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

Evaluation of Proximal Femoral Bone Mineral Density in Cementless Total Hip Arthroplasty: A 3-Arm Prospective Randomized Controlled Trial

BACKGROUND

Femoral stem design affects periprosthetic bone mineral density (BMD), which may impact long-term survival of cementless implants in total hip arthroplasty (THA). The aim of this study was to examine proximal femoral BMD in 3 morphologically different uncemented femoral stem designs to investigate whether any particular design resulted in better preservation of BMD.

METHODS

A total of 119 patients were randomized to receive a proximally coated collarless dual-taper wedge stem, a proximally coated collarless anatomic stem, or a fully coated collarless triple-taper stem. All surgeries were performed via the posterior approach, with mobilization on the day of surgery. Dual x-ray absorptiometry scans (Lunar iDXA, GE Healthcare) assessed BMD across the 7 Gruen zones preoperatively and at 6 weeks and 2 years postoperatively; if available, the native contralateral femur was also assessed as a control. Patient-reported outcomes of pain, function, and health were also assessed at these follow-ups.

RESULTS

Averaged across all stems, BMD increased in zones 1 (2.5%), 2 (17.1%), 3 (13.0%), 5 (10%), and 6 (17.9%) at 2 years. Greater preservation of BMD was measured on the lateral cortex (zone 2) for both the dual-taper wedge and anatomic stems (p = 0.019). The dual-taper wedge stem also demonstrated preservation of BMD in the medial calcar (zone 7), while the anatomic and triple-taper stems declined in this region; however, the difference did not reach significance (p = 0.059). Averaged across all stems, BMD decreased in the mid-diaphysis region, distal to the stem tip (zone 4). All stems performed similarly at the time of final follow-up with respect to the patient-reported outcomes.

CONCLUSIONS

This study demonstrated maintenance of femoral BMD after use of 3 different cementless femoral stem designs, with all achieving excellent improvements in patient-reported outcomes. The stems designed to load the proximal metaphyseal region resulted in higher BMD in that region. No significant stress-shielding was observed; however, longer follow-up is required to elucidate the impact of this finding on implant survivorship.

LEVEL OF EVIDENCE

Therapeutic Level I . See Instructions for Authors for a complete description of levels of evidence.

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.

Bone Health Management in Elective Orthopaedic Surgery: A Claims-Based Observational Study

Introduction

There are limited data on the management of bone health, including bone mineral density (BMD) evaluation and osteoporosis (OP) treatment, in patients undergoing elective orthopaedic surgeries.

Methods

This was a retrospective cohort study using administrative claims data from Symphony Health, PatientSource for patients aged ≥50 years with documented kyphoplasty/vertebroplasty (KP/VP), total knee arthroplasty (TKA), and total hip arthroplasty (THA). Risk stratification to identify patients at very high risk for fracture (VHRFx) was based on clinical practice guideline recommendations to the extent information on variables of interest were available from the claims database.

Results

A total of 251 919 patients met inclusion criteria: KP/VP (31 018), TKA (149 849), and THA (71 052). The majority were female (80.3%) with a mean (SD) age of 68.5 (7.5) years. Patients undergoing KP/VP were older and had a greater comorbidity burden associated with risk for falls, mobility issues, muscle weakness, and respiratory and cardiovascular diseases. In the 6 months before surgery, 11.8% of patients were tested and/or received treatment for OP. Patients undergoing KP/VP were more likely to be tested and/or treated (17.5%) than patients undergoing TKA (11.0%) or THA (10.9%). Overall, men had a lower rate of testing and/or treatment than women (4.6% vs 13.5%). In the 12 months before surgery, patients with an OP diagnosis and at VHRFx (30.8%) had a higher rate of treatment and/or testing than those without OP (11.5%), or those without OP but with a fracture in the year preceding surgery (10.2%).

Conclusions

Bone health management is suboptimal in patients undergoing elective orthopaedic surgeries and is worse in men than in women. Proper management of OP before and after surgery may improve outcomes.

Does Perioperative Use of Bisphosphonate Affect the Implant Revision Rate of Total Ankle Arthroplasty?

BACKGROUND

It is unknown whether perioperative bisphosphonate (BP) use reduces revision rates in total ankle replacement arthroplasty (TAR) although its effect has been demonstrated to be effective in reducing revision rates in total knee or hip replacement arthroplasty.

METHODS

We reviewed National Health Insurance Service data based on national health insurance service claims data and health care utilization, health screening, sociodemographic variables, medication history, operation codes, and mortality data for 50 million Koreans. From 2002 to 2014, 6391 of 7300 patients who underwent TAR were BP nonusers, whereas 909 patients were BP users. The revision rate according to BP medication and comorbidities was investigated. The Kaplan-Meier estimate and extended Cox proportional hazard model were also used.

RESULTS

The revision rate of TAR was 7.9% for BP users and 9.5% for BP nonusers, which showed no significant difference (P = .251). Implant survival over time decreased constantly. Adjusted hazard ratio for hypertension was 1.242 (P = .017), whereas other comorbidities such as diabetes had no effect on the revision rate of TAR.

CONCLUSION

We found that the perioperative BP use did not reduce the revision rate of TAR. Comorbidities (except hypertension) did not affect the revision rate of TAR. More research regarding various factors affecting the revision of TAR could be warranted.

LEVEL OF EVIDENCE

Level III, retrospective cohort study.

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.

Early Femoral Insufficiency Fractures After Primary Total Knee Arthroplasty

Background

Periprosthetic femur fracture following total knee arthroplasty (TKA) is a devastating complication. Although trauma-related periprosthetic femur fractures have been well studied, early atraumatic insufficiency periprosthetic fractures (IPFs) are gaining attention. We present the largest IPF series to date to better understand and prevent this complication.

Methods

A retrospective study of all patients who underwent a revision surgery for periprosthetic fracture within 6 months of primary TKA between 2007 and 2020 was performed. Patient demographics, preoperative radiographs, implant details, and fracture radiographs were reviewed. Alignment measurements and fracture characteristics were assessed.

Results

Sixteen patients met criteria (rate 0.05%), and 11 had posterior-stabilized TKAs. The mean age was 79 years, mean body mass index was 31 kg/m², and 94% (15/16) were female. Seven (47%) patients had a confirmed history of osteoporosis. IPF occurred on average 4 weeks (range, 4 days-13 weeks) after the index TKA. Overall, 12 of 16 (73%) had preoperative valgus deformities, and 11 patients (10 valgus, 1 varus) had preoperative deformities >10 degrees. A characteristic radiographic appearance of femoral condylar impaction and collapse was noted in 12 of 16 cases (75%); 11 of these 12 fractures (92%) involved the unloaded compartment based on preoperative varus/valgus deformity.

Conclusions

Patients who developed IPFs were most commonly elderly, obese women with osteoporosis and severe preoperative valgus deformities. The apparent mechanism of failure was overloading of previously unloaded osteopenic femoral condyle. In high-risk patients, the use of a cruciate-retaining femoral component or a femoral stem for a posterior-stabilized femur may be considered to help avoid this catastrophic complication.

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.

Zoledronic Acid Ameliorates the Bone Turnover Activity and Periprosthetic Bone Preservation in Cementless Total Hip Arthroplasty

The administration of zoledronic acid (ZA) to patients who received cementless total hip arthroplasty (THA) has been reported to reduce bone turnover markers (BTMs) and increase bone mineral density (BMD). The effects of two-dose ZA versus placebo on cementless THA patients were analyzed in this five-year extension study. Alkaline phosphatase (ALP), osteocalcin (OC), procollagen 1 intact N-terminal propeptide (P1NP), serum calcium, renal function, radiological findings, and functional outcomes were compared in 49 patients, and the periprosthetic BMD of seven Gruen zones were compared in 19 patients. All the patients had normal renal function and calcium levels at their final follow-up. The mean ALP level in the ZA group was significantly lower at the fifth year, mean OC levels were significantly lower at the second and fifth year, and mean P1NP levels were significantly lower from 6 weeks to 5 years as compared with the control group. Fifth-year BMD levels were not found to be different between the ZA and control groups. The BMD Change Ratios in the ZA group were significantly increased in Gruen zone 6 at 1, 2, and 5 years. Our study results suggest that short-term ZA treatment with a subsequent 4-year drug holiday may inhibit serum BTMs and provide periprosthetic bone preservation at five years without adverse events.

Fragility fracture following total hip arthroplasty

BACKGROUND

While periprosthetic fractures following total hip arthroplasty (THA) are a well-known phenomenon for orthopedic surgeons, fragility fractures following THA are also a significant, though less studied, concern. Furthermore, patients who have undergone THA have several additional risk factors for fragility fractures, including motor weakness, bone atrophy, and limping. The aims of this study were to evaluate the incidence of fragility fractures following THA and to clarify the characteristics of these fractures.

METHODS

This study included 5678 primary THA procedures in 4589 female patients. This study evaluated body morphology data, disease type leading to THA, Japanese Orthopaedic Association hip score, range of motion of the hip joint, and medical history. Distal radius and patella fractures were defined as fragility fractures. Risk factors for fragility fractures after THA were calculated by comparing the fragility fracture group with the non-fracture group.

RESULTS

Fifty-three fragility fractures were confirmed in 53 patients (distal radius fracture: 32 fractures in 32 patients, patella fracture: 21 fractures in 21 patients). In the univariate analysis, the following eight risk factors for fragility fractures were significantly different between the groups: height, weight, follow-up period, developmental dysplasia of the hip, primary osteoarthritis, abduction before THA, internal rotation before THA, and external rotation before THA. Medical histories were not significantly different between the groups. There was no difference in any study factor and in the time of occurrence between the radius fractures and patella fractures analyzed as fragility fractures.

CONCLUSIONS

This study revealed that there are significant preoperative factors of fragility fractures following THA. These factors will serve as useful data for THA treatment strategies, preoperative explanations, and future studies.

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.

Team Approach: Preoperative Management of Metabolic Conditions in Total Joint Replacement

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Total joint arthroplasties (TJAs) of the knee and hip have been considered 2 of the most successful surgical procedures performed to date.

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Frailty is defined as increased vulnerability to adverse outcomes with physiologic stress.

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Preoperative optimization of frailty and metabolic bone conditions, including osteoporosis, vitamin D deficiency, and diabetes, through a multidisciplinary approach can help improve outcomes and minimize costs after TJA.

Alendronate enhances osseointegration in a murine implant model

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

Intra-operative Clodronate Rinsing Improves the Integration of the Femoral Stem in a Prospective, Double-blinded, Randomized, Placebo-controlled Clinical RSA-study

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

Inhibition Effect of Zoledronate on the Osteoclast Differentiation of RAW264.7 Induced by Titanium Particles

OBJECTIVE

This study is aimed at studying the effect of zoledronate (ZOL) on the differentiation of osteoclast precursor RAW264.7 cells induced by titanium (Ti) particles and explores the possibility of preventing and treating periprosthetic osteoporosis using ZOL.

METHODS

RAW264.7 cells were cultured in vitro. Ti particles were prepared. The cell proliferation curve of RAW264.7 cells was plotted using the MTT assay to find the best concentration of ZOL for intervention. The cells were divided into three groups: control, Ti particles, and Ti particles+ZOL. The cell morphology was observed using tartaric acid-resistant acid phosphatase (TRAP) staining, and the activity of TRAP in cell supernatant was determined using the biochemical method. The number of bone resorption lacunae was detected using toluidine blue staining. The mRNA expression of RANK, NFATcl, CAII, and MMP-9 was detected using real-time polymerase chain reaction. The protein expression of RANK, NFATcl, and MMP-9 was detected using Western blot analysis.

RESULTS

Ti particles stimulated the differentiation of RAW264.7 cells into osteoclasts. They also increased the activity of TRAP, number of bone resorption lacunae, and mRNA and protein expression of RANK, NFATcl, and MMP-9. However, ZOL could suppress the effect of TI particles on the osteoclast differentiation of RAW264.7 cells.

CONCLUSIONS

ZOL could effectively inhibit the differentiation of RAW264.7 cells into osteoclasts induced by Ti particles, decrease the activity of TRAP, reduce the number of bone resorption lacunae, and decrease the mRNA and protein expression of RANK, NFATcl, and MMP-9. Hence, it may be a promising candidate for preventing and treating periprosthetic osteoporosis after the artificial joint operation.

Contributing factors to the initial femoral stem migration in cementless total hip arthroplasty of postmenopausal women

In cementless total hip arthroplasty (THA), femoral stems rely on the initial press-fit fixation against cortical bone to achieve osseointegration. Decreased bone mineral density (BMD) in postmenopausal women poses natural difficulties in achieving axial and rotational femoral stem stability. The present study examined contributing demographic, surgery-related and postoperative factors in determining the magnitude of early stem migration prior to osseointegration. A prospective cohort of 65 postmenopausal women with hip osteoarthritis (Dorr type A or B femur anatomy) underwent THA with implantation of an uncemented parallel-sided femoral component. Postoperative femoral stem translation and rotation were measured using model-based radiostereometric analysis. Based on analysis of covariance, which controlled for outliers and randomized antiresorptive treatment with denosumab or placebo, none of the analyzed demographics (including BMI) and surgery-related variables (including the stem-to-canal fil ratio) was associated with stem subsidence. Stem subsidence (mean 1.8 mm, 95% CI 1.2 to 2.4) occurred even in women with normal hip BMD. Total hip BMD and postoperative walking activity (measured three months after surgery) were significantly associated with stem rotation, and height acted as a confounding factor. The effect of walking activity on stem rotation was significant at 5 months (p = 0.0083) and at 11 months (p = 0.0117). This observation confirms the previous results of instrumented hip prostheses on torsional moments affecting stems during daily activities. High-resolution imaging modalities of local bone quality are needed to explore reasons for RSA-measurable stem subsidence even in women with normal hip BMD.

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.

An Assessment of Randomized Controlled Trial Quality in The Journal of Bone & Joint Surgery: Update from 2001 to 2013

BACKGROUND

The quality of reporting of randomized controlled trials (RCTs) published in The Journal of Bone & Joint Surgery (JBJS) from 1988 to 2000 was previously analyzed. The purpose of this current study was to analyze the quality of reporting of RCTs published in JBJS from 2001 to 2013 to identify trends over time and potential areas of improvement for future clinical trials.

METHODS

A manual search of the JBJS database identified RCTs published between January 2001 and December 2013. Quality assessments, using the Detsky quality-of-reporting index (Detsky score), a modified Cochrane risk-of-bias tool, and abstraction of relevant data identifying predictors of quality, were conducted.

RESULTS

A total of 5,780 publications were identified in JBJS from 2001 to 2013, with 285 RCTs (4.9%), representing an increase from the prior 13-year period. The overall mean transformed Detsky score (and standard error) increased significantly (p < 0.001) from 68.1% ± 1.67% to 76.24% ± 0.72%. The percentage of multicenter RCTs decreased from 67% to 31%. The percentage of positive trials also decreased from 80% to 50.5%, as did the mean sample size (212 to 166). Regression analysis indicated that trials with an epidemiologist as the first author and nonsurgical trials were significantly associated (p = 0.001) with a higher overall trial quality score. The categories of the lowest mean methodology scores were randomization and concealment, eligibility criteria, and reasons for patient exclusion, as identified with the Detsky score, and patient and assessor blinding, as identified with the risk-of-bias assessment.

CONCLUSIONS

The quantity and quality of published RCTs in JBJS have increased in the 2001 to 2013 time period compared with the previous time period. Although these improvements are encouraging, trends to smaller, single-center trials were also observed. To efficiently determine the efficacy of orthopaedic treatments and limit bias, high-quality randomized trials of appropriate sample size and rigorous design are needed.

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.

The use of bisphosphonates to meet orthopaedic challenges

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.

Bone Mineral Density and Cortical-Bone Thickness of the Distal Radius Predict Femoral Stem Subsidence in Postmenopausal Women

BACKGROUND

The distal radius is an optional site for evaluation of bone quality in postmenopausal women before cementless total hip arthroplasty. We hypothesized that dual-energy X-ray absorptiometry (DXA) and pulse-echo ultrasonometry of the distal radius may help discriminate subjects at high risk of femoral stem subsidence.

METHODS

A prospective cohort of postmenopausal women with primary hip osteoarthritis underwent total hip arthroplasty with implantation of a parallel-sided femoral stem. Postoperative stem migration was measured using radiostereometric analysis. Preoperatively, subjects had multisite DXA measurement of bone mineral density (BMD) and pulse-echo ultrasonometry of the cortical-bone thickness. The diagnostic abilities of these methods to discriminate <2 mm and ≥2 mm femoral stem subsidence were tested.

RESULTS

The accuracy of the distal radius BMD and cortical-bone thickness of the distal radius were moderate (area under the curve, 0.737 and 0.726, respectively) in discriminating between <2 mm and ≥2 mm stem subsidence. Women with low cortical-bone thickness of the radius were more likely (odds ratio = 6.7; P = .002) to develop stem subsidence ≥2 mm. These subjects had lower total hip BMD (P = .007) and reduced thickness of the medial cortex of the proximal femur (P = .048) with lower middle (P < .001) and distal (P = .004) stem-to-canal fill ratios.

CONCLUSION

Femoral stem stability and resistance to subsidence are sensitive to adequate bone stock and unaltered anatomy. DXA and pulse-echo ultrasonometry of the distal radius may help discriminate postmenopausal women at high risk of stem subsidence.

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.

Denosumab Prevents Early Periprosthetic Bone Loss After Uncemented Total Hip Arthroplasty: Results from a Randomized Placebo-Controlled Clinical Trial

Implant loosening is the most common indication for revision surgery after total hip arthroplasty (THA). Although bone resorption around the implants plays a pivotal role in the pathophysiology of loosening, it is unknown whether potent early inhibition of osteoclasts could mitigate this process and thus reduce the need for revision surgery. We performed a randomized, double-blind, placebo-controlled phase 2 trial in 64 patients aged 35 to 65 years with unilateral osteoarthritis of the hip. They underwent surgery with an uncemented THA and were randomized to either two subcutaneous doses of denosumab (n = 32) or placebo (n = 32) given 1 to 3 days and 6 months after surgery. Patients were followed for 24 months. Primary outcome was periprosthetic bone mineral density (BMD) of the hip at 12 months as measured by dual-energy X-ray absorptiometry (DXA). In addition, [¹⁸ F] sodium fluoride positron emission tomography/CT (F-PET) was performed in half of the patients for analysis of periprosthetic standardized uptake value (SUV). Analyses were made according to intention-to-treat principles. The trial was registered at ClinicalTrials.gov 2011-001481-18, NCT01630941. Denosumab potently inhibited early periprosthetic bone loss. After 12 months, BMD in the denosumab group was 32% (95% confidence interval [CI] 22-44) higher in Gruen zone 7 and 11% (95% CI 8-15) higher in zones 1 to 7. After 24 months, the difference in BMD between groups had decreased to 15% (95% CI 4-27) in zone 7 and 4% (95% CI 0-8) in zones 1 to 7. In both groups, SUV increased after surgery, but the increase was less pronounced in the denosumab group. Biochemical markers of bone metabolism decreased in the denosumab group in the first 12 months, but a rebound effect with marker concentrations above baseline was observed after 24 months. Denosumab potently prevents early periprosthetic bone loss after uncemented THA; however, the effect diminishes after discontinuation of treatment. Further research is needed to determine whether this bone loss will prove to be of clinical importance and, if so, whether the positive effect observed in this study could be preserved by either prolonged treatment with denosumab or additional antiresorptive treatment. © 2019 American Society for Bone and Mineral Research. © 2019 American Society for Bone and Mineral Research.

Diagnosis and management of implant debris-associated inflammation

Introduction: Total joint replacement is one of the most common, safe, and efficacious operations in all of surgery. However, one major long-standing and unresolved issue is the adverse biological reaction to byproducts of wear from the bearing surfaces and modular articulations. These inflammatory reactions are mediated by the innate and adaptive immune systems.Areas covered: We review the etiology and pathophysiology of implant debris-associated inflammation, the clinical presentation and detailed work-up of these cases, and the principles and outcomes of non-operative and operative management. Furthermore, we suggest future strategies for prevention and novel treatments of implant-related adverse biological reactions.Expert opinion: The generation of byproducts from joint replacements is inevitable, due to repetitive loading of the implants. A clear understanding of the relevant biological principles, clinical presentations, investigative measures and treatments for implant-associated inflammatory reactions and periprosthetic osteolysis will help identify and treat patients with this issue earlier and more effectively. Although progressive implant-associated osteolysis is currently a condition that is treated surgically, with further research, it is hoped that non-operative biological interventions could prolong the lifetime of joint replacements that are otherwise functional and still salvageable.

Total hip arthroplasty in patients with chronic liver disease: A systematic review

INTRODUCTION

Chronic liver disease (CLD) is a significant and increasingly prevalent co-morbidity in patients undergoing total hip arthroplasty (THA). These patients may develop metabolic bone disease (MBD) and systemic dysfunction, which pose challenges to THA surgery. This systematic review of literature aims to examine clinical outcomes and complications in patients with CLD undergoing THA and provide evidence-based approaches as to the optimization of their perioperative care.

METHODS

A Pubmed search was performed, identifying eight studies on 28 514 THAs for inclusion. Two additional studies reported on 44 patients undergoing THA post liver transplant. These were reviewed separately.

RESULTS

Increased early perioperative complications are reported recurrently. Review of long-term complications demonstrates an increased postoperative infection rate of 0.5% (p < 0.001) and perioperative mortality of 4.1% (p < 0.001). The need for revision surgery is more frequent at 4% (p < 0.001). Aetiology of need for revision surgery included; periprosthestic infection (70%), aseptic loosening (13%), instability (13%), periprosthetic fracture (2%) and liner wear (2%). THA in patients with liver transplants seems to offer functional improvement; however, no studies have formally assessed functional outcomes in the patient with active CLD.

DISCUSSION

A multidisciplinary perioperative approach is suggested in order to minimize increased complication risks. Specific measures include optimizing haemoglobin and taking measures to reduce infection. This review also highlights gaps in available literature and guides future research to appraise functional outcomes, further detail long-term failure reasons and study any differences in outcomes and complications based on the range of operative approaches and available implant choices.

Effect of Denosumab on Femoral Periprosthetic BMD and Early Femoral Stem Subsidence in Postmenopausal Women Undergoing Cementless Total Hip Arthroplasty

Antiresorptive denosumab is known to improve the quality and strength of cortical bone in the proximal femurs of osteoporotic women, but its efficacy in preventing periprosthetic bone loss and reducing femoral stem migration has not been studied in women undergoing cementless total hip arthroplasty. We conducted a single-center, randomized, double-blinded, placebo-controlled trial of 65 postmenopausal women with primary hip osteoarthritis and Dorr type A or B proximal femur anatomy. The patients randomly received subcutaneous injections of denosumab 60 mg or placebo once every 6 months for 12 months, starting 1 month before surgery. The primary endpoint was the change in bone mineral density (BMD) of the proximal femur (Gruen zone 7) at week 48, and the secondary endpoint was stem subsidence measured by radiostereometric analysis (RSA) at week 48. Exploratory endpoints included changes in BMDs of the contralateral hip, lumbar spine and distal radius, serum levels of bone turnover markers, walking speed, walking activity, patient-reported outcome measures, and radiographic assessment of stem osseointegration. The participants underwent vertebral-fracture assessment in an extension safety study at 3 years. Denosumab significantly decreased bone loss in the medial femoral neck (zone 7) and increased periprosthetic BMD in the greater trochanteric region (zone 1) and lesser trochanteric region (zone 6). Denosumab did not reduce temporary femoral stem migration. The migration occurred mainly during the settling period (0 to 12 weeks) after implantation of the prosthesis. All of the stems osseointegrated, as evaluated by RSA and radiographs. There were no intergroup differences in functional recovery. Discontinuation of denosumab did not lead to any adverse events. In conclusion, denosumab increased periprosthetic BMD in the clinically relevant regions of the proximal femur, but the treatment response was not associated with any reduction of initial stem migration. © 2019 The Authors. JBMR Plus published by Wiley Periodicals, Inc. on behalf of the American Society for Bone and Mineral Research.

The use of bisphosphonates after joint arthroplasty is associated with lower implant revision rate

PURPOSE

This study hypothesized that the use of bisphosphonates (BPs) after total joint arthroplasty (TJA) is associated with a lower implant revision rate. This study aimed (1) to investigate the association between BP use and the revision rate of TJA and (2) to determine the relationship between the medication period and the revision rate of TJA.

METHODS

National Health Insurance Service data on surgeries, medications, diagnoses, and screenings of 50 million Koreans were reviewed. People who underwent TJA in the period from 2002 to 2012 were identified and followed until 2016. During that period, 331,660 patients underwent total knee arthroplasty (TKA), and 56,043 patients underwent total hip arthroplasty (THA). Among them, 8447 knee patients (2.5%) and 2851 hip patients (5.0%) required revision surgery due to aseptic loosening. Demographic data, the duration of BP medication, and comorbidities were identified. The rate of revision surgery according to BP medication was investigated. The extended Cox proportional hazard model was used to evaluate the effect of the medication period.

RESULTS

The rate of TKA revision was 1.4% for BP users and 2.9% for BP non-users (p < 0.001). The THA revision rate was 2.8% and 5.3% for BP users and non-users, respectively (p < 0.001). The hazard ratio (HR) of revision was significantly lower in patients who took BP medication for more than one year (TKA HR = 0.472, 95% CI [0.350-0.637]; THA HR = 0.490, 95% CI [0.247-0.972]) compared to that in short-term users (less than 1 year).

CONCLUSIONS

The use of BPs after TJA was associated with a lower revision rate. The use of BPs for more than one year further reduced the risk of revision. Bisphosphonate use can be highly recommended to reduce the revision rate of TJA.

LEVEL OF EVIDENCE

Retrospective cohort study, Level III.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

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

INTRODUCTION

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Restoration of proximal periprosthetic bone loss by denosumab in cementless total hip arthroplasty

Denosumab contributed to the restoration of proximal periprosthetic bone loss around the femoral stem that were measured using a DEXA, especially in zone 7, at 1 year after cementless THA in elderly osteoporotic patients.

INTRODUCTION

Although bone quality is an important issue in elderly osteoporotic patients who underwent total hip arthroplasty (THA) with a cementless stem, periprosthetic bone mineral density (BMD) in the proximal femur has been reported to be decreased by 15-40% postoperatively. Some authors have examined the use of several types of bisphosphonates to prevent decreases in BMD in the proximal femur after cementless THA; however, few reports have demonstrated success in restoring BMD in the proximal medial femoral bone, such as zone 7.

METHODS

We conducted prospective study comparing patients who underwent cementless THA administered with denosumab (10 patients) and without denosumab (10 patients). BMD around the femoral stem were measured using a DEXA immediately after surgery, and at 6 months and at 1 year after surgery. No difference was found between the two groups referred to the patient's demographic data.

RESULTS

We found that denosumab displayed definitive effects in increasing the % change in periprosthetic BMD at zone 7 by an average of 7.3% in patients with cementless THA, compared to control group who were given only vitamin D.

CONCLUSION

Denosumab is one of a number of anti-osteoporotic agents to have a definitive effect on the restoration of proximal periprosthetic bone loss, especially in zone 7, after cementless THA. Denosumab contributed to the restoration of decreased periprosthetic BMD to normal levels. As the decrease in BMD in the proximal femur after THA is considered to be apparent at 6-12 months after surgery, it is believed that prevention of the deterioration of bone quality is important in the proximal femur immediately after cementless THA for elderly female patients with osteoporosis.

A long-lasting bisphosphonate partially protects periprosthetic bone, but does not enhance initial stability of uncemented femoral stems: A randomized placebo-controlled trial of women undergoing total hip arthroplasty

Low bone quality may compromise the success of cementless total hip arthroplasty in high-risk patients such as elderly women. Zoledronic acid is a long-lasting antiresorptive agent, which is known to reduce short-term periprosthetic bone loss. However, its effect on femoral stem stability is not well known. Forty-nine female patients with a mean age of 68 years (range, 51-85 years) scheduled to undergo cementless total hip arthroplasty due to osteoarthritis were randomized in this double-blind, placebo-controlled trial to receive a single postoperative infusion of zoledronic acid or placebo. Patients were evaluated for up to four years postoperatively for femoral stem migration measured by radiostereometric analysis, bone mineral density (BMD) measured by dual X-ray absorptiometry, functional recovery, and patient-reported outcome scores. Implant survival was determined at nine years postoperatively. Zoledronic acid did not reduce the femoral stem migration that occurred predominantly during the settling period of the first 3-6 months. Subsequently, all femoral stems were radiographically osseointegrated. Zoledronic acid maintained periprosthetic BMD, while the expected loss of periprosthetic bone during the first 12 months was found in controls. Thereafter, periprosthetic BMD of Gruen zone 7 decreased even in the zoledronic acid group but remained 14.6% higher than that in the placebo group at four years postoperatively. Functional recovery was comparable across the groups. At nine years postoperatively, no revision arthroplasty had been performed. In conclusion, in women at high-risk for low BMD, zoledronic acid had a long-lasting, partially protective effect on periprosthetic bone loss, but the treatment did not enhance the initial femoral stem stability.

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

Background

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

Methods

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

Results

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

Conclusion

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

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

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

OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Current methods of preventing aseptic loosening and improving osseointegration of titanium implants in cementless total hip arthroplasty: a review

Hip osteoarthritis is the most common joint disorder, and is represented by a degenerative process, resulting in pain and functional impairment. If conservative treatment for hip osteoarthritis fails, the only remaining option is hip arthroplasty. Despite good survival of implants, loosening of components is the most common complication. This leads to revision surgeries, which are technically demanding, expensive, and result in a low satisfaction rate. Uncemented hip replacements require proper osseointegration for increased survival. Physical characteristics of implants include biocompatibility, Young’s modulus of elasticity, strength, and corrosion resistance, and each influence fixation of implants. Moreover, implant surface treatments, pore size, pore density, and femoral stem design should be appropriately selected. Patients’ optimization of obesity, osteoporosis, cardiovascular disease, psychotic disorders, and smoking cessation are associated with a higher survival of implants. Surgical factors, such as approach, drilling and rasping, acetabular bone coverage, acetabular cup positioning, and implant size, also affect survival of implants. Avoiding drugs, which may impair osseointegration of implants, and having an appropriate rehabilitation protocol are important. Future directions include anabolic and anti-catabolic bone-acting drugs to enhance osseointegration of implants. Comprehensive knowledge of the factors mentioned above is important for preventing aseptic loosening, with important socioeconomic consequences.

Periprosthetic femoral bone loss in total hip arthroplasty: systematic analysis of the effect of stem design

INTRODUCTION

Periprosthetic bone loss may lead to major complications in total hip arthroplasty (THA), including loosening, migration, and even fracture. This study analysed the influence of femoral implant designs on periprosthetic bone mineral density (BMD) after THA.

METHODS

The results of all previous published studies reporting periprosthetic femoral BMD following THA were compiled. Using these results, we compared percent changes in bone loss as a function of: femoral stem fixation, material, and geometry.

RESULTS

The greatest bone loss was in the calcar region (Gruen Zone 7). Overall, cemented stems had more bone loss distally than noncemented stems, while noncemented stems had more proximal bone loss than cemented stems. Within noncemented stems, cobalt-chromium (CoCr) stems had nearly double the proximal bone loss compared to titanium (Ti) alloy stems. Finally, within noncemented titanium alloy group, straight stems had less bone loss than anatomical, tapered, and press-fit designs.

DISCUSSION

The findings from the present study quantified percent changes in periprosthetic BMD as a function of fixation method, alloy, and stem design. While no one stem type was identified as ideal, we now have a clearer understanding of the influence of stem design on load transfer to the surrounding bone.

Systemic drugs that influence titanium implant osseointegration

Titanium implants are widely used on an increasing number of patients in orthopedic and dental medicine. Despite the good survival rates of these implants, failures that lead to important socio-economic consequences still exist. Recently, research aimed at improving implant fixation, a process called osseointegration, has focused on a new, innovative field: systemic delivery of drugs. Following implant fixation, patients receive systemic drugs that could either impair or enhance osseointegration; these drugs include anabolic and anti-catabolic bone-acting agents in addition to new treatments. Anabolic bone-acting agents include parathyroid hormone (PTH) peptides, simvastatin, prostaglandin EP4 receptor antagonist, vitamin D and strontium ranelate; anti-catabolic bone-acting agents include compounds like calcitonin, biphosphonates, RANK/RANKL/OPG system and selective estrogen receptor modulators (SERM). Examples of the new therapies include DKK1- and anti-sclerostin antibodies. All classes of treatments have proven to possess positive impacts such as an increase in bone mineral density and on osseointegration. In order to prevent complications from occurring after surgery, some post-operative systemic drugs are administered; these can show an impairment in the osseointegration process. These include nonsteroidal anti-inflammatory drugs, proton pump inhibitors and selective serotonin reuptake inhibitors. The effects of aspirin, acetaminophen, opioids, adjuvants, anticoagulants and antibiotics in implant fixations are not fully understood, but studies are being carried out to investigate potential ramifications. It is currently accepted that systemic pharmacological agents can either enhance or impair implant osseointegration; therefore, proper drug selection is essential. This review aims to discuss the varying effects of three different classes of treatments on improving this process.

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

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

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

BACKGROUND

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

QUESTIONS/PURPOSES

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

LEVEL OF EVIDENCE

Level III, therapeutic study.

Lower periprosthetic bone loss and good fixation of an ultra-short stem compared to a conventional stem in uncemented total hip arthroplasty

BACKGROUND AND PURPOSE

We hypothesized that an ultra-short stem would load the proximal femur in a more physiological way and could therefore reduce the adaptive periprosthetic bone loss known as stress shielding.

PATIENTS AND METHODS

51 patients with primary hip osteoarthritis were randomized to total hip arthroplasty (THA) with either an ultra-short stem or a conventional tapered stem. The primary endpoint was change in periprosthetic bone mineral density (BMD), measured with dual-energy x-ray absorptiometry (DXA), in Gruen zones 1 and 7, two years after surgery. Secondary endpoints were change in periprosthetic BMD in the entire periprosthetic region, i.e. Gruen zones 1 through 7, stem migration measured with radiostereometric analysis (RSA), and function measured with self-administered functional scores.

RESULTS

The periprosthetic decrease in BMD was statistically significantly lower with the ultra-short stem. In Gruen zone 1, the mean difference was 18% (95% CI: -27% to -10%). In zone 7, the difference was 5% (CI: -12% to -3%) and for Gruen zones 1-7 the difference was also 5% (CI: -9% to -2%). During the first 6 weeks postoperatively, the ultra-short stems migrated 0.77 mm more on average than the conventional stems. 3 months after surgery, no further migration was seen. The functional scores improved during the study and were similar in the 2 groups.

INTERPRETATION

Up to 2 years after total hip arthroplasty, compared to the conventional tapered stem the ultra-short uncemented anatomical stem induced lower periprosthetic bone loss and had equally excellent stem fixation and clinical outcome.

Anterior and Anterolateral Approaches for THA Are Associated With Lower Dislocation Risk Without Higher Revision Risk

BACKGROUND

Lack of consensus continues regarding the benefit of anteriorly based surgical approaches for primary total hip arthroplasty (THA). The purpose of this study was to evaluate the risk of aseptic revision, septic revision, and dislocations for various approaches used in primary THAs from a community-based healthcare organization.

QUESTIONS/PURPOSES

(1) What is the incidence of aseptic revision, septic revision, and dislocation for primary THA in a large community-based healthcare organization? (2) Does the risk of aseptic revision, septic revision, and dislocation vary by THA surgical approach?

METHODS

The Kaiser Permanente Total Joint Replacement Registry was used to identify primary THAs performed between April 1, 2001 and December 31, 2011. Endpoints were septic revisions, aseptic revisions, and dislocations. The exposure of interest was surgical approach (posterior, anterolateral, direct lateral, direct anterior). Patient, implant, surgeon, and hospital factors were evaluated as possible confounders. Survival analysis was performed with marginal multivariate Cox models. Hazard ratios (HRs) and 95% confidence intervals (CIs) are reported. A total of 42,438 primary THAs were available for analysis of revision outcomes and 22,237 for dislocation. Median followup was 3 years (interquartile range, 1-5 years). The registry's voluntary participation is 95%. The most commonly used approach was posterior (75%, N = 31,747) followed by anterolateral (10%, N = 4226), direct anterior (4%, N = 1851), and direct lateral (2%, N = 667).

RESULTS

During the study period 785 hips (2%) were revised for aseptic reasons, 213 (0.5%) for septic reasons, and 276 (1%) experienced a dislocation. The revision rate per 100 years of observation was 0.54 for aseptic revisions, 0.15 for septic revisions, and 0.58 for dislocations. There were no differences in adjusted risk of revision (either septic or aseptic) across the different THA approaches. However, the anterolateral approach (adjusted HR, 0.29; 95% CI, 0.13-0.63, p = 0.002) and direct anterior approach (adjusted HR, 0.44; 95% CI, 0.22-0.87, p = 0.017) had a lower risk of dislocation relative to the posterior approach. There were no differences in any of the outcomes when comparing the direct anterior approach with the anterolateral approach.

CONCLUSIONS

Anterior and anterolateral surgical approaches had the advantage of a lower risk of dislocation without increasing the risk of early revision.

LEVEL OF EVIDENCE

Level III, therapeutic study.

Bisphosphonate Use and Risk of Implant Revision after Total Hip/Knee Arthroplasty: A Meta-Analysis of Observational Studies

Objective

Several studies investigated the association between bisphosphonate use and the risk of implant revision after total hip or knee arthroplasty (THA or TKA); However, the findings were inconsistent. We performed this meta-analysis to evaluate the overall relative risk of such an event.

Methods

We searched the PubMed, EMBASE and Cochrane library databases to identify relevant publications on April 22, 2015. To calculate the pooled risk ratios (RRs) with 95% confidential intervals (CIs), a fixed- or random-effects model was applied based on the heterogeneity across studies.

Results

Three cohort studies and one case-control study were included in this meta-analysis. Compared with the bisphosphonate nonusers, the patients who used bisphosphonates for a long period of time had a significantly decreased risk of implant revision after THA/TKA (summary adjusted RR = 0.48, 95% CI: 0.38–0.61), and the summary adjusted RRs for the users who underwent THA and those who underwent TKA were 0.47 (95% CI: 0.36–0.61) and 0.45 (95% CI: 0.21–0.95), respectively.

Conclusions

Long-term use of bisphosphonates is correlated with a significantly decreased risk of implant revision after THA/TKA. However, due to limited number of the included studies, the findings of the present study should be treated with caution. More well-designed studies are required to further confirm our findings.

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

BACKGROUND AND PURPOSE

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

PATIENTS AND METHODS

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

RESULTS

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

INTERPRETATION

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

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

Background

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

Method

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

Results

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

Conclusion

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