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  • 1.
    Borens, Olivier
    et al.
    CHU Vaudois, Dept Musculoskeletal Syst, Orthopaed Trauma Unit, Dept Sept Surg, Lausanne, Switzerland.
    Corona, Pablo S
    Hosp Valle De Hebron, Dept Orthopaed Surg, Reconstruct & Sept Surg Unit, Barcelona, Spain.
    Frommelt, Lars
    Helios ENDO Klin, Hamburg, Germany.
    Lazarinis, Stergios
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Reed, Michael Richard
    Northumbria HelathCare NHS Fdn Trust, North Shields, England.
    Romano, Carlo Luca
    Ctr Reconstruct Surg & Osteoarticular, Milan, Italy; Inst Galeazzi, Orthopaed Res, Milan, Italy.
    Algorithm to Diagnose Delayed and Late PJI: Role of Joint Aspiration2017In: A Modern Approach to Biofilm-Related Orthopaedic Implant Infections: Advances in Microbiology, Infectious Diseases and Public Health Volume 5 / [ed] Drago, Lorenzo, Cham, Switzerland: Springer, 2017, p. 101-111Chapter in book (Refereed)
    Abstract [en]

    Total Joint Arthroplasty (TJA) continues to gain acceptance as the standard of care for the treatment of severe degenerative joint disease, and is considered one of the most successful surgical interventions in the history of medicine. A devastating complication after TJA is infection. Periprosthetic joint infection (PJI), represents one of the major causes of failure and remains a significant challenge facing orthopaedics today. PJI usually requires additional surgery including revision of the implants, fusion or amputations causing tremendous patient suffering but also a heavy health economics burden. PJI is at the origin of around 20–25 % of total knee arthroplasty (Bozic et al. 2010; de Gorter et al. 2015; Sundberg et al. 2015) and 12–15 % of total hip arthroplasty (Bozic et al. 2009; Garellick et al. 2014; de Gorter et al. 2015) failures.

  • 2. Chen, Antonia
    et al.
    Haddad, Fares
    Lachiewicz, Paul
    Bolognesi, Michael
    Cortes, Luis E
    Franceschini, Massimo
    Gallo, Jiri
    Glynn, Aaron
    Della Valle, Alejandro Gonzalez
    Gahramanov, Aydin
    Khatod, Monti
    Lazarinis, Stergios
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Lob, Guenther
    Nana, Arvind
    Ochsner, Peter
    Tuncay, Ibrahim
    Winkler, Tobias
    Zeng, YiRong
    Prevention of late PJI2014In: Journal of Orthopaedic Research, ISSN 0736-0266, E-ISSN 1554-527X, Vol. 32, no Suppl. 1, p. S158-S171Article in journal (Refereed)
  • 3. Chen, Antonia
    et al.
    Haddad, Fares
    Lachiewicz, Paul
    Bolognesi, Michael
    Cortes, Luis E
    Franceschini, Massimo
    Gallo, Jiri
    Glynn, Aaron
    Gonzalez Della Valle, Alejandro
    Gahramanov, Aydin
    Khatod, Monti
    Lazarinis, Stergios
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Lob, Guenther
    Nana, Arvind
    Ochsner, Peter
    Tuncay, Ibrahim
    Winkler, Tobias
    Zeng, Yirong
    Prevention of Late PJI2014In: The Journal of Arthroplasty, ISSN 0883-5403, E-ISSN 1532-8406, Vol. 29, no 2, p. 119-128Article in journal (Refereed)
  • 4.
    Eriksson, Hannah K.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Nordström, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Gabrysch, Katja
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Medicinska och farmaceutiska vetenskapsområdet, centrumbildningar mm, UCR-Uppsala Clinical Research Center.
    Hailer, Nils P.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Lazarinis, Stergios
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Does the Alpha-defensin Immunoassay or the Lateral Flow Test Have Better Diagnostic Value for Periprosthetic Joint Infection?: A Systematic Review2018In: Clinical Orthopaedics and Related Research, ISSN 0009-921X, E-ISSN 1528-1132, Vol. 476, no 5, p. 1065-1072Article, review/survey (Refereed)
    Abstract [en]

    Background: Measuring alpha-defensin concentrations in synovial fluid may help to diagnose periprosthetic joint infection (PJI). There are two commercially available methods for measuring alpha-defensin in synovial fluid: the enzyme-linked immunosorbent assay-based Synovasure (R) alpha-defensin immunoassay, which gives a numeric readout within 24 hours, and the Synovasure lateral flow test, which gives a binary readout within 20 minutes. There is no compilation of the existing literature to support the use of one of these two tests over the other.

    Questions/purposes: Does the immunoassay or the lateral flow test have better diagnostic value (sensitivity and specificity) in diagnosing PJI?

    Methods: We followed PRISMA guidelines and identified all studies on alpha-defensin concentration in synovial fluid as a PJI diagnostic marker, indexed to April 14, 2017, in PubMed, JSTOR, Google Scholar, and OVID databases. The search retrieved 1578 records. All prospective and retrospective studies on alpha-defensin as a PJI marker (PJI classified according to the criteria of the Musculoskeletal Infection Society) after THA or TKA were included in the analysis. All studies used only one of the two commercially available test methods, but none of them was comparative. After excluding studies with overlapping patient populations, four studies investigating the alpha-defensin immunoassay and three investigating the lateral flow test remained. Alpha-defensin immunoassay studies included 482 joints and lateral flow test studies included 119. The quality of the trials was assessed according to the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool. The heterogeneity among studies was evaluated by the I-2 index, indicating that the heterogeneity of the included studies was low. Pooled sensitivity, specificity, positive and negative likelihood ratios, and receiver operating curves were calculated for each method and compared with each other.

    Results: The alpha-defensin immunoassay had superior overall diagnostic value compared with the lateral flow test (area under the curve, 0.98 versus 0.75) with higher sensitivity (96% [90%-98%] versus 71% [55%-83%], p < 0.001), but no difference in specificity with the numbers available (96% [93%-97%] versus 90% [81%-95%], p = 0.060).

    Conclusions: Measurement of alpha-defensin in synovial fluid is a valuable complement to existing diagnostic criteria, and the immunoassay test detects PJI more accurately than the lateral flow test. The lateral flow test has lower sensitivity, making it difficult to rule out infection, but its relatively high specificity combined with the advantage of a quick response time can make it useful to rule in infection perioperatively.

    Level of Evidence: Level III, diagnostic study.

  • 5.
    Hailer, Nils P
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Lazarinis, Stergios
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Mäkelä, Keijo T
    Eskelinen, Antti
    Fenstad, Anne M
    Hallan, Geir
    Havelin, Leif
    Overgaard, Søren
    Pedersen, Alma B
    Mehnert, Frank
    Kärrholm, Johan
    Hydroxyapatite coating does not improve uncemented stem survival after total hip arthroplasty!: An analysis of 116,069 THAs in the Nordic Arthroplasty Register Association (NARA) database2015In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 86, no 1, p. 18-25Article in journal (Refereed)
    Abstract [en]

    Background and purpose

    It is still being debated whether HA coating of uncemented stems used in total hip arthroplasty (THA) improves implant survival. We therefore investigated different uncemented stem brands, with and without HA coating, regarding early and long-term survival.

    Patients and methods

    We identified 152,410 THA procedures using uncemented stems that were performed between 1995 and 2011 and registered in the Nordic Arthroplasty Register Association (NARA) database. We excluded 19,446 procedures that used stem brands less than 500 times in each country, procedures performed due to diagnoses other than osteoarthritis or pediatric hip disease, and procedures with missing information on the type of coating. 22 stem brands remained (which were used in 116,069 procedures) for analysis of revision of any component. 79,192 procedures from Denmark, Norway, and Sweden were analyzed for the endpoint stem revision. Unadjusted survival rates were calculated according to Kaplan-Meier, and Cox proportional hazards models were fitted in order to calculate hazard ratios (HRs) for the risk of revision with 95% confidence intervals (CIs).

    Results

    Unadjusted 10-year survival with the endpoint revision of any component for any reason was 92.1% (CI: 91.8-92.4). Unadjusted 10-year survival with the endpoint stem revision due to aseptic loosening varied between the stem brands investigated and ranged from 96.7% (CI: 94.4-99.0) to 99.9% (CI: 99.6-100). Of the stem brands with the best survival, stems with and without HA coating were found. The presence of HA coating was not associated with statistically significant effects on the adjusted risk of stem revision due to aseptic loosening, with an HR of 0.8 (CI: 0.5-1.3; p = 0.4). The adjusted risk of revision due to infection was similar in the groups of THAs using HA-coated and non-HA-coated stems, with an HR of 0.9 (CI: 0.8-1.1; p = 0.6) for the presence of HA coating. The commonly used Bimetric stem (n = 25,329) was available both with and without HA coating, and the adjusted risk of stem revision due to aseptic loosening was similar for the 2 variants, with an HR of 0.9 (CI: 0.5-1.4; p = 0.5) for the HA-coated Bimetric stem.

    Interpretation

    Uncemented HA-coated stems had similar results to those of uncemented stems with porous coating or rough sand-blasted stems. The use of HA coating on stems available both with and without this surface treatment had no clinically relevant effect on their outcome, and we thus question whether HA coating adds any value to well-functioning stem designs.

  • 6.
    Lazarinis, Stergios
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Form and Finish of Implants in Uncemented Hip Arthroplasty: Effects of Different Shapes and Surface Treatments on Implant Stability2013Doctoral 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.

    List of papers
    1. A prospective cohort study on the short collum femoris preserving (CFP) stem using RSA and DXA: Primary stability but no prevention of proximal bone loss in 27 patients followed for 2 years
    Open this publication in new window or tab >>A prospective cohort study on the short collum femoris preserving (CFP) stem using RSA and DXA: Primary stability but no prevention of proximal bone loss in 27 patients followed for 2 years
    Show others...
    2013 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 84, no 1, p. 32-39Article in journal (Refereed) Published
    Abstract [en]

    Background and purpose Short femoral stems have been introduced in total hip arthroplasty in order to save proximal bone stock. We hypothesized that a short stem preserves periprosthetic bone mineral density (BMD) and provides good primary stability. Methods We carried out a prospective cohort study of 30 patients receiving the collum femoris-preserving (CFP) stem. Preoperative total hip BMD and postoperative periprosthetic BMD in Gruen zones 1-7 were investigated by dual-energy x-ray absorptiometry (DXA), stem migration was analyzed by radio-stereometric analysis (RSA), and the Harris hip score (HHS) was determined. Results 2 patients were excluded intraoperatively and 1 patient was revised due to a deep infection, leaving 27 patients for analysis. The mean HHS increased from 49 (24-79) preoperatively to 99 (92-100) after 2 years. DXA after 1 year showed substantial loss of BMD in Gruen zone 7 (-31%), zone 6 (-19%), and zone 2 (-13%, p < 0.001) compared to baseline BMD determined immediately postoperatively. The bone loss in these regions did not recover after 2 years, whereas the more moderate bone loss in Gruen zones 1, 3, and 5 partially recovered. There was a correlation between low preoperative total hip BMD and a higher amount of bone loss in Gruen zones 2, 6 and 7. RSA showed minor micromotion of the stem: mean subsidence was 0.13 (95% CI: -0.28 to 0.01) mm and mean rotation around the longitudinal axis was 0.01 (95% CI: -0.1 to 0.39) after 2 years. Interpretation We conclude that substantial loss in proximal periprosthetic BMD cannot be prevented by the use of a novel type of short, curved stem, and forces appear to be transmitted distally. However, the stems showed very small migration-a characteristic of stable uncemented implants.

    National Category
    Orthopaedics
    Identifiers
    urn:nbn:se:uu:diva-185296 (URN)10.3109/17453674.2013.765623 (DOI)000314897500007 ()
    Available from: 2012-11-21 Created: 2012-11-21 Last updated: 2018-01-12Bibliographically approved
    2. Demineralization around a stable uncemented modular cup: A prospective cohort study on a hemispherical, partly threaded and hydroxyapatite-coated cup using RSA and DXA
    Open this publication in new window or tab >>Demineralization around a stable uncemented modular cup: A prospective cohort study on a hemispherical, partly threaded and hydroxyapatite-coated cup using RSA and DXA
    Show others...
    (English)Manuscript (preprint) (Other academic)
    National Category
    Orthopaedics
    Identifiers
    urn:nbn:se:uu:diva-185297 (URN)
    Available from: 2012-11-21 Created: 2012-11-21 Last updated: 2018-01-12
    3. Increased risk of revision of acetabular cups coated with hydroxyapatite: A Swedish Hip Arthroplasty Register study involving 8,043 total hip replacements
    Open this publication in new window or tab >>Increased risk of revision of acetabular cups coated with hydroxyapatite: A Swedish Hip Arthroplasty Register study involving 8,043 total hip replacements
    2010 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 81, no 1, p. 53-59Article in journal (Refereed) Published
    Abstract [en]

    Background Hydroxyapatite (HA) is the main inorganic component of bone, and HA coating is widely used on acetabular cups in hip arthroplasty. It has been suggested that this surface finish improves cup survival. Methods All patients registered in the Swedish Hip Arthroplasty Register between 1992 and 2007 with an uncemented acetabular implant that was available either with or without HA coating were identified. 8,043 total hip arthroplasties (THAs) with the most common cup types (Harris-Galante, Romanus, and Trilogy) were investigated. A Cox regression model including type of coating, age, sex, primary diagnosis, cup type, and type of stem fixation was used to calculate adjusted risk ratios (RRs) for the risk of revision. Results HA coating was a risk factor for cup revision due to aseptic loosening (adjusted RR 1.7; 95% CI: 1.3-2). Age at primary arthroplasty of < 50 years, a diagnosis of pediatric hip disease, the use of a cemented stem, and the Romanus and Harris-Galante cup types were also associated with statistically significantly increased risk of cup revision due to aseptic loosening. Interpretation Our findings question the routine use of HA-coated cups in primary total hip arthroplasty. With some designs, this practice may even increase the risk of loosening-resulting in revision surgery.

    National Category
    Surgery
    Research subject
    Orthopaedics
    Identifiers
    urn:nbn:se:uu:diva-112790 (URN)10.3109/17453670903413178 (DOI)000276167300011 ()19968603 (PubMedID)
    Available from: 2010-01-20 Created: 2010-01-20 Last updated: 2017-12-12Bibliographically approved
    4. Effects of hydroxyapatite coating on survival of an uncemented femoral stem: A Swedish Hip Arthroplasty Register study on 4,772 hips
    Open this publication in new window or tab >>Effects of hydroxyapatite coating on survival of an uncemented femoral stem: A Swedish Hip Arthroplasty Register study on 4,772 hips
    2011 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 82, no 4, p. 399-404Article in journal (Refereed) Published
    Abstract [en]

    Background and purpose: Hydroxyapatite (HA) is widely used as a coating for uncemented total hip arthroplasty components. This has been suggested to improve implant ingrowth and long-term stability. However, the evidence behind the use of HA coating on femoral stems is ambiguous. We investigated survival of an uncemented, tapered titanium femoral stem that was available either with or without HA coating (Bi-Metric).

    Patients and methods: The stem had been used in 4,772 total hip arthroplasties (THAs) in 4,169 patients registered in the Swedish Hip Arthroplasty Register between 1992 and 2009. 59% of the stems investigated were coated with HA and 41% were uncoated. Kaplan-Meier survival analysis and a Cox regression model with adjustment for age, sex, primary diagnosis, and the type of cup fixation were used to calculate survival rates and adjusted risk ratios (RRs) of the risk of revision for various reasons.

    Results: The 10-year survival rates of the HA-coated version and the uncoated version were about equal when we used revision for any reason as the endpoint: 98% (95% CI: 98-99) and 98% (CI: 97-99), respectively. A Cox regression model adjusting for the covariates mentioned above showed that the presence of HA coating did not have any influence on the risk of stem revision for any reason (RR = 1.0, 95% CI: 0.6-1.6) or due to aseptic loosening (RR = 0.5, CI: 0.2-1.5). There was no effect of HA coating on the risk of stem revision due to infection, dislocation, or fracture.

    Interpretation: The uncemented Bi-Metric stem showed excellent 10-year survival. Our findings do not support the use of HA coating on this stem to enhance implant survival.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-159485 (URN)10.3109/17453674.2011.597699 (DOI)000294851100002 ()
    Available from: 2011-10-03 Created: 2011-10-03 Last updated: 2017-12-08Bibliographically approved
    5. Effects of hydroxyapatite coating of cups used in hip revisionarthroplasty: A Swedish Hip Arthroplasty Register study of 1,780 revisions
    Open this publication in new window or tab >>Effects of hydroxyapatite coating of cups used in hip revisionarthroplasty: A Swedish Hip Arthroplasty Register study of 1,780 revisions
    2012 (English)In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 83, no 5, p. 427-435Article 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.

    Methods

    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.

    Results

    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).

    Interpretation

    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.

    National Category
    Orthopaedics
    Identifiers
    urn:nbn:se:uu:diva-185295 (URN)10.3109/17453674.2012.720117 (DOI)000310015700001 ()22937978 (PubMedID)
    Available from: 2012-11-21 Created: 2012-11-21 Last updated: 2018-01-12Bibliographically approved
  • 7.
    Lazarinis, Stergios
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Kärrholm, Johan
    Swedish Hip arthroplasty Register and Department of Orthopaedics, Institute of Clinical Sciences, The Sahlgrenska Akademy, University of Gothenburg, Gothenburg, Sweden.
    Hailer, Nils P.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Effects of hydroxyapatite coating of cups used in hip revisionarthroplasty: A Swedish Hip Arthroplasty Register study of 1,780 revisions2012In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 83, no 5, p. 427-435Article in journal (Refereed)
    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.

    Methods

    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.

    Results

    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).

    Interpretation

    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.

  • 8.
    Lazarinis, Stergios
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Kärrholm, Johan
    Hailer, Nils P.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Increased risk of revision of acetabular cups coated with hydroxyapatite: A Swedish Hip Arthroplasty Register study involving 8,043 total hip replacements2010In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 81, no 1, p. 53-59Article in journal (Refereed)
    Abstract [en]

    Background Hydroxyapatite (HA) is the main inorganic component of bone, and HA coating is widely used on acetabular cups in hip arthroplasty. It has been suggested that this surface finish improves cup survival. Methods All patients registered in the Swedish Hip Arthroplasty Register between 1992 and 2007 with an uncemented acetabular implant that was available either with or without HA coating were identified. 8,043 total hip arthroplasties (THAs) with the most common cup types (Harris-Galante, Romanus, and Trilogy) were investigated. A Cox regression model including type of coating, age, sex, primary diagnosis, cup type, and type of stem fixation was used to calculate adjusted risk ratios (RRs) for the risk of revision. Results HA coating was a risk factor for cup revision due to aseptic loosening (adjusted RR 1.7; 95% CI: 1.3-2). Age at primary arthroplasty of < 50 years, a diagnosis of pediatric hip disease, the use of a cemented stem, and the Romanus and Harris-Galante cup types were also associated with statistically significantly increased risk of cup revision due to aseptic loosening. Interpretation Our findings question the routine use of HA-coated cups in primary total hip arthroplasty. With some designs, this practice may even increase the risk of loosening-resulting in revision surgery.

  • 9.
    Lazarinis, Stergios
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Lidgren, Lars
    Stefansdottir, Anna
    W-Dahl, Annette
    Consensus document on prosthetic joint infections2013In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 84, no 6, p. 507-508Article in journal (Other academic)
  • 10.
    Lazarinis, Stergios
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Mattsson, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Milbrink, Jan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Mallmin, Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Hailer, Nils P.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    A prospective cohort study on the short collum femoris preserving (CFP) stem using RSA and DXA: Primary stability but no prevention of proximal bone loss in 27 patients followed for 2 years2013In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 84, no 1, p. 32-39Article in journal (Refereed)
    Abstract [en]

    Background and purpose Short femoral stems have been introduced in total hip arthroplasty in order to save proximal bone stock. We hypothesized that a short stem preserves periprosthetic bone mineral density (BMD) and provides good primary stability. Methods We carried out a prospective cohort study of 30 patients receiving the collum femoris-preserving (CFP) stem. Preoperative total hip BMD and postoperative periprosthetic BMD in Gruen zones 1-7 were investigated by dual-energy x-ray absorptiometry (DXA), stem migration was analyzed by radio-stereometric analysis (RSA), and the Harris hip score (HHS) was determined. Results 2 patients were excluded intraoperatively and 1 patient was revised due to a deep infection, leaving 27 patients for analysis. The mean HHS increased from 49 (24-79) preoperatively to 99 (92-100) after 2 years. DXA after 1 year showed substantial loss of BMD in Gruen zone 7 (-31%), zone 6 (-19%), and zone 2 (-13%, p < 0.001) compared to baseline BMD determined immediately postoperatively. The bone loss in these regions did not recover after 2 years, whereas the more moderate bone loss in Gruen zones 1, 3, and 5 partially recovered. There was a correlation between low preoperative total hip BMD and a higher amount of bone loss in Gruen zones 2, 6 and 7. RSA showed minor micromotion of the stem: mean subsidence was 0.13 (95% CI: -0.28 to 0.01) mm and mean rotation around the longitudinal axis was 0.01 (95% CI: -0.1 to 0.39) after 2 years. Interpretation We conclude that substantial loss in proximal periprosthetic BMD cannot be prevented by the use of a novel type of short, curved stem, and forces appear to be transmitted distally. However, the stems showed very small migration-a characteristic of stable uncemented implants.

  • 11.
    Lazarinis, Stergios
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Milbrink, Jan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Mattsson, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Mallmin, Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Hailer, Nils P.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Bone loss around a stable, partly threaded hydroxyapatite-coated cup: a prospective cohort study using RSA and DXA2014In: HIP International, ISSN 1120-7000, E-ISSN 1724-6067, Vol. 24, no 2, p. 155-166Article in journal (Refereed)
    Abstract [en]

    Study purpose: Aseptic loosening of the acetabular component is the most common reason for revision after primary THA, and periprosthetic demineralisation has been described as a potential cause for this process. The trabeculae-oriented pattern (TOP)-cup is a flat, hydroxyapatite (HA)-coated titanium shell with a threaded rim that was developed in order to minimise periprosthetic bone loss. We hypothesised that this cup provides good primary stability and improves preservation of periprosthetic bone mineral density (BMD). Basic procedures: A prospective cohort study on 30 patients receiving the TOP cup was carried out. Preoperative total hip BMD and postoperative periprosthetic BMD in five periprosthetic regions of interest were investigated by dual energy radiographic absorptiometry (DXA), cup migration was analysed by radiostereometry (RSA), and the Harris hips score (HHS) was determined. Main findings: Mean HHS increased from 49 (24-79) preoperatively to 99 (92-100) after two years. DXA after one year demonstrated substantial BMD loss in the proximal periprosthetic zones 1 (-18%), zone 2 (-16%) and zone 3 (-9%, all p<0.001 when compared with baseline BMD determined immediately postoperatively). The bone loss in these regions did not recover after two years. RSA (performed on 16 patients) showed that only very limited micromotion of the implant occurred: Mean cranial migration was 0.01 mm (95% confidence interval (CI): -0.09-0.12) and mean inclination decreased by 0.02 degrees (CI: -0.43-0.39) after two years. Conclusion: We conclude that the TOP cup provides good primary stability in the short-term. However, substantial BMD loss in proximal periprosthetic areas indicates that the design of this cup cannot prevent periprosthetic bone loss that has also been observed around other uncemented cups.

  • 12.
    Lazarinis, Stergios
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Milbrink, Jan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Mattsson, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Mallmin, Hans
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Hailer, Nils P.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Demineralization around a stable uncemented modular cup: A prospective cohort study on a hemispherical, partly threaded and hydroxyapatite-coated cup using RSA and DXAManuscript (preprint) (Other academic)
  • 13.
    Lazarinis, Stergios
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics. Univ Gothenburg, Swedish Hip Arthroplasty Register, Gothenburg, Sweden.; Univ Gothenburg, Sahlgrenska Acad, Inst Clin Sci, Dept Orthopaed, Gothenburg, Sweden.
    Mäkelä, K T
    Department of Orthopaedics and Traumatology, Turku University Hospital, Turku, Finland.
    Eskelinen, A
    Coxa Hospital for Joint Replacement, Tampere, Finland.
    Havelin, L
    The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.
    Hallan, G
    The Norwegian Arthroplasty Register, Department of Orthopaedic Surgery, Haukeland University Hospital, Bergen, Norway.; Department of Clinical Medicine, University of Bergen, Bergen, Norway.
    Overgaard, S
    The Danish Hip Arthroplasty Register, Denmark.; Department of Orthopaedic Surgery and Traumatology, Odense University Hospital and Department of Clinical Research, University of Southern Denmark, Odense, Denmark.
    Pedersen, A B
    The Danish Hip Arthroplasty Register, Denmark.; Department of Clinical Epidemiology, Aarhus University Hospital, Aarhus, Denmark.
    Kärrholm, J
    Univ Gothenburg, Swedish Hip Arthroplasty Register, Gothenburg, Sweden.; Univ Gothenburg, Sahlgrenska Acad, Inst Clin Sci, Dept Orthopaed, Gothenburg, Sweden.
    Hailer, Nils
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics. Univ Gothenburg, Swedish Hip Arthroplasty Register, Gothenburg, Sweden.; Univ Gothenburg, Sahlgrenska Acad, Inst Clin Sci, Dept Orthopaed, Gothenburg, Sweden.
    Does hydroxyapatite coating of uncemented cups improve long-term survival?: An analysis of 28,605 primary total hip arthroplasty procedures from the Nordic Arthroplasty Register Association (NARA)2017In: Osteoarthritis and Cartilage, ISSN 1063-4584, E-ISSN 1522-9653, Vol. 25, no 12, p. 1980-1987, article id S1063-4584(17)31137-8Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE: It is unclear whether hydroxyapatite (HA) coating of uncemented cups used in primary total hip arthroplasty (THA) improves bone ingrowth and reduces the risk of aseptic loosening. We therefore investigated survival of different uncemented cups that were available with or without HA coating.

    METHOD: We investigated three different cup types used with or without HA coating registered in the Nordic Arthroplasty Register Association (NARA) database that were inserted due to osteoarthritis (n = 28,605). Cumulative survival rates and adjusted hazard ratios (HRs) for the risk of revision were calculated.

    RESULTS: Unadjusted 13-year survival for cup revision due to aseptic loosening was 97.9% (CI: 96.5-99.4) for uncoated and 97.8% (CI: 96.3-99.4) for HA-coated cups. Adjusted HRs were 0.66 (CI 0.42-1.04) for the presence of HA coating during the first 10 years and 0.87 (CI 0.14-5.38) from year 10-13, compared with uncoated cups. When considering the endpoint cup revision for any reason, unadjusted 13-year survival was similar for uncoated (92.5% [CI: 90.1-94.9]) and HA-coated (94.7% [CI: 93.2-96.3]) cups. The risk of revision of any component due to infection was higher in THA with HA-coated cups than in THA with uncoated cups (adjusted HR 1.4 [CI 1.1-1.9]).

    CONCLUSIONS: HA-coated cups have a similar risk of aseptic loosening as uncoated cups, thus the use of HA coating seems to not confer any added value in terms of implant stability. The risk of infection seemed higher in THA with use of HA-coated cups, an observation that must be investigated further.

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