Teriparatide Versus Alendronate for the Preservation of Bone Mineral Density After Total Hip Arthroplasty - A randomized Controlled Trial

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.

Preoperative prediction for periprosthetic bone loss and individual evaluation of bisphosphonate effect after total hip arthroplasty using artificial intelligence

Aims

This study was designed to develop a model for predicting bone mineral density (BMD) loss of the femur after total hip arthroplasty (THA) using artificial intelligence (AI), and to identify factors that influence the prediction. Additionally, we virtually examined the efficacy of administration of bisphosphonate for cases with severe BMD loss based on the predictive model.

Methods

The study included 538 joints that underwent primary THA. The patients were divided into groups using unsupervised time series clustering for five-year BMD loss of Gruen zone 7 postoperatively, and a machine-learning model to predict the BMD loss was developed. Additionally, the predictor for BMD loss was extracted using SHapley Additive exPlanations (SHAP). The patient-specific efficacy of bisphosphonate, which is the most important categorical predictor for BMD loss, was examined by calculating the change in predictive probability when hypothetically switching between the inclusion and exclusion of bisphosphonate.

Results

Time series clustering allowed us to divide the patients into two groups, and the predictive factors were identified including patient- and operation-related factors. The area under the receiver operating characteristic (ROC) curve (AUC) for the BMD loss prediction averaged 0.734. Virtual administration of bisphosphonate showed on average 14% efficacy in preventing BMD loss of zone 7. Additionally, stem types and preoperative triglyceride (TG), creatinine (Cr), estimated glomerular filtration rate (eGFR), and creatine kinase (CK) showed significant association with the estimated patient-specific efficacy of bisphosphonate.

Conclusion

Periprosthetic BMD loss after THA is predictable based on patient- and operation-related factors, and optimal prescription of bisphosphonate based on the prediction may prevent BMD loss.

Anti-osteoporotic drug efficacy for periprosthetic bone loss after total hip arthroplasty: A systematic review and network meta-analysis

BACKGROUND

Periprosthetic bone loss following total hip arthroplasty (THA) threatens prosthesis stability. This systematic review and network meta-analysis aimed to compare the efficacy of anti-osteoporotic drugs for measures of hip function according to functional outcomes, periprosthetic femoral bone mineral density loss in each Gruen zone, and revision surgery after THA.

METHODS

The systematic search of six literature databases was conducted in December 2021 in accordance with PRISMA guidelines. Adult participants who underwent primary THA were included. A random-effects network meta-analysis was performed within a frequentist framework, and the confidence in the evidence for each outcome was evaluated using the CINeMA tool, which assessed the credibility of results from the network meta-analysis. We included 22 randomized controlled trials (1243 participants) comparing the efficacy and safety of bisphosphonates (including etidronate, clodronate, alendronate, risedronate, pamidronate, and zoledronate), denosumab, selective estrogen receptor modulator, teriparatide, calcium + vitamin D, calcium, and vitamin D. We defined the period for revision surgery as the final follow-up period.

RESULTS

Raloxifene, bisphosphonate, calcium + vitamin D, and denosumab for prosthetic hip function might have minimal differences when compared with placebos. The magnitude of the anti-osteoporotic drug effect on periprosthetic femoral bone loss varied across different Gruen zones. Bisphosphonate, denosumab, teriparatide might be more effective than placebo in Gruen zone 1 at 12 months after THA. Additionally, bisphosphonate might be more effective than placebo in Gruen zones 2, 5, 6, and 7 at 12 months after THA. Denosumab was efficacious in preventing bone loss in Gruen zones 6 and 7 at 12 months after THA. Teriparatide was likely to be efficacious in preventing bone loss in Gruen zone 7 at 12 months after THA. Raloxifene was slightly efficacious in preventing bone loss in Gruen zones 2 and 3 at 12 months after THA. Calcium was slightly efficacious in preventing bone loss in Gruen zone 5 at 12 months after THA. None of the studies reported revision surgery.

CONCLUSIONS

Bisphosphonate and denosumab may be effective anti-osteoporotic drugs for preventing periprosthetic proximal femoral bone loss due to stress shielding after THA, particularly in cementless proximal fixation stems, which are the most commonly used prostheses worldwide.

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.

Potential effects of teriparatide (PTH (1-34)) on osteoarthritis: a systematic review

Osteoarthritis (OA) is a common and prevalent degenerative joint disease characterized by degradation of the articular cartilage. However, none of disease-modifying OA drugs is approved currently. Teriparatide (PTH (1-34)) might stimulate chondrocyte proliferation and cartilage regeneration via some uncertain mechanisms. Relevant therapies of PTH (1-34) on OA with such effects have recently gained increasing interest, but have not become widespread practice. Thus, we launch this systematic review (SR) to update the latest evidence accordingly. A comprehensive literature search was conducted in PubMed, Web of Science, MEDLINE, the Cochrane Library, and Embase from their inception to February 2022. Studies investigating the effects of the PTH (1-34) on OA were obtained. The quality assessment and descriptive summary were made of all included studies. Overall, 307 records were identified, and 33 studies were included. In vivo studies (n = 22) concluded that PTH (1-34) slowed progression of OA by alleviating cartilage degeneration and aberrant remodeling of subchondral bone (SCB). Moreover, PTH (1-34) exhibited repair of cartilage and SCB, analgesic, and anti-inflammatory effects. In vitro studies (n = 11) concluded that PTH (1-34) was important for chondrocytes via increasing the proliferation and matrix synthesis but preventing apoptosis or hypertrophy. All included studies were assessed with low or unclear risk of bias in methodological quality. The SR demonstrated that PTH (1-34) could alleviate the progression of OA. Moreover, PTH (1-34) had beneficial effects on osteoporotic OA (OPOA) models, which might be a therapeutic option for OA and OPOA treatment.

The prevalence and treatment of osteoporosis in patients undergoing total hip arthroplasty and the levels of biochemical markers of bone turnover

AIMS

Osteoporosis is common in total hip arthroplasty (THA) patients. It plays a substantial factor in the surgery's outcome, and previous studies have revealed that pharmacological treatment for osteoporosis influences implant survival rate. The purpose of this study was to examine the prevalence of and treatment rates for osteoporosis prior to THA, and to explore differences in osteoporosis-related biomarkers between patients treated and untreated for osteoporosis.

METHODS

This single-centre retrospective study included 398 hip joints of patients who underwent THA. Using medical records, we examined preoperative bone mineral density measures of the hip and lumbar spine using dual energy X-ray absorptiometry (DXA) scans and the medications used to treat osteoporosis at the time of admission. We also assessed the following osteoporosis-related biomarkers: tartrate-resistant acid phosphatase 5b (TRACP-5b); total procollagen type 1 amino-terminal propeptide (total P1NP); intact parathyroid hormone; and homocysteine.

RESULTS

The prevalence of DXA-proven hip osteoporosis (T-score ≤ -2.5) among THA patients was 8.8% (35 of 398). The spinal osteoporosis prevalence rate was 4.5% (18 of 398), and 244 patients (61.3%; 244 of 398) had osteopenia (-2.5 < T-score ≤ -1) or osteoporosis of either the hip or spine. The rate of pharmacological osteoporosis treatment was 22.1% (88 of 398). TRACP-5b was significantly lower in the osteoporosis-treated group than in the untreated group (p < 0.001).

CONCLUSION

Osteoporosis is common in patients undergoing THA, but the diagnosis and treatment for osteoporosis were insufficient. The lower TRACP-5b levels in the osteoporosis-treated group - that is, osteoclast suppression - may contribute to the reduction of the postoperative revision rate after THA.Cite this article: Bone Joint Res 2022;11(12):873-880.

Effects of denosumab treatment on the expression of receptor activator of nuclear kappa-B ligand (RANKL) and TNF-receptor TNFRSF9 after total hip arthroplasty-results from a randomized placebo-controlled clinical trial

We investigated whether the drug denosumab modulates the inflammatory response after total hip arthroplasty in a randomized controlled trial. Significantly increased expression of RANKL was found in patients treated with denosumab. This could provide an explanation for the rebound effect with rapid loss of BMD seen after discontinuation of denosumab treatment.

PURPOSE

To evaluate whether denosumab, a human monoclonal antibody directed against receptor activator of nuclear factor kappa-B ligand (RANKL), modulates the inflammatory response after cementless total hip arthroplasty (THA) in patients with osteoarthritis of the hip.

METHODS

Sixty-four patients operated with cementless THA were randomized to two doses of 60-mg denosumab or placebo 1-3 days and 6 months postoperatively. Serum samples were analyzed by a multiplex extension assay detecting 92 inflammation-related proteins. Bone turnover markers were assessed. Proteins were analyzed using linear mixed effect models. Validation of conspicuous findings was performed with ELISA.

RESULTS

Two proteins were significantly affected by denosumab treatment: RANKL and tumor necrosis factor receptor super family member 9 (TNFRSF9). Serum levels of RANKL were more than twice as high in the denosumab than in the placebo group 3 months after surgery (ratio 2.10, p<0.001). Six and 12 months after surgery, the expression of RANKL was still elevated in the denosumab-treated group (ratios 1.50, p < 0.001; 1.47, p =0.002). The expression of TNFRSF9 was lower in the denosumab group at 3 months (ratio 0.68, p<0.001). In the denosumab group, concentrations of bone turnover markers were substantially reduced after 3 months, remained suppressed after 6 and 12 months, but increased above baseline at 24 months after surgery.

CONCLUSION

Two subcutaneous denosumab injections 6 months apart increase RANKL and depress TNFRSF9 after THA. This provides a possible explanation for the rebound effect on bone turnover markers as well as bone mineral density (BMD) upon withdrawal of denosumab. None of the other measured markers of inflammation was influenced by denosumab treatment.

Total Joint Arthroplasty and Osteoporosis: Looking Beyond the Joint to Bone Health

BACKGROUND

Metabolic bone diseases in the total joint arthroplasty (TJA) population are undertested and undertreated, leading to increased risk of adverse outcomes such as periprosthetic fractures. This study aims to better characterize the current state of bone care in TJA patients using Fracture Risk Assessment Tool (FRAX) score risk stratifications.

METHODS

In total, 505 consecutive TJA patients who meet the Endocrine Society guidelines for osteoporosis screening were included for review. They were divided into a high risk or low risk group depending on FRAX scores and were compared based on screening, diagnosis, and treatment of metabolic bone disease. Logistic regression models were used to analyze factors influencing screening and treatment. A population analysis involving 2,000 TJA patients, and a complication analysis involving 40 periprosthetic fracture patients were conducted.

RESULTS

Among high risk patients undergoing TJA, 90% did not receive any pharmacological treatment for osteoporosis, 45% were not treated with vitamin D or calcium, and 88% did not receive bone density testing in the routine care period. Among patients with pre-existing osteoporosis undergoing TJA, 80% were not treated with any osteoporosis medications and 33% of these patients were not taking vitamin D or calcium. Female gender and past fracture history contributed to whether patients received screening and treatment. Patients with periprosthetic hip fractures have significantly higher FRAX scores compared to control THA patients.

CONCLUSION

There are significant gaps in metabolic bone care of the geriatric TJA population regarding both screening and treatment. Metabolic bone care and risk identification with FRAX should be highly considered for TJA patients.

Effect of implant composition on periprosthetic bone mineral density after total hip arthroplasty

BACKGROUND

The severity of bone mineral density (BMD) loss after total hip arthroplasty (THA) depends on both implant- and patient-related factors. While implant fixation type is an important factor, but few studies have considered the effect of material composition on the same implant fixation type. In particular, differences in mechanical stiffness due to material composition are of great interest. Here, we compared changes in periprosthetic BMD after THA using proximal fixation concept stems comprising different titanium alloys, i.e., β titanium alloys stem and α + β titanium alloys stem.

METHODS

This retrospective cohort included 122 patients (β titanium alloys stem, 61 cases; α + β titanium alloys stem, 61 cases) who underwent primary THA between January 2009 and December 2019. The primary outcome was the change in periprosthetic BMD from base line. Age, body mass index, diagnosis, stem size, canal flare index, surgical approach, pre-operative lumbar BMD, and pre-operative activity scores were reviewed and changes in periprosthetic BMD between the two groups were compared using analysis of covariance. The secondary outcome was radiographic response after THA.

RESULTS

There was significant difference in periprosthetic BMD in zone 6 and 7 at 2 years (p < 0.05) between the two groups. There was no significant difference in other zones. A significant difference in radiographic response was noted only for the Engh classification.

CONCLUSION

α + β titanium alloys stem resulted in a significantly higher rate of BMD loss in zones 6 and 7 compared with the β titanium alloys stem. These results may be due to differences in mechanical stiffness due to the different titanium alloy composition of the prosthetics.

The Diagnosis and Treatment of Acetabular Bone Loss in Revision Hip Arthroplasty: An International Consensus Symposium

Despite growing evidence supporting the evaluation, classification, and treatment of acetabular bone loss in revision hip replacement, advancements have not been systematically incorporated into a single document, and therefore, a comprehensive review of the treatment of severe acetabular bone loss is needed. The Stavros Niarchos Foundation Complex Joint Reconstruction Center at Hospital for Special Surgery held an Acetabular Bone Loss Symposium on June 21, 2019, to answer the following questions: What are the trends, emerging technologies, and areas of future research related to the evaluation and management of acetabular bone loss in revision hip replacement? What constitutes the optimal workup and management strategies for acetabular bone loss? The 36 international experts convened were divided into groups, each assigned to discuss 1 of 4 topics: (1) preoperative planning and postoperative assessment; (2) implant selection, management of osteolysis, and management of massive bone loss; (3) the treatment challenges of pelvic discontinuity, periprosthetic joint infection, instability, and poor bone biology; and (4) the principles of reconstruction and classification of acetabular bone loss. Each group came to consensus, when possible, based on an extensive literature review. This document provides an overview of these 4 areas, the consensus each group arrived at, and directions for future research.

Zoledronic Acid for Periprosthetic Bone Mineral Density Changes in Patients With Osteoporosis After Hip Arthroplasty-An Updated Meta-Analysis of Six Randomized Controlled Trials

Introduction: Periprosthetic bone mineral density (BMD) loss following total hip arthroplasty (THA) may threaten the survival of the implant, especially in patients with osteoporosis. Zoledronic acid (ZA) is the representative of the third generation of bisphosphonates, which were effective in reducing bone loss in conditions associated with accelerated bone turnover. The aim of this study was to evaluate the efficacy and safety of ZA in patients with osteoporosis after THA. Methods: Randomized controlled trials (RCTs) associated with ZA and THA were searched from the MEDLINE, PubMed, EMBASE, Wanfang database, and the Web of Science (August 2021). Other methods, such as hand search and email request were also tried. The methodological quality was assessed by the Risk of Bias (RoB) 2.0. Relevant data were abstracted from the included RCTs and authors were contacted when necessary. Results: In this study, six RCTs involving a total of 307 patients were finally included and analyzed. The pooled data demonstrated that significantly less periprosthetic BMD loss in Gruen zone seven had occurred in the ZA-treated patients than in the control patients at 3 months (mean difference [MD] = 4.03%; 95% CI: 0.29-7.76%; P = 0.03), 6 months (MD = 7.04%; 95% CI: 2.12-11.96%; P = 0.005), and 12 months (MD = 7.12%; 95% CI: 0.33-13.92%; P = 0.04). The Harris Hip Score (HHS) was also significantly increased in ZA group at 6 and 12 months after operation (P = 0.03 and P = 0.02, respectively). Influenza-like symptom was found related to the usage of ZA [relative risk (RR) = 7.03, P < 0.0001]. Conclusion: A meta-analysis of six RCTs suggested that ZA was beneficial in maintaining the periprosthetic BMD in patients with osteoporosis at 6 and 12 months after THA. In addition, the HHS was significantly improved in patients treated with ZA. However, the short length of follow-up of the available studies resulted in the lack of analyses regarding the survival of implants including the rate of aseptic loosing, periprosthetic fracture, and revision. It still needs to be determined in research with longer follow-up period. Clinical Trial Registration: Researchregistry.com, identifier: reviewregistry1087.

Zoledronic Acid for Periprosthetic Bone Mineral Density Changes in Patients With Osteoporosis After Hip Arthroplasty-An Updated Meta-Analysis of Six Randomized Controlled Trials

Introduction: Periprosthetic bone mineral density (BMD) loss following total hip arthroplasty (THA) may threaten the survival of the implant, especially in patients with osteoporosis. Zoledronic acid (ZA) is the representative of the third generation of bisphosphonates, which were effective in reducing bone loss in conditions associated with accelerated bone turnover. The aim of this study was to evaluate the efficacy and safety of ZA in patients with osteoporosis after THA. Methods: Randomized controlled trials (RCTs) associated with ZA and THA were searched from the MEDLINE, PubMed, EMBASE, Wanfang database, and the Web of Science (August 2021). Other methods, such as hand search and email request were also tried. The methodological quality was assessed by the Risk of Bias (RoB) 2.0. Relevant data were abstracted from the included RCTs and authors were contacted when necessary. Results: In this study, six RCTs involving a total of 307 patients were finally included and analyzed. The pooled data demonstrated that significantly less periprosthetic BMD loss in Gruen zone seven had occurred in the ZA-treated patients than in the control patients at 3 months (mean difference [MD] = 4.03%; 95% CI: 0.29-7.76%; P = 0.03), 6 months (MD = 7.04%; 95% CI: 2.12-11.96%; P = 0.005), and 12 months (MD = 7.12%; 95% CI: 0.33-13.92%; P = 0.04). The Harris Hip Score (HHS) was also significantly increased in ZA group at 6 and 12 months after operation (P = 0.03 and P = 0.02, respectively). Influenza-like symptom was found related to the usage of ZA [relative risk (RR) = 7.03, P < 0.0001]. Conclusion: A meta-analysis of six RCTs suggested that ZA was beneficial in maintaining the periprosthetic BMD in patients with osteoporosis at 6 and 12 months after THA. In addition, the HHS was significantly improved in patients treated with ZA. However, the short length of follow-up of the available studies resulted in the lack of analyses regarding the survival of implants including the rate of aseptic loosing, periprosthetic fracture, and revision. It still needs to be determined in research with longer follow-up period. Clinical Trial Registration: Researchregistry.com, identifier: reviewregistry1087.

The Effect of Teriparatide on the Hip: A Literature Review

Teriparatide (TPTD) is a bone-forming agent used to treat postmenopausal osteoporosis. Since hip fractures are related to higher morbidity and mortality rates than other fractures, efficacious osteoporosis drugs for the hip are critical. We reviewed research articles reporting the efficacy of TPTD in terms of bone mineral density (BMD), fractures prevention, changes in the outer diameter, cortical thickness and porosity, post-operative periprosthetic BMD loss, and healing of typical and atypical fractures of the hip. Data meta-analyses indicated that TPTD not only increased the BMD of the proximal femur but also decreased the risk of hip fractures. Even though TPTD increases the cortical bone porosity of the proximal femur, the bone strength does not decrease as the majority of the porosity is located at the endocortex; further, it increases the outer diameter and thickens the cortical bone. TPTD stimulates bone remodeling and facilitates callus maturity and fracture healing. There have been many reports on improving the effect of TPTD on the healing of atypical fractures; therefore it is advisable to use TPTD considering the increase benefit compared to the risk.

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.

[Progress of change in bone mineral density after knee arthroplasty]

Objective

To summarize research progress of change in bone mineral density (BMD) after knee arthroplasty and its diagnostic methods, influencing factors, and drug prevention and treatment.

Methods

The relevant literature at home and abroad was reviewed and summarized from research status of the advantages and disadvantages of BMD assessment methods, the trend of changes in BMD after knee arthroplasty and its influencing factors, and the differences in effectiveness of drugs.

Results

The central BMD and mean BMD around the prosthesis decrease after knee arthroplasty, which is closely associated with body position, age, weight, daily activities, and the fixation methods, design, and material of prosthesis. Denosumab, bisphosphonates, and teriparatide et al. can decrease BMD loss after knee arthroplasty.

Conclusion

BMD after knee arthroplasty decreases, which is related to various factors, but the mechanism is unclear. At present, some inhibitors of bone resorption can decrease BMD loss after knee arthroplasty. However, its long-term efficacy remains to be further explored.

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.

Periprosthetic femoral re-fractures pathogenesis, classification, and surgical implications

Periprosthetic femoral re-fractures (PFRFs) represent an emerging challenge for orthopaedic surgeons, since their incidence is growing in the last years, but very few experiences about their management have been currently published. The present study aims to (1) introduce, for the first time, an etiologic classification for PRFRs and (2) to provide surgical and pharmacological tips for the correct management of these injuries. Periprosthetic femoral re-fractures (PFRFs) could be classified into traumatic-PFRFs (T-PFRFs) and pathological-PFRFs (P-PFRFs). T-PFRFs, i.e. the "true" periprosthetic re-fractures, present as new fracture lines occurring proximally or distally to a previous periprosthetic fracture, that has correctly healed. They are generally unpredictable injuries but, in selected cases, it is possible to predict them by analyzing the construct used in the treatment of the previous periprosthetic fracture. P-PFRFs, on the other hand, define re-fractures occurring on a previous periprosthetic non-union or delayed union: the new fracture line appears in the same district of the old one. According to the etiologic factors influencing the P-PFRFs pathogenesis, it is possible to define re-fractures caused by mechanical failures, biological failures, septic failures and multifactorial failures, i.e., a combination of the previously mentioned concerns. A successful postoperative outcome, following the surgical management of PFRFs, requires the correct identification of all the underlying causes, which should be promptly and appropriately managed.

Biomechanics of Implant Fixation in Osteoporotic Bone

PURPOSE OF REVIEW

The purpose of this review is to critically evaluate the current literature regarding implant fixation in osteoporotic bone.

RECENT FINDINGS

Clinical studies have not only demonstrated the growing prevalence of osteoporosis in patients undergoing total joint replacement (TJR) but may also indicate a significant gap in screening and treatment of this comorbidity. Osteoporosis negatively impacts bone in multiple ways beyond the mere loss of bone mass, including compromising skeletal regenerative capacity, architectural deterioration, and bone matrix quality, all of which could diminish implant fixation. Recent findings both in preclinical animal models and in clinical studies indicate encouraging results for the use of osteoporosis drugs to promote implant fixation. Implant fixation in osteoporotic bone presents an increasing clinical challenge that may be benefitted by increased screening and usage of osteoporosis drugs.

Total hip arthroplasty in patients with osteoporosis

There is a high prevalence of osteoporosis in patients undergoing total hip arthroplasty. There are several clinically relevant questions related to the management of such cases: the effect of ageing; the initial osseointegration of implants, especially when cementless THA is used; the effect of medical osteoporosis treatment on bone-implant interface; the incidence of intraoperative and late periprosthetic fractures, and the long-term survival of both cemented and cementless total hip arthroplasty performed for proximal femoral fractures and hip osteoarthritis. A critical review of the literature is presented in an attempt to draw practical conclusions.

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.

Prophylactic efficacy on periprosthetic bone loss in calcar region after total hip arthroplasty of antiosteoporotic drugs: a network meta-analysis of randomised controlled studies

OBJECTIVES

The aim of this study was to evaluate the effect of antiosteoporotic drugs on preventing periprosthetic bone loss in calcar 6 and 12 months after total hip arthroplasty.

METHODS

The network meta-analysis was conducted guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA) guideline. A systematic literature search was conducted and 21 studies that enrolled a total of 955 patients with 9 antiosteoporotic drugs met the inclusion criteria. Network meta-analysis and conventional meta-analysis were carried out for calculating standard mean difference (SMD) and the surface under cumulative ranking curve (SUCRA) of the bone mineral density (BMD) in calcar (Gruen zone 7) as well as bone turnover markers (BTMs) including bone-specific alkaline phosphatase (BSAP) and collagen type I cross-linked N telopeptide (NTX) at 6 and 12 months between different antiosteoporotic drugs.

RESULTS

At 6 months after total hip arthroplasty, zoledronate (SUCRA=86.4%), risedronate (SUCRA=51.3%) and etidronate (SUCRA=44.5%) were effective in retaining BMD in calcar; zoledronate was significantly more effective than etidronate (SMD=0.65, 95% CI 0.03 to 1.27). Teriparatide (SUCRA=84.5%), denosumab (SUCRA=82.5%), zoledronate (SUCRA=69.2%), alendronate+alfacalcidol (SUCRA=66.2%) and etidronate (SUCRA=51.5%) were the top five drugs in retaining BMD in calcar at 12 months after total hip arthroplasty and the efficacy were comparable. After simultaneously excluding studies in which the prosthesis were cement and the drug dosages as well as treatment durations were inconsistent with those in treating osteoporosis, the above results were robust with the exception that alendronate showed significant efficacy compared with placebo (SMD=1.22, 95% CI 0.46 to 1.99) and was comparable with those effective drugs at 12 months. Long-term residual effect was corroborated only in etidronate, alendronate and zoledronate from previous studies. BTMs were significantly decreased as early as 6 months (SMD of BSAP -0.49, 95% CI -0.84 to -0.13; SMD of NTX -0.93, 95% CI -1.21 to -0.64) and sustained until 12 months (SMD of BSAP -0.27, 95% CI -0.50 to -0.03; SMD of NTX -0.84, 95% CI -1.11 to -0.56) during the prophylaxis.

CONCLUSIONS

Antiosteoporotic drugs showed prophylactic efficacy on periprosthetic bone loss after total hip arthroplasty in calcar, the effectiveness varied. Zoledronate was the best recommendation due to its optimal efficacy both within 6 and 12 months as well as its residual effect in the long term. BTMs could be used as indicators for monitoring through the treatment. More head-to-head clinical trials are needed to confirm those findings.

Effects of Chronic Kidney Disease on Hemiarthroplasty Outcomes for Fragility Hip Fracture in Diabetic Patients: A Nationwide Population-Based Observational Study

BACKGROUND

The aim of this study is to compare perioperative outcomes, readmission, and mortality after hemiarthroplasty for hip fractures in diabetic patients with different renal function statuses.

METHODS

In this retrospective population-based cohort study, diabetic patients who received primary hemiarthroplasty for hip fracture between January 1997 and December 2013 were identified from the Taiwan National Health Insurance Research Database. Primary outcomes were perioperative outcomes including infection and revision. Secondary outcomes were all-cause readmission and mortality.

RESULTS

A total of 29,535 diabetic patients were included: 8270 patients had chronic kidney disease (CKD group), 1311 patients underwent permanent dialysis (dialysis group), and 19,954 patients did not have CKD (non-CKD group). During a mean follow-up of 4.5 years, these 3 groups had comparable risks of any infection, including superficial and deep infection. Dialysis patients had a significantly higher risk of revision than did CKD and non-CKD patients (subdistribution hazard ratio 1.65, 95% confidence interval 1.16-2.36; subdistribution hazard ratio 1.57, 95% confidence interval 1.10-2.24, respectively). Compared with the non-CKD group, the dialysis group had significantly higher risks of readmission and mortality at all time points, namely 3 months after surgery, 1 year after surgery, and the final follow-up. The CKD group also had higher risks of readmission and mortality than did the non-CKD group at all time points.

CONCLUSION

CKD is associated with poor outcomes following hemiarthroplasty for fragility hip fracture. CKD patients may have higher risks of surgical complications including revision than non-CKD patients, and they have significantly elevated risks of readmission and mortality.

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.

Use of Bone Health Evaluation in Orthopedic Surgery: 2019 ISCD Official Position

This position development conference (PDC) Task Force examined the assessment of bone status in orthopedic surgery patients. Key questions included which orthopedic surgery patients should be evaluated for poor bone health prior to surgery and which subsets of patients are at high risk for poor bone health and adverse outcomes. Second, the reliability and validity of using bone densitometry techniques and measurement of specific geometries around the hip and knee before and after arthroplasty was determined. Finally, the use of computed tomography (CT) attenuation coefficients (Hounsfield units) to estimate bone quality at anatomic locations where orthopedic surgery is performed including femur, tibia, shoulder, wrist, and ankle were reviewed. The literature review identified 665 articles of which 198 met inclusion exclusion criteria and were selected based on reporting of methodology, reliability, or validity results. We recommend that the orthopedic surgeon be aware of established ISCD guidelines for determining who should have additional screening for osteoporosis. Patients with inflammatory arthritis, chronic corticosteroid use, chronic renal disease, and those with history of fracture after age 50 are at high risk of osteoporosis and adverse events from surgery and should have dual energy X-ray absorptiometry (DXA) screening before surgery. In addition to standard DXA, bone mineral density (BMD) measurement along the femur and proximal tibia is reliable and valid around implants and can provide valuable information regarding bone remodeling and identification of loosening. Attention to positioning, selection of regions of interest, and use of special techniques and software is required. Plain radiographs and CT provide simple, reliable methods to classify the shape of the proximal femur and to predict osteoporosis; these include the Dorr Classification, Cortical Index, and critical thickness. Correlation of these indices to central BMD is moderate to good. Many patients undergoing orthopedic surgery have had preoperative CT which can be utilized to assess regional quality of bone. The simplest method available on most picture archiving and communications systems is to simply measure a regions of interest and determine the mean Hounsfield units. This method has excellent reliability throughout the skeleton and has moderate correlation to DXA based on BMD. The prediction of outcome and correlation to mechanical strength of fixation of a screw or implant is unknown.

Preoperative Morphology of the Proximal Femoral Canal Did Not Affect the Postoperative Bone Mineral Density Change Around the Zweymüller-Type Stem

The bone mineral density (BMD) around a femoral component changes after total hip arthroplasty (THA). The aim of this study was to investigate the influence of the morphology of the preoperative proximal femoral canal on the postoperative BMD change of the femur around a Zweymüller-type stem. The authors performed a retrospective review of their institutional arthroplasty database. Patients were classified into following 3 groups according to canal flare index (CFI): CFI<3.0, stovepipe group; 3.0<CFI<4.7, normal group; and CFI>4.7, champagne-flute group. This study included 120 hips of 112 patients (26 hips with stovepipe femurs, 72 hips with normal femurs, and 22 hips with champagne-flute femurs) in patients who had undergone THA using the Zweymüller-type stem. The BMD of the proximal femur (Gruen's zones 1-7) was measured at 3 weeks and 6, 12, and 24 months postoperatively. At each follow-up period, the differences in the relative change in the BMD were not statistically significant in any regions of interest among the 3 groups. This study showed the lack of significant differences in the relative change in the BMD among the different morphologies of the proximal femoral canal. The preoperative morphology of the femoral canal did not affect the postoperative BMD change around the Zweymüller-type stem at 2 years postoperatively. [Orthopedics. 2019; 42(5):e449-e453.].

Bone Health Optimization: Beyond Own the Bone: AOA Critical Issues

Worldwide, osteoporosis management is in crisis because of inadequate delivery of care, competing guidelines, and confusing recommendations. Additionally, patients are not readily accepting the diagnosis of poor bone health and often are noncompliant with treatment recommendations. Secondary fracture prevention, through a program such as Own the Bone, has improved the diagnosis and medical management after a fragility fracture. In patients who undergo elective orthopaedic procedures, osteoporosis is common and adversely affects outcomes. Bone health optimization is the process of bone status assessment, identification and correction of metabolic deficits, and initiation of treatment, when appropriate, for skeletal structural deficits. The principles of bone health optimization are similar to those of secondary fracture prevention and can be initiated by all orthopaedic surgeons. Patients who are ≥50 years of age should be assessed for osteoporosis risk and, if they are in a high-risk group, bone density should be measured. All patients should be counseled to consume adequate vitamin D and calcium and to discontinue use of any toxins (e.g., tobacco products and excessive alcohol consumption). Patients who meet the criteria for pharmaceutical therapy for osteoporosis should consider delaying surgery for a minimum of 3 months, if feasible, and begin medication treatment. Orthopaedic surgeons need to assume a greater role in the care of bone health for our patients.

Effects of zoledronic acid on bone mineral density around prostheses and bone metabolism markers after primary total hip arthroplasty in females with postmenopausal osteoporosis

INTRODUCTION

To investigate the effect of zoledronic acid on periprosthetic bone mineral density (BMD) and bone metabolism markers after primary total hip arthroplasty in females with postmenopausal osteoporosis.

METHODS

From November 2015 to April 2016, 40 female patients who met the inclusion criteria were randomized into two groups: a control group (calcium + calcitriol) and a zoledronic acid group (calcium + calcitriol + zoledronic acid). At 1 week and 3, 6, and 12 months after operation, BMD was obtained through dual-energy X-ray absorptiometry (DEXA). At pre-operation and at 3, 6, and 12 months after the operation, levels of bone metabolism markers were obtained by serum examination.

RESULTS

Loss of BMD was significantly more pronounced in the control group than in the ZOL group in zones 1, 4, 6, and 7 at 6 months and in zones 1, 2, 4, 6, and 7 at 12 months after the operation. The levels of bone-resorption marker (β-CTX) were significantly lower in the ZOL group than in the control group at 3, 6, and 12 months after operation. The levels of bone-formation marker (TP1NP) performed statistically differences only at 12 months after the operation in these two groups.

CONCLUSIONS

Receiving an intravenous infusion of 5 mg zoledronic acid after THA can effectively reduce periprosthetic BMD loss and improve bone remodeling in females with postmenopausal osteoporosis. Zoledronic acid significantly inhibited bone mass loss in zones 1, 2, 4, 6, and 7 after THA and inhibited bone-resorption marker (β-CTX) to improve bone remodeling. Zoledronic acid treatment is potentially important for patients with osteoporosis after THA.

The effectiveness and safety of parathyroid hormone in fracture healing: A meta-analysis

The very large economic and social burdens of fracture-related complications make rapid fracture healing a major public health goal. The role of parathyroid hormone (PTH) in treating osteoporosis is generally accepted, but the effect of PTH on fracture healing is controversial. This meta-analysis was designed to investigate the efficacy and safety of PTH in fracture healing. The EMBASE, PubMed, and Cochrane Library databases were systematically searched from the inception dates to April 26, 2018. The primary randomized clinical trials comparing PTH treatment for fracture healing with placebo or no treatment were identified. We did not gain additional information by contacting the authors of the primary studies. Two reviewers independently extracted the data and evaluated study quality. This meta-analysis was executed to determine the odds ratio, mean difference, standardized mean difference, and 95% confidence intervals with random-effects models. In total, 8 randomized trials including 524 patients met the inclusion criteria. There were significant differences in fracture healing time, pain relief and function improvement. There were no significant differences in the fracture healing rate or adverse events, including light-headedness, hypercalcemia, nausea, sweating and headache, except for slight bruising at the injection site. We determined that the effectiveness and safety of PTH in fracture healing is reasonably well established and credible.

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.

Anabolic agents: what is beyond osteoporosis?

Osteoporosis is a common skeletal disorder characterized by low bone mass, which leads to reduced bone strength and an increased risk of fractures. Anabolic agents have been shown to improve bone mass and decrease fracture risk in osteoporosis patients by directly stimulating osteoblasts to produce new bone. Currently, two anabolic agents are available in the USA: recombinantly produced teriparatide (TPTD), which is the fully active (1-34) amino active sequence of human parathyroid hormone (PTH), and abaloparatide (APTD), a synthetic analog of parathyroid hormone-related peptide (PTHrP). At present, both agents are approved only for treatment of patients with osteoporosis at high risk of fracture. Nonetheless, their anabolic properties have led to off-label application in additional settings which include spine fusion, osteonecrosis of the jaw, arthroplasty, and fracture healing. In this article, we summarize available scientific literature regarding the efficacy, effectiveness, and safety of TPTD in these off-label settings.

Teriparatide Administration Increases Periprosthetic Bone Mineral Density After Total Knee Arthroplasty: A Prospective Study

BACKGROUND

Teriparatide is a currently available therapeutic agent for osteoporosis. Previous studies have reported that teriparatide affects periprosthetic bone mineral density (BMD) after total knee arthroplasty (TKA). However, little agreement has been reached concerning the treatment of periprosthetic BMD after TKA with teriparatide. Moreover, BMD in the femoral and tibial sides of the joints together has never been examined. We investigated the efficacy of teriparatide to inhibit BMD loss in the femoral and tibial side and considered complications such as migration and periprosthetic fractures after TKA.

METHODS

Twenty-two knees in 17 patients were included in this study, and a control group of patients who underwent TKA was identified according to their medical records. Dual-energy X-ray absorptiometry was performed for different locations (knee, hip, and lumbar spine), and regions of interest were measured to estimate BMD at initiation of the study as a baseline reference, followed by subsequent measurements at 6 and 12 months.

RESULTS

As a result of adjusting the difference between the BMDs of the 2 groups at initiation, there was a significant increase in R3 (posterior condyle) and R4 (lateral) at 6 months. Furthermore, there was a significant increase in R2 (anterior condyle), R3 (posterior condyle), and R6 (tibial diaphysis) at 12 months. The study group had a higher adjusted mean BMD in all regions than did the control group at 6 and 12 months.

CONCLUSION

Teriparatide may be a reasonable treatment option for osteoporotic patients to preserve or improve periprosthetic BMD after TKA.

Effect of Teriparatide or Risedronate in Elderly Patients With a Recent Pertrochanteric Hip Fracture: Final Results of a 78-Week Randomized Clinical Trial

We present final results of a study comparing teriparatide 20 μg every day (QD) with risedronate 35 mg once per week (QW) started within 2 weeks after surgery for a pertrochanteric hip fracture. Patients with BMD T-score ≤ -2.0 and 25OHD ≥9.2 ng/mL were randomized to receive 26-week double-dummy treatment plus calcium and vitamin D, followed by 52-week open-label treatment with the same assigned active drug. Primary endpoint was change from baseline in lumbar spine (LS) BMD at 78 weeks. Secondary and exploratory endpoints were change in BMD at the proximal femur, function, hip pain (Charnley score and 100 mm Visual Analog Scale [VAS]), quality of life (Short Form-36), radiology outcomes, and safety. Data were analyzed with mixed models for repeated measures (MMRM) and logistic regression. Totally, 224 patients were randomized; 171 (teriparatide: 86) contributed to the efficacy analyses (mean ± SD age: 77 ± 7.7 years, 77% females). Mean baseline LS, femoral neck (FN), and total hip (TH) T-scores were -2.16, -2.63, and -2.51, respectively. At 78 weeks, BMD increased significantly more with teriparatide compared to risedronate at the LS (+11.08% versus +6.45%; p < 0.001) and FN (+1.96% versus -1.19%; p = 0.003), with no significant between-group difference in TH BMD. Timed up-and-go (TUG) test was significantly faster with teriparatide at 6, 12, 18, and 26 weeks (differences: -3.2 to -5.9 s; p = 0.045 for overall difference). Hip pain during TUG test by 100 mm VAS was significantly lower with teriparatide at 18 weeks (adjusted difference: -11.3 mm, p = 0.033; -10.0 and -9.3 mm at 12 and 26 weeks, respectively; p = 0.079 for overall difference). Other secondary and exploratory outcomes were not different. Teriparatide group showed two new hip fractures versus seven with risedronate (p = 0.171) and more frequent hypercalcemia and hyperuricemia. In conclusion, 78-week treatment with teriparatide showed significantly greater increases in LS and FN BMD, less pain, and a faster TUG test versus risedronate. © 2016 American Society for Bone and Mineral Research.

Effects of teriparatide on cementless bipolar hemiarthroplasty in patients with osteoporotic femoral neck fractures

Background

For osteoporotic femoral neck fractures, suitable bone-implant stability is critical for pain relief, early return to daily activities and reduction of complications. Teriparatide (parathyroid hormone [PTH1-34]) can improve bone-implant stability in some basic studies. However it’s use in osteoporotic femoral neck fractures treated by cementless hemiarthroplasties for the beneficial effects on bone-implant stability is sparse in the literature. The aim of this study was to determine if post-operative teriparatide administration can reduce femoral stem migration and improve early functional recovery and health-related quality of life (HRQoL).

Methods

Between 2010 and 2014, patients with osteoporotic femoral neck fracture who underwent cementless bipolar hemiarthroplasty were included into this retrospective cohort study. Group A included patients treated with cementless bipolar hemiarthroplasty only; Group B patients had additional teriparatide. Demographic data, complications, radiographic and functional outcomes as well as health-related quality of life (HRQoL) were compared.

Results

There were 52 hips in group A (no teriparatide) and 40 hips in group B (patient who received teriparatide). The subsidence of the femoral stem tended to be significantly decreased in the teriparatide group at 6 and 12 weeks post-operatively (p = 0.003 and p = 0.008, respectively). The Harris Hip Score (HHS) increased significantly from pre-operation to 6 weeks post-operatively and thereafter up to one year in both groups. However, there were no significant differences in terms of subsequent fracture, mortality, HHS, and HRQoL between two groups during the entire study period.

Conclusions

Teriparatide significantly reduces the subsidence of the cementless femoral stem in elderly patients in the early post-operative period, but this benefit does not reflect better functional outcomes and HRQoL. Further prospective randomized large-scale cohort study is warranted for evidence-based recommendations.

The Effect of Teriparatide on Fracture Healing of Osteoporotic Patients: A Meta-Analysis of Randomized Controlled Trials

Purpose. This meta-analysis is to assess the effectiveness of teriparatide in fracture healing and clinical function improvement of the osteoporotic patients. Methods. We searched PubMed, Embase, Web of Science, and the Cochrane databases for randomized and quasi-randomized controlled trials comparing teriparatide to placebo, no treatment, or comparator interventions in the osteoporotic patients. Results. Five studies with 251 patients were included. Patients treated with teriparatide therapy had a significant shorter radiological fracture healing time compared with those in the control group (mean difference [MD] −4.54 days, 95% confidence interval [CI] −8.80 to −0.28). Stratified analysis showed that lower limb group had significant shorter healing time (MD −6.24 days, 95% CI −7.20 to −5.29), but upper limb group did not (MD −1 days, 95% CI −2.02 to 0.2). Patients treated with teriparatide therapy showed better functional outcome than those in the control group (standardized mean difference [SMD] −1.02, 95% CI −1.81 to −0.22). Patients with therapy duration over 4 weeks would have better functional outcome (SMD −1.68, 95% CI −2.07 to −1.29). Conclusions. Teriparatide is effective in accelerating fracture healing and improving functional outcome of osteoporotic women. However, more clinical studies are warranted in order to determine whether the results are applicable to males and the clinical indications for teriparatide after osteoporotic fractures.