Total hip replacement: A meta-analysis to evaluate survival of cemented, cementless and hybrid implants. World Journal of Orthopedics. 8(2): 192–207. Doi: 10.5312/wjo.v8.i2.192.
³ 14th Annual Report. (2017). National Joint Registry for England, Wales, Northern Ireland and the Isle of Man. Retrieved from: http://www.njrreports.org.uk/Portals/0/PDFdownloads/NJR%2014th%20Annual%20Report%202017.pdf
⁴ Maggs J., Wilson M. (2017). The Relative Merits of Cemented and Uncemented Prostheses in Total Hip Arthroplasty. 51(4): 377–385. doi: 10.4103/ortho.IJOrtho_405_16

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Yulia Sorokina is a Research Analyst at iData Research. As the lead analyst for European research on Large Joint Reconstruction, she has extensive experience covering many orthopedics markets in most major regions around the world.
 
Jeffrey Wong is the Analyst Director at iData Research. Through many years of analysis, he has been the lead on most of iData’s medical, dental, and pharmaceutical market research and now drives research strategy, product development, and consulting research.