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The Uncemented Cup in Total Hip Arthroplasty: stability, Wear and Osteolysis
Umeå universitet, Medicinska fakulteten, Institutionen för kirurgisk och perioperativ vetenskap, Ortopedi.
2019 (engelsk)Doktoravhandling, med artikler (Annet vitenskapelig)
Abstract [en]

Background: Artificial hip joint replacement has undergone tremendous development in the past 100 years. In the beginning, complications, such as infection and early loosening, were the rule rather than the exception. Today, complications of any sort are rare during the first decade after the operation. Artificial hip joint replacement has been chosen as the "Operation of the Century" and has dramatically improved the quality of life of millions of patients. Unfortunately, in the long-term, prosthesis loosening due to pathological bone resorption (osteolysis) around the prosthesis is still common. Traditionally, the prosthesis is anchored in the bone with bone cement (Plexiglas). However, since this cementation method was suspected to cause late loosening, alternative methods, such as the implantation of so-called uncemented prostheses, have been developed and are being increasingly applied. Because the early movement of a prosthesis (migration) increases the risk of loosening, uncemented cups are often augmented with additional screws. The mechanisms regulating the early and late loosening of uncemented cups are not fully established. Wear particles from the artificial joint and intermittent fluid pressure on the bone appear to accelerate or even cause bone loss and can eventually lead to loosening of the prosthesis. Therefore, screw holes in the uncemented cup have been suspected to be a risk factor.

Aims: We have studied whether the additional augmentation of modern uncemented cups with screws, pegs or hydroxyapatite increases the long-term stability, affects the wear rate, influences the development of osteolysis, or has any impact on the risk of cup revision. Furthermore, we investigated whether computed tomography (CT), which is needed to detect osteolysis around the prosthesis, could also be used in the follow-up of migration studies without losing significant precision compared to radiostereometry (RSA), which is the gold standard for these measurements.

Patients and Methods: In studies I-III, we evaluated 48 hips (45 patients) randomized to receive cups with or without augmentation. As part of the 14-year follow-up with conventional radiographs of the pelvis, two pairs of stereo radiographs and a CT scan were obtained. Migration and wear were measured by RSA. The volume and type of osteolysis were determined on CT. Furthermore, we calculated the precision and limit of agreement of RSA and CT to compare these two modalities as tools for migration measurements.

In study IV, we compared the risk of cup revision between 10,371 uncemented cups with and 12,354 without screw holes, using data from the Swedish Hip Arthroplasty Register.

Results: Study I: Cup stability was equally good regardless of cup augmentation. The mean wear rate of the cup liner was high, at 0.21 mm/year, with no significant difference between the groups.

Study II: The limit of agreement between CT and RSA was 1.15°, 1.51°, and 0.70° for rotation and 0.46, 0.43, and 0.52 mm for translation. These results were within the described normal 99% confidence limits for precision in RSA: 0.3° to 2° for rotation and 0.15 to 0.6 mm for translation.

Study III: Osteolysis of some degree was visible in all 48 hips on CT. We found three different types of osteolytic lesions: type 1A, absent trabecular bone and a sclerotic border around the lesion; type 1B, absent trabecular bone and no sclerotic border; and type 2, reduced radiodensity and reduced trabecular number. Cups with screw holes were surrounded with larger osteolytic lesions, and osteolysis around these cups was more likely to be a type 1A lesion.

Study IV: Cups without screw holes showed a decreased risk of cup revision (implant exchange or removal) due to any reason at both 2 years (adjusted hazard ratio, HR: 0.6, confidence interval, CI: 0.5-0.8) and 10 years (HR: 0.7, CI: 0.5- 0.9). However, for aseptic loosening, there was no significant difference between cups with and without screw holes, with an implant survival rate of 99.9% (CI: 99.8-99.9) at 2 years and 99.1% (CI: 98.6-99.7) at 10 years.

Conclusion: Uncemented cups augmented with screws, pegs, or hydroxyapatite do not have improved long-term stability compared with cups with press-fit only. Unsealed screw holes in uncemented cups appear to be a risk factor for the development of larger osteolytic lesions. CT showed three different types of osteolytic lesions. The risk of aseptic loosening for modern uncemented cup designs is very low, and cups without additional augmentation do not have an increased revision rate. In contrast, the risk of cup revision for any reason was higher for cups with screw holes. CT can be used for migration studies for the longitudinal evaluation of patients with tantalum markers with precision comparable to that of RSA.

sted, utgiver, år, opplag, sider
Umeå: Umeå Universitet , 2019. , s. 93
Serie
Umeå University medical dissertations, ISSN 0346-6612 ; 2019
HSV kategori
Identifikatorer
URN: urn:nbn:se:umu:diva-157459ISBN: 978-91-7855-038-8 (tryckt)OAI: oai:DiVA.org:umu-157459DiVA, id: diva2:1297744
Disputas
2019-04-12, Sal B, trapphus A, 9 trappor, Norrlands universitetssjukhus, 13:00 (svensk)
Opponent
Veileder
Merknad

Felaktigt ISBN i kappan och spikbladet. Korrekt ISBN: 978-91-7855-038-8.

Tilgjengelig fra: 2019-03-22 Laget: 2019-03-20 Sist oppdatert: 2019-03-22bibliografisk kontrollert
Delarbeid
1. Stability of Uncemented Cups - Long-Term Effect of Screws, Pegs and HA Coating: A 14-Year RSA Follow-Up of Total Hip Arthroplasty
Åpne denne publikasjonen i ny fane eller vindu >>Stability of Uncemented Cups - Long-Term Effect of Screws, Pegs and HA Coating: A 14-Year RSA Follow-Up of Total Hip Arthroplasty
Vise andre…
2016 (engelsk)Inngår i: The Journal of Arthroplasty, ISSN 0883-5403, E-ISSN 1532-8406, Vol. 31, nr 1, s. 156-161Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Screws, pegs and hydroxyapatite-coating are used to enhance the primary stability of uncemented cups. We present a 14-year follow-up of 48 hips randomized to four groups: press-fit only, press-fit plus screws, press-fit plus pegs and hydroxyapatite-coated cups. Radiostereometric migration measurements showed equally good stability regardless cup augmentation. The mean wear rate was high, 0.21mm/year, with no differences between the groups. Seven hips had radiographical osteolysis but only in hips with augmented cups. Cups without screw-holes compared with cups with screw-holes resulted in better clinical outcome at the 14-year follow-up. Thus, augmentation of uncemented cups with screws, pegs, or hydroxyapatite did not appear to improve the long-term stability compared with press-fit only.

Emneord
THA, cup, migration, wear, clinical outcome, radiostereometry
HSV kategori
Identifikatorer
urn:nbn:se:umu:diva-112202 (URN)10.1016/j.arth.2015.07.012 (DOI)000366677000031 ()26260783 (PubMedID)2-s2.0-84953839160 (Scopus ID)
Tilgjengelig fra: 2015-12-03 Laget: 2015-12-03 Sist oppdatert: 2019-03-20bibliografisk kontrollert
2. Are CT Scans a Satisfactory Substitute for the Follow-Up of RSA Migration Studies of Uncemented Cups?: A Comparison of RSA Double Examinations and CT Datasets of 46 Total Hip Arthroplasties
Åpne denne publikasjonen i ny fane eller vindu >>Are CT Scans a Satisfactory Substitute for the Follow-Up of RSA Migration Studies of Uncemented Cups?: A Comparison of RSA Double Examinations and CT Datasets of 46 Total Hip Arthroplasties
Vise andre…
2017 (engelsk)Inngår i: BioMed Research International, ISSN 2314-6133, E-ISSN 2314-6141, Vol. 2017, artikkel-id 3681458Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

As part of the 14-year follow-up of a prospectively randomized radiostereometry (RSA) study on uncemented cup fixation, two pairs of stereo radiographs and a CT scan of 46 hips were compared. Tantalum beads, inserted during the primary operation, were detected in the CT volume and the stereo radiographs and used to produce datasets of 3D coordinates. The limit of agreement between the combined CT and RSA datasets was calculated in the same way as the precision of the double RSA examination. The precision of RSA corresponding to the 99% confidence interval was 1.36 degrees, 1.36 degrees, and 0.60 degrees for X-, Y-, and Z-rotation and 0.40, 0.17, and 0.37mm for X-, Y-, and Z-translation. The limit of agreement between CT and RSA was 1.51 degrees, 2.17 degrees, and 1.05 degrees for rotation and 0.59, 0.56, and 0.74mm for translation. The differences between CT and RSA are close to the described normal 99% confidence interval for precision in RSA: 0.3 degrees to 2 degrees for rotation and 0.15 to 0.6mm for translation. We conclude that measurements using CT and RSA are comparable and that CT can be used for migration studies for longitudinal evaluations of patients with RSA markers.

sted, utgiver, år, opplag, sider
Hindawi Publishing Corporation, 2017
HSV kategori
Identifikatorer
urn:nbn:se:umu:diva-131265 (URN)10.1155/2017/3681458 (DOI)000394010400001 ()
Tilgjengelig fra: 2017-02-10 Laget: 2017-02-10 Sist oppdatert: 2019-03-20bibliografisk kontrollert
3. Osteolysis around uncemented cups withand without screw holes: Analysis of osteolytic lesions on CT images in 48 hips at a 14-year follow-up
Åpne denne publikasjonen i ny fane eller vindu >>Osteolysis around uncemented cups withand without screw holes: Analysis of osteolytic lesions on CT images in 48 hips at a 14-year follow-up
Vise andre…
(engelsk)Manuskript (preprint) (Annet vitenskapelig)
Abstract [en]

Osteolysis around uncemented cups is a major complication for THA. We present a 14-year follow-up of 48 hips previously randomized to four groups of cup fixation – sealed cups with press-fit only, cups with hydroxyapatite coating, cups with screws, and cups with pegs. CT scans revealed three types of osteolytic lesions – Type 1A (absence of trabecular bone and a sclerotic border), Type 1B (absence of trabecular bone without a sclerotic border), and Type 2 (reductions in radiodensity and trabeculae). Cups with screw-holes were surrounded with larger osteolytic lesions that were predominantly Type 1A. Unsealed screw holes in uncemented cups appeared to be a risk factor for osteolysis development. Modern CT scans reveal three types of osteolytic lesions. Distinction between types is important for comparability between studies.

Emneord
Osteolysis, Total Hip Arthroplasty, CT
HSV kategori
Forskningsprogram
ortopedi
Identifikatorer
urn:nbn:se:umu:diva-157456 (URN)
Tilgjengelig fra: 2019-03-20 Laget: 2019-03-20 Sist oppdatert: 2019-03-21
4. Uncemented cups with and without screw holes in primary THA: a Swedish Hip Arthroplasty Register study with 22725 hips
Åpne denne publikasjonen i ny fane eller vindu >>Uncemented cups with and without screw holes in primary THA: a Swedish Hip Arthroplasty Register study with 22725 hips
Vise andre…
(engelsk)Manuskript (preprint) (Annet vitenskapelig)
Abstract [en]

Background and purpose: Uncemented cups in total hip arthroplasty (THA) are often augmented with additional screws to enhance their primary stability. We investigated whether there is a difference in the risk for revision between cups with screw holes and cups without screw holes.

Patients and methods: We analyzed the risk for cup revision of uncemented cups registered in the Swedish Hip Arthroplasty Register (SHAR) between 2000 and 2017 with respect to the presence of screw holes. Only patients with primary osteoarthritis (OA) were included. 22725 cups, including 12354 without screw holes and 10371 with screw holes, were evaluated. Revision rates at 2 and 10 years after the primary operation were analyzed.

Results: At a median follow-up time of 3.4 (0-18) years, 459 cup revisions were reported. The main reasons for cup revision during the whole observations time were infection, 52% of all cup revisions, and dislocation, 26% of all cup revisions. The survival rate with cup revision due to aseptic loosening as endpoint was 99.9% (95% CI 99.8-99.9) at 2 years for both cups with and cups without screw holes, and the survival rates at 10 years were 99.5% (CI 99.3-99.7) and 99.1% (CI 98.6-99.5), respectively. Cups without screw holes showed a decreased risk of revision due to any reason at both 2 years (adjusted hazard ratio [HR] 0.6, CI 0.5-0.8) and 10 years (HR 0.7, CI 0.5-0.9).

Interpretation: We found a very low revision rate for aseptic loosening with modern, uncemented cup designs. Cups with screw holes had an increased risk for revision due to any reason in patients with primary OA.

Emneord
Total Hip Arthroplasty, uncemented, cup, revision, registry
HSV kategori
Forskningsprogram
ortopedi
Identifikatorer
urn:nbn:se:umu:diva-157458 (URN)
Tilgjengelig fra: 2019-03-20 Laget: 2019-03-20 Sist oppdatert: 2019-03-21

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