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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.
    Brodén, Cyrus
    et al.
    Imperial Coll London, Dept Surg & Canc, London, England; Karolinska Inst, Danderyd Hosp, Dept Clin Sci, Stockholm, Sweden.
    Sandberg, Olof
    ‎ Sectra, Linköping, Sweden.
    Sköldenberg, Olof
    Karolinska Inst, Danderyd Hosp, Dept Clin Sci, Stockholm, Sweden.
    Stigbrand, Hampus
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Centre for Research and Development, Gävleborg. Länssjukhuset, Dept Orthoped Surg, Gävle, Sweden.
    Hänni, Mari
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Radiology.
    Giles, Joshua W
    Univ Victoria, Dept Mech Engn, Victoria, BC, Canada.
    Emery, Roger
    St Marys Hosp, Dept Orthopaed Surg, London, England.
    Lazarinis, Stergios
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Nyström, Andreas
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Olivecrona, Henrik
    Karolinska Inst, Dept Mol Med & Surg, Stockholm, Sweden.
    Low-dose CT-based implant motion analysis is a precise tool for early migration measurements of hip cups: a clinical study of 24 patients2020In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 91, no 3, p. 260-265Article in journal (Refereed)
    Abstract [en]

    Background and purpose - Early implant migration is known to be a predictive factor of clinical loosening in total hip arthroplasty (THA). Radiostereometric analysis (RSA) is the gold standard used to measure early migration in patients. However, RSA requires costly, specialized imaging equipment and the image process is complex. We determined the precision of an alternative, commercially available, CT method in 3 ongoing clinical THA studies, comprising 3 different cups.

    Materials and methods - 24 CT double examinations of 24 hip cups were selected consecutively from 3 ongoing prospective studies: 2 primary THA (1 cemented and 1 uncemented) and 1 THA (cemented) revision study. Precision of the CT-based implant motion analysis (CTMA) system was calculated separately for each study, using both the surface anatomy of the pelvis and metal beads placed in the pelvis.

    Results - For the CTMA analysis using the surface anatomy of the pelvis, the precision ranged between 0.07 and 0.31 mm in translation and 0.20° and 0.39° for rotation, respectively. For the CTMA analysis using beads the precision ranged between 0.08 and 0.20 mm in translation and between 0.20° and 0.43° for rotations. The radiation dose ranged between 0.2 and 2.3 mSv.

    Interpretation - CTMA achieved a clinically relevant and consistent precision between the 3 different hip cups studied. The use of different hip cup types, different CT scanners, or registration method (beads or surface anatomy) had no discernible effect on precision. Therefore, CTMA without the use of bone markers could potentially be an alternative to RSA to measure early migration.

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  • 3. 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)
  • 4. 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)
  • 5.
    Eriksson, Hannah K.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Ahadpour, David
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Hailer, Nils
    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.
    Järhult, Josef D.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Infectious Diseases.
    Linezolid in the treatment of periprosthetic joint infection caused by coagulase-negative staphylococci2019In: Infectious Diseases, ISSN 2374-4235, E-ISSN 2374-4243, Vol. 51, no 9, p. 683-690Article in journal (Refereed)
    Abstract [en]

    Background: Periprosthetic joint infection (PJI) caused by coagulase-negative staphylococci (CoNS) is increasingly common and is sometimes treated with off-label use of linezolid.

    Methods: We conducted a retrospective study of patients with PJI caused by CoNS treated with surgical intervention and orally administrated linezolid during the period 1995-2014 (n = 28). Clinical outcomes and adverse events related to linezolid administration were evaluated. Mean time to follow-up was 4.3 years (range: 0.2-12).

    Results: Twenty-two of 28 patients were infection-free at follow-up. No CoNS strain was resistant to vancomycin, but 16 of 28 were resistant to rifampicin, 23 of 28 to clindamycin and 20 of 27 to quinolones. The mean duration of linezolid treatment was 4.2 weeks (range: 1-12). Eleven of 28 patients had an adverse event related to the antimicrobial treatment, and four had to discontinue linezolid, but all adverse events were reversible within 2 months after discontinuation.

    Conclusions: Oral linezolid administration combined with adequate surgical treatment may be useful for the treatment of PJIs caused by CoNS.

  • 6.
    Eriksson, Hannah K.
    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.
    Low accuracy in preoperative tissue biopsies for diagnosing chronic periprosthetic joint infection: an observational retrospective single-centre study2023In: Journal of international medical research, ISSN 0300-0605, E-ISSN 1473-2300, Vol. 51, no 6, article id 03000605231158972Article in journal (Refereed)
    Abstract [en]

    Objective Diagnosing periprosthetic joint infection (PJI) can be challenging. The ability to distinguish between septic and aseptic failure of a joint prosthesis is crucial for treatment strategy optimisation and prognosis prediction. Preoperative tissue cultures are included in many diagnostic algorithms; however, studies report different degrees of concordance (63%-85%) with intraoperative cultures. This study aimed to investigate the diagnostic performance of tissue biopsies in the preoperative diagnostic process with the 2018 International Consensus Meeting criteria as a reference and to describe the concordance between microbiological findings in pre- and intraoperative biopsies.

    Methods This observational retrospective study included 44 patients requiring revision surgery of a total hip or knee arthroplasty, where the diagnostic workup included biopsies of periprosthetic tissue. The accuracy of preoperative biopsies was calculated, and concordance between microbiological findings in pre- and intraoperative biopsies was described.

    Results The accuracy was 59%, with a sensitivity of 50% and specificity of 79%. Full concordance between microbiological findings in pre- and intraoperative biopsies was found in 64% of the cases.

    Conclusion An open biopsy of periprosthetic tissue cannot reliably confirm or exclude PJI, and, therefore, should not be performed.

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  • 7.
    Eriksson, Hannah K.
    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.
    Patient-related factors associated with superficial surgical site infection and progression to a periprosthetic joint infection after elective primary total joint arthroplasty: a single-centre, retrospective study in Sweden2022In: BMJ Open, E-ISSN 2044-6055, Vol. 12, article id e060754Article in journal (Refereed)
    Abstract [en]

    Objectives: Superficial surgical site infection (SSSI) may increase the risk of serious complications such as periprosthetic joint infection (PJI). This study aims to identify patient-related risk factors associated with SSSI and investigate their correlation with the progression of PJI.

    Design: In this retrospective study, 1191 elective hip and knee prostheses were included. Patients were interviewed 3-5 months after surgery to answer questions about the postoperative period. Patient records were reviewed to determine whether there had been any documentation of wound-healing difficulties or whether antibiotics were prescribed to treat an infection related to arthroplasty surgery.

    Setting: Uppsala University Hospital, patients treated between November 2008 and December 2012.

    Participants: The study population comprised 433 knees and 758 hips.

    Outcome measures: We studied patient-related risk factors (joint, age, sex, the American Society of Anesthesiologists (ASA) classification, body mass index (BMI), smoking, diabetes and rheumatic disease) to determine whether they were associated with (1) SSSI and (2) the progress from SSSI to PJI.

    Results: 84 (7%) patients of the total cohort developed SSSI. This infection progressed to a PJI in 24 (29%) of the patients. Factors with increased adjusted risk ratios (aRRs) for SSSIs were knee surgery (1.7; 95% CI: 1.1 to 2.7), age >= 65 years (1.7; 95% CI: 1.1 to 2.8), BMI >= 30 (1.9; 95% CI: 1.0 to 3.4) and ASA classification >= 3 (1.7; 95% CI: 1.0 to 2.9). ASA classification >= 3 was the only factor showing a significant progression from SSSI to PJI (aRR=3.3; 95% CI: 1.0 to 10.3).

    Conclusions: The risk of progressing from an SSSI to a PJI is high. Older patients, patients with obesity, and those with a high ASA classification considered for elective total knee arthroplasty seem to have an increased risk of developing SSSI. Patients with a high ASA classification seem to have an increased risk of progressing from SSSI to PJI.

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  • 8.
    Eriksson, Hannah K.
    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.
    Järhult, Josef D.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Infection medicine.
    Hailer, Nils
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Early Staphylococcal Periprosthetic joint infection (PJI) caused by Staphylocci resistant to rifampicin: Inferior outcomes after Debridement, Antibiotics and Implant retention (DAIR)Manuscript (preprint) (Other academic)
    Abstract [en]

    Objectives: The purpose of this retrospective cohort study was to investigate whether rifampicin resistance in early periprosthetic joint infection (PJI) caused by Staphylococci (Coagulase negative staphylococci (CoNS) or Staphyloccocus aureus (SA)) affects the treatment outcome after debridement, antibiotics and implant retention (DAIR).

    Patients and methods: 81 patients (42 women) with a mean age of 72 (41-93) years affected by early PJI (30 knees, 51 hips) were included. Early PJI was defined as infection diagnosed within 6 weeks after the index surgical procedure, where index procedures could be either primary or revision surgeries. The diagnosis of PJI was based on MSIS (Musculoskeletal Infection Society) criteria and all patients were treated surgically by DAIR, repeated if needed. Infection-free survival was estimated using the Kaplan Meier method, and Cox regression models were fitted to assess the risk of unsuccessful treatment outcome, adjusted for the potential confounders sex, joint (hip or knee), type of index surgery (primary or revision) and age (dichotomised into age ˂ 70 or ≥ 70). 

    Outcome measures: The primary endpoint was to compare treatment outcome in patients with PJI caused by rifampicin-resistant or rifampicin-sensitive Staphylococci after one DAIR procedure and secondary endpoint to compare outcome after two DAIR procedures. 

    Results: The treatment was unsuccessful in 58% of patients after one DAIR procedure and in 42% after two DAIR procedures. In the group of patients with rifampicin-resistant Staphylococci, treatment was unsuccessful in 80% after one DAIR and 70% after two DAIR procedures. In patients with rifampicin-sensitive bacteria, 49% of the patients had an unsuccessful treatment after one DAIR and 33% after two DAIR. Patients with rifampicin-resistant staphylococcal PJI had a risk of infection relapse of 1.9 (95% CI: 1.1-3.6, p=0.04) after one DAIR when compared with patients with rifampicin-sensitive bacteria, and a 4.1 (95% CI: 1.2-14.1, p=0.03) -fold risk of treatment failure after two DAIR procedures.

    Conclusion: Staphylococcal resistance to rifampicin is associated with inferior outcomes in early PJI treated by DAIR. These findings are suggestive of a change in practice since DAIR may not be a useful strategy under these circumstances. 

  • 9.
    Eriksson, Hannah K.
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics and Handsurgery.
    Lazarinis, Stergios
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics and Handsurgery.
    Järhult, Josef D.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Infection medicine.
    Hailer, Nils
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics and Handsurgery. Department of Surgical Sciences, Section of Orthopaedics, Uppsala University, 751 83 Uppsala, Sweden.
    Early Staphylococcal Periprosthetic Joint Infection (PJI) Treated with Debridement, Antibiotics, and Implant Retention (DAIR): Inferior Outcomes in Patients with Staphylococci Resistant to Rifampicin2023In: Antibiotics, ISSN 0066-4774, E-ISSN 2079-6382, Vol. 12, no 11, article id 1589Article in journal (Refereed)
    Abstract [en]

    It is unknown how rifampicin resistance in staphylococci causing a periprosthetic joint infection (PJI) affects outcomes after debridement, antibiotics, and implant retention (DAIR). We thus aimed to compare the risk of relapse in DAIR-treated early PJI caused by staphylococci with or without rifampicin resistance. In total, 81 patients affected by early PJI were included, and all patients were treated surgically with DAIR. This was repeated if needed. The endpoint of relapse-free survival was estimated using the Kaplan–Meier method, and Cox regression models were fitted to assess the risk of infection relapse for patients infected with rifampicin-resistant bacteria, adjusted for age, sex, type of joint, and type of index surgery. In patients with rifampicin-resistant staphylococci, relapse was seen in 80% after one DAIR procedure and in 70% after two DAIR procedures. In patients with rifampicin-sensitive bacteria, 51% had an infection relapse after one DAIR procedure and 33% had an infection relapse after two DAIR procedures. Patients with rifampicin-resistant staphylococcal PJI thus had an increased adjusted risk of infection relapse of 1.9 (95% CI: 1.1–3.6, p = 0.04) after one DAIR procedure compared to patients with rifampicin-sensitive bacteria and a 4.1-fold (95% CI: 1.2–14.1, p = 0.03) increase in risk of infection relapse after two DAIR procedures. Staphylococcal resistance to rifampicin is associated with inferior outcomes after DAIR. These findings suggest that DAIR may not be a useful strategy in early PJI caused by rifampicin-resistant staphylococci.

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  • 10.
    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.

  • 11.
    Eriksson, Hannah
    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.
    Mediocre accuracy in preoperative tissue biopsies diagnosing chronic periprosthetic joint infection: An observational retrospective single-centre studyManuscript (preprint) (Other academic)
    Abstract [en]

    Objective: Diagnosing periprosthetic joint infection (PJI) can be challenging. The ability to distinguish between septic and aseptic failure of a joint prosthesis is crucial for treatment strategy optimisation and prognosis prediction. Preoperative tissue cultures are included in many diagnostic algorithms, but studies report different degree of concordance (63-85%) with intraoperative cultures. This study aimed to investigate the diagnostic performance of tissue biopsies as part of the preoperative diagnostic process with the 2018 International Consensus Meeting criteria as a reference and to describe the concordance between microbiological findings in pre- and intraoperative biopsies. 

    Methods: This observational retrospective study included 44 patients requiring revision surgery of a total hip or knee arthroplasty, where the diagnostic workup included biopsies of periprosthetic tissue. The accuracy of preoperative biopsies was calculated and concordance between microbiological findings in pre- and intraoperative biopsies described.

    Results: The accuracy was 59% with a sensitivity of 50% and a specificity of 79%. Full concordance between microbiological findings in pre- and intraoperative biopsies was found in 64 % of the cases. 

    Conclusion: The accuracy of preoperative tissue biopsies in diagnosing PJI should be considered mediocre, and not reliable to confirm or exclude PJI, and should therefore not be performed routinely.

  • 12.
    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.

  • 13.
    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: 2022-01-28Bibliographically 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
    Download full text (pdf)
    fulltext
  • 14.
    Lazarinis, Stergios
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics and Handsurgery.
    Hailer, Nils
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics and Handsurgery.
    Järhult, Josef D.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Medical Sciences, Infection medicine.
    Brüggemann, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics and Handsurgery.
    Incidence of Rifampicin Resistance in Periprosthetic Joint Infection: A Single-Centre Cohort Study on 238 Patients2023In: Antibiotics, ISSN 0066-4774, E-ISSN 2079-6382, Vol. 12, no 10, article id 1499Article in journal (Refereed)
    Abstract [en]

    Background: Rifampicin is a pillar in the treatment of periprosthetic joint infection (PJI). However, rifampicin resistance is an increasing threat to PJI treatment. This study explores the incidence of rifampicin-resistant bacteria over time in a Swedish tertiary referral centre and the association of rifampicin resistance with infection-free survival after PJI.

    Methods: The study included 238 staphylococcal PJIs treated between 2001 and 2020 for which susceptibility data for rifampicin were available. Data on causative bacteria, rifampicin resistance, treatment, and outcome were obtained. Kaplan-Meier survival analysis and Cox regression modelling estimated the infection-free cumulative survival and adjusted hazard ratios (HRs) for the risk of treatment failure.

    Results: Rifampicin-resistant causative bacteria were identified in 40 cases (17%). The proportion of rifampicin-resistant agents decreased from 24% in 2010-2015 to 12% in 2016-2020. The 2-year infection-free survival rates were 78.6% (95% CI, 66.4-93.1%) for the rifampicin-resistant group and 90.0% (95% CI, 85.8-94.4%) for the rifampicin-sensitive group. Patients with PJI caused by rifampicin-resistant bacteria had an increased risk of treatment failure (adjusted HR, 4.2; 95% CI, 1.7-10.3).

    Conclusions: The incidence of PJI caused by rifampicin-resistant bacteria did not increase over the past 20 years. The risk of treatment failure in PJI caused by rifampicin-resistant bacteria is more than four times that caused by rifampicin-sensitive bacteria, highlighting the importance of limiting the development of rifampicin resistance.

    Download full text (pdf)
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  • 15.
    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.

  • 16.
    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.

  • 17.
    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)
  • 18.
    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.

  • 19.
    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.

  • 20.
    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)
  • 21.
    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.

  • 22. Mukka, Sebastian
    et al.
    Hailer, Nils P.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Möller, Michael
    Gordon, Max
    Lazarinis, Stergios
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Rogmark, Cecilia
    Östlund, Ollie
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Disciplinary Domain of Medicine and Pharmacy, research centers etc., Uppsala Clinical Research Center (UCR).
    Sköldenberg, Olof
    Wolf, Olof
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics. Swedish Fracture Register, Registercentrum Västra Götaland, Gothenburg.
    Study protocol: The DAICY trial-dual versus single-antibiotic impregnated cement in primary hemiarthroplasty for femoral neck fracture-a register-based cluster-randomized crossover-controlled trial2022In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 93, p. 794-800Article in journal (Refereed)
    Abstract [en]

    BACKGROUND AND PURPOSE: Older patients with a displaced femoral neck fracture (FNF) are often treated with a cemented primary hemiarthroplasty (HA). The DAICY trial investigates whether high-dose dual-impregnated antibioticloaded cement (DIAC) including gentamicin and clindamycin can reduce the risk of periprosthetic joint infection (PJI) in comparison with low-dose single-impregnated gentamicin antibiotic-loaded cement (SIAC), in patients ≥ 60 years treated with a cemented HA for a displaced FNF.

    STUDY DESIGN: The trial is a national, multicenter, register-based, cluster-randomized, crossover trial. Patients ≥ 60 years with a non-pathological, displaced FNF (Type Garden 3-4/AO 31-B2 or B3) suitable for HA according to local guidelines are eligible for inclusion. Participating orthopedic departments will be randomized to start with either SIAC (control group) or DIAC treatment (intervention group) for 2 years. After 2 years, the study departments will then change to the other treatment arm for the remaining 2 years of the study. Approximately 7,000 patients will be included. The study is pragmatic in that the choice of implant brands, surgical approach and peri- and postoperative protocols follow the local routines of each participating department. All outcome variables will be retrieved after linkage of the study cohort to the following Swedish registers: the Fracture Register, the Arthroplasty Register, the National Patient Register and the Prescribed Drug Registry Outcome: The primary outcome will be periprosthetic joint infection of the index joint within 1 year after surgery. Secondary outcomes will be any reoperation on the index joint, mortality within 90 days and 1 year, resistance patterns of causative bacteria in cases of PJI, and health economics. Potential added value: This trial is designed to support or refute the efficacy of DIAC used in patients with a displaced FNF, potentially reducing PJI and resource allocation. Start of the trial and estimated duration - The DAICY trial started recruiting patients in January 2022 and will continue recruiting for approximately 4 years. Complete follow-up expected in 5 years.

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  • 23.
    Nyström, Andreas
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Kiritopoulos, Demostenis
    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.
    Lazarinis, Stergios
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics.
    Continuous periprosthetic bone loss but preserved stability for a collum femoris-preserving stem: follow-up of a prospective cohort study of 21 patients with dualenergy X-ray absorptiometry and radiostereometric analysis with minimum 8 years of follow-up.2022In: Acta Orthopaedica, ISSN 1745-3674, E-ISSN 1745-3682, Vol. 93, p. 206-211Article in journal (Refereed)
    Abstract [en]

    Background and purpose - We previously described a decrease in bone mineral density (BMD) in the calcar region 2 years after insertion of the collum femoris-preserving (CFP) stem, but the implants were stable. Now we have examined the long-term changes in periprosthetic BMD and stability of the CFP stem. Patients and methods - We conducted a minimum 8-year follow-up of 21 patients from our original investigation. We examined periprosthetic BMD by dual-energy X-ray absorptiometry (DEXA) and implant stability by radiostereometric analysis (RSA). Results - Between 2 and 8 years 1 stem was revised due to aseptic loosening. Between 2 and 8 years we found a 14% (95% confidence interval [CI] 9-19) reduction in BMD in Gruen zone 6 and 17% (CI 6-28) in Gruen zone 7. From baseline the reduction in BMD was 30% (CI 23-36) in Gruen zone 6, 39% (CI 31-47) in Gruen zone 7, and 19% (CI 14-23) in Gruen zone 2. Between 2 and 8 years, RSA (n = 17) showed a mean translation along the stem axis of 0.02mm (CI -0.02 to 0.06) and a mean rotation around the stem axis of 0.08° (CI -0.26 to 0.41). From baseline mean subsidence was 0.07 mm (CI -0.16 to 0.03) and mean rotation around the stem axis was 0.23° (CI -0.23 to 0.68) at 8 years. Interpretation - There was continuous loss of proximomedial BMD at 8 years while the CFP stem remained stable. Proximal periprosthetic bone loss cannot be prevented by this stem.

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  • 24.
    Persson, Anders
    et al.
    Karolinska Inst, Inst Klin Vetenskaper Danderyds Sjukhus, Danderyd, Sweden..
    Atroshi, Isam
    Lund Univ, Dept Clin Sci, Lund, Sweden.;Hassleholm Kristianstad Hosp, Dept Orthopaed, Kristianstad, Sweden..
    Tyszkiewicz, Thomas
    Lund Univ, Dept Clin Sci, Lund, Sweden.;Hassleholm Kristianstad Hosp, Dept Orthopaed, Kristianstad, Sweden..
    Hailer, Nils
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics. Uppsala Univ Hosp, Dept Orthopaed, Uppsala, Sweden..
    Lazarinis, Stergios
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Orthopaedics. Uppsala Univ Hosp, Dept Orthopaed, Uppsala, Sweden..
    Eisler, Thomas
    Karolinska Inst, Inst Klin Vetenskaper Danderyds Sjukhus, Danderyd, Sweden..
    Brismar, Harald
    Karolinska Inst, Dept Clin Sci Intervent & Technol, Huddinge, Sweden.;Karolinska Univ Sjukhuset & Huddinge, Dept Orthopaed & Biotechnol, Huddinge, Sweden..
    Mukka, Sebastian
    Umeå Univ, Dept Surg & Perioperat Sci, Umeå, Sweden.;Umeå Univ Hosp, Umeå, Sweden..
    Kernell, Per-Juan
    Löwenströmska Hosp, GHP Ortho Ctr Stockholm, Upplands Väsby, Sweden..
    Mohaddes, Maziar
    Swedish Hip Arthroplasty Register, Gothenburg, Sweden.;Univ Gothenburg, Sahlgrenska Acad, Inst Clin Sci, Dept Orthopaed, Gothenburg, Sweden..
    Skoldenberg, Olof
    Karolinska Inst, Inst Klin Vetenskaper Danderyds Sjukhus, Danderyd, Sweden..
    Gordon, Max
    Karolinska Inst, Inst Klin Vetenskaper Danderyds Sjukhus, Danderyd, Sweden..
    EPOS trial: the effect of air filtration through a plasma chamber on the incidence of surgical site infection in orthopaedic surgery: a study protocol of a randomised, double-blind, placebo-controlled trial2022In: BMJ Open, E-ISSN 2044-6055, Vol. 12, no 2, article id e047500Article in journal (Refereed)
    Abstract [en]

    Introduction There is controversy regarding the importance of air-transmitted infections for surgical site infections (SSIs) after orthopaedic surgery. Research has been hindered by both the inability in blinding the exposure, and by the need for recruiting large enough cohorts. The aim of this study is to investigate whether using a new form of air purifier using plasma air purification (PAP) in operating rooms (ORs) lowers the SSI rate or not. Methods and analysis Multicentre, double-blind, cluster-randomised, placebo-controlled trial conducted at seven hospitals in 2017-2022. All patients that undergo orthopaedic surgery for minimum 30 min are included. Intervention group: patients operated in OR with PAP devices turned on. Control group: patients operated in OR with PAP devices turned off. Randomisation: each OR will be randomised in periods of 4 weeks, 6 weeks or 8 weeks to either have the devices on or off. Primary outcome: any SSI postoperatively defined as a composite endpoint of any of the following: use of isoxazolylpenicillin, clindamycin or rifampicin for 2 days or more, International Classification of Diseases codes or Nordic Medico-Statistical Committee codes indicating postoperative infection. In a second step, we will perform a chart review on those patients with positive indicators of SSI to further validate the outcome. Secondary outcomes are described in the Methods section. Power: we assume an SSI rate of 2%, an SSI reduction rate of 25% and we need approximately 45 000 patients to attain a power of 80% at a significance level of 0.05. Ethics and dissemination The study is approved by the Swedish Ethical Review Authority. The interim analysis results from the study will be presented only to the researchers involved unless the study thereafter is interrupted for whatever reason. Publication in a medical journal will be presented after inclusion of the last patient.

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