All
We have recently completed a fully powered large (964 patient) NIHR portfolio multicenter RCT http://www.white3hemi.org.uk/ - funded by Stryker - which showed no difference in health related quality of life, mobility, and mortality with the Thompson v the Exeter / Unitrax (large unipolar head) in patients with displaced femoral neck fractures. This trial will be reviewed by the NICE guidance committee next year.
white3hemi.org.uk<http://www.white3hemi.org.uk/>
www.white3hemi.org.uk<http://www.white3hemi.org.uk/>
?Welcome ? ? ? WHiTE 3: HEMI is a randomised controlled trial comparing the Thompsons hemiarthroplasty versus the Exeter® polished taper stem and Unitrax ...
Given that Thompson implants are £200-500 cheaper than the alternatives, some of major companies are stopping production, presumably on the basis of increasing profits.
There are other smaller companies interested in starting production of the (easy to revise) cobalt chrome version. I want to encourage them!
Could I ask hear from anyone who is currently using the Thompson and wants to carry on, or those that are interested in the cost improvement of switching. This seems like an evidence based switch that will help stave of the 12% cut in tariff next year.
Mike Reed
Northumbria
We have recently completed a fully powered large (964 patient) NIHR portfolio multicenter RCT http://www.white3hemi.org.uk/ - funded by Stryker - which showed no difference in health related quality of life, mobility, and mortality with the Thompson v the Exeter / Unitrax (large unipolar head) in patients with displaced femoral neck fractures. This trial will be reviewed by the NICE guidance committee next year.
white3hemi.org.uk<http://www.white3hemi.org.uk/>
www.white3hemi.org.uk<http://www.white3hemi.org.uk/>
?Welcome ? ? ? WHiTE 3: HEMI is a randomised controlled trial comparing the Thompsons hemiarthroplasty versus the Exeter® polished taper stem and Unitrax ...
Given that Thompson implants are £200-500 cheaper than the alternatives, some of major companies are stopping production, presumably on the basis of increasing profits.
There are other smaller companies interested in starting production of the (easy to revise) cobalt chrome version. I want to encourage them!
Could I ask hear from anyone who is currently using the Thompson and wants to carry on, or those that are interested in the cost improvement of switching. This seems like an evidence based switch that will help stave of the 12% cut in tariff next year.
Mike Reed
Northumbria
We used to use the Thompsons, (cemented) but it had a high complication rate. We switched to the Exeter Unitrax ( a modular system) and
demonstrated a reduction in length of stay and complications
As a hip surgeon, I do not like the Thompsons at all. It has very little offset (about 13mm compared to an Exeter Unitrax of 35 to 44 + head
adjustabiility) and so weakens the abductors in this frail population. Our hemi dislocation rate was around 3% with the Thompsons, and has come down to <1% now. The Exeter
is also much easier to revise. One complication will cost your hospital many more times what you save from the Thompsons
We are looking to save money by decreasing length of stay and complication rate rather than skimping on the prosthesis
Phil Stott
Brighton
From: orthodirectors@yahoogroups.com <orthodirectors@yahoogroups.com> on behalf of 'Deakin Sue' Sue.Deakin@wsh.nhs.uk[orthodirectors] <orthodirectors@yahoogroups.com>
Sent: 09 October 2016 15:35
To: orthodirectors@yahoogroups.com; orthodirectors@yahoogroups.com
Subject: RE: [orthodirectors] Thompson for displaced femoral neck fractures
Sent: 09 October 2016 15:35
To: orthodirectors@yahoogroups.com; orthodirectors@yahoogroups.com
Subject: RE: [orthodirectors] Thompson for displaced femoral neck fractures
Hi we use exter trauma stem for cemented and austin moore when patient is
well enough for cement.
Sue
-----Original Message-----
Subject: RE: [orthodirectors] Thompson for displaced femoral neck fractures
We did an increasingly small number of Austin Moore's for the same reasons as Siten said, but the manufacturer is stopping supplying them, I heard, in November. So, either we lose that option and cement everyone or I get another low cost uncemented hemi in - but wasn't planning for Thompsons.
Kind regards,
Chris
Chris Huber
Consultant Orthopaedic Surgeon and Service Director,
Trauma and Orthopaedics
West Middlesex University Hospital
From: orthodirectors@yahoogroups.com [mailto:orthodirectors@yahoogroups.com]
Sent: 07 October 2016 13:08
To: orthodirectors@yahoogroups.com
Subject: Re: [orthodirectors] Thompson for displaced femoral neck fractures
Mike
We were forced to move to ETS from Thompsons by our lower limb colleagues on the basis that it was more difficult for them to revise a thompsons with its curved stem and increased bone loss than a small polished stem allowing cement-in-cement option. Have you compared the outcomes from revision as welll? As an upper limb surgeon, I would love to use Thompsons for al the reasons Siten alluded to.
sudhi
On 7 Oct 2016, at 12:27, SITEN Roy sitenroy@hotmail.com<mailto:sitenroy@hotmail.com> [orthodirectors] <orthodirectors@yahoogroups.com<mailto:orthodirectors@yahoogroups.com>> wrote:
Interesting study Mike. This has always been a sticking point, in view of the NICE guidelines.
We still do a small number of Thompson in patients with minimal mobility for apin relief and in patients with major CV disease to avoid cement related complication.
It will be an interesting review by NICE .....
It is not only cost, but also surgical time, cement related complications, skill required to do a cemented stem for non-hip surgeons, comapratively non-forgiving surgery if not done correctly and future management in case of complication/ infection.
Regards
Siten Roy
Sandwell & City Hospitals
-----------------------------------------------
Sue
-----Original Message-----
Subject: RE: [orthodirectors] Thompson for displaced femoral neck fractures
We did an increasingly small number of Austin Moore's for the same reasons as Siten said, but the manufacturer is stopping supplying them, I heard, in November. So, either we lose that option and cement everyone or I get another low cost uncemented hemi in - but wasn't planning for Thompsons.
Kind regards,
Chris
Chris Huber
Consultant Orthopaedic Surgeon and Service Director,
Trauma and Orthopaedics
West Middlesex University Hospital
From: orthodirectors@yahoogroups.com [mailto:orthodirectors@yahoogroups.com]
Sent: 07 October 2016 13:08
To: orthodirectors@yahoogroups.com
Subject: Re: [orthodirectors] Thompson for displaced femoral neck fractures
Mike
We were forced to move to ETS from Thompsons by our lower limb colleagues on the basis that it was more difficult for them to revise a thompsons with its curved stem and increased bone loss than a small polished stem allowing cement-in-cement option. Have you compared the outcomes from revision as welll? As an upper limb surgeon, I would love to use Thompsons for al the reasons Siten alluded to.
sudhi
On 7 Oct 2016, at 12:27, SITEN Roy sitenroy@hotmail.com<mailto:sitenroy@hotmail.com> [orthodirectors] <orthodirectors@yahoogroups.com<mailto:orthodirectors@yahoogroups.com>> wrote:
Interesting study Mike. This has always been a sticking point, in view of the NICE guidelines.
We still do a small number of Thompson in patients with minimal mobility for apin relief and in patients with major CV disease to avoid cement related complication.
It will be an interesting review by NICE .....
It is not only cost, but also surgical time, cement related complications, skill required to do a cemented stem for non-hip surgeons, comapratively non-forgiving surgery if not done correctly and future management in case of complication/ infection.
Regards
Siten Roy
Sandwell & City Hospitals
-----------------------------------------------
Thank you for that. That is certainly not our experience with the Thompson. This paper looks at survivorship, and not function. We audited our patients during the change
from Thompson to Unitrax, and found that we made significant savings by reducing length of stay, complications and return to theatre.
Phil Stott
Brighton
All
Although the Thompsons was not designed for cement, that is how it has been used, very successfully. In fact the stem design is the same or very similar to the McKee Farrar cemented MOM hip. The success of which if you will remember was one of the justifications for the resurgence of metal on metal THRs. No Trunnion See image attached. NICE seems to have forgotten that particular stem design. The ETS of course is not a proven stem design, as the surface finish is not fully polished, and we have published this. There is no registry for hemiarthroplasty, maybe there should be.
We reviewed 1700 Thompson's, dislocation occurred in only 1.1%. and there was a 94% implant survivorship at 8 years. Patient survivorship only 20% at 8 years.
Regarding revision or Thompsons, we haven't needed to do many, but most are for infection, where stem design makes little difference to the procedure. The few done for acetabular erosion are actually easily managed using the Exeter 'C in C' 125mm stem. Using some impressions in flower arranging foam, you can see how the stem fits in the cement mantle of the Thompsons comfortably, and with a little bit of cement removal the mild varus can be corrected if thought necessary.
Trusts may be missing significant cost improvements by not considering cemented Thompsons rather than more expensive alternatives. The training issue is an interesting one, as consultant involvement seems to be increased with THR type stems like the ETS, which might be why some units get better results, with more consultant involvement.
I guess we are saying, if you are still using the Thompsons, then don't stop until you have thought carefully about it. If you have stopped, then look again at the data, including Mikes paper which compared Exeter (not ETS) stems with a modular monoblock head (not bipolar) vs Thompsons, and consider the CIP that this stem will safely bring to your units. If you want to carry on using Thompsons, then let us know and we will lobby manufacturers to keep making them.
Paul Partington
Arthroplasty Lead
Northumbria Trust.
Although the Thompsons was not designed for cement, that is how it has been used, very successfully. In fact the stem design is the same or very similar to the McKee Farrar cemented MOM hip. The success of which if you will remember was one of the justifications for the resurgence of metal on metal THRs. No Trunnion See image attached. NICE seems to have forgotten that particular stem design. The ETS of course is not a proven stem design, as the surface finish is not fully polished, and we have published this. There is no registry for hemiarthroplasty, maybe there should be.
We reviewed 1700 Thompson's, dislocation occurred in only 1.1%. and there was a 94% implant survivorship at 8 years. Patient survivorship only 20% at 8 years.
Regarding revision or Thompsons, we haven't needed to do many, but most are for infection, where stem design makes little difference to the procedure. The few done for acetabular erosion are actually easily managed using the Exeter 'C in C' 125mm stem. Using some impressions in flower arranging foam, you can see how the stem fits in the cement mantle of the Thompsons comfortably, and with a little bit of cement removal the mild varus can be corrected if thought necessary.
Trusts may be missing significant cost improvements by not considering cemented Thompsons rather than more expensive alternatives. The training issue is an interesting one, as consultant involvement seems to be increased with THR type stems like the ETS, which might be why some units get better results, with more consultant involvement.
I guess we are saying, if you are still using the Thompsons, then don't stop until you have thought carefully about it. If you have stopped, then look again at the data, including Mikes paper which compared Exeter (not ETS) stems with a modular monoblock head (not bipolar) vs Thompsons, and consider the CIP that this stem will safely bring to your units. If you want to carry on using Thompsons, then let us know and we will lobby manufacturers to keep making them.
Paul Partington
Arthroplasty Lead
Northumbria Trust.
We made a relatively early switch to ETS around 2007 and showed
significantly reduced dislocation rate and LOS. Would never want to switch back to Thompsons for majority of hemis, but would like to continue to source an Austin-Moore to
use as a quick spacer in the really high risk elderly – now struggling to keep a stock of all sizes.
Ben
Mr Ben Lankester
Consultant and Clinical Director Trauma and
Orthopaedics
Yeovil District Hospital
Derby has been using an exeter stem on all our hemis for some time now (bipolar head on the top, not unitrax or ETS).
It may not be the cheapest but it is great training for the juniors in how to cement a stem in exactly the same way as a total hip.
the pts do well out of it too, we feel, with regard to functional outcomes and return to home and the last but one national hip fracture data base report had us at the top of
the pile of 180 trusts for length of stay (several days under the average).
Easy revision if need be too, as stated.
no going back to Thompsons/Austin moore for us!
Arthur Stephen
On 12 Oct 2016, at 20:29, 'REED, Mike (NORTHUMBRIA HEALTHCARE NHS FOUNDATION TRUST)' mike.reed@nhs.net [orthodirectors] <orthodirectors@yahoogroups.com> wrote:
Evening
Sorry for the late re-entry into the string.
The large multicenter RCT (thompsons v exeter/unitrax) looked at health related quality as it's primary endpoint. This is the endpoint that patients feel
is the most important (lots of work on that has been done). No difference in outcome. Also no difference in walking ability, and mortality. The complication /
return to theatre shows no hint of difference (but analysis is incomplete for that). LOS no different. In fairness it is worth awaiting the publication if you
are sceptical. It was kindly funded by stryker..
Since the advent of short cement in cement stems these are easy revisions if you have used a cobalt chrome stem.
Worth keeping an open mind.
I can see Phil isn’t convinced but we have a reassuringly long list of Thompson users, so can others let me know if your centre is interested in continuing.
Night!
Mike