Factors influencing the preferred method of fixation in total hip arthroplasty

Aims: The aim of this study was to report the findings of a national survey of consultant hip surgeons in the UK investigating their practice and factors which influence their choice of the method of fixation when undertaking primary elective total hip arthroplasty (THA). Methods: An online survey was conducted in 2024 with questions about surgeons' practice, a rating exercise with open text questions, and a discrete choice experiment (DCE). In the DCE, surgeons were presented with ten randomly assigned profiles of patients described by age, sex, level of activity, risk of medical problems, and risk of fracture, and were asked to choose their preferred method of fixation (cemented, uncemented, or hybrid) for each. Results: A total of 101 consultants performing a mean 121 (SD 81) primary elective THAs annually for a mean 12.5 years (SD 8.5) completed the survey. For patients aged < 70 years, 61 (60%) would use hybrid, 31 (31%) uncemented, and nine (9%) cemented THAs. For patients aged > 70 years, 56 (55%) would use hybrid, 33 (33%) cemented, 11 (11%) uncemented, and one (1%) a reverse hybrid. In the DCE, the most influential characteristics of a patient were their age and level of activity. For a 'moderately active' male patient, the probability of surgeons choosing a cemented THA was 10% at the age of 65 years and 39% at the age of 85 years. These probabilities were 15% and 47% for a female patient. An increased perceived risk of fracture decreased the probability of choosing an uncemented THA. A total of 24 surgeons chose the same implant regardless of the patient's profile. In the rating exercise, the most influential factors besides the characteristics of the patient were the revision rate, the personal audit of the surgeon's practice, and the published evidence and guidelines. Analysis of free-text responses identified further important influencing factors such as the patient's anatomy and bone quality, and the surgeons' training, skill, and experience. Conclusion: This is the largest survey of UK consultant hip surgeons providing an understanding of the determinants of choices of the type of THA when undertaking primary THA in patients with hip osteoarthritis. These findings will inform the implementation of the findings of studies involving THA in relation to the practices of surgeons in the 'real world'.