1
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Herndon CL, McCormick KL, Gazgalis A, Bixby EC, Levitsky MM, Neuwirth AL. Fragility Index as a Measure of Randomized Clinical Trial Quality in Adult Reconstruction: A Systematic Review. Arthroplast Today 2021; 11:239-251. [PMID: 34692962 PMCID: PMC8517286 DOI: 10.1016/j.artd.2021.08.018] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Revised: 08/08/2021] [Accepted: 08/29/2021] [Indexed: 12/16/2022] Open
Abstract
Background The Fragility Index (FI) and Reverse Fragility Index are powerful tools to supplement the P value in evaluation of randomized clinical trial (RCT) outcomes. These metrics are defined as the number of patients needed to change the significance level of an outcome. The purpose of this study was to calculate these metrics for published RCTs in total joint arthroplasty (TJA). Methods We performed a systematic review of RCTs in TJA over the last decade. For each study, we calculated the FI (for statistically significant outcomes) or Reverse Fragility Index (for nonstatistically significant outcomes) for all dichotomous, categorical outcomes. We also used the Pearson correlation coefficient to evaluate publication-level variables. Results We included 104 studies with 473 outcomes; 92 were significant, and 381 were nonstatistically significant. The median FI was 6 overall and 4 and 7 for significant and nonsignificant outcomes, respectively. There was a positive correlation between FI and sample size (R = 0.14, P = .002) and between FI and P values (R = 0.197, P = .000012). Conclusions This study is the largest evaluation of FI in orthopedics literature to date. We found a median FI that was comparable to or higher than FIs calculated in other orthopedic subspecialties. Although the mean and median FIs were greater than the 2 recommended by the American Academy of Orthopaedic Surgeons Clinical Practice Guidelines to demonstrate strong evidence, a large percentage of studies have an FI < 2. This suggests that the TJA literature is on par or slightly better than other subspecialties, but improvements must be made. Level of Evidence Level I; Systematic Review.
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Affiliation(s)
- Carl L Herndon
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Kyle L McCormick
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Anastasia Gazgalis
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Elise C Bixby
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Matthew M Levitsky
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
| | - Alexander L Neuwirth
- Department of Orthopedic Surgery, Columbia University Irving Medical Center, New York, NY, USA
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2
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Mjöberg B. Hip prosthetic loosening: A very personal review. World J Orthop 2021; 12:629-639. [PMID: 34631447 PMCID: PMC8472441 DOI: 10.5312/wjo.v12.i9.629] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/20/2021] [Revised: 05/03/2021] [Accepted: 08/03/2021] [Indexed: 02/06/2023] Open
Abstract
Hip prosthetic loosening is often difficult to detect at an early stage, and there has been uncertainty for a long time as to when the loosening occurs and thus to the basic causes. By comparing different diagnostic methods, we found that loosening is best defined as prosthetic migration and measured by radiostereometric analysis. Convincing evidence indicates that poor interlock, poor bone quality, and resorption of a necrotic bone bed may initiate loosening during or shortly after surgery; this forms the basis of the theory of early loosening. Biomechanical factors do affect the subsequent progression of loosening, which may increase subclinically during a long period of time. Eventually, the loosening may be detected on standard radiographs and may be interpreted as late loosening but should to be interpreted as late detection of loosening. The theory of early loosening explains the rapid early migration, the development of periprosthetic osteolysis and granulomas, the causality between wear and loosening, and largely the epidemiology of clinical failure of hip prostheses. Aspects discussed are definition of loosening, the pattern of early migration, the choice of migration threshold, the current understanding of loosening, a less exothermic bone cement, cemented taper-slip stems, a new exciting computed tomography-based technique for simpler implant migration studies, and research suggestions.
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Affiliation(s)
- Bengt Mjöberg
- Department of Orthopedics, Lund University, Lund SE-221 00, Sweden
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3
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The Effects of Local Alendronate With or Without Recombinant Human Bone Morphogenetic Protein 2 on Dental Implant Stability and Marginal Bone Level: A Randomized Controlled Study. J Craniofac Surg 2021; 33:1003-1007. [PMID: 34456283 DOI: 10.1097/scs.0000000000008102] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
ABSTRACT The aim of this study was to evaluate the effects of local application of bisphosphonate gel and recombinant human bone morphogenic protein 2 gel, on titanium dental implant stability and marginal bone level. Twenty-seven patients with upper and lower missing posterior tooth/teeth were included in the study with a total of 71 implants that were used for rehabilitation. The implants were randomly divided into 4 groups: 3 study groups and 1 control. Group1; local application of bisphosphonate gel, group 2; local application of recombinant human bone morphogenic protein 2 gel, group 3; local application of a mixed formula of both gels. The gel application was immediately preimplant insertion, group 4; implant insertion without application of any medication. Using resonance frequency analyzer, implant stability was measured 4 times; primary, 8 weeks (second stage surgery), 12 weeks, and at least 14 weeks post functional loading. The level of the marginal bone around each implant were assessed using cone beam computed tomography. Four implants failed. Generally, there was a similar pattern of changes in implant stability over the study period in all groups and the stability was dependent on the healing time with no significant difference between groups. There was no significant treatment effect regarding marginal bone level differences of study groups against control, although there were significant differences on palatal and mesiodistal surfaces among the study (test) groups.
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4
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Kiuttu J, Lehenkari P, Leskelä HV, Yrjämä O, Ohtonen P, Valkealahti M. Intra-operative Clodronate Rinsing Improves the Integration of the Femoral Stem in a Prospective, Double-blinded, Randomized, Placebo-controlled Clinical RSA-study. Open Orthop J 2021. [DOI: 10.2174/1874325002115010001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/22/2023] Open
Abstract
Background:
Periprosthetic bone loss after Total Hip Arthroplasty (THA), detected as an early migration of the prosthesis may predict later loosening of the implant.
Objective:
We hypothesized that intra-operative bisphosphonate rinsing would reduce bone resorption after THA. It might therefore be possible to achieve better early fixation of the implant.
Methods:
Nineteen patients suffering from arthrosis were recruited in a prospective, double-blinded, randomized, placebo-controlled clinical pilot trial. Patients were operated with an uncemented Bimetric stem using tantalum markers. The femoral proximal intramedullary canal was rinsed with 1mM clodronate in nine patients and with saline in 10 patients. These patients were followed for two years using radiostereometric analysis (RSA), dual energy x-ray absorptiometry (DXA) and the Harris Hip Score (HHS).
Results:
We did not found any significant differences between the study groups with regards to the primary output measures (maximum total point motion, MTPM). However, there was evidence that clodronate could affect periprosthetic bone quality; a beneficial effect in BMD in Gruen zone 3 during the two-year follow-up was observed, BMD decreased less in the clodronate group (p = 0.02). The maximal x-translation of the stem at 3-24 months was significantly two-fold, being higher in the placebo group (p = 0.02). The baseline BMD and the maximal total point motion (MTPM) at 3-24 months showed a positive correlation in the clodronate group and a negative correlation in the placebo group.
Conclusion:
In conclusion, further studies with larger patient groups and longer follow-up periods are needed to estimate the clinical importance of these findings and further to prove if an intraoperative clodronate rinsing prior to application of femoral stem during THA can prevent periprosthetic bone loss.
Clinical Trial Registration No.: NCT03803839
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5
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Brandt J, Ledin H, Ranstam J, Roos E, Aspenberg P, Schilcher J. Single postoperative infusion of zoledronic acid to improve patient-reported outcome after hip or knee replacement: study protocol for a randomised, controlled, double-blinded clinical trial. BMJ Open 2020; 10:e040985. [PMID: 32998932 PMCID: PMC7528432 DOI: 10.1136/bmjopen-2020-040985] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2020] [Revised: 08/23/2020] [Accepted: 08/25/2020] [Indexed: 11/08/2022] Open
Abstract
INTRODUCTION In Sweden, roughly 3000 patients are reoperated each year due to pain and loss of function related to a loosened hip or knee prosthesis. These reoperations are strenuous for the patient, technically demanding and costly for the healthcare system. Any such reoperation that can be prevented would be of great benefit. Bisphosphonates are drugs that inhibit osteoclast function. Several clinical trials suggest that bisphosphonates lead to improved implant fixation and one small study even indicates better functional outcome. Furthermore, in epidemiological studies, bisphosphonates have been shown to decrease the rate of revision for aseptic loosening by half. Thus, there are several indirect indications that bisphosphonates could improve patient-reported outcome, but no firm evidence. METHODS AND ANALYSIS This is a pragmatic randomised, placebo-controlled, double-blinded, academic clinical trial of a single postoperative dose of zoledronic acid, in patients younger than 80 years undergoing primary total hip or knee replacement for osteoarthritis. Participants will be recruited from two orthopaedic departments. All surgeries will be performed, and study drugs given at Motala Hospital, Sweden. The primary endpoint is to investigate between-group differences in the Hip dysfunction and Osteoarthritis Outcome Score and the Knee injury and Osteoarthritis Outcome Score at 3-year follow-up. Secondary outcomes will be investigated at 1 year, 3 years and 6 years, and stratified for hip and knee implants. These secondary endpoints are supportive, exploratory or explanatory. A total of 1000 patients will be included in the study. ETHICS AND DISSEMINATION The study has been approved by the Regional Ethical Review Board in Linköping (DNR 2015/286-31). The study will be reported in accordance with the Consolidated Standards of Reporting Trials statement for pharmacological trials. The results will be submitted for publication in peer-reviewed academic journals and disseminated to patient organisations and the media. TRIAL REGISTRATION NUMBER EudraCT: No 2015-001200-55; Pre-results.
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Affiliation(s)
- Jonathan Brandt
- Department of Orthopaedic Surgery, Capio Specialistvård Motala, Motala, Sweden
| | - Håkan Ledin
- Department of Orthopaedic Surgery, Capio Specialistvård Motala, Motala, Sweden
| | - Jonas Ranstam
- Department of Clinical sciences, Lund University, Lund, Sweden
| | - Ewa Roos
- Department of Sports Science and Clinical Biomechanics, Syddansk Universitet Det Sundhedsvidenskabelige Fakultet, Odense, Denmark
| | - Per Aspenberg
- Department of Orthopaedic Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Faculty of health Sciences, Linköping University, Linköping, Sweden
| | - Jörg Schilcher
- Department of Orthopaedic Surgery, Linköping University Hospital, Linköping, Sweden
- Department of Biomedical and Clinical Sciences, Faculty of health Sciences, Linköping University, Linköping, Sweden
- Wallenberg Centre for Molecular Medicine, Linköping University, Linköping, Sweden
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6
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Wilkinson JM. The use of bisphosphonates to meet orthopaedic challenges. Bone 2020; 137:115443. [PMID: 32445893 DOI: 10.1016/j.bone.2020.115443] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2020] [Revised: 05/14/2020] [Accepted: 05/19/2020] [Indexed: 11/17/2022]
Abstract
The anti-resorptive properties of bisphosphonates have been explored to manage several conditions that traditionally have required a surgical solution. In osteonecrosis, their use is predicated on the principle that bone collapse occurs during the revascularisation phase of the disease. If the associated resorptive activity were modulated, the resultant preserved joint architecture may improve clinical outcome and reduce the need for joint replacement. Pre-clinical and small-scale clinical studies have given non-conclusive support for this principle. Adequately powered clinical trials with relevant long-term endpoints are still required to firmly clarify the clinical efficacy of this treatment. Several clinical studies have shown that bisphosphonates can reduce periprosthetic bone loss and, in some situations, enhance implant fixation in the early period after joint replacement. This may be advantageous in settings where osseointegration is problematic. However, the ultimate goals of their use in joint replacement has been to reduce the incidence of late periprosthetic inflammatory osteolysis, the main cause of prosthesis failure. Population-based observational studies have associated bisphosphonate use with a lower incidence of revision surgery, supported by pre-clinical data. However, clinical trials have, to date, failed to demonstrate any efficacy for the human disease. The timing of bisphosphonate administration for secondary prevention after acute osteoporotic fracture has been subject to extensive investigation, with pre-clinical studies showing increased callus formation but decreased remodelling and no effect on the restoration of mechanical integrity of bone. Meta-analysis of clinical trial data indicates that early administration of bisphosphonate after acute fracture does not adversely affect fracture union, pain or functional outcomes. Finally, bisphosphonates have also been explored as a treatment for complex regional pain syndrome type-I. A recent meta-analysis has shown a beneficial effect on visual analogue scale pain scores, but an increase in mild adverse events.
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Affiliation(s)
- J Mark Wilkinson
- Department of Oncology and Metabolism, University of Sheffield, United Kingdom.
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7
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Vajapey SP, Morris J, Li D, Greco NG, Li M, Spitzer AI. Outcome Reporting Patterns in Total Hip Arthroplasty. JBJS Rev 2020; 8:e0197. [DOI: 10.2106/jbjs.rvw.19.00197] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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8
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Abstract
Prosthetic loosening has been debated for decades, both in terms of the timing and nature of the triggering events. Multiple radiostereometric studies of hip prostheses have now shown that early migration poses a risk of future clinical failure, but is this enough to explain late clinical loosening?To answer this question, the progression of loosening from initiation to radiographic detection is described; and the need for explanations other than early prosthetic loosening is analysed, such as stress-shielding, particle disease, and metal sensitivity.Much evidence indicates that prosthetic loosening has already been initiated during or shortly after the surgery, and that the subsequent progression of loosening is affected by biomechanical factors, fluid pressure fluctuations and inflammatory responses to necrotic cells and cell fragments, i.e. the concept of late loosening appears to be a misinterpretation of late-detected loosening.Clinical implications: atraumatic surgery and initial prosthetic stability are crucial in ensuring low risk of prosthetic loosening. Cite this article: EFORT Open Rev 2020;5:113-117. DOI: 10.1302/2058-5241.5.190014.
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Affiliation(s)
- Bengt Mjöberg
- Department of Orthopaedics, Lund University, Lund, Sweden
- Bengt Mjöberg, Västra Vallgatan 29, SE-27135 Ystad, Sweden.
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9
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Anderson PA, Morgan SL, Krueger D, Zapalowski C, Tanner B, Jeray KJ, Krohn KD, Lane JP, Yeap SS, Shuhart CR, Shepherd J. Use of Bone Health Evaluation in Orthopedic Surgery: 2019 ISCD Official Position. J Clin Densitom 2019; 22:517-543. [PMID: 31519473 DOI: 10.1016/j.jocd.2019.07.013] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2019] [Accepted: 07/16/2019] [Indexed: 02/07/2023]
Abstract
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.
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Affiliation(s)
- Paul A Anderson
- Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin UWMF Centennial Building, Madison, WI, USA.
| | - Sarah L Morgan
- UAB Osteoporosis Prevention and Treatment Clinic, University of Alabama Birmingham, Birmingham, AL, USA
| | - Diane Krueger
- University of Wisconsin, Osteoporosis Clinical Research Program, Madison, WI, USA
| | | | - Bobo Tanner
- Division Rheumatology, Vanderbilt University, Nashville, TN, USA
| | - Kyle J Jeray
- Greenville Health System, Deparment of Orthopaedic Surgery, Greenville, SC, USA
| | | | - Joseph P Lane
- Department of Orthopedic Surgery, Hospital for Special surgery, New York, USA
| | | | | | - John Shepherd
- University of Hawaii Cancer Center, University of Hawaii, Honolulu, HI, USA
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10
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Galea VP, Rojanasopondist P, Laursen M, Muratoglu OK, Malchau H, Bragdon C. Infographic: Total hip arthroplasty component wear and stability. Bone Joint J 2019; 101-B:758-759. [PMID: 31256662 DOI: 10.1302/0301-620x.101b7.bjj-2019-0683] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- V P Galea
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - P Rojanasopondist
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - M Laursen
- Department of Orthopaedics, Aalborg University Hospital, Aalborg, Denmark
| | - O K Muratoglu
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - H Malchau
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
| | - C Bragdon
- Harris Orthopaedic Laboratory, Massachusetts General Hospital, Boston, Massachusetts, USA.,Department of Orthopaedic Surgery, Harvard Medical School, Boston, Massachusetts, USA
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11
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Hu B, Wu H, Shi Z, Ying Z, Zhao X, Lin T, Hong J, Wang Y, Yang Y, Cai X, Yan S. Effects of sequential treatment with intermittent parathyroid hormone and zoledronic acid on particle-induced implant loosening: Evidence from a rat model. J Orthop Res 2019; 37:1489-1497. [PMID: 30644138 DOI: 10.1002/jor.24217] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 12/26/2018] [Indexed: 02/04/2023]
Abstract
Particle-induced implant loosening is a major challenge to long-term survival of joint prostheses. Administration of intermittent parathyroid hormone (PTH) has shown potential in the treatment of cases of early-stage periprosthetic osteolysis, while sequential administration of intermittent PTH (iPTH) and bisphosphonates (Bps) has achieved significant effects on treatment of postmenopausal osteoporosis. The objective of this study was to determine whether sequential treatment could preserve bone mass and implant fixation during a pathological course of peri-implant osteolysis in a rat model. Ninety male Sprague Dawley rats were randomly divided into nine groups, four of which were used for confirmation of establishment of the peri-implant osteolysis model at two time points, while the other five were used to determine the efficiency of the sequential treatment on peri-implant osteolysis. Implant fixation and peri-implant bone mass were evaluated using biomechanical testing, micro-CT analysis, and histology at 6 and 12 weeks postoperative. The biomechanical test demonstrated that the maximum loading force during a push-out test was significantly elevated in the sequential treatment group compared to the osteolysis group and iPTH withdrawal group at 12 weeks. Peri-implant bone morphology also indicated a robust increase in bone volume in the sequential treatment group. Sequential administration of iPTH and Bps was effective in preventing experimental peri-implant osteolysis, resulting in improved implant fixation and increased peri-implant bone volume. Clinical significance: The innovative application of sequential treatment in peri-implant osteolysis could be used clinically to improve the prognosis of patients with early-stage periprosthetic osteolysis. © 2019 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 37:1489-1497, 2019.
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Affiliation(s)
- Bin Hu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, People's Republic of China.,Orthopedic Research Institute of Zhejiang University, No. 88 Jiefang Road, Hangzhou, People's Republic of China
| | - Haobo Wu
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, People's Republic of China.,Orthopedic Research Institute of Zhejiang University, No. 88 Jiefang Road, Hangzhou, People's Republic of China
| | - Zhongli Shi
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, People's Republic of China.,Orthopedic Research Institute of Zhejiang University, No. 88 Jiefang Road, Hangzhou, People's Republic of China
| | - Zhimin Ying
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, People's Republic of China.,Orthopedic Research Institute of Zhejiang University, No. 88 Jiefang Road, Hangzhou, People's Republic of China
| | - Xiang Zhao
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, People's Republic of China.,Orthopedic Research Institute of Zhejiang University, No. 88 Jiefang Road, Hangzhou, People's Republic of China
| | - Tiao Lin
- Department of Orthopedic Surgery, First Affiliated Hospital of Sun Yat-sen University, No.58 Zhongshan 2nd Road, Guangzhou, People's Republic of China
| | - Jianqiao Hong
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, People's Republic of China.,Orthopedic Research Institute of Zhejiang University, No. 88 Jiefang Road, Hangzhou, People's Republic of China
| | - Yangxin Wang
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, People's Republic of China.,Orthopedic Research Institute of Zhejiang University, No. 88 Jiefang Road, Hangzhou, People's Republic of China
| | - Yute Yang
- Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Road, Hangzhou, People's Republic of China
| | - Xunzi Cai
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, People's Republic of China.,Orthopedic Research Institute of Zhejiang University, No. 88 Jiefang Road, Hangzhou, People's Republic of China
| | - Shigui Yan
- Department of Orthopedic Surgery, The Second Affiliated Hospital, Zhejiang University School of Medicine, No. 88 Jiefang Road, Hangzhou, People's Republic of China.,Orthopedic Research Institute of Zhejiang University, No. 88 Jiefang Road, Hangzhou, People's Republic of China
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12
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Belfrage O, Tägil M, Sundberg M, Kesteris U, Flivik G. Locally administered bisphosphonate in hip stem revisions using the bone impaction grafting technique: a randomised, placebo-controlled study with DXA and five-year RSA follow-up. Hip Int 2019; 29:26-34. [PMID: 29932001 DOI: 10.1177/1120700018781809] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND: Bisphosphonates have previously been shown to increase the density of impacted graft bone. In the present study we hypothesise that bisphosphonates also reduce early stem subsidence. We examined the effect of locally applied bisphosphonate to allografts on prosthetic micromotion and bone density in femoral stem revision with impaction grafting. METHODS: 37 patients were randomised to either clodronate or saline as local adjunct to the morsellised allograft bone. 24 patients were finally analysed per protocol and evaluated by dual-energy x-ray absorptiometry (DXA) during the first year and with radiostereometric analysis (RSA) for 5 years. RESULTS: There were no significant differences neither in bone density, nor in migratory behaviour between the groups. The femoral stems had subsided 3.6 mm in both groups (p = 0.99) at 5 years and there was no difference as measured over time with mixed models analysis. The clinical outcome was good in both groups. CONCLUSION: Clodronate as a local addendum to allograft bone in hip revision did not increase bone density or reduce micromotion of the implant.
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Affiliation(s)
- Ola Belfrage
- 1 Orthopaedics, Skåne University Hospital, Lund, Sweden.,2 Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Magnus Tägil
- 1 Orthopaedics, Skåne University Hospital, Lund, Sweden.,2 Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Martin Sundberg
- 1 Orthopaedics, Skåne University Hospital, Lund, Sweden.,2 Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Uldis Kesteris
- 1 Orthopaedics, Skåne University Hospital, Lund, Sweden.,2 Department of Clinical Sciences Lund, Lund University, Lund, Sweden
| | - Gunnar Flivik
- 1 Orthopaedics, Skåne University Hospital, Lund, Sweden.,2 Department of Clinical Sciences Lund, Lund University, Lund, Sweden
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13
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Bratengeier C, Bakker AD, Fahlgren A. Mechanical loading releases osteoclastogenesis-modulating factors through stimulation of the P2X7 receptor in hematopoietic progenitor cells. J Cell Physiol 2018; 234:13057-13067. [PMID: 30536959 DOI: 10.1002/jcp.27976] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Accepted: 11/20/2018] [Indexed: 01/20/2023]
Abstract
Mechanical instability of bone implants stimulate osteoclast differentiation and peri-implant bone loss, leading to prosthetic loosening. It is unclear which cells at the periprosthetic interface transduce mechanical signals into a biochemical response, and subsequently facilitate bone loss. We hypothesized that mechanical overloading of hematopoietic bone marrow progenitor cells, which are located near to the inserted bone implants, stimulates the release of osteoclast-inducing soluble factors. Using a novel in vitro model to apply mechanical overloading, we found that hematopoietic progenitor cells released adenosine triphosphate (ATP) after only 2 min of mechanical loading. The released ATP interacts with its specific receptor P2X7 to stimulate the release of unknown soluble factors that inhibit (physiological loading) or promote (supraphysiological loading) the differentiation of multinucleated osteoclasts derived from bone marrow cultures. Inhibition of ATP-receptor P2X7 by Brilliant Blue G completely abolished the overloading-induced stimulation of osteoclast formation. Likewise, stimulation of P2X7 receptor on hematopoietic cells by BzATP enhanced the release of osteoclastogenesis-stimulating signaling molecules to a similar extent as supraphysiological loading. Supraphysiological loading affected neither gene expression of inflammatory markers involved in aseptic implant loosening (e.g., interleukin-1β (IL-1β), IL-6, tumor necrosis factor-α, and PTGES2) nor expression of the osteoclast modulators receptor activator of nuclear factor κ-Β ligand and osteoprotegerin. Our findings suggest that murine hematopoietic progenitor cells are a potential key player in local mechanical loading-induced bone implant loosening via the ATP/P2X7-axis. Our approach identifies potential therapeutic targets to prevent prosthetic loosening.
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Affiliation(s)
- Cornelia Bratengeier
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
| | - Astrid D Bakker
- Department of Oral Cell Biology, ACTA, University of Amsterdam and Vrije Universiteit Amsterdam, Amsterdam Movement Sciences, Amsterdam, The Netherlands
| | - Anna Fahlgren
- Department of Clinical and Experimental Medicine, Division of Cell Biology, Linköping University, Linköping, Sweden
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Zampelis V, Belfrage O, Tägil M, Sundberg M, Flivik G. Decreased migration with locally administered bisphosphonate in cemented cup revisions using impaction bone grafting technique. Acta Orthop 2018; 89:17-22. [PMID: 28895428 PMCID: PMC5810827 DOI: 10.1080/17453674.2017.1371468] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Background and purpose - Impaction bone grafting (IBG) in revision hip surgery is an established method in restoring bone stock deficiencies. We hypothesized that local treatment of the morsellized allograft with a bisphosphonate in cemented revision would, in addition to increased bone density, also reduce the early migration of the cup as measured by radiostereometry (RSA). Patients and methods - 20 patients with aseptic cup loosening underwent revision using the IBG technique. The patients were randomized to either clodronate (10 patients) or saline (10 patients, control group) as local adjunct to the morsellized bone. The outcome was evaluated by dual-energy X-ray absorptiometry (DXA) during the first year regarding periacetabular bone density and with radiostereometric analysis (RSA) for the first 2 years regarding cup migration. Results - 2 patients were lost to follow-up: 9 patients remained in the clodronate and 9 in the control group. Less proximal migration was found in the clodronate group compared with the controls, measured both over time (mixed-models analysis, p = 0.02) as well as at the specified time points up to 2 years (0.22 mm and 0.59 mm respectively, p = 0.02). Both groups seemed to have stabilized at 1 year. We found similar bone mineral density measured by DXA, and similar RSA migration in the other directions. No cups were re-revised. Interpretation - Local treatment of the allograft bone with clodronate reduced early proximal migration of the revised cup but without any measurable difference in periacetabular bone density.
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Jakobsen T, Kold S, Shiguetomi-Medina J, Baas J, Soballe K, Rahbek O. Topical zoledronic acid decreases micromotion induced bone resorption in a sheep arthroplasty model. BMC Musculoskelet Disord 2017; 18:441. [PMID: 29132335 PMCID: PMC5683542 DOI: 10.1186/s12891-017-1802-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/03/2017] [Indexed: 12/28/2022] Open
Abstract
Background Initial micromotion of a total hip replacement is associated with aseptic loosening. The use of bisphosphonates could be one way to reduce peri-implant bone resorption induced by micromotion. Bisphosphonates compounds are inhibitors of bone resorption. The aim of this study was to investigate whether local treatment with bisphosphonate would reduce bone resorption and fibrous tissue around an experimental implant subjected to micromotion. Methods One micromotion implant were inserted into each medial femoral condyle in ten sheep. During each gait cycle the implant axially piston 0.5 mm. During surgery one of the femoral condyles were locally treated with 0.8 mg zoledronate. The other condyle served as control. Observation period was 12 weeks. Results Histological evaluation showed a fibrous capsule around both the control and bisphosphonate implants. Histomorphometrical analysis showed that 97% of the surface on both control and bisphosphonate implants were covered by fibrous tissue. However, the bisphosphonate was able to preserve bone in a 1 mm zone around the implants. Conclusion This study indicates that local treatment with bisphosphonate cannot prevent the formation of a fibrous capsule around an implant subjected to micromotion, but bisphosphonate is able to reduce resorption of peri-prosthetic bone.
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Affiliation(s)
- Thomas Jakobsen
- Orthopaedic Research Laboratory, Department of Orthopaedics, Aarhus University Hospital, Norrebrogade 44, Building 1A, DK-8000, Aarhus, Denmark. .,Department of Orthopaedics, Aalborg University Hospital, Aalborg, Denmark.
| | - Søren Kold
- Orthopaedic Research Laboratory, Department of Orthopaedics, Aarhus University Hospital, Norrebrogade 44, Building 1A, DK-8000, Aarhus, Denmark.,Department of Orthopaedics, Aalborg University Hospital, Aalborg, Denmark
| | - Juan Shiguetomi-Medina
- Orthopaedic Research Laboratory, Department of Orthopaedics, Aarhus University Hospital, Norrebrogade 44, Building 1A, DK-8000, Aarhus, Denmark
| | - Jorgen Baas
- Orthopaedic Research Laboratory, Department of Orthopaedics, Aarhus University Hospital, Norrebrogade 44, Building 1A, DK-8000, Aarhus, Denmark
| | - Kjeld Soballe
- Orthopaedic Research Laboratory, Department of Orthopaedics, Aarhus University Hospital, Norrebrogade 44, Building 1A, DK-8000, Aarhus, Denmark
| | - Ole Rahbek
- Orthopaedic Research Laboratory, Department of Orthopaedics, Aarhus University Hospital, Norrebrogade 44, Building 1A, DK-8000, Aarhus, Denmark
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16
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Amirhosseini M, Andersson G, Aspenberg P, Fahlgren A. Mechanical instability and titanium particles induce similar transcriptomic changes in a rat model for periprosthetic osteolysis and aseptic loosening. Bone Rep 2017; 7:17-25. [PMID: 28795083 PMCID: PMC5544474 DOI: 10.1016/j.bonr.2017.07.003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2016] [Revised: 07/24/2017] [Accepted: 07/26/2017] [Indexed: 01/30/2023] Open
Abstract
Wear debris particles released from prosthetic bearing surfaces and mechanical instability of implants are two main causes of periprosthetic osteolysis. While particle-induced loosening has been studied extensively, mechanisms through which mechanical factors lead to implant loosening have been less investigated. This study compares the transcriptional profiles associated with osteolysis in a rat model for aseptic loosening, induced by either mechanical instability or titanium particles. Rats were exposed to mechanical instability or titanium particles. After 15 min, 3, 48 or 120 h from start of the stimulation, gene expression changes in periprosthetic bone tissue was determined by microarray analysis. Microarray data were analyzed by PANTHER Gene List Analysis tool and Ingenuity Pathway Analysis (IPA). Both types of osteolytic stimulation led to gene regulation in comparison to unstimulated controls after 3, 48 or 120 h. However, when mechanical instability was compared to titanium particles, no gene showed a statistically significant difference (fold change ≥ ± 1.5 and adjusted p-value ≤ 0.05) at any time point. There was a remarkable similarity in numbers and functional classification of regulated genes. Pathway analysis showed several inflammatory pathways activated by both stimuli, including Acute Phase Response signaling, IL-6 signaling and Oncostatin M signaling. Quantitative PCR confirmed the changes in expression of key genes involved in osteolysis observed by global transcriptomics. Inflammatory mediators including interleukin (IL)-6, IL-1β, chemokine (C-C motif) ligand (CCL)2, prostaglandin-endoperoxide synthase (Ptgs)2 and leukemia inhibitory factor (LIF) showed strong upregulation, as assessed by both microarray and qPCR. By investigating genome-wide expression changes we show that, despite the different nature of mechanical implant instability and titanium particles, osteolysis seems to be induced through similar biological and signaling pathways in this rat model for aseptic loosening. Pathways associated to the innate inflammatory response appear to be a major driver for osteolysis. Our findings implicate early restriction of inflammation to be critical to prevent or mitigate osteolysis and aseptic loosening of orthopedic implants.
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Affiliation(s)
- Mehdi Amirhosseini
- Division of Cell Biology, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
- Corresponding author.
| | - Göran Andersson
- Division of Pathology, Department of Laboratory Medicine, Karolinska Institutet, Karolinska University Hospital, Huddinge, Sweden
| | - Per Aspenberg
- Orthopedics, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
| | - Anna Fahlgren
- Division of Cell Biology, Department of Clinical and Experimental Medicine, Faculty of Medicine and Health Sciences, Linköping University, Linköping, Sweden
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17
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Affiliation(s)
- Fares S Haddad
- The Bone & Joint Journal, 22 Buckingham Street, London, WC2N 6ET and NIHR University College London Hospitals Biomedical Research Centre, UK
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