# How to Prevent Aseptic Loosening in Cementless Arthroplasty: A Review
## 9 Experimental Studies on the Process of Osseointegration  
When we compared the current data with a previous work of our team regarding the prevention of aseptic loosening, we found out that researchers and clinicians have added new recommendations in the last years, while the previous remained generally unchanged. A summary of the current recommendations is available in Table 1. \begin{table}
\begin{tabular}{c c c c} \hline \hline
**Stage** & **Category** & **Recommendations** & **Type of Recommendation** \\ \hline \multirow{8}{*}{Preoperative} & \multirow{4}{*}{Acetabular cup} & Acetabular cups without screw holes & Controversial \\  & & Trabecular metal acetabular cups & Generally accepted \\  & & Highly porous acetabular components & Controversial \\  & & Porous implant or hydroxyapatite coated & Controversial \\  & & Titanium alloy femoral stems & Generally accepted \\  & & Type 1, 2, 4 and 7 femoral stem designs & Generally accepted \\  & & Bearing surfaces & Ceramic-on-polyethylene & Generally accepted \\  & & Dual mobility cup & Controversial \\  & & BODY mass index \textless{}35 & Generally accepted \\  & & Patients with the following are higher risk: & \\  & & - age \textless{}70 years: & \\  & & - genetic variations (ex. IFIT2/IFIT3, CERK, & \\  & & PAPPA, etc.); & \\  & & - Hyperglycemia; & \\  & & - Rheumatoid arthritis; & \\  & & - Femoral head AVN; & Generally accepted \\  & & - Hip dysplasia; & \\  & & - Sickle cell disease; & \\  & & - Parkinson disease; & \\  & & - Chronic liver disease; & \\  & & - Lumbar spinal fusion; & \\  & & - History of hip arthroscopy. & \\  & & More than 100 total hip replacements per & \\  & & & year performed by the surgeon & \\  & & Use of fewer types of implant by the same & \\  & & & surgeon & \\  & & & Lateral or posterior approach & \\  & & Avoid excessive drilling and rasping & \\  & & & Obtain good stability of implant & \\  & & Obtain acetabular bone coverage of more & \\  & & & than 60\% & \\  & & Acetabular cup horizontal inclination of & \\  & & around 45 degrees & \\  & & & Immediate full weight bearing is accepted & \\  & & Postoperative protocol & Avoid high impact activities & \\  & & Use of bisphosphonates & \\  & & Use of statins & \\ Postoperative & & Use of beta-blockers & \\  & & Postoperative drugs & Avoid opioids & \\  & & Avoid nonsteroidal anti-inflammatory drugs & \\  & & NSAIDsIDs & \\  & & Replace selective serotonin reuptake & \\  & & inhibitors (SSRIs) & \\  & & Replace loop diuretics with thiazides. & \\ \hline \hline \end{tabular}
\end{table} 
Table 1: Previous and recent recommendations regarding the factors affecting aseptic loosening. Although the studies which will be further discussed in this chapter are not specifically performed on aseptic loosening in the case of total hip arthroplasty, they are focused on the osseointegration process or survival rates, which are closely related to a decrease in aseptic loosening. As previous studies showed, the recommended pore size for a better bone ingrowth is 600 \(\upmu\)m, when compared to 300 \(\upmu\)m and 900 \(\upmu\)m [87]. The impact of osteoporosis on the total hip arthroplasty aseptic loosening has not been decided, but studies show a delayed osseointegration process due to a decreased bone metabolism and estrogen deficiency [7]. Other comorbidities to impact hip replacement survival are cardiovascular disease and psychotic disorders [7]. Surgeon's experience is important in decreasing the revision rate of total hip replacements according to [PERSON] et al. [83]. They showed that surgeons who perform 30 THAs per year are more likely to have a higher revision rate compared to those with over 60 THAs per year [88]. In terms of surgical technique, the main purposes are ensuring good stability and good coverage of the implant, while avoiding any excessive reaming and rasping [7]. Moreover, the use of worn reamers and rasps can alter the bone surrounding the implant, thus reducing the osseointegration process [7; 89].