Efficacy of Alendronate for the Prevention of Bone Loss in Calcar Region Following 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.

Periprosthetic fractures are osteoporotic fractures: missed opportunities for osteoporosis diagnosis

Joint replacement surgery is common in older adults, leading to increasing periprosthetic fracture (PPFx) occurrence. We reviewed all PPFx seen over a 4-year period at an academic hospital. Clinical osteoporosis could be diagnosed based on existing data in 104 (67%) at the time of PPFx. Periprosthetic fractures are generally osteoporosis-related.

PURPOSE

Periprosthetic fractures (PPFx) cause morbidity, mortality, and cost. This study's purpose was to describe osteoporosis-related data available at the time of PPFx.

METHODS

The electronic medical record (EMR) of PPFx patients seen over 4 years in a university orthopedic practice were reviewed. Demographic data and osteoporosis relevant parameters were collected. Prior DXA studies were reviewed, and L1 Hounsfield unit (HU) measurements were performed on CT scans obtained within 2 years before PPFx. Clinical osteoporosis was defined as prior diagnosis, prescribed osteoporosis treatment, T-score ≤  - 2.5, HU ≤ 100, or prior fracture.

RESULTS

Records of 156 PPFx patients (115 F/41 M), mean (SD) age 75.4 (11.9), were reviewed. Almost all 153/156 (98%) of these fractures were femoral. Falls caused 139 (89%); 12 (8%) were spontaneous. Mean time post-arthroplasty was 7.9 (6.3) years. Prior fragility fracture(s) occurred in 72 (46%); 14 were PPFx. Osteoporosis was previously diagnosed in 45 (29%) and medications prescribed in 41 (26%). Prior to PPFx, DXA data were available in 62, mean (SD) lowest T-score was - 1.9 (0.9) and was ≤  - 2.5 in 19. CT data were available in 46; mean (SD) L1 HU was 79.0 (29.4) and was ≤ 100 in 35. Based on existing data, clinical osteoporosis could have been diagnosed in 104 (67%) at the time of PPFx.

CONCLUSION

Periprosthetic fractures are osteoporosis-related. They occur in older adults, often female, and result from falls; BMD, when assessed, is low. Data available at the time of PPFx often allows osteoporosis diagnosis; this should prompt evaluation and pharmacologic treatment consideration.

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.

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.

Stress Shielding in the Setting of Osteogenesis Imperfecta and the Effect of Downsizing an Intramedullary Rod: A Case Report

CASE

Cortical atrophy, or stress shielding, secondary to a large-diameter femoral intramedullary rod was noted over almost a decade in a now 14-year-old girl with osteogenesis imperfecta (OI). After an initial minimally invasive unsuccessful revision, we downsized the left femur rod with realignment and noted restoration of the left femur cortical thickness.

CONCLUSION

We demonstrate the significant functional impact of stress shielding and its evolution over a protracted period and outline treatment principles. To our knowledge, this is the first report of treatment of stress shielding of a long bone in the setting of OI.

Factors Affecting Periprosthetic Bone Loss after Hip Arthroplasty

Periprosthetic bone loss may lead to major complications in hip arthroplasty, including aseptic loosening, implant migration, and even periprosthetic fracture. Such a complication leads to revision surgeries, which are expensive, technically demanding, and result in a low satisfaction rate. Therefore, a study was conducted of the factors affecting the periprosthetic bone loss around the stem that caused these complications. Factors influencing periprosthetic bone loss include demographic factors such as age, sex, obesity, smoking, and comorbidity including diabetes and osteoporosis. The implant design and fixation method are also factors that are determined before surgery. In addition, there are surgical factors, such as surgical approach and surgical technique, and we wish to investigate the factors affecting periprosthetic bone loss around the stem by comparing the effects of postoperative rehabilitation protocols and osteoporosis drugs.

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.

Perioperative patient-specific factors-based nomograms predict short-term periprosthetic bone loss after total hip arthroplasty

BACKGROUND

Although medical intervention of periprosthetic bone loss in the immediate postoperative period was recommended, not all the patients experienced periprosthetic bone loss after total hip arthroplasty (THA). Prediction tools that enrolled all potential risk factors to calculate an individualized prediction of postoperative periprosthetic bone loss were strongly needed for clinical decision-making.

METHODS

Data of the patients who underwent primary unilateral cementless THA between April 2015 and October 2017 in our center were retrospectively collected. Candidate variables included demographic data and bone mineral density (BMD) in spine, hip, and periprosthetic regions that measured 1 week after THA. Outcomes of interest included the risk of postoperative periprosthetic bone loss in Gruen zone 1, 7, and total zones in the 1st postoperative year. Nomograms were presented based on multiple logistic regressions via R language. One thousand Bootstraps were used for internal validation.

RESULTS

Five hundred sixty-three patients met the inclusion criteria were enrolled, and the final analysis was performed in 427 patients (195 male and 232 female) after the exclusion. The mean BMD of Gruen zone 1, 7, and total were decreased by 4.1%, 6.4%, and 1.7% at the 1st year after THA, respectively. 61.1% of the patients (261/427) experienced bone loss in Gruen zone 1 at the 1st postoperative year, while there were 58.1% (248/427) in Gruen zone 7 and 63.0% (269/427) in Gruen zone total. Bias-corrected C-index for risk of postoperative bone loss in Gruen zone 1, 7, and total zones in the 1st postoperative year were 0.700, 0.785, and 0.696, respectively. The most highly influential factors for the postoperative periprosthetic bone loss were primary diagnosis and BMD in the corresponding Gruen zones at the baseline.

CONCLUSIONS

To the best of our knowledge, our study represented the first time to use the nomograms in estimating the risk of postoperative periprosthetic bone loss with adequate predictive discrimination and calibration. Those predictive models would help surgeons to identify high-risk patients who may benefit from anti-bone-resorptive treatment in the early postoperative period effectively. It is also beneficial for patients, as they can choose the treatment options based on a reasonable expectation following surgery.

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.

Long-term follow-up of bone remodelling after cementless hip arthroplasty using different stems

The present paper is concerned with the investigation of the phenomenon of long-term bone remodelling on cementless hip replacements. Changes in bone density in the periprosthetic region around the stem, measured by dual X–ray absorptiometry (DXA), were used as a measure of the osseous adaptation reaction. A postoperative follow-up of the use of four different types of prostheses of varying design after on average 13.3 (11.4–14.5) years. Specifically, the prostheses assessed in this study were the CLS/Spotorno stem with the Allofit cup by Zimmer, the Vision 2000 stem with the Duraloc cup by DePuy Synthes, the AlphaFit stem with the AlphaLock cup by Corin and the Mayo stem with the Trilogy cup by Zimmer. For the DXA measurement, the femur was divided into the zones suggested by Gruen et al. On the femur, there was a significant reduction in bone mineral density (BMD) in the proximal Region Of Interest (ROI) 1 (p = 0.003) and 7 (p < 0.001), whilst there was a significant increase in ROI 4 (p = 0.03). A greater degree of bone atrophy was seen in patients aged 60 years and older and in female patients. A remarkable finding when comparing the stems was a significantly greater reduction in BMD in ROI 6 (p = 0.003) in the case of the Vision 2000 stem and a markedly, but not statistically significantly smaller reduction in BMD in ROI 7 (p = 0.18) in the case of the short-stem Mayo-type prosthesis. The best clinical results were found with the use of the latter. The investigations provide a starting point for establishing a differential indication in the choice of prosthesis types, depending on age and sex, the use of short-stem prostheses, as well as the administration of bone-effective drugs for the prevention of stress shielding.

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 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.