Risedronate reduces postoperative bone resorption after cementless total hip arthroplasty

Comparing the Efficacy of Antiosteoporotic Drugs in Preventing Periprosthetic Bone Loss Following Total Hip Arthroplasty: A Systematic Review and Bayesian Network Meta-Analysis

BACKGROUND

Periprosthetic bone loss is a well-known phenomenon following total hip arthroplasty (THA). However, the choice of drugs for prevention remains controversial. Therefore, the aim of this study was to determine the best drug to treat periprosthetic bone loss by comparing changes in bone mineral density (BMD) at different times after THA.

METHODS

A comprehensive search of five databases and two clinical trial registration platforms was undertaken from their inception through to August 31, 2023 to identify eligible randomized controlled trials. A Bayesian network meta-analysis (NMA) was carried out for calculating the standardized mean difference (SMD) and the surface under cumulative ranking curve (SUCRA) of the BMD in calcar (Gruen zone 7) at 6 months, 12 months, and 24 months and over.

RESULTS

Twenty-nine trials involving 1427 patients and 10 different interventions were included. The results demonstrated that at 6 months, denosumab had the highest ranking (SUCRA = 0.90), followed by alendronate (SUCRA = 0.76), and zoledronate (SUCRA = 0.73). At 12 months, clodronate ranked highest (SUCRA = 0.96), followed by denosumab (SUCRA = 0.84) and teriparatide (SUCRA = 0.82). For interventions with a duration of 24 months and over, denosumab had the highest SUCRA value (SUCRA = 0.96), followed by raloxifene (SUCRA = 0.90) and zoledronate (SUCRA = 0.75).

CONCLUSION

Investigating the existing body of evidence revealed that denosumab demonstrates potential as an intervention of superior efficacy at the three specifically examined time points. However, it remains crucial to conduct further research to confirm these findings and determine the most effective treatment strategy.

Denosumab prevented periprosthetic bone resorption better than risedronate after total hip arthroplasty

INTRODUCTION

Periprosthetic fracture caused by periprosthetic bone loss is an important concern in total hip arthroplasty (THA). Denosumab has been approved for postmenopausal women with osteoporosis who are at high risk of fracture. In this randomized controlled trial, we compared the effects of denosumab and risedronate on periprosthetic bone mineral density (BMD) after THA.

MATERIALS AND METHODS

The current study analyzed 108 patients who were scheduled to have THA. For 2 years, the patients were randomly assigned to the following two treatment groups: denosumab (60 mg subcutaneously every 6 months) or risedronate (17.5 mg oral weekly). The BMD changes in all Gruen zones and bone turnover markers were measured at the 5th postoperative day (baseline) and 6, 12, 18, and 24 months postoperatively.

RESULTS

The mean BMD in zones 1, 2, 6, and 7 was significantly higher with denosumab all administration at all postoperative time points compared to the risedronate group. The mean percentage changes in the BMD in these zones from baseline to 24 months postoperatively were + 11.9, + 2.9, + 8.1, and + 5.9% with denosumab group and - 9.6% -3.6, - 2.3, and - 19.2% with risedronate, respectively. The osteoclastic marker, tartrate-resistant acid phosphatase-5b (TRACP-5b), was significantly lower in the denosumab group compared to the risedronate group by 2 months.

CONCLUSION

Denosumab is more effective in preventing periprosthetic bone resorption than risedronate in the proximal femur. It also increased BMD around the stem implant following THA.

Alendronate enhances osseointegration in a murine implant model

Administration of bisphosphonates following total joint arthroplasty might be beneficial to reduce aseptic loosening. However, their effects on peri-implant bone formation and bone-implant interface strength have not been investigated yet. We used a physiologically loaded mouse implant model to investigate the short-term effects of postoperative systemic alendronate on osseointegration. A titanium implant with a rough surface was inserted in the proximal tibiae of 17-week-old female C57BL/6 mice (n = 44). Postimplantation mice were given alendronate (73 μg/kg/days, n = 22) or vehicle (n = 22) 5 days/week. At 7- and 14-day postimplantation, histology and histomorphometry were conducted. At 28 days, microcomputed tomography and biomechanical testing were performed (n = 10/group). Postoperative alendronate treatment enhanced osseointegration, increasing maximum pullout load by 45% (p < .001) from 19.1 ± 4.5 N in the control mice to 27.6 ± 4.9 N in the treated mice, at day 28 postimplantation. Alendronate treatment increased the bone volume fraction by 139% (p < .001) in the region distal to the implant and 60% (p < .05) in the peri-implant region. At 14-day postimplantation, alendronate treatment decreased the number of osteoclasts per bone perimeter (p < .05) and increased bone volume fraction (p < .01) when compared with the control group. Postimplantation, short-term alendronate treatment enhanced osseointegration as demonstrated by increased bone mass, trabecular bone thickness, and maximum pullout load. Alendronate decreased peri-implant osteoclasts while preserving peri-implant osteoblasts and endothelial cells, in turn, increasing bone volume fraction. This data supports the postoperative clinical use of bisphosphonates, especially in patients with high risks of aseptic loosening.

Preoperative factors predicting the severity of BMD loss around the implant after Total hip Arthroplasty

Background

Stress shielding after total hip arthroplasty (THA) leads to loss of bone mineral density (BMD) around the femoral implants, particularly in the proximal area. Loss of BMD around the implant is likely to occur within 1 year after THA; however, its severity depends on patient characteristics. This study evaluated preoperative factors correlated with the severity of zone 7 BMD loss after THA.

Methods

This retrospective cohort study included 48 patients who underwent primary THA from October 2011 to December 2015. All patients underwent implantation of a Zweymüller-type femoral component without any postoperative osteoporosis medications. The objective variable was a change in zone 7 BMD after 1 year. Factors evaluated included age, body mass index, Japanese Orthopaedic Association score, Harris Hip Score, Canal Flare Index (CFI), and lumbar BMD on the frontal and lateral sides. Univariate and multivariate regression analyses identified factors correlated with loss of zone 7 BMD.

Results

Univariate regression analysis identified CFI (P = 0.003) and preoperative lumbar BMD on the anterior-posterior (P = 0.003) and lateral (P < 0.001) sides as being correlated with loss of zone 7 BMD. Multivariate regression analysis identified CFI (P = 0.014) and lumbar BMD on the lateral side (P < 0.001) as being correlated independently with loss of zone 7 BMD.

Conclusion

Lower preoperative lumbar BMD on the lateral side and lower CFI were correlated with zone 7 BMD loss after THA. Patients with these characteristics should be monitored carefully for severe BMD loss after THA.

Osseointegration Pharmacology: A Systematic Mapping Using Artificial Intelligence

Clinical performance of osseointegrated implants could be compromised by the medications taken by patients. The effect of a specific medication on osseointegration can be easily investigated using traditional systematic reviews. However, assessment of all known medications requires the use of evidence mapping methods. These methods allow assessment of complex questions, but they are very resource intensive when done manually. The objective of this study was to develop a machine learning algorithm to automatically map the literature assessing the effect of medications on osseointegration. Datasets of articles classified manually were used to train a machine-learning algorithm based on Support Vector Machines. The algorithm was then validated and used to screen 599,604 articles identified with an extremely sensitive search strategy. The algorithm included 281 relevant articles that described the effect of 31 different drugs on osseointegration. This approach achieved an accuracy of 95%, and compared to manual screening, it reduced the workload by 93%. The systematic mapping revealed that the treatment outcomes of osseointegrated medical devices could be influenced by drugs affecting homeostasis, inflammation, cell proliferation and bone remodeling. The effect of all known medications on the performance of osseointegrated medical devices can be assessed using evidence mappings executed with highly accurate machine learning algorithms.

Bisphosphonates Can Maintain Periprosthetic Bone Mass Density after Total Hip Replacement, with Controversy in Region of Interest 5

BACKGROUND

Total hip replacement (THR) is the standard surgical treatment of hip diseases. Periprosthetic bone mass density (BMD) loss may be a cause for revision surgery. Bisphosphonates (BPs) are now the principal class medications for osteoporosis.

OBJECTIVE

To demonstrate the effect of BPs on treating periprosthetic osteoporosis after THR via a meta-analysis of randomized controlled trials (RCTs).

METHODS

A comprehensive search of PubMed, EMBASE, the Web of Science and the Cochrane Central Register of Controlled Trials was performed for RCTs on the effect of BPs on treating periprosthetic osteoporosis after THR and clinical outcomes relative to controls. The primary outcome measures were the change in BMD in each region of interest (ROI), the change in serum bone turnover marker levels, the change in functional parameters and the risk of adverse effects (AEs). The final search was performed in March, 2020.

RESULTS

Nine RCTs were included. A total of 359 patients met the inclusion criteria. BPs can clearly maintain periprosthetic BMD in ROIs at 1, 2, 3, 4, 6 and 7 at 6, 12 and 24 months. In addition, BPs can clearly decrease serum procollagen type 1 N-terminal propeptide (P1NP) levels at 12 months. There was no significant difference in the risk of AEs between the BP and control groups; however, BPs can cause more patients to decline participation.

CONCLUSION

BPs can effectively maintain overall periprosthetic BMD, but BMD in ROI 5 remains controversial. In addition, the safety of BPs is relatively high, but the compliance may be relatively low.

Effect of switching administration of alendronate after teriparatide for the prevention of BMD loss around the implant after total hip arthroplasty, 2-year follow-up: a randomized controlled trial

BACKGROUND

Stress shielding after total hip arthroplasty (THA) can induce bone mineral density (BMD) loss around the femoral implant. Several studies using drug have described methods to prevent BMD loss around implants following THA. Switching from teriparatide to alendronate was reported to increase lumbar BMD; on the other hands, it is unclear whether switching from teriparatide to alendronate is effective around the implant. The aim of this study is that changes in BMD is compared in patients switched from teriparatide to alendronate, in patients treated with alendronate alone, and in control patients without medication after total hip arthroplasty.

PATIENTS AND METHODS

Patients were randomized into three groups, those switched to alendronate after teriparatide (switch: n = 17), those receiving continuous alendronate (ALD: n = 15), and control untreated patients (control: n = 16) and followed up for 2 years after THA. Baseline periprosthetic BMD was measured by dual-energy X-ray absorptiometry (DEXA) 1 week after THA, followed by subsequent measurements at 1 and 2 years postoperatively. Lumbar BMD was also evaluated at preoperatively, 1 and 2 years postoperatively.

RESULTS

Two years after surgery, BMD (%) at zone 1 was significantly higher in the switch group than in the control group (P = 0.02). BMD (%) at zone 7 was significantly higher in the switch and ALD groups than in the control group (P = 0.01, P = 0.03). Lumbar BMD (%) anterior-posterior (AP) side was significantly higher in the switch group than in the ALD and control groups 2 years after surgery. On the other hand, lumbar BMD (%) lateral side was significantly higher in the switch and ALD groups than control group 2 years after surgery.

CONCLUSIONS

Switching therapy had a significant effect on BMD of the lumbar spine and zones 1 and 7 at 2 years postoperatively. At zone 1 in particular, it was found to be more effective than ALD alone.

TRIAL REGISTRATION

UMIN, registry number UMIN000016158. Registered 8 January 2015.

The Status of Assessments and Treatments for Osteoporosis in Patients 5 Years after Total Hip Arthroplasty: A Cross-Sectional Survey of 194 Post-THA Patients

BACKGROUND

Assessments for osteoporosis in patients who have undergone total hip arthroplasty (THA) are very important with respect to the clinical results. However, few studies have investigated the status of the assessments and treatments for osteoporosis in post-THA patients. The purpose of this multicenter study was to investigate the status of assessments and treatments for osteoporosis in post-THA patients.

METHODS

The results of a self-report questionnaire and the medical records of 194 post-THA patients over 40 years of age who visited the outpatient departments of the five hospitals participating in the study were analyzed.

RESULTS

A total of 125 patients (64.4%) had been examined for osteoporosis, and 69 patients (35.6%) had never been assessed for osteoporosis. It was assumed, based on the questionnaire results, that 50 (40%) of the 125 patients should have been receiving treatment for osteoporosis. Forty-five (90%) of these 50 patients were actually taking medication for osteoporosis at the time of the investigation. Overall, a total of 58 (29.9%) patients were receiving treatment for osteoporosis.

CONCLUSIONS

The present survey revealed that 64.4% of post-THA patients had been evaluated for osteoporosis. Moreover, while 40% of post-THA patients over 40 years of age may require treatment for osteoporosis, only 29.9% were actually receiving treatment.

To withhold or to implement bisphosphonate after cementless hip arthroplasty: a dilemma in elderly hip fracture patients

Background

Prior studies reported ambivalent effects of bisphosphonates on the fixation of cementless stem in hip arthroplasty patients. To set up the postoperative guide of bisphosphonate use after cementless hip arthroplasty, we investigated whether zoledronate has beneficial or negative effects in the stem migration and walking ability after cementless hemi-arthroplasty in elderly patients, who were operated due to femoral neck fracture.

Methods

We compared 59 patients (zoledronate group), who received zoledronate after cementless hemi-arthroplasty, and 66 patients (control group), who did not receive that agent. We evaluated stem subsidence, cortical porosis around the stem, and walking ability with the use of Koval’s categories at 2-year follow-up.

Results

No patient had more than 2 mm of stem subsidence in both groups. One patient in the control group had cortical porosis around the stem, but none in the zoledronate group. There were no significant differences in the postoperative Koval scores (p = 0.769) and in the proportion of walking recovery to pre-fracture status (p = 0.695) between the two groups.

Conclusion

We did not find neither beneficial nor negative effect of this agent in terms of stem fixation and walking ability. Zoledronate can be used after cementless hemi-arthroplasty to manage the osteoporosis in elderly patients.

Efficacy of risedronate in improving bone mineral density in patients undergoing total hip arthroplasty: A meta-analysis of randomized controlled trials

BACKGROUND

Risedronate is widely used in the therapy of osteoporosis and other metabolic bone diseases. This meta-analysis was aimed to assess whether administration risedronate could increase the bone mineral density (BMD) in patients undergoing primary total hip arthroplasty (THA).

METHODS

Electronic databases: PubMed, EMBASE, Web of Science, Cochrane Library, and Chinese Wanfang database were searched for all relevant studies. Inclusion criterion was that patients prepared for THA and use risedronate as intervention group and placebo as control group. BMD change in Gruen zone 1 and 7 were primary outcomes. Meta-analysis was performed using Stata 12.0 software.

RESULTS

Six RCTs were finally included in this meta-analysis. Compared with control group, risedronate has a beneficial role in increasing BMD in Gruzen 1, 2 6, and 7 at 3 months (P < .05). Oral risedronate has a beneficial role in preservation of BMD in all of the Gruen zones at 6 and 12 months (P < .05). Moreover, oral risedronate could significantly increase the Harris hip scores and bone alkaline phosphatase than control group (P < .05).

CONCLUSION

Oral risedronate has an effect on the preservation of periprosthetic BMD in proximal regions (Gruen zone 1, 2, 3, and 7) at 3 months and all of the regions at 6 and 12 months after THA.

Effects of bisphosphonates in preventing periprosthetic bone loss following total hip arthroplasty: a systematic review and meta-analysis

BACKGROUND

Periprosthetic bone loss following total hip arthroplasty (THA) was a well-known phenomenon. This systematic review was to assess the effectiveness of bisphosphonates (BPs) for decreasing periprosthetic bone resorption.

METHODS

The MEDLINE, EMBASE, and Cochrane Library databases were searched up to March 2018. Randomized controlled trials compared the effects between administrating BPs and placebo or no medication were eligible; the target participants were patients who underwent THA. Mean differences (MD) and 95% confidence interval (95% CI) were calculated by using the random-effects models. Statistical analyses were performed by RevMan 5.3 software.

RESULTS

Fourteen trials involving 620 patients underwent THA were retrieved. BPs significantly prevented the loss of periprosthetic bone mineral density at 1 year (MD, 0.06 [95% CI, 0.03 to 0.08], p < 0.001), between 2 and 4 years (MD, 0.04 [95% CI, 0.01 to 0.07], p = 0.02), and more than 5 years after THA (MD, 0.08 [95% CI, 0.06 to 0.11], p < 0.001). Both serum bone alkaline phosphatase (MD, - 7.28 [95% CI, - 9.81 to - 4.75], p < 0.001) and urinary N-telopeptide of type I collagen (MD, - 24.37 [95% CI, - 36.37 to - 12.37], p < 0.001) in BP group were significantly lower. Subgroup analyses showed that the third-generation BPs were more effective in decreasing periprosthetic bone loss than the first and second generation within 1 year after THA (p = 0.001).

CONCLUSION

BPs were beneficial to decreasing periprosthetic bone loss. The third-generation BPs showed significantly efficacy for patients in short-term observation.

Bisphosphonates for the preservation of periprosthetic bone mineral density after total joint arthroplasty: a meta-analysis of 25 randomized controlled trials

The present meta-analysis aimed to evaluate the long-term efficacy of bisphosphonates (BPs) on preservation of periprosthetic bone mineral density (BMD) after joint arthroplasty. It confirmed the protective effect of BPs in a long-term follow-up, and found the influence factors on this effect.

INTRODUCTION

Periprosthetic bone loss is believed to cause aseptic loosening and failed prosthetic fixation in joint arthroplasty. This meta-analysis which included high-quality randomized controlled trials aimed to analyze the effect of bisphosphonates on maintaining periprosthetic bone mineral density after total joint arthroplasty.

METHODS

Twenty-five RCTs were included and the total number of participants was 1163 by computerized searches of bibliographic databases. The weighted mean differences with 95% confidence interval were calculated to evaluate the efficacy of BPs on total periprosthetic BMD and the BMD of different Gruen zones. Subgroup analyses identified the potentially influencing factors such as surgical site, cement fixation, and generation of BPs. A descriptive review was conducted for BP-related adverse effects.

RESULTS

The BPs group presented significantly higher total periprosthetic BMD in the BPs group than that in the control group at 3, 6, 12 months, 2-4 years, and 5-10 years after arthroplasty (P < 0.05). The BPs group presented significantly higher periprosthetic BMD in femoral Gruen Zone 1 and 7 than that in the control group at 3, 6, 12 months, 2-4 years, and 5-10 years (P < 0.05). The heterogeneity was minimized by dividing THA and TKA into two subgroups. Subgroup analyses revealed that the effect of BPs on preservation of BMD was significantly greater in arthroplasty with cemented component than in that with uncemented component at 12 months and 5-10 years (P < 0.05), and the administration of the second and third generation BPs was significantly more effective than the first-generation BPs at 6 and 12 months (P < 0.05). None of the included studies described severe or fatal adverse effects related to BPs.

CONCLUSIONS

BPs have significantly long-term efficacy on the preservation of periprosthetic BMD after joint arthroplasty. To obtain a better efficacy, the cemented components and the second and third generation BPs are recommended.

Oral risedronate increases Gruen zone bone mineral density after primary total hip arthroplasty: a meta-analysis

BACKGROUND

This meta-analysis was performed to assess the efficacy of risedronate in increasing bone mineral density (BMD) in patients undergoing primary total hip arthroplasty (THA).

METHODS

We systematically searched the following databases: PubMed, Embase, Web of Science, Cochrane Library, and Chinese Wanfang database from inception up to October 2017. Included patients were prepared for THA and were separated into two groups: intervention group (risedronate treatment) and control group (placebo treatment). BMD change in Gruen zone 1 and 7 were primary outcomes. Meta-analysis was performed using Stata 12.0 software.

RESULTS

Five randomized controlled trials (RCTs) involving 259 patients (risedronate group = 127, control group = 132) were finally included in this meta-analysis. Meta-analysis indicated that oral risedronate significantly increased the BMD change in Gruen zone 1. However, there was little clinical significance between the risedronate and control group in terms of the Gruen zones 2, 3, and 7. Oral risedronate significantly increased the Harris hip scores compared with the control group (P < 0.05).

CONCLUSION

Oral risedronate could significantly reduce peri-prosthetic bone resorption around an uncemented femoral stem (Gruen zone 1) after THA. Due to the limited included studies, more high-quality randomized controlled trials (RCTs) were still needed to identify the efficacy of risedronate for bone loss in THA.

The efficiency of risedronate in reducing bone resorption after total hip arthroplasty: a meta-analysis of randomized control trials at a minimum of 6 months' follow-up

Background

Recently risedronate is suggested to be effective for the prevention and treatment of for osteoporosis in total hip arthroplasty. This meta-analysis aimes to evaluate the efficacy of risedronate in reducing femoral periprosthetic bone mineral density loss in patients undergoing primary total hip arthroplasty.

Methods

A systematic search was performed in Medline (1966-31 October 2017), PubMed (1966-31 October 2017), Embase (1980-31 October 2017), ScienceDirect (1985-31 October 2017) and the Cochrane Library. Only randomized controlled trial (RCT) were included. Fixed/random effect model was used according to the heterogeneity tested by I2 statistic. Meta-analysis was performed using Stata 11.0 software. The outcome measures included periprosthetic bone mineral density, length of stay and adverse effects.

Results

Four RCTs including 198 patients met the inclusion criteria. The present meta-analysis showed that there were significant differences between treatment groups in terms of periprosthetic bone mineral density in Gruen zones 1 (standard mean difference (SMD) = 0.758, 95% CI 0.469 to 1.047, P = 0.000), 2 (SMD = 0.814, 95% CI 0.523 to 1.106, P = 0.000), 3 (SMD = 0.340, 95% CI 0.059 to 0.622, P = 0.018), 6 (SMD = 2.400, 95% CI 2.029 to 2.771, P = 0.000), and 7 (SMD = 2.400, 95% CI 2.029 to 2.771, P = 0.000).

Conclusion

Oral risedronate could significantly reduce periprosthetic bone resorption around an uncemented femoral stem (Gruen zones 1, 2, 3, 6, and 7) up to 6 months after THA. In addition, no severe adverse events were identified. Future trials of risedronate treatment after THA should focus on clinically relevant end points such as the risks of fracture and revision arthroplasty.

Effect of risedronate on femoral periprosthetic bone loss following total hip replacement: A systematic review and meta-analysis

BACKGROUND

Recent study has reported that risedronate was effective in reducing periprosthesis bone loss after total hip arthroplasty (THA). The meta-analysis was performed to compare the clinical outcomes of THA with oral risedronate versus placebo.

METHODS

Electronic databases: PubMed (1950-March 2018), EMBASE (1974-March 2018), the Cochrane Central Register of Controlled Trials, Web of Science (1950-March 2018) were systematically searched. Two authors independently graded the methodological quality of each eligible study using the Cochrane Collaboration tool and extracted relevant data. Statistical heterogeneity among the trials were evaluated with chi-square and I-square tests. This meta-analysis was performed using STATA 14.0.

RESULTS

A total of 4 randomized controlled trials (RCTs) published between 2006 and 2015 were included in our study. The meta-analysis demonstrated that risedronate was associated with a significantly reduction of periprosthetic bone mineral density after THA. No increased postoperative complications were observed.

CONCLUSION

Oral risedronate might reduce the periprosthetic bone resorption after cementless THA. Additionally, no severe adverse effects were observed. High-quality RCTs with large sample size were still required.

Risedronate reduces postoperative bone resorption after cementless total hip arthroplasty: A systematic review and meta-analysis

OBJECTIVE

To examine the effects of risedronate for reducing periprosthetic bone loss after total hip arthroplasty (THA).

METHODS

Two reviewers performed an electronic literature search for randomized controlled trial (RCTs) evaluating the risedronate in the management of periprosthetic bone loss after primary THA. The electronic databases include PubMed, Medline, Embase, Web of Science and the Cochrane Library from inception to January 2018. We assessed the risk of bias using the Cochrane risk-of-bias tool. STATA 14.0 was used to perform the meta-analysis.

RESULTS

Four RCTs were included in our study. Current meta-analysis indicated that postoperative reduciton of periprosthetic BMD in the risedronate group was significantly lower than that in the placebo group in zones 1, 2, 3, 4, 6, and 7. There was no increased risk of adverse effects.

CONCLUSION

The administration of risedronate was associates with a significantly improved periprosthetic BMD after primary THA. No increased risk of adverse events were observed. Higher quality RCTs are still required for further research.

Efficacy of Alendronate for the Prevention of Bone Loss in Calcar Region Following Total Hip Arthroplasty

BACKGROUND

Bone mineral density (BMD) loss around femoral implants, particularly in the proximal femur, is a common outcome after total hip arthroplasty. Previous studies reported the prevention of postsurgical decrease in BMD with the use of osteoporosis drug therapy. This randomized study evaluated the efficacy of alendronate and alfacalcidol for preserving BMD over a long-term follow-up.

METHODS

Sixty consecutive patients with hip osteoarthritis who had undergone primary cementless total hip arthroplasty were randomly assigned to an alendronate (n = 20), alfacalcidol (n = 18), or control (n = 22) group. Periprosthetic BMD was measured using dual-energy X-ray absorptiometry at 1 week, 1 year, and the current follow-up (minimum 9 years after surgery). Changes in BMD are reported as mean percentages relative to the values at 1 week (baseline reference).

RESULTS

All groups showed a significant decrease in the BMD of the calcar at the current follow-up compared to the values at both 1 week and 1 year postoperatively (P < .001). The BMD values were significantly higher in the alendronate group than in the alfacalcidol and control groups (P < .05). The BMD values at the current follow-up were 76% ± 30% (alendronate group), 64% ± 22% (alfacalcidol group), and 59% ± 22% (control group) of the baseline values.

CONCLUSION

Our findings demonstrate the efficacy of early administration of alendronate for the prevention of bone loss in the calcar region.

[Periprosthetic fractures following total hip and knee arthroplasty: Risk factors, epidemiological aspects, diagnostics and classification systems]

Periprosthetic fractures following hip and knee arthroplasty are potentially severe complications. As a fundament in diagnostic and therapeutic procedures, specific classification systems are necessary to ensure an optimal individualized treatment of these sometimes complicated fractures. This review article summarizes the epidemiological aspects, risk factors and diagnostics of periprosthetic hip and knee fractures. The most frequently used location related fracture classifications systems are explained. In addition, the recently introduced unified classification system (UCS), which is applicable to any location of periprosthetic fractures, is described in detail. Initial studies have shown a reliable applicability of the UCS to periprosthetic hip and knee fractures.

Association of Bisphosphonate Use and Risk of Revision After THA: Outcomes From a US Total Joint Replacement Registry

BACKGROUND

Total hip arthroplasty (THA) is often performed in patients who are older and may take bisphosphonates to treat a variety of conditions, most commonly osteoporosis. However, the clinical effects of bisphosphonate use on patients who have undergone THA are not well described.

QUESTIONS/PURPOSES

(1) Is bisphosphonate use in patients with osteoarthritis undergoing primary THA associated with a change in the risk of all-cause revision, aseptic revision, or periprosthetic fracture compared with patients not treated with bisphosphonates? (2) Does the risk of bisphosphonate use and revision and periprosthetic fracture vary by patient bone mineral density and age?

METHODS

A retrospective cohort study of 12,878 THA recipients for the diagnosis of osteoarthritis was conducted; 17.8% of patients were bisphosphonate users. Data sources for this study included a joint replacement registry (93% voluntary participation) and electronic health records and an osteoporosis screening database with complete capture of cases as part of the Kaiser Permanente integrated healthcare system. The endpoints for this study were revision surgery for any cause, aseptic revision, and periprosthetic fracture. The exposure of interest was bisphosphonate use; patients were considered users if prescriptions were continuously refilled for a period equal to or longer than 6 months. Bone quality (based on dual-energy x-ray absorptiometery ordered based on the National Osteoporosis Foundation's clinical guidelines taken within 5 years of the THA) and patient age (< 65 versus ≥ 65 years) were evaluated as effect modifiers. Patient, surgeon, and hospital factors were evaluated as confounders. Cox proportional hazards models were used. Hazard ratios (HRs) and 95% confidence intervals (CIs) were determined.

RESULTS

Age- and sex-adjusted risks of all-cause (HR, 0.50; 95% CI, 0.33-0.74; p < 0.001) and aseptic revision (HR, 0.53; 95% CI, 0.34-0.81; p = 0.004) was lower in bisphosphonate users than in nonusers. The adjusted risk of periprosthetic fractures in patients on bisphosphonates was higher than in patients not on bisphosphonates (HR, 1.92; 95% CI, 1.13-3.27; p = 0.016). Lower risks of all-cause revision and aseptic revision were observed in patients with osteopenia (HR, 0.49; 95% CI, 0.29-0.84; and HR, 0.53; 95% CI, 0.29-0.99, respectively) and osteoporosis (HR, 0.22; 95% CI, 0.08-0.62; and HR, 0.33; 95% CI, 0.11-0.99, respectively).

CONCLUSIONS

Patients considered bisphosphonate users who underwent THA had a lower risk for revision surgery. Bisphosphonate use was associated with a higher risk of periprosthetic fractures in younger patients with normal bone quantity. Evaluation of bone quality and bisphosphonate use for the diagnosis of osteoporosis is encouraged in patients with osteoarthritis who are candidates for primary THA. Further research is required to determine the optimal duration of therapy because long-term bisphosphonate use has been associated with atypical femur fractures.

LEVEL OF EVIDENCE

Level III, therapeutic study.

No effect of risedronate on femoral periprosthetic bone loss following total hip arthroplasty. A 4-year follow-up of 61 patients in a double-blind, randomized placebo-controlled trial

BACKGROUND AND PURPOSE

We have previously shown that during the first 2 years after total hip arthroplasty (THA), periprosthetic bone resorption can be prevented by 6 months of risedronate therapy. This follow-up study investigated this effect at 4 years.

PATIENTS AND METHODS

A single-center, double-blind, randomized placebo-controlled trial was carried out from 2006 to 2010 in 73 patients with osteoarthritis of the hip who were scheduled to undergo THA. The patients were randomly assigned to receive either 35 mg risedronate or placebo orally, once a week, for 6 months postoperatively. The primary outcome was the percentage change in bone mineral density (BMD) in Gruen zones 1 and 7 in the proximal part of the femur at follow-up. Secondary outcomes included migration of the femoral stem and clinical outcome scores.

RESULTS

61 of the 73 patients participated in this 4-year (3.9- to 4.1-year) follow-up study. BMD was similar in the risedronate group (n = 30) and the placebo group (n = 31). The mean difference was -1.8% in zone 1 and 0.5% in zone 7. Migration of the femoral stem, the clinical outcome, and the frequency of adverse events were similar in the 2 groups.

INTERPRETATION

Although risedronate prevents periprosthetic bone loss postoperatively, a decrease in periprosthetic BMD accelerates when therapy is discontinued, and no effect is seen at 4 years. We do not recommend the use of risedronate following THA for osteoarthritis of the hip.

Effect of bisphosphonates in preventing femoral periprosthetic bone resorption after primary cementless total hip arthroplasty: a meta-analysis

Background

Bone loss leading to aseptic loosening of the prosthesis and periprosthetic fracture is a mode of failure in cementless total hip arthroplasty (THA). The aim of this meta-analysis was to evaluate the effect of bisphosphonates in preventing femoral periprosthetic bone resorption following primary cementless THA zone by zone.

Method

Clinical randomized controlled trials concerning bisphosphonates application after primary cementless THA published up to October 2014 were retrieved from PubMed, Cochrane library, and Embase databases. The methodological quality of the included studies was assessed by the Physiotherapy Evidence Database (PEDro) scale. Data analysis was performed using StataSE12.0.

Results

Ten randomized controlled trials involving a total of 502 patients were assessed; the bisphosphonates group included 256 patients and the control group included 246 patients. The meta-analysis showed that the bone mineral density (BMD) of most femoral periprosthetic zones in bisphosphonates group was significantly higher than that in the control group at 3 months postoperatively except zone 5 with no significant difference. At 6 and 12 months, the BMD of bisphosphonates group was much higher than that in control group except zone 5, which showed no statistical difference. The BMD of bisphosphonates group was persistently higher than control group in zone 6 and 7 at 5 years postoperatively, while the other zones had no significant difference. Both serum bone alkaline phosphatase and urinary type I collagen N-telopeptide were significantly suppressed by bisphosphonates at 3, 6, and 12 months.

Conclusion

Bisphosphonates seem to decrease early femoral periprosthetic bone resorption after primary cementless THA. Drug efficacy was found to be long-standing in the main load-bearing zones.

Effect of one-year post-operative alendronate treatment on periprosthetic bone after total knee arthroplasty

Total knee arthroplasty (TKA) is known to lead to a reduction in periprosthetic bone mineral density (BMD). In theory, this may lead to migration, instability and aseptic loosening of the prosthetic components. Bisphosphonates inhibit bone resorption and may reduce this loss in BMD. We hypothesised that treatment with bisphosphonates and calcium would lead to improved BMD and clinical outcomes compared with treatment with calcium supplementation alone following TKA. A total of 26 patients, (nine male and 17 female, mean age 67 years) were prospectively randomised into two study groups: alendronate and calcium (bisphosphonate group, n = 14) or calcium only (control group, n = 12). Dual energy X-ray absorptiometry (DEXA) measurements were performed post-operatively, and at three months, six months, one, two, four, and seven years post-operatively.

Mean femoral metaphyseal BMD was significantly higher in the bisphosphonate group compared with controls, up to four years following surgery in some areas of the femur (p = 0.045). BMD was observed to increase in the lateral tibial metaphysis in the bisphosphonate group until seven years (p = 0.002), and was significantly higher than that observed in the control group throughout (p = 0.024). There were no significant differences between the groups in the central femoral metaphyseal, tibial medial metaphyseal or diaphyseal regions of interest (ROI) of either the femur or tibia.

Bisphosphonate treatment after TKA may be of benefit for patients with poor bone quality. However, further studies with a larger number of patients are necessary to assess whether this is clinically beneficial.

Cite this article: Bone Joint J 2015;97-B:337–45.

Perioperative alendronate, risedronate, calcitonin and indomethacin treatment alters femoral stem fixation and periprosthetic bone mineral density in ovariectomized rats

BACKGROUND

Many factors affect implant stability and periprosthetic bone mineral density (BMD) following total joint arthroplasty. We asked whether perioperative alendronate, risedronate, calcitonin and indomethacine administration altered (1) femoral stem shear strength and periprosthetic bone mineral density BMD in ovariectomized rats and (2) whether there were differences in the effect of these drugs.

METHODS

Thirty overiectomized rats were divided into five groups and implanted with intramedullary mini-cortical screws in the femur. Four groups were treated with alendronate, risedronate, salmon calcitonin and indomethacin for 4 weeks preoperatively and 8 weeks postoperatively.

RESULTS

Although alendronate and risedronate increased the periprosthetic BMD more than calcitonin, they did not alter implant fixation compared to calcitonin. Indomethacin significantly decreased the BMD around the stem and implant stability compared to all other groups.

CONCLUSIONS

This study showed that perioperative treatment with bisphosphonates and calcitonin improved the BMD around the stems and implant stability. Although bisphosphonates increased the BMD more than calcitonin, there was no difference in implant stability. Indomethacin markedly decreased the periprosthetic BMD and implant stability. The main clinical significance of our study was the finding about the need to strictly avoid long-term use of high-dose nonsteroidal antiinflammatory drugs for patients who have major joint arthritis and a previous history of arthroplasty.

Risedronate does not enhance fixation or BMD in revision cups: randomised study with three years follow-up

BACKGROUND

Bisphosphonates may improve implant fixation by inhibition of bone resorption and stimulation of osteoblasts by up regulation of BMP-2. However, there are few clinical studies in this area.

QUESTIONS/PURPOSE

Does treatment with oral bisphosphonates improve implant fixation and bone remodelling around the acetabular component after revision arthroplasty with or without use of morselised allograft?

PATIENTS AND METHODS

Fifty-three patients received university pharmacy blinded medication for three months: 5 mg risedronate or placebo one dosage and 1 g calcium carbonate and 800IE cholecalciferol per day. Forty-one patients were operated upon with revision of the cup. The revisions were performed with an uncemented (Trilogy, Zimmer, Warsaw, USA) or a cemented (Ogee, Depuy Int, England) cup. Radiostereometric analysis was obtained within one week after the operation, at three and six months, and after one, two and three years to study cup migration. Bone mineral density was measured postoperatively, at six months, one and two years, using DEXA. The presence and extension of radiolucent lines and graft remodelling were studied on conventional radiography.

RESULTS

The risendronate group revealed less anterior-posterior rotation at 6 months. We found no significant differences in migration at three years, change in bone mineral density, or graft remodelling and radiolucent lines formation between groups.

CONCLUSIONS

We could not demonstrate any beneficial effects of oral administration of risedronate on the fixation, bone mineral density or bone remodelling of revision cups using various amount of bone graft.

The effectiveness of mono or combined osteoporosis drug therapy against bone mineral density loss around femoral implants after total hip arthroplasty

Several previous studies have reported that bone mineral density (BMD) loss around femoral implants is a common outcome, particularly in the proximal femur, after total hip arthroplasty (THA). The purpose of this study was to investigate the effectiveness of alendronate monotherapy and combined therapy using alendronate and alfacalcidol for BMD preservation around femoral implants after primary THA. This study series included 60 patients who were classified into monotherapy (alendronate alone) (n = 18), combined-therapy (alendronate and alfacalcidol) (n = 20) or non-medication (n = 22) groups. The periprosthetic BMD and profile of the biochemical markers such as bone-specific alkaline phosphatase and serum N-terminal telopeptides of type-1 collagen (NTX) were measured at 1, 12, 24 and 48 weeks after surgery. The BMD values in the region of the calcar of monotherapy and combined-therapy patients were maintained and were significantly higher than those of non-medication patients at each measurement period. The plasma levels of NTX in the monotherapy and combined-therapy groups were found to be significantly lower than those in the non-medication group at each measurement period. In conclusion, the monotherapy and combined-therapy regimens significantly prevent periprosthetic BMD loss around femoral implants, most notably in the calcar, compared to no medication.

Systematic analysis of bisphosphonate intervention on periprosthetic BMD as a function of stem design

The purpose of this study was to determine the effects of bisphosphonates periprosthetic BMD in THA patients as a function of stem design. Specifically, the goals were to determine if bisphosphonates as a group could significantly inhibit periprosthetic bone loss, time needed to see an effect, if one drug was more effective than the others, and if there was a difference due to stem design or cement. Thirteen articles met the inclusion criteria. Overall, groups treated with bisphosphonate therapy preserved significantly more BMD than the control groups as early as six months postoperatively, and orally delivered bisphosphonates were most effective. Furthermore, the biggest differences were in patients with non-cemented stems, and of those, the largest differences were seen in patients with fully coated CoCr stems.

Pharmacologic augmentation of implant fixation in osteopenic bone

Osteoporosis presents a challenge for successful implant fixation due to an impaired healing response. Preclinical studies have consistently reported reduced osseointegration capability in trabecular bone. Although clinical studies of implant success in dentistry have not found a negative effect due to osteoporosis, low bone mass is a significant risk factor for implant migration in orthopedics. Pharmacologic treatment options that limit bone resorption or upregulate formation have been studied preclinically. While, both treatment options improve implant fixation, direct comparisons to-date have found anti-catabolic more effective than anabolic treatments for establishing implant fixation, but combination approaches are better than either treatment alone. Clinically, anti-catabolic treatments, particularly bisphosphonates have been shown to increase the longevity of implants, while limited clinical evidence on the effects of anabolic treatment exists. Preclinical experiments are needed to determine the effects of osteoporosis and subsequent treatment on the long-term maintenance of fixation and recovery after bone loss.

A meta-analysis of bisphosphonates for periprosthetic bone loss after total joint arthroplasty

BACKGROUND

Periprosthetic bone loss, which is common after joint arthroplasty, may cause bone loosening and lead to failed prosthetic fixation. Two previous meta-analyses have confirmed the mid-term effect of bisphosphonates (BPs) in preventing bone loss after arthroplasty. To determine long-term efficacy and gender bias of BPs after joint arthroplasty, we conducted a meta-analysis based on 17 RCTs involving 781 patients to evaluate the effect of BPs.

METHODS

Meta-analysis was conducted after a systematic search of Medline, Embase, the Cochrane Collaboration Central Register of Controlled Clinical Trials, CINAHL, and ISI Web of Science, and manual examination of references in selected articles and conference abstracts of key orthopedic journals. Methodological quality and abstracted relevant data were evaluated. In addition to analysis of bone mineral density (BMD), we also conducted systematic analysis of clinically relevant outcomes and bone biochemical markers.

RESULTS

Seventeen trials involving a total of 781 patients were assessed. Significantly less periprosthetic bone loss occurred in the BP-treated group than in the control group at 6 and 12 months (p < 0.0001). This protective effect was not noted at 3 months (p = 0.11) nor from 24-72 months (p = 0.14). The efficacy of BPs in the gender balance, shorter duration, and the non-nitrogenous BPs groups was no different from that for controls. Biochemical bone markers were suppressed in the BPs group. However, clinically relevant outcomes in the BPs group and controls were similar at all times.

CONCLUSIONS

The overall moderate-quality evidence from the RCTs confirmed the significant mid-term efficacy of BPs on periprosthetic bone loss after joint arthroplasty. Long-term efficacy of BPs was not observed, and the therapy was of more benefit to women, especially postmenopausal women. To achieve better efficacy, nitrogenous BPs and long duration of treatment may be recommended.

Effect of zoledronic acid on reducing femoral bone mineral density loss following total hip arthroplasty: preliminary results of a prospective randomized trial

This randomized trial evaluated the effect of zoledronic acid on femoral bone mineral density (BMD) following primary total hip arthroplasty. Bone mineral density was compared for up to 2years in 27 patients receiving 5mg zoledronic acid intravenous infusion and in 24 patients receiving placebo at 2weeks and 1year after surgery. Zoledronic acid prevented loss of bone mineral density at 1year (+13.8% vs +1.4%, P=.0065) and 2years (+14.3% vs -4.0%, P<.0001) in Gruen zone 1, at 1year (-8.4% vs -25.4%, P<.0001) and 2years (-9.6% vs -27.3%, P<.0001) in Gruen zone 7, at 6weeks, 6months, and 1 or 2years in Gruen zones 4 and 6. For all Gruen zones, prevention of BMD loss by ZOL was significant at 6weeks, 6months, 1year (+0.80% vs -6.03%, P<.0001) and 2years (-0.16% vs -7.13%, P<.0001).

Bisphosphonates for periprosthetic bone loss after joint arthroplasty: a meta-analysis of 14 randomized controlled trials

The present meta-analysis aimed to evaluate the middle-term efficacy of bisphosphonates on maintaining periprosthetic bone mass after joint arthroplasty and the potential influential factors. It was found that the protective effect of bisphosphonates, probably modified by its generation and the prosthesis location, could persist in a middle-term follow-up after surgery and after drug discontinuation.

INTRODUCTION

A previous meta-analysis of 6 RCTs with follow-up of 12 months suggested that bisphosphonates (BPs) could prevent bone loss after arthroplasty up to 6 months. Our meta-analysis based on 14 RCTs involving 671 patients with follow-up up to 72 months aimed to evaluate the middle-term efficacy of BPs, understand the sources of heterogeneity, and comprehensively identify the potential influential factors.

METHODS

Electronic databases searching and hand searching of conference proceedings were conducted. We evaluated the methodological quality and abstracted relevant data. With fixed effect model we calculated the weighted mean differences to evaluate bone mineral density at different time points. We also conducted a systematic review for BP-related adverse effects.

RESULTS

The significantly less periprosthetic bone loss occurred in the BP-treated group than in the control group at 3, 6, and 12 months, and between 24 and 72 months after the index surgery. The protective effect persisted during 18 to 70 months after discontinuation of BPs. The heterogeneity was minimized with the separation of hip and knee trials during the analysis. The efficacy was more potent for the second and the third generation of BPs than the first generation. None of the trials noted serious or fatal adverse effects related to BPs.

CONCLUSIONS

The overall moderate evidence from the RCTs confirmed the significantly short-term and middle-term efficacy of BPs on periprosthetic bone loss after joint arthroplasty. To obtain a better efficacy, the second and the third generation of BPs may be the choice.

The effect of weekly risedronate on periprosthetic bone resorption following total hip arthroplasty: a randomized, double-blind, placebo-controlled trial

BACKGROUND

Bone loss leading to late-occurring periprosthetic femoral fracture is a mode of failure in cementless total hip arthroplasty. The aim of this trial was to investigate the effect of a bisphosphonate, risedronate, on femoral periprosthetic bone resorption following total hip arthroplasty in patients with osteoarthritis of the hip.

METHODS

We enrolled seventy-three patients between the ages of forty and seventy years who were scheduled to undergo total hip arthroplasty in a single-center, randomized, double-blind, placebo-controlled trial. Subjects were randomly assigned to receive either 35 mg of risedronate (n = 36) or a placebo (n = 37) orally once weekly for six months. The primary end point was the change in bone mineral density in Gruen femoral zones 1 and 7. Bone mineral density scans were made preoperatively and at two days and three, six, twelve, and twenty-four months postoperatively. Secondary end points included migration of the femoral stem and clinical outcome.

RESULTS

Seventy of the seventy-three patients (thirty-three in the risedronate group and thirty-seven in the placebo group) were analyzed for the primary end point. The mean bone mineral density in zone 1 was 9.2% higher (95% confidence interval [CI], 4.2% to 14.1%) in the risedronate group than in the placebo group at six months postoperatively and 7.2% higher (95% CI, 1.0% to 13.3%) at one year. The mean bone mineral density in zone 7 was 8.0% higher (95% CI, 2.7% to 13.4%) in the risedronate group than in the placebo group at six months postoperatively and 4.3% higher (95% CI, -1.5% to 10.1%) at one year. Migration of the femoral stem, the clinical outcome, and the frequency of adverse events did not differ between the groups.

CONCLUSIONS

Risedronate taken once weekly for six months following total hip arthroplasty was effective in reducing periprosthetic bone resorption around an uncemented femoral stem up to one year after surgery but had no discernible effect on implant migration or clinical outcome. Future studies of bisphosphonate treatment following total hip arthroplasty should focus on clinically relevant end points such as the risks of fracture and revision arthroplasty.

A comparison of the effects of alendronate and alfacalcidol on bone mineral density around the femoral implant and in the lumbar spine after total hip arthroplasty

BACKGROUND

Several previous studies have demonstrated that bone mineral density loss around femoral implants is common, particularly in the proximal part of the femur, soon after total hip arthroplasty. The purpose of the present study was to compare the effects of alendronate and alfacalcidol on bone mineral density loss around the femoral implant and in the lumbar spine after total hip arthroplasty.

METHODS

The present study included sixty patients with osteoarthritis of the hip who had undergone a primary cementless total hip arthroplasty. We assigned these individuals to treatment with alendronate (n = 20), alfacalcidol (n = 18), or no medication (n = 22). Periprosthetic and lumbar spine bone mineral density was measured one week after surgery, and biochemical markers (bone-specific alkaline phosphatase and serum N-terminal telopeptides of type-1 collagen) were measured before surgery as a reference baseline. Subsequent measurements were performed at twelve, twenty-four, and forty-eight weeks after surgery. The periprosthetic measurement area in the femur was defined as Regions 1 to 7, which are consecutively located around the implant from the greater trochanter to the lesser trochanter and calcar.

RESULTS

Bone mineral density in the alendronate group was maintained in all regions. In the alfacalcidol and no-medication groups, bone mineral density in Region 7 was lower than in Regions 3 to 6 throughout the study period (p < 0.0001 as a result of repeated measures analysis of variance). Bone mineral density in the lumbar spine in the alendronate and alfacalcidol groups was higher than in the no-medication group at forty-eight weeks. The serum level of N-terminal telopeptides of type-1 collagen in the alendronate group was lower than that in the no-medication group throughout the study period (p = 0.003, 0.02 and 0.005).

CONCLUSIONS

Alendronate prevented bone mineral density loss around femoral implants, particularly in Region 7 (calcar), but alfacalcidol did not show any effects in any regions. However, bone mineral density losses in the lumbar spine were effectively prevented by either alendronate or alfacalcidol.

Risedronate does not reduce mechanical loading-related increases in cortical and trabecular bone mass in mice

To establish whether the combination of anti-resorptive therapy with mechanical loading has a negative, additive or synergistic effect on bone structure, we assessed the separate and combined effects of risedronate and non-invasive dynamic loading on trabecular and cortical bone. Seventeen-week-old female C57BL/6 mice were given daily subcutaneous injections of vehicle (n=20) or risedronate at a dose of 0.15, 1.5, 15 or 150 μg/kg/day (n=10 in each) for 17 days. From the fourth day of treatment, the right tibiae were subjected to a single period of axial loading (40 cycles/day) for three alternate days per week for two weeks. The left tibiae were used as internal controls. Trabecular and cortical sites in the tibiae were analyzed by high-resolution micro-computed tomography and imaging of fluorochrome labels. In the non-loaded tibiae, treatment with the higher doses of risedronate at 15 or 150 μg/kg/day resulted in higher trabecular bone volume and trabecular number than in vehicle-treated controls, whereas such treatment was associated with no differences in cortical bone volume at any dose. In the loaded tibiae, loading induced increases in trabecular and cortical bone volume compared with contra-lateral controls primarily through increased trabecular thickness and periosteal expansion, respectively, independently of risedronate treatment. In conclusion, the response to mechanical loading in both trabecular and cortical bone in mice is therefore not impaired by short-term treatment with risedronate, even over a 1000-fold dose range. In considering the optimization of treatments for osteoporosis, it is reassuring that anti-resorptive therapy and mechanical loading can exert independent beneficial effects.

A systematic review assessing the effectiveness of alendronate in reducing periprosthetic bone loss after cementless primary THA

Periprosthetic bone loss, especially in the proximal part of the femur, is common after cementless total hip arthroplasty (THA). To determine the short- and long-term effect of alendronate on periprosthetic bone mineral density after THA, we conducted computerized searches for randomized, controlled trials evaluating the use of alendronate in patients treated with cementless primary THA. A review of PubMed, the Cochrane Central Register of Controlled Trials, Web of Science, and Embase from their inception to May 2010 was completed, and we assessed methodological quality and abstracted relevant data. Of 310 citations that were initially identified, 5 studies assessing 146 patients were reviewed. Those studies showed that significantly less periprosthetic bone loss had occurred in the alendronate-treated group than in the placebo-treated group during the short-term period after THA. For long-term investigation, the studies reported that the periprosthetic bone density was a bit higher in the alendronate-treated group compared to the placebo-treated group, but the differences did not reach statistical significance.This systematic review suggests that alendronate has a beneficial effect with regard to preservation of periprosthetic bone short-term after cementless THA. However, the studies could not provide enough evidence that the positive effect noted in the early postoperative period is maintained long-term. A longer follow-up with a larger number of participants is needed to confirm the outcome of cementless THA patients treated with alendronate.

Decreased periprosthetic bone loss in patients treated with clodronate: a 1-year randomized controlled study

The efficacy of clodronate to reduce bone loss around uncemented stems after total hip arthroplasty(THA) was evaluated. Ninety-one patients operated with uncemented THA were randomized to receive either intramuscular clodronate at a dose of 100 mg weekly for 12 months or no treatment. Periprosthetic and contralateral bone mineral density (BMD) scans were performed and biochemical markers of bone turnover measured at baseline and at 3, 6, and 12 months. At month 12, with the exception of Gruen zones 4 and 5, patients treated with clodronate showed less bone loss at all zones, reaching statistical significance (P\0.05) in Gruen zones 2 and 6 (difference of 6.6 and 5.9%, respectively). Analysis of data according to gender revealed sex-related differences in bone loss and efficacy of treatment. After 12 months, the difference in bone loss between treated and untreated women in five out of seven Gruen zones ranged from 6.2 to 13.3% (SS at zones 2 and 6), whereas comparison between treated and untreated men showed no BMD differences in all zones(P[0.05). Median percent changes in serum levels of markers of bone metabolism by gender were consistent with BMD changes. A 1-year treatment with intramuscular clodronate determined a significant reduction of bone loss after THA. This was mainly attributed to its greater efficacy in the female population, which is at higher risk for bone loss. This observation suggests the need for the characterization of high-risk subjects as potential candidates for prevention strategies.

Postoperative use of bisphosphonates and risk of revision after primary total hip arthroplasty: a nationwide population-based study

BACKGROUND

Recently, bisphosphonates have been linked with mechanisms that may influence longevity of orthopedic implants. We therefore evaluated the association between the use of bisphosphonates and the risk of revision after primary total hip arthroplasty (THA).

METHODS

We conducted a nationwide population-based nested case-control study using medical databases in Denmark. From the Danish Hip Arthroplasty Register (DHR) we included primary THA patients diagnosed with either osteoporosis or a previous osteoporotic fracture (n=16,145). Among these patients we identified 632 cases that were revised after primary THA in the period 1995-2006. The cases were matched on gender, age and year of primary THA surgery with 1262 non-revised osteoporotic THA controls. Using conditional logistic regression we estimated the risk of revision due to all causes and due to specific causes according to postoperative bisphosphonate use.

RESULTS

The 10-year cumulated implant revision rate in the underlying cohort of 16,145 primary THA procedures among osteoporotic patients was 8.3% (95% confidence interval (CI): 7.3-9.3). The use of bisphosphonates was associated with an adjusted relative risk of revision due to deep infections of 2.59 (95% CI; 1.30-6.53). Further, the duration of bisphosphonates use up to 120days, 120 and 240days, and more than 240days was associated with adjusted relative risks of revision due to all causes of 2.77 (95% CI; 1.65-4.64), 1.33 (95% CI; 0.63-2.72), and 0.58 (95% CI; 0.32-1.05) respectively.

CONCLUSIONS

The use of bisphosphonates following primary THA was associated with an increased risk of revision due to deep infection. However, long-term use was associated with a reduced risk of revision of any type. Further research is warranted in order to clarify whether these associations are truly causal.

Changes of femoral periprosthetic bone mineral density 6 years after treatment with alendronate following total hip arthroplasty

Earlier osteodensitometric results of femoral periprosthetic bone showed that postoperative antiresorptive treatment with alendronate following total hip arthroplasty (THA) reduces the periprosthetic bone loss that commonly occurs in the first months after surgery. However, whether alendronate can prevent periprosthetic bone loss over the long term, or if bone loss occurs after discontinuing alendronate is unknown. Femoral periprosthetic bone mineral density (BMD) was assessed in 49 patients 6 years after cementless total hip arthroplasty using dual energy X-ray absorptiometry. Twenty-nine patients were treated postoperatively with alendronate and 20 control patients received no treatment. All patients were followed up at 12 months after surgery in a prospective randomized study. The bone mineral density was evaluated in 7 regions of interest according to the Gruen protocol. Six years after total hip arthroplasty, no significant changes were detected in femoral periprosthetic BMD when compared with results at 1 year, and the bone loss in patients with postoperative alendronate treatment was still significantly less than those without treatment. These results suggest that the prevention of femoral periprosthetic bone loss following THA achieved by postoperative antiresorptive treatment with alendronate is of long-standing effect, and further bone loss does not occur after the first postoperative year.

Bisphosphonates: mechanism of action and role in clinical practice

Bisphosphonates are primary agents in the current pharmacological arsenal against osteoclast-mediated bone loss due to osteoporosis, Paget disease of bone, malignancies metastatic to bone, multiple myeloma, and hypercalcemia of malignancy. In addition to currently approved uses, bisphosphonates are commonly prescribed for prevention and treatment of a variety of other skeletal conditions, such as low bone density and osteogenesis imperfecta. However, the recent recognition that bisphosphonate use is associated with pathologic conditions including osteonecrosis of the jaw has sharpened the level of scrutiny of the current widespread use of bisphosphonate therapy. Using the key words bisphosphonate and clinical practice in a PubMed literature search from January 1, 1998, to May 1, 2008, we review current understanding of the mechanisms by which bisphosphonates exert their effects on osteoclasts, discuss the role of bisphosphonates in clinical practice, and highlight some areas of concern associated with bisphosphonate use.