Skip to content

Advertisement

  • Systematic review
  • Open Access

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

Contributed equally
Journal of Orthopaedic Surgery and Research201813:225

https://doi.org/10.1186/s13018-018-0918-7

  • Received: 17 June 2018
  • Accepted: 20 August 2018
  • Published:

Abstract

Background

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

Methods

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

Results

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

Conclusion

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

Keywords

  • Bisphosphonates
  • Total hip arthroplasty
  • Bone resorption
  • Meta-analysis

Background

Total hip arthroplasty (THA) has become the most effective therapy for severe osteoarthritis [13]. It was estimated that approximately 572,000 patients will demand primary THA in the USA by the year 2030 [4]. Periprosthetic bone resorption following THA was a well-known phenomenon [5]. It may increase late-occurring periprosthetic fractures [6]. Moreover, bone resorption may decrease the primary stability of the implant and lead to progressive implant loosening [7], which was considered as the most common reason for revision [8]. Compared with primary THA, the risk of local and systemic complications increased and favorable benefits decreased in revision surgeries [9]. Therefore, strategies for inhibiting periprosthetic bone resorption and maintaining bone stock were essential.

Bisphosphonates (BPs), a family of drugs with a strong anti-osteoclast activity, were widely used for the first-line treatment of osteoporosis [10]. Mass data had showed that BPs inhibited bone resorption, increased bone mineral density, and reduced the risk of fractures [11]. Nevertheless, there was still controversy about the effect and mechanism of BPs on inhibiting periprosthetic bone loss after THA. Some studies indicated that BPs had no significant effect on suppressing bone loss after THA [12, 13]. In contrast, previous meta-analyses suggested BPs could inhibit early bone resorption around the implant [1417]. However, these studies only included randomized controlled trials (RCTs) published before 2011. And target participants were not only THA but also total knee arthroplasty (TKA) and hemiarthroplasty in some studies. Compared with previous articles, this meta-analysis complemented the latest RCTs and had a larger sample size (620 patients). Moreover, it applied more rigorous eligibility of criteria and excluded trials involving TKA or hemiarthroplasty to reduce heterogeneity.

It was essential to perform a meta-analysis based on the latest evidence. This systematic review was to assess the effectiveness of BPs for decreasing periprosthetic bone resorption.

Methods

Literature search

The electronic literature search lasted up to 10 March 2018. Without language restrictions, reviewers searched PubMed (1966 to present), EMBASE (1980 to present), Ovid (1860 to present), and the Cochrane Library (Issue 1, 2017) by using the following items: “total hip arthroplasty,” “bisphosphonates,” “bone resorption,” and their associated words. Reference lists of all the selected studies were hand-searched for any additional trials. Two reviewers independently assessed trials for inclusion and resolved disagreements by discussion.

Inclusion and exclusion criteria

Studies were eligible for inclusion: (1) target participants were patients who underwent THA, (2) compared the effects between administrating BPs and placebo or no medication, and (3) randomized controlled trials. We excluded studies if (1) participants had a history of metabolic bone diseases, bone tumor, or renal failure; (2) the same randomized controlled trial was reanalyzed with a shorter follow-up.

Outcome measure

The primary outcome was periprosthetic bone mineral density (BMD) because this data is the most intuitive index to reflect the extent of periprosthetic bone loss. In order to analyze the bone turnover activity, researchers also collected the data of biochemical bone turnover (serum bone alkaline phosphates (BAP, U/L) and urinary N-telopeptide of type I collagen (NTX-I, nmol/mmol Cr)) as the second outcome.

Quality assessment

Two reviewers independently assessed quality. Quality assessment consisted of random sequence generation, allocation concealment, blinding, incomplete outcome data, selective reporting, and other potential bias.

Data extraction

The data was extracted in table that included the first author, year of publication, original country, primary disease, type of THA, type of BPs, control group, the number of participants, treatment duration, time of following, and the number of loss to follow-up. If the data was not reported in the text or the table in the article, it was extrapolated from the accompanying graphs. Reviewers asked the corresponding author of the eligible study for additional information when necessary.

Statistical analysis

Statistical analysis was performed using Review Manager 5.3. Mean differences (MD) and 95% confidence interval (95% CI) were calculated for continuous outcomes. Meta-analysis was done according to a random-effects model. P < 0.05 was considered statistically significant. Heterogeneity was tested by using chi-square test with significance being set at p > 0.1 and I-square (I2) was used to estimate total variation across studies due to heterogeneity in percentage. I2 greater than 50% was considered as denoting substantial heterogeneity.

Result

Study identification

The search identified 1625 potentially relevant references. Four hundred forty trials were excluded for duplicates. And 1185 trials were eliminated all based on titles and abstracts but 22 trials. After requiring full-text review, 14 trials met the inclusion criteria. Eight trials were excluded for several reasons: participants underwent hemiarthroplasty (two trials), shorter follow-up and reanalyzed data (three trials), and shared groups of participants because participants, authors, and designs were similar (three trials). The rest of 14 trials were included in qualitative synthesis. Finally, these 14 trials published from 2004 to 2017 were included in our systematic review [1831] (Fig. 1).
Fig. 1
Fig. 1

Flow diagram of included studies

Characteristic of the studies

The included 14 studies were published from 2004 to 2017, with 318 participants receiving BPs and 302 receiving placebo or no medication. Table 1 provided more detailed information on these studies. Types of BPs were consisted of alendronate (six trials), etidronate (two trials), risedronate (three trials), pamidronate (one trial), zoledronate (one trial), and clodronate (one trial). G 1–2 BPs (etidronate, clodronate, and pamidronate) have simple R2 side chains. And G 3 BPs (alendronate, risedronate, and zoledronate) were developed by modifying the R2 side chain to include an amino group and heterocyclic structures. The dose and the duration of BP administration were different among the studies. The sample size ranged from 16 to 91 patients. Eleven trials reported BMD at different time points after THA surgery (ranged from 24 weeks to more than 9 years), and four trials reported biochemical markers of postoperativebone turnover markers. Table 2 provided outcomes of the 14 including articles.
Table 1

Characteristics of the 14 including articles

Study (author/year)

Country

Primary disease

Type of THA

Type of BPs

Control group

Men

Women

Treatment duration

Time of following

Loss to follow-up

BPs

control

BPs

control

BPs

control

BPs

control

BPs

control

Tapaninen TS/2010 [18]

Finland

Primary hip osteoarthritis

Uncemented

Alendronate (G3)

Calcium

2

5

5

4

0.5 year

0.5 year

5 years

5 years

0

0

Trevisan C/2010 [19]

Italy

NA

Uncemented

Clodronate (G2)

No medication

26

27

16

22

1 year

No medication

1 year

1 year

4

8

Arabmotlagh M/2009 [20]

Germany

Degenerative osteoarthritis

Uncemented

Alendronate (G3)

No medication

16

9

13

11

5/10 weeks

No medication

6 years

6 years

2

1

Yamasaki S/2007 [21]

Japan

Osteoarthritis secondary to acetabular dysplasia

Uncemented

Risedronate (G3)

Placebo

2

2

17

19

0.5 year

0.5 year

0.5 year

0.5 year

3

0

Fokter SK/2006 [22]

Slovenia

Primary or secondary osteoarthritis

Cemented

Etidronate (G1)

Placebo

6

3

12

10

1 year

1 year

1 year

1 year

2

1

Arabmotlagh M/2006 [23]

Germany

Degenerative primary osteoarthritis

Uncemented

Alendronate (G3)

Placebo

14

12

13

12

0.5 year

0.5 year

52 weeks

52 weeks

0

0

Yamaguchi K/2004 [24]

Japan

Osteoarthritis secondary to hip dysplasia

Uncemented

Etidronate (G1)

No medication

5

2

26

22

1 year

No medication

30 months

30 months

2

0

Iwamoto N/2011 [25]

Japan

Osteoarthritis

Uncemented

Alendronate (G3)

No medication

4

5

16

17

48 weeks

no medication

48 weeks

48 weeks

2

0

Kinov P/2006 [26]

Bulgaria

Osteoarthritis, osteonecrosis, or hip fracture

Cemented or hybrid

Risedronate (G3)

Placebo

4

5

8

7

0.5 year

0.5 year

0.5 year

0.5 year

0

0

Shetty N/2006 [27]

England

Primary or secondary osteoarthritis

Hybrid

Pamidronate (G2)

Placebo

12

10

6

9

50 days

50 days

5 years

5 years

1

1

Scott DF/2013 [28]

America

NA

Uncemented

Zoledronate (G3)

Placebo + calcium

12

11

15

13

Twice administration

Twice administration

2 years

2 years

0

0

Yukizawa Y/2017 [29]

Japan

Osteoarthritis

Uncemented

Alendronate (G3)

No medication

4

7

14

9

≥ 2 years

no medication

≥ 9 years

≥ 9 years

0

0

Muren O/2015 [30]

Sweden

Osteoarthritis

Uncemented

Risedronate (G3)

Placebo + calcium

20

18

10

13

0.5 year

0.5 year

4 years

4 years

0

0

Nehme A/2003 [31]

Lebanon

Degenerative hip disease

Cemented

Alendronate (G3)

Placebo + calcium

NA

NA

NA

NA

2 years

2 years

2 years

2 years

0

0

THA total hip arthroplasty, BPs bisphosphonates, NA not applicable

Publication bias

The quality of included trials was assessed by the Cochrane collaboration’s tool for assessing risk of bias (Fig. 2). All included trials were randomized controlled trials, most of which were low risk of bias and documented randomization, allocation concealment, blinding, and complete outcomes.
Fig. 2
Fig. 2

Quality assessment. a Risk of bias graph: the author’s judgments about each risk of bias item presented as percentages across all included studies. b Risk of bias summary: the author’s judgments about each risk of bias item for all included studies

Table 2

Outcomes of the 14 including articles

Study (author/year)

BMD (mean ± SD) (g/cm2)

BAP (mean ± SD) (U/L) (BPs vs. control)

NTX-I (mean ± SD) (nmol/mmol Cr) (BPs vs. control)

1 year (BPs vs. control)

2–4 years (BPs vs. control)

≥ 5 years (BPs vs. control)

Tapaninen TS/2010 [18]

− 0.04 ± 0.09 vs. − 0.12 ± 0.10

− 0.05 ± 0.12 vs. − 0.18 ± 0.21

− 0.06 ± 0.12 vs. − 0.16 ± 0.24

NA

NA

Trevisan C/2010 [19]

− 0.04 ± 0.07 vs. − 0.07 ± 0.08

NA

NA

NA

NA

Arabmotlagh M/2009 [20]

− 0.02 ± 0.16 vs. − 0.04 ± 0.09

NA

− 0.02 ± 0.17 vs. − 0.06 ± 0.20

NA

NA

Yamasaki S/2007 [21]

NA

NA

NA

21.5 ± 7.7 vs. 31.2 ± 9.6

39.2 ± 15.9 vs.70.3 ± 27.7

Fokter SK/2006 [22]

− 0.06 ± 0.07 vs. − 0.06 ± 0.23

NA

NA

NA

NA

Arabmotlagh M/2006 [23]

0 ± 0.16 vs. − 0.07 ± 0.22

NA

NA

17.9 ± 6 vs. 27.1 ± 8.9

NA

Yamaguchi K/2004 [24]

− 0.06 ± 0.12 vs. − 0.12 ± 0.14

− 0.09 ± 0.13 vs. − 0.13 ± 0.13

NA

25.2 ± 6.6 vs. 29.6 ± 8.7

52.5 ± 29.2 vs. 71.3 ± 17.8

Iwamoto N/2011 [25]

0 ± 0.12 vs. − 0.08 ± 0.14

NA

NA

NA

NA

Kinov P/2006 [26]

NA

NA

NA

19.93 ± 6.6 vs. 26.9 ± 5.9

NA

Shetty N/2006 [27]

− 0.01 ± 0.07 vs. − 0.02 ± 0.14

− 0.02 ± 0.05 vs. − 0.01 ± 0.16

− 0.02 ± 0.01 vs. − 0.03 ± 0.2

NA

NA

Scott DF/2013 [28]

0.80 ± 10.4 vs. − 6.03 ± 13.2

− 0.16 ± 14.0 vs. − 7.13 ± 12.7

NA

NA

NA

Yukizawa Y/2017 [29]

− 0.04 ± 0.02 vs. − 0.13 ± 0.02

NA

− 0.12 ± 0.03 vs. − 0.21 ± 0.02

NA

NA

Muren O/2015 [30]

NA

− 0.19 ± 0.02 vs. − 0.22 ± 0.03

NA

NA

NA

Nehme A/2003 [31]

− 0.24 ± 0.07 vs. − 0.32 ± 0.07

− 0.09 ± 0.06 vs. − 0.16 ± 0.06

NA

NA

NA

BPs bisphosphonates, BMD bone mineral density, BAP serum bone alkaline phosphates, NTX-I urinary N-telopeptide of type I collagen, NA not applicable

Periprosthetic bone mineral density (BMD)

BMD at 1 year after THA

Eleven trials including 465 participants compared BPs with placebo or no medication at 1 year after THA. As showed in Fig. 3, periprosthetic bone resorption in the BP group was significantly less than that in the control group (MD, 0.06 [95% CI, 0.03 to 0.08], p < 0.001). Both G 3 BPs and G 1–2 BPs observably inhibit bone resorption, respectively [(MD, 0.03 [95% CI, 0.01 to 0.06], p = 0.01); (MD, 0.09 [95% CI, 0.07 to 0.11], p < 0.001)]. The difference in BMD between G 3 BP group and the control group was greater than that in between G 1–2 BP group and the control group (p = 0.001).
Fig. 3
Fig. 3

Forest plots showing the effects on BMD at 1 year after THA between BP group and control group

In subgroup analysis, the efficacy of BPs for BMD was significant in the uncemented THA subgroup (MD, 0.05 [95% CI, 0.02 to 0.09], p = 0.002), but no significant difference in cemented THA subgroup (MD, 0.06 [95% CI, 0.00 to 0.13], p = 0.05). These two subgroup difference was not significant (p = 0.76). The duration of BP administration more than 6 months dramatically inhibit bone resorption (MD, 0.07 [95% CI, 0.04 to 0.09], p < 0.001). And it seemly obtained more benefit for BMD than the duration less than 6 months, but no difference was showed between the subgroup analysis (p = 0.45) (Table 3).
Table 3

Subgroup analysis of association between BPs and BMD for each variable

Variable

No. of trials

No. of participants

MD

95% CI

p value

BPs

Control

1 year after THA

 Type of THA

  Cemented

2

38

31

0.06

0.00–0.13

0.76

  Uncemented

9

202

194

0.05

0.02–0.09

 Treatment duration of BPs

   ≤ 6 months

5

96

88

0.04

− 0.01–0.10

0.32

   > 6 months

6

124

122

0.07

0.04–0.09

2–4 year after THA

 Type of THA

  Cemented

1

20

18

0.05

0.02–0.09

0.46

  Uncemented

4

80

88

0.07

0.03–0.11

 Treatment duration of BPs

   ≤ 6 months

4

86

86

0.03

− 0.03–0.09

0.32

   > 6 months

2

36

42

0.06

0.03–0.10

≥ 5 year after THA

 Type of THA

  Cemented

0

0

0

Not estimable

Not estimable

NA

  Uncemented

3

54

45

0.09

0.07–0.11

 Treatment duration of BPs

   ≤ 6 months

3

54

48

0.03

− 0.03–0.10

0.12

   > 6 months

1

18

16

0.09

0.07–0.11

THA total hip arthroplasty, BPs bisphosphonates, MD mean differences, CI confidence interval, NA not applicable

BMD between 2 to 4 years after THA

Six trials including 250 participants compared BPs with placebo or no medication between 2 to 4 years after THA. As showed in Fig. 4, periprosthetic bone resorption in the BP group was significantly less than that in the control group (MD, 0.04 [95% CI, 0.01 to 0.07], p = 0.02). G 3 BPs observably inhibit bone resorption (MD, 0.05 [95% CI, 0.01 to 0.10], p = 0.03), but not in G 1–2 BP subgroup (MD, 0.01 [95% CI, − 0.04 to 0.06], p = 0.69).
Fig. 4
Fig. 4

Forest plots showing the effects on BMD between 2 to 4 years after THA between BP group and control group

In subgroup analysis, the efficacy of BPs for BMD was significant in the cemented THA subgroup (MD, 0.07 [95% CI, 0.03 to 0.11], p = 0.0003). But no significant difference was observed comparing uncemented THA group with cemented THA group (p = 0.46). The duration of BP administration more than 6 months dramatically inhibit bone resorption (MD, 0.06 [95% CI, 0.03 to 0.10], p = 0.0003). However, subgroup difference was not significant on the treatment duration (p = 0.32) (Table 3).

BMD at more than 5 years after THA

Four trials including 136 participants compared BPs with placebo or no medication at more than 5 years after THA. As showed in Fig. 5, periprosthetic bone resorption in the BP group was significantly less than that in the control group (MD, 0.08 [95% CI, 0.06 to 0.11], p < 0.001). G 3 BPs observably inhibit bone resorption (MD, 0.09 [95% CI, 0.07 to 0.11], p < 0.001). No difference was showed in G 1–2 BP subgroup (MD, 0.01 [95% CI, − 0.09 to 0.11], p = 0.85).
Fig. 5
Fig. 5

Forest plots showing the effects on BMD more than 5 years after THA between BP group and control group

In subgroup analysis, the duration of BP administration more than 6 months dramatically inhibit bone resorption (MD, 0.09 [95% CI, 0.07 to 0.11], p < 0.001). However, subgroup difference was not significant on the treatment duration (p = 0.12) (Table 3).

Serum bone alkaline phosphatase (BAP)

Four trials including 179 participants compared BPs with placebo or no medication on serum bone alkaline phosphatase. BAP in the control group were significantly higher than that in the BP group (MD, − 7.28 [95% CI, − 9.81 to − 4.75], p < 0.001) (Fig. 6). Reviewers did not performed subgroup analyses for BAP as the eligible trials were not enough.
Fig. 6
Fig. 6

Forest plots showing the effects on BAP between BP group and control group

Urinary N-telopeptide of type I collagen (NTX-I)

Two trials including 104 participants compared BPs with placebo or no medication on NTX-I. NTX-I in the BP group were significantly lower than that in the control group (MD, − 24.37 [95% CI, − 36.3 to − 12.37], p < 0.001) (Fig. 7). Reviewers did not perform subgroup analyses for BAP as the eligible trials were not enough.
Fig. 7
Fig. 7

Forest plots showing the effects on NTX-I between BP group and control group

Discussion

This systematic review indicated that BPs could significantly decrease periprosthetic bone resorption at short-, medium-, and long-term observation. The third-generation BPs (G 3 BPs) showed significant efficacy for patients. In addition, this review found that both BAP and NTX-I in the BP group were significantly lower than that in the control group. In subgroup analysis, administration of BPs more than 6 months seemly obtained more benefit for BMD than the duration less than 6 months at long-term observation.

Compared with placebo or no medication, patient in BP group obtained more benefit for BMD especially in the G 3 BP group. Previous studies indicated that aseptic loosening was associated with poor bone quality [32]. The surrounding bone stock provided primary stability of the prosthesis and osseointegration, sealed the bone-implant interfaces, and reduced the implant migration. It was a key factor to avoid aseptic loosening [33]. In the current analysis, BPs could effectively decrease short, medium, and long phase of periprosthetic bone resorption. Besides, low-bone mineral density was a major risk factor for osteoporotic fracture [34]. Meanwhile, the rate of bone loss was an important risk factor for osteoporotic fracture [35]. In our eligible trials, the most of participants were over 50 years old and some of them are postmenopausal women who underwent osteoporosis. Thus, the risk of fracture was high in these participants and it may threaten the longevity of the implant. So BPs may be beneficial for reducing the risk of periprosthetic fracture. In support of us, Alhambra et al. [36] suggested that the use of BPs decreased the fracture risk among THA patients who received BPs as primary prevention (hazard ratio 0.56, 95% CI 0.38 to 0.82) and also among THA patients who had experienced a previous osteoporotic fracture (HR 0.48, 95% CI 0.23 to 0.99).

Base on the present evidence, this study suggested that G 3 BPs were more effective in decreasing periprosthetic bone loss than G 1–2 BPs. Variations in the structure of the side chains determine the strength with which the biphosphonate binds to bone, the distribution through bone, and the amount of time, and it remains in the bone after treatment is discontinued [37]. G 1–2 BPs (etidronate, clodronate, pamidronate, and olpadronate) have simple R2 side chains [38]. Differently, G 3 BPs (alendronate, neridronate, olpadronate, risedronate, ibandronate, and zoledronate) were developed by modifying the R2 side chain to include an amino group and heterocyclic structures, which were found to be up to 1000 times more potent with respect to antiresorptive activity [10]. What is more, G 3 BPs selectively inhibited the cholesterol pathway and subsequently disrupted the osteoclast cytoskeleton with associated osteoclast inactivation [39]. Therefore, G 3 BPs had less effect on osteoblasts and bone formation compared with G 1 BPs [40]. Black and bone also demonstrated the safety of 10 years’ treatment with alendronate for osteoporosis in postmenopausal women [41, 42]. Our result was consistent with it, which also can be applied to inhibit periprosthetic bone resorption.

The significantly lower BAP value in BP group suggested that an influence of BPs may play a role on osteoblast function. Previous studies had found that G 3 BPs had inhibitory effects on terminal differentiation of osteoblasts for bone remodeling, consequently leading to a delay in bone healing [43]. Besides, the unusual mid-shaft long bone fractures were observed in some patients receiving BPs for osteoporosis [44, 45]. Lately, Park et al. demonstrated treatment with BPs more than 5 years was associated with an increased risk of subtrochanteric or femoral shaft fractures [46]. So further investigations were necessary to clarify the duration of BPs or to monitor the bone markers to avoid oversuppression of bone turnover.

With regard to NTX-I, the current analysis suggested that BPs has a strong effect on anti-osteoclast activity. Bone resorption also occurred in the later period, that was focal bone resorption at the prosthesis-bone interface, as a part of the host response to wear debris generated from the prosthesis materials [47, 48]. The wear debris stimulated the release of pro-inflammatory cytokines at the prosthesis-bone interface membrane, the differentiation and activation of osteoclasts, then gave rise to periprosthetic osteolyticlesions [49]. This wear-related osteolysis could also lead to aseptic loosening, which accounting for over 60% of revision surgeries [50]. BPs have been shown promising in reducing osteoclast activity in animal models of particle-induced osteolysis. Shanbhag et al. advocated it for the first time that oral alendronate treatment (5 mg/day for 6 months) could reduce periprosthetic osteolysis in a cementless THA canine model of wear particle-induced osteolysis [51]. Then, Wise et al. further demonstrated that high-dose intravenous zoledronate therapy (10 μg/kg/week) decreased periprosthetic cortical bone porosity and enhanced its mechanical strength in a similar model [52]. In clinical trials, Nishii et al. suggested that alendronate treatment could prevent and restore periprosthetic osteolysis, which was generally thought to require surgical intervention [53].

Bhandari M et al. indicated that BPs presented more efficacies for the cemented group than the uncemented group [16]. However, the report has only included six RCTs of THA and did not conduct any subgroup analysis according to the follow-up time. In the current review, the efficacy of BPs for BMD was significant in the uncemented subgroup at short-term observation, but significant in the cemented subgroup at medium-term observation. Many uncemented implants are larger than cemented implants; thus, stiff stems of uncemented THA may produce more stress shielding and result in greater bone loss at short-term observation [54]. At long-term observation, cemented particles can induce osteoclast differentiation and lead to greater bone resorption compared with uncemented particles [55]. Therefore, the effects of BPs may be magnified by this difference. It may explain BPs worked differently on cemented and uncemented THA. However, only three RCTs were involved in cemented subgroup, which may be difficult to avoid publication bias. To explore the potential efficacies of BPs in different types of THA, more high-quality RCTs were needed.

Administration of BPs more than 6 months seemly obtained more benefit for BMD than the duration less than 6 months. In this subgroup analysis, BMD in more than 6-month group were higher than that in less than 6-month group at all terms of observation. However, the subgroup difference was not significant. These results suggested a significant association of BPs’ long treatment duration with inhibited periprosthetic bone resorption, but the current analysis may lack statistical power to show this association. It was consistent with the previous meta-analysis [17].

Four studies that explored the potential efficacies of BPs have been published [1417]. However, they had the following limitations: (1) most of them ignored the difference between generation of BPs and did not describe it separately. (2) Target participants in some studies included not only THA but also TKA and hemiarthroplasty. In contrast to previous meta-analyses, this analysis applied more rigorous eligibility criteria and excluded trials involving TKA or hemiarthroplasty to reduce heterogeneity. Furthermore, this analysis not only focused on the efficacies between different generations of BPs, but also discussed effects on treatment duration and types of THA.

Meanwhile, some limitations of this current meta-analysis should be taken into account. First, BMD and biochemical bone turnover outcomes were used to extrapolate the risk of implant revision in this study. However, revision rate in the later follow-up was more objective and ideal. Second, the limited numbers of studies and participants in long-term observation could decrease the strength of our results. Therefore, further RCTs were needed to determine whether a maximum benefit obtainable by BPs, whether benefits increase with increasing duration of administration, whether benefits persist after administration stop, and whether BAP or NTX-I is still suppressed in the later follow-up.

Conclusion

In conclusion, this study indicated that BPs were beneficial to decreasing periprosthetic bone loss following THA. In short-term observation, G 3 BPs showed greater efficacy for patients.

Notes

Abbreviations

95% CI: 

95% confidence interval

BAP: 

Bone alkaline phosphates

BMD: 

Bone mineral density

BPs: 

Bisphosphonates

I2

I-square

MD: 

Mean differences

NTX-I: 

Urinary N-telopeptide of type I collage

THA: 

Total hip arthroplasty

Declarations

Acknowledgements

We are grateful to all colleagues in our department for their generous support.

Funding

This study was supported by the fund of the Natural Science Foundation of Guangxi Province (2016JB140086). The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

Availability of data and materials

The datasets used and analyzed during the current study are available from the corresponding author on reasonable request.

Authors’ contributions

JS drafted the article and prepared all figures. GL acquired the data and prepared all tables. RH performed the statistical analysis. LL and DQ designed this study. All authors read and approved the final manuscript.

Ethics approval and consent to participate

Not applicable

Consent for publication

Not applicable

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Authors’ Affiliations

(1)
Guangxi Medical University, No. 22, Shuang Yong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, China
(2)
The first affiliated Hospital of Guangxi Medical University, The First Clinical Medical College, No. 6, Shuang Yong Road, Nanning, 530021, Guangxi Zhuang Autonomous Region, China
(3)
Department of the Second Endocrinology Ward, Jiangbin Hospital of Guangxi Zhuang Autonomous Region, Nanning, 530021, Guangxi Zhuang Autonomous Region, China

References

  1. Harris WH, Sledge CB. Total hip and total knee replacement. N Engl J Med. 1990;323(11):7.View ArticleGoogle Scholar
  2. Engh CA, Culpepper WJ, Engh CA, Virginia A. Long-term results of use of the anatomic medullary locking prosthesis in total hip arthroplasty. J Bone Joint Surg. 1997;79(2):8.View ArticleGoogle Scholar
  3. Xenos JS, Callaghan JJ, Heekin RD, Hopkinson WJ, Savory CG, Moore MS. The porous-coated anatomic total hip prosthesis, inserted without cement. A prospective study with a minimum of ten years of follow-up. J Bone Joint Surg. 1999;81(1):9.View ArticleGoogle Scholar
  4. Kurtz S, Ong K, Lau E, Mowat F, Halpern M. Projections of primary and revision hip and knee arthroplasty in the United States from 2005 to 2030. J Bone Joint Surg Am. 2007;89(4):780–5. https://doi.org/10.2106/JBJS.F.00222.PubMedGoogle Scholar
  5. Venesmaa PK, Kpoger HPJ, Miettinen HJA, Jurvelin JS, Suomalainen OT, Alhava EM. Monitoring of periprosthetic BMD after uncemented total hip arthroplasty with dual-energy X-ray absorptiometry—a 3-year follow-up study. J Bone Miner Res. 2001;16(6):6.View ArticleGoogle Scholar
  6. Lindahl H. Epidemiology of periprosthetic femur fracture around a total hip arthroplasty. Injury. 2007;38(6):651–4. https://doi.org/10.1016/j.injury.2007.02.048.View ArticlePubMedGoogle Scholar
  7. Kobayashi S, Saito N, Horiuchi H, Iorio R, Takaoka K. Poor bone quality or hip structure as risk factors affecting survival of total-hip arthroplasty. Lancet. 2000;355(9214):1499–504. https://doi.org/10.1016/s0140-6736(00)02164-4.View ArticlePubMedGoogle Scholar
  8. Havelin LI, Engesæter LB, Espehaug B, Furnes O, Lie SA, Vollset SE. The Norwegian arthroplasty register 11 years and 73,000 arthroplasties. Acta Orthop Scand. 2000;71(4):17.View ArticleGoogle Scholar
  9. de Steiger RN, Miller LN, Prosser GH, Graves SE, Davidson DC, Stanford TE. Poor outcome of revised resurfacing hip arthroplasty. Acta Orthop. 2010;81(1):72–6. https://doi.org/10.3109/17453671003667176.View ArticlePubMedPubMed CentralGoogle Scholar
  10. Morris CD, Einhorn TA. Current concepts review—bisphosphonates in orthopaedic surgery. J Bone Joint Surg. 2005;87-A:10.Google Scholar
  11. Woolf AD, Åkesson K. Preventing fractures in elderly people. Br Med J. 2003;327:7.Google Scholar
  12. Wells VM, Hearn TC, McCaul KA, Anderton SM, Wigg AER, Graves SE. Changing incidence of primary total hip arthroplasty and total knee arthroplasty for primary osteoarthritis. J Arthroplast. 2002;17(3):267–73. https://doi.org/10.1054/arth.2002.30414.View ArticleGoogle Scholar
  13. Sibanda N, Copley LP, Lewsey JD, Borroff M, Gregg P, MacGregor AJ, et al. Revision rates after primary hip and knee replacement in England between 2003 and 2006. PLoS Med. 2008;5(9):11. https://doi.org/10.1371/journal.pmed.0050179.View ArticleGoogle Scholar
  14. Zhao X, Hu D, Qin J, Mohanan R, Chen L. Effect of bisphosphonates in preventing femoral periprosthetic bone resorption after primary cementless total hip arthroplasty: a meta-analysis. J Orthop Surg Res. 2015;10:65. https://doi.org/10.1186/s13018-015-0206-8.View ArticlePubMedPubMed CentralGoogle Scholar
  15. Knusten AR, Ebramzadeh E, Longjohn DB, Sangiorgio SN. Systematic analysis of bisphosphonate intervention on periprosthetic BMD as a function of stem design. J Arthroplast. 2014;29(6):1292–7. https://doi.org/10.1016/j.arth.2014.01.015.View ArticleGoogle Scholar
  16. Bhandari M, Bajammal S, Guyatt GH, Griffith L, Busse JW, Schunemann H, et al. Effect of bisphosphonates on periprosthetic bone mineral density after total joint arthroplasty. A meta-analysis. J Bone Joint Surg. 2005;87-A:10.Google Scholar
  17. Lin T, Yan SG, Cai XZ, Ying ZM. Bisphosphonates for periprosthetic bone loss after joint arthroplasty: a meta-analysis of 14 randomized controlled trials. Osteoporos Int. 2012;23(6):1823–34. https://doi.org/10.1007/s00198-011-1797-5.View ArticlePubMedGoogle Scholar
  18. Tapaninen TS, Venesmaa PK, Jurvelin JS, Miettinen HJA, Kröger HPJ. Alendronate reduces periprosthetic bone loss after uncemented primary total hip arthroplasty—a 5-year follow-up of 16 patients. Scand J Surg. 2010;99:6.View ArticleGoogle Scholar
  19. Trevisan C, Ortolani S, Romano P, Isaia G, Agnese L, Dallari D, et al. Decreased periprosthetic bone loss in patients treated with clodronate: a 1-year randomized controlled study. Calcif Tissue Int. 2010;86(6):436–46. https://doi.org/10.1007/s00223-010-9356-1.View ArticlePubMedGoogle Scholar
  20. Arabmotlagh M, Pilz M, Warzecha J, Rauschmann M. Changes of femoral periprosthetic bone mineral density 6 years after treatment with alendronate following total hip arthroplasty. J Orthop Res. 2009;27(2):183–8. https://doi.org/10.1002/jor.20748.View ArticlePubMedGoogle Scholar
  21. Yamasaki S, Masuhara K, Yamaguchi K, Nakai T, Fuji T, Seino Y. Risedronate reduces postoperative bone resorption after cementless total hip arthroplasty. Osteoporos Int. 2007;18(7):1009–15. https://doi.org/10.1007/s00198-007-0339-7.View ArticlePubMedGoogle Scholar
  22. Fokter SK, Komadina R, Repse-Fokter A. Effect of etidronate in preventing periprosthetic bone loss following cemented hip arthroplasty: a randomized, double blind, controlled trial. Wien Klin Wochenschr. 2006;118(Suppl 2):23–8. https://doi.org/10.1007/s00508-006-0556-7.View ArticlePubMedGoogle Scholar
  23. Arabmotlagh M, Rittmeister M, Hennigs T. Alendronate prevents femoral periprosthetic bone loss following total hip arthroplasty: prospective randomized double-blind study. J Orthop Res. 2006;24(7):1336–41. https://doi.org/10.1002/jor.20162.View ArticlePubMedGoogle Scholar
  24. Yamaguchi K, Masuhara K, Yamasaki S, Fuji T, Seino Y. Effects of discontinuation as well as intervention of cyclic therapy with etidronate on bone remodeling after cementless total hip arthroplasty. Bone. 2004;35(1):217–23. https://doi.org/10.1016/j.bone.2004.03.017.View ArticlePubMedGoogle Scholar
  25. Iwamoto N, Inaba Y, Kobayashi N, Ishida T, Yukizawa Y, Saito T. A comparison of the effects of alendronate and alfacalcidol on bone mineral density around the femoral implant and in the lumbar spine after total hip arthroplasty. J Bone Joint Surg Am. 2011;93(13):1203–9. https://doi.org/10.2106/JBJS.I.01714.View ArticlePubMedGoogle Scholar
  26. Kinov P, Tivchev P, Doukova P, Leithner A. Effect of risedronate on bone metabolism after total hip arthroplasty a prospective randomised study. Acta Orthop Belg. 2006;72(1):7.Google Scholar
  27. Shetty N, Hamer AJ, Stockley I, Eastell R, Wilkinson JM. Clinical and radiological outcome of total hip replacement five years after pamidronate therapy: a trial extension. J Bone Joint Surg. 2006;88-B:7. https://doi.org/10.1302/0301-620x.88b10.Google Scholar
  28. Scott DF, Woltz JN, Smith RR. Effect of zoledronic acid on reducing femoral bone mineral density loss following total hip arthroplasty: preliminary results of a prospective randomized trial. J Arthroplasty. 2013;28(4):671–5. https://doi.org/10.1016/j.arth.2012.08.007.View ArticlePubMedGoogle Scholar
  29. Yukizawa Y, Inaba Y, Kobayashi N, Choe H, Kubota S, Saito T. Efficacy of alendronate for the prevention of bone loss in calcar region following total hip arthroplasty. J Arthroplast. 2017;32(7):2176–80. https://doi.org/10.1016/j.arth.2017.02.036.View ArticleGoogle Scholar
  30. Muren O, Akbarian E, Salemyr M, Boden H, Eisler T, Stark A, et al. 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. Acta Orthop. 2015;86(5):569–74. https://doi.org/10.3109/17453674.2015.1041846.View ArticlePubMedPubMed CentralGoogle Scholar
  31. Nehme A, Maalouf G, Tricoire JL, Giordano G, Chiron P, Puget J. Effect of alendronate on periprosthetic bone loss after cemented primary total hip arthroplasty: a prospective randomized study. Rev Chir Orthop Reparatrice Appar Mot. 2003;6:593–8.Google Scholar
  32. Nixon M, Taylor G, Sheldon P, Iqbal SJ, Harper W. Does bone quality predict loosening of cemented total hip replacements. J Bone Joint Surg. 2007;89-B:6. https://doi.org/10.1302/0301-620X.89B10.View ArticleGoogle Scholar
  33. Sundfeldt M, Carlsson LV, Johansson CB, Thomsen P, Gretzer C. Aseptic loosening, not only a question of wear: a review of different theories. Acta Orthop. 2006;77(2):21. https://doi.org/10.1080/17453670610045902.View ArticleGoogle Scholar
  34. Marshall D, OlofJohnell, Wedel H. Meta-analysis of how well measures of bone mineral density predict occurrence of osteoporotic fractures. Br Med J. 1996;312:6.View ArticleGoogle Scholar
  35. Riis BJ, Hansen MA, Jensen AM, Overgaard K, Christiansen C. Low bone mass and fast rate of bone loss at menopause equal risk factors for future fracture: a 15-year follow-up study. Bone. 1996;19:4.View ArticleGoogle Scholar
  36. Prieto-Alhambra D, Javaid MK, Judge A, Maskell J, Kiran A, Fd V, et al. Fracture risk before and after total hip replacement in patients with osteoarthritis potential benefits of bisphosphonate use. Arthritis Rheum. 2011;64:10. https://doi.org/10.1002/art.30214.Google Scholar
  37. Russell RG, Watts NB, Ebetino FH, Rogers MJ. Mechanisms of action of bisphosphonates: similarities and differences and their potential influence on clinical efficacy. Osteoporos Int. 2008;19:27.View ArticleGoogle Scholar
  38. MR M. Bisphosphonates. Endocrinol Metab Clin North Am. 2003;32:19.Google Scholar
  39. Fisher JE, Rodan GA, Reszka AA. In vivo effects of bisphosphonates on the osteoclast mevalonate pathway. Endocrinology. 2000;141:4.View ArticleGoogle Scholar
  40. Russell RGG, Rogers MJ, Frith JC, Luckman SP, Coxon FP, Benford HL, et al. The pharmacology of bisphosphonates and new insights into their mechanisms of action. J Bone Miner Res. 1999;14:13.Google Scholar
  41. Black DM, Schwartz AV, Ensrud KE, Cauley JA, Levis S, Quandt SA, et al. Effects of continuing or stopping alendronate after 5 years of treatment: the Fracture Intervention Trial Long-term Extension (FLEX) a randomized trial. J Am Med Assoc. 2006;296:12.View ArticleGoogle Scholar
  42. Bone HG, Hosking D, Devogelaer J-P, Tucci JR, Emkey RD, Tonino RP, et al. Ten years’ experience with alendronate for osteoporosis in postmenopausal women. N Engl J Med. 2004;350(12):11.View ArticleGoogle Scholar
  43. Nagashima M, Sakai A, Uchida S, Tanaka S, Tanaka M, Nakamura T. Bisphosphonate (YM529) delays the repair of cortical bone defect after drill-hole injury by reducing terminal differentiation of osteoblasts in the mouse femur. Bone. 2005;36:10. https://doi.org/10.1016/j.bone.2004.11.013.View ArticleGoogle Scholar
  44. Lenart BA, Lorich DG, Lane JM. Atypical fractures of the femoral diaphysis in postmenopausal women taking alendronate. N Engl J Med. 2008;358(12):3.View ArticleGoogle Scholar
  45. Neviaser AS, Lane JM, Lenart BA, Edobor-Osula F, Lorich DG. Low-energy femoral shaft fractures associated with alendronate use. J Orthop Trauma. 2008;22:5.View ArticleGoogle Scholar
  46. Park-Wyllie LY, Mamdani MM, Juurlink DN, Hawker GA, Gunraj N, Austin PC, et al. Bisphosphonate use and the risk of subtrochanteric or femoral shaft fractures in older women. JAm Med Assoc. 2011;305:7.Google Scholar
  47. Goldring SR, Jasty M, Roelke MS, Rourke CM, Bringhurst FR, Harris WH. Formation of a synovial-like membrane at the bone-cement interface. Its role in bone resorption and implant loosening after total hip replacement. Arthritis Rheum. 1986;29:7.View ArticleGoogle Scholar
  48. Wilkinson JM, Little DG. Bisphosphonates in orthopedic applications. Bone. 2011;49:8. https://doi.org/10.1016/j.bone.2011.01.009.View ArticleGoogle Scholar
  49. Tuan RS, Lee FY-I, Konttinen Y, Wilkinson, Smith RL. What are the local and systemic biological reactions and mediators to wear debris and what host factors determine or modulate the biological response to wear particles? J Am Acad Orthop Surg. 2008;16:10.View ArticleGoogle Scholar
  50. Herberts P, Malchau H. Long-term registration has improved the quality of hip replacement a review of the Swedish THR register comparing 160,000 cases. Acta Orthop Scand. 2000;71(2):11.View ArticleGoogle Scholar
  51. Shanbhag AS, Hasselman CT, Rubash HE. The John Charnley award. Inhibition of wear debris mediated osteolysis in a canine total hip arthroplasty model. Clin Orthop Relat Res. 1997;344:11.View ArticleGoogle Scholar
  52. Wise LM, Waldman SD, Kasra M, Cheung R, Binnington A, Kandel RA, et al. Effect of zoledronate on bone quality in the treatment of aseptic loosening of hip arthroplasty in the dog. Calcif Tissue Int. 2005;77:9. https://doi.org/10.1007/s00223-005-0062-3.View ArticleGoogle Scholar
  53. Nishii, Takashi, Sugano, Nobuhiko, Miki, Hidenobu. Restoration of periprosthetic osteolysis by systemic alendronate treatment. J Bone Joint Surg Br. 2008;90:5.Google Scholar
  54. Huiskes R, Stolk J. Biomechanics and preclinical testing of artifical joints: the hip. In: Basic orthopaedic biomechanics and mechanobiology; 2005. p. 72.Google Scholar
  55. Sabokbar A, Fujikawa Y, Brett J. Increased osteoclastic differentiation by PMMA particle-associated macrophages: inhibitory effect by interleukin 4 and leukemia inhibitory factor. Acta Orthop Scand. 1996;67:593–8.View ArticlePubMedGoogle Scholar

Copyright

Advertisement