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Effects of hydroxyapatite coating of cups used in hip revisionarthroplasty: A Swedish Hip Arthroplasty Register study of 1,780 revisions
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
Swedish Hip arthroplasty Register and Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Akademy, University of Gothenburg, Gothenburg, Sweden.
Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
2012 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 83, no 5, 427-435 p.Article in journal (Refereed) Published
Abstract [en]

Background and purpose

Coating of acetabular revision implants with hydroxyapatite (HA) has been proposed to improve ingrowth and stability. We investigated whether HA coating of revision cups can reduce the risk of any subsequent re-revision.


We studied uncemented cups either with or without HA coating that were used at a primary acetabular revision and registered in the Swedish Hip Arthroplasty Register (SHAR). 2 such cup designs were identified: Harris-Galante and Trilogy, both available either with or without HA coating. These cups had been used as revision components in 1,780 revisions of total hip arthroplasties (THA) between 1986 and 2009. A Cox proportional hazards model including the type of coating, age at index revision, sex, cause of cup revision, cup design, the use of bone graft at the revision procedure, and the type of cup fixation at primary THA were used to calculate adjusted risk ratios (RRs with 95% CI) for re-revision for any reason or due to aseptic loosening.


71% of the cups were coated with HA and 29% were uncoated. At a mean follow-up time of 6.9 (0–24) years, 159 (9%) of all 1,780 cups had been re-revised, mostly due to aseptic loosening (5%), dislocation (2%), or deep infection (1%). HA coating had no significant influence on the risk of re-revision of the cup for any reason (RR = 1.4, CI: 0.9–2.0) or due to aseptic loosening (RR = 1.1, 0.6–1.9). In contrast, HA coating was found to be a risk factor for isolated liner re-revision for any reason (RR = 1.8, CI: 1.01–3.3). Age below 60 years at the index cup revision, dislocation as the cause of the index cup revision, uncemented cup fixation at primary THA, and use of the Harris-Galante cup also increased the risk of re-revision of the cup. In separate analyses in which isolated liner revisions were excluded, bone grafting was found to be a risk factor for re-revision of the metal shell due to aseptic loosening (RR = 2.1, CI: 1.05–4.2).


We found no evidence to support the notion that HA coating improves the performance of the 2 studied cup designs in revision arthroplasty. In contrast, patient-related factors such as younger age and dislocation as the reason for cup revision, and technical factors such as the choice of revision cup were found to influence the risk of subsequent re-revision of the cup. The reason for inferior results after revision of uncemented cups is not known, but it is possible that these hips more often had pronounced bone loss at the index cup revision.

Place, publisher, year, edition, pages
2012. Vol. 83, no 5, 427-435 p.
National Category
URN: urn:nbn:se:uu:diva-185295DOI: 10.3109/17453674.2012.720117ISI: 000310015700001PubMedID: 22937978OAI: oai:DiVA.org:uu-185295DiVA: diva2:571209
Available from: 2012-11-21 Created: 2012-11-21 Last updated: 2014-08-27Bibliographically approved
In thesis
1. Form and Finish of Implants in Uncemented Hip Arthroplasty: Effects of Different Shapes and Surface Treatments on Implant Stability
Open this publication in new window or tab >>Form and Finish of Implants in Uncemented Hip Arthroplasty: Effects of Different Shapes and Surface Treatments on Implant Stability
2013 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

The design of an uncemented hip arthroplasty implant affects its long-term survival. Characteristics such as the form and the finish of the implant are crucial in order to achieve the best possible conditions for long-term implant survival. In this thesis we hypothesized that different shapes of stems and cups used in primary and revision total hip arthroplasty (THA), and their finish with hydroxyapatite (HA) coating affect implant stability and thus long-term survival.

In 2 prospective cohort studies the clinical outcome, the stability measured with radiostereometric analysis (RSA), and the periprosthetic changes in bone mineral density (BMD) measured with dual-energy x-ray absorptiometry (DXA) were investigated in 2 uncemented THA implants – the CFP stem and the TOP cup. In 3 register studies the effect of HA coating on uncemented THA implants used in primary and revision arthroplasty was investigated.

Both implants investigated in the prospective cohort studies showed an excellent short-term clinical outcome with good primary stability, but neither their novel form nor the finish with HA protected the implants from the proximal periprosthetic demineralization that usually occurs around other uncemented THA implants.

The register studies revealed that HA coating on cups used in primary and revision THA is a risk factor for subsequent revision of the implant. The use of HA coating on the stem in primary THA did not affect long-term survival. Additionally, the shape of an implant plays a crucial role for implant stability and survival.

In conclusion, this thesis highlights that the finish of implants with HA coating does not prevent periprosthetic proximal femoral bone loss and can even enhance the risk of revision of both primary and secondary cups. Importantly, the shape of uncemented THA implants affect their stability, showing that the implant form is a crucial factor for the long-term survival.

Place, publisher, year, edition, pages
Uppsala: Acta Universitatis Upsaliensis, 2013. 74 p.
Digital Comprehensive Summaries of Uppsala Dissertations from the Faculty of Medicine, ISSN 1651-6206 ; 845
Form, Finish, Total hip arthroplasty, Swedish Hip Arthroplasty Register, Hydroxyapatite, RSA, DXA, BMD, Stability.
National Category
Research subject
urn:nbn:se:uu:diva-185299 (URN)978-91-554-8549-8 (ISBN)
Public defence
2013-01-11, Grönwallsalen, Akademiska sjukhuset, Akademiska sjukhus, Uppsala, 09:00 (Swedish)
Available from: 2012-12-21 Created: 2012-11-21 Last updated: 2013-08-06Bibliographically approved

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