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Innovative hip and knee replacement devices do not improve function more than conventional devices and may increase need for revision surgery

Nieuwenhuijse MJ, Nelissen RG, Schoones JW, et al. Appraisal of evidence base for introduction of new implants in hip and knee replacement: a systematic review of five widely used device technologies. BMJ. 2014;349:g5133.

Review question

In people with symptomatic osteoarthritis who need total hip or total knee replacement, are newer implantable devices effective and safe compared with conventional devices?


Some people who have symptomatic osteoarthritis of the hip or knee need to have joint replacement surgery. The damaged joint surfaces are removed and replaced with plastic, metal, or ceramic parts. Ideally, replacing the joint improves function and movement of the hips or knees. Sometimes these artificial joints wear out or come loose and need to be replaced (revision surgery). There have been a number of innovations in artificial joint devices. The innovative devices are widely used in joint replacement surgery, but we don’t know if they are better than conventional devices.

How the review was done

The researchers did a systematic review, searching for published studies up to April 2014. They found 118 studies of 94 cohorts, with 13,164 people.

In the studies, people 21 years or older were having their first total hip or knee replacement for symptomatic primary or secondary osteoarthritis.

Newer joint replacement devices were compared with a conventional device.

Newer devices for total hip replacement included ceramic-on-ceramic bearings, modular femoral necks, and uncemented monoblock (not metal-on-metal) acetabular cups.

Newer devices for total knee replacement included high-flexion implants and gender-specific implants.

What the researchers found

Studies of 9 cohorts were of high quality, 14 were moderate to high quality, 17 were moderate quality, and the rest were low to moderate or low quality.

There was no high-quality evidence that newer devices improved function.

Newer devices may increase the rate of revision surgery.


In people with osteoarthritis having total hip or knee replacement, newer innovative devices do not perform better than conventional devices and may increase the rate of revision surgery.

Newer total hip or knee replacement devices vs conventional devices in people with osteoarthritis

Type of surgery

Device type

Number of cohorts (number of people)

Effect of newer device on function and flexion

Effect of newer device on safety*

Total hip replacement

Ceramic-on-ceramic articulation

23 cohorts (4,807 people)

No difference in function

Squeaking occurred only in new-device group

Increased revision rate

No difference in complications


Uncemented monoblock acetabular component

5 cohorts (540 people)

No difference in function

No difference in revision rate

Total knee replacement

High-flexion components

52 cohorts (5,769 people)

No clinically relevant increase in flexion

No difference in other outcomes

Increased revision rate


Gender-specific components

10 cohorts (1,396 people)

No clinically relevant increase in flexion

No difference in other outcomes

No difference in revision rate

*Revision is the surgical removal of joint replacement devices and replacement with new components.



Systematic review
A comprehensive evaluation of the available research evidence on a particular topic.

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