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The use of bone turnover markers for monitoring the treatment of osteoporosis in postmenopausal females undergoing total knee arthroplasty: a prospective randomized study

Journal of Orthopaedic Surgery and Research volume 16, Article number: 195 (2021) Cite this article

Abstract

Background

Osteoporosis (OP) and osteoarthritis (OA) commonly coexist in postmenopausal females. The decrease in bone density and increase in bone resorption in postmenopausal females with OP may consequently affect the surgical outcome of total knee arthroplasty (TKA). However, clinicians often ignore monitoring the treatment of OP in the perioperative management of TKA. Bone turnover marker (BTM) can timely and accurately reflect bone metabolism to monitor the treatment of OP. The purpose of this study was to investigate the effect of BTM monitoring to guide the treatment of OP in postmenopausal females undergoing TKA.

Methods

Postmenopausal females with OP who underwent primary unilateral TKA were randomly divided into two groups (monitoring group and control group), given oral medication (alendronate, calcitriol, and calcium), and followed for 1 year. In the monitoring group, serum BTMs (C-telopeptide of type I collagen (CTX-I), N-terminal propeptide of type I procollagen (PINP), and 25(OH)D) were assessed preoperatively and repeated postoperatively; alendronate was withdrawn when CTX-I and PINP reached the reference interval; and calcitriol and calcium were withdrawn when 25(OH)D reached the reference interval. In the control group, oral medication was implemented for a uniform duration of 3 months. During the 1-year follow-up, the mean maximum total point motion (MTPM) of the tibial component, bone mineral density (BMD), visual analog scale (VAS) score, range of motion, and Oxford Knee Score (OKS) score were obtained.

Results

In the monitoring group, BTM monitoring prolonged the medication duration, but did not cause more adverse reactions than in the control group. The mean MTPM values at 6 m and 12 m in the monitoring group were lower than those in the control group, and the BMD at 12 m in the monitoring group was significantly higher than that in the control group. Patients in the monitoring group had lower VAS scores at 6 m and higher OKS scores at 6 m and 12 m than those in the control group.

Conclusion

In postmenopausal females with osteoporosis undergoing primary TKA, the application of BTM monitoring to guide the treatment of osteoporosis can enhance bone density, maintain prosthesis stability, and improve surgical outcome.

Trial registration

ChiCTR ChiCTR-INR-17010495. Registered on 22 January 2017

Background

Osteoarthritis (OA) is a common disorder that causes cartilage destruction in joints, particularly in knee joints. Total knee arthroplasty (TKA) is a successful procedure in treating severely damaged knee joints by providing pain relief and improving the mobility and stability of knees. Osteoarthritis and osteoporosis (OP) commonly coexist in postmenopausal females [1]. Due to estrogen deficiency, postmenopausal females have active bone turnover (bone resorption > bone formation) and increased bone loss, which can last for more than 10 years after menopause [2]. A more active bone turnover and decreased bone quality at the TKA bone-cement/implant interface in postmenopausal females brings potentially unstable fixation [3]. Aseptic loosening secondary to periprosthetic bone loss remains a major cause of TKA failure [4]. In addition, poor bone quality may negatively affect satisfaction with the surgical outcome of TKA [3]. For these reasons, preventing bone loss and prolonging the duration of a prosthesis is a vital issue in TKA [5].

Bisphosphonates are a class of first-line drugs used in the treatment of osteoporosis. They can reduce bone turnover, increase bone mass, and reduce fracture rate [6]. Bisphosphonates were shown to effectively reduce periprosthetic bone resorption and improve the long-term duration of knee prosthesis [7]. Guidance from the UK National Institute for Health and Care Excellence (NICE) recommends alendronate as the first choice of OP treatment [8], and oral administration is the most commonly used way for using bisphosphonates to treat osteoporosis [9]. It has been reported that oral alendronate not only prevented osteoclast-mediated bone loss and associated implant loosening in total hip arthroplasty (THA) [10], but also significantly reduced early postoperative periprosthetic bone loss in TKA patients [11]. However, the use of bisphosphonates to monitor the therapeutic effect in postmenopausal osteoporosis females undergoing TKA has not been clearly reported.

Bone turnover markers (BTMs) are biochemical markers in the blood and/or urine that are released during bone formation or bone resorption [12]. BTM can reflect systemic bone metabolism in a timely and accurate manner [13]. The examination of BTM is not expensive and noninvasive, and BTM can be measured repeatedly. Changes in BTMs after treatment might be more informative than changes in bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DEXA) [14]. BTMs may show large and rapid responses to the treatments used for osteoporosis, which may allow the best choice of dose and dose frequency [15]. The biochemical response to bisphosphonate therapy can be assessed using a decrease in BTMs to within a reference interval (RI) [15, 16].

BTMs are a useful adjunct for the therapeutic monitoring of osteoporosis, but no related research has reported on the use of bone turnover markers for monitoring osteoporosis treatment in postmenopausal females undergoing TKA. The purpose of this study was to investigate the clinical value of perioperative BTM monitoring to guide the treatment of osteoporosis in postmenopausal females after TKA. The hypothesis was that BTM monitoring in postmenopausal females with OP can bring potentially stable fixation and achieve satisfactory surgical outcomes after TKA.

Methods

Patients

This was a randomized controlled intervention trial with consecutive enrollment. From April 2017 to December 2018, female OA patients (aged 55–75 years) at the Second Affiliated Hospital of Xi'an Jiaotong University who underwent primary TKA were screened. The females in the postmenopausal period (at least 1 year of amenorrhea), with lumbar/hip BMD expressed as T score < 2.5 standard deviation (SD) [17], were included. The exclusion criteria were as follows: (1) other metabolic bone diseases; (2) malignant tumor; (3) fracture within 1 year; and (4) history of taking vitamin D, calcitonin, estrogen, or bisphosphonates within 1 year. This study was registered by the Chinese Clinical Trial Registry (ChiCTR-INR-17010495) and approved by the Medical Ethics Committee of the Second Affiliated Hospital of Xi’an Jiaotong University (2017011). All participants gave written informed consent and agreed for the publication. Finally, 64 patients were included (Fig. 1).

Fig. 1
figure 1

Patient flow diagram

Full size image

Surgery

All operations were performed under general anesthesia by Professor Kunzheng Wang. Total knee arthroplasty was performed using cemented, posterior-stabilized prostheses through an anterior median incision, and patella arthroplasty was performed. After the operation, all patients underwent active and passive knee exercises of full range of motion and began walking with crutches or walking aids when active knee flexion reached 90°. The age, body weight index (BMI, kg/m2), years since menopause, operation time, and ambulation time of all patients were recorded. All included patients experienced a 1-year follow-up, and 7 patients were lost to follow-up (Fig. 1).

Grouping

All patients were randomized into two groups (monitoring group and control group). After the operation, all patients were given oral anti-osteoporosis treatment, which was alendronate (70 mg/week; Fosamax, Merck, Germany) + calcitriol (0.50 μg/day; Adcal D3, ProStrakan, UK) + calcium (Ca) carbonate (0.3 g/day; D-Cai, Ace, UK). In the monitoring group (n = 28), serum BTM (CTX-I, P1NP) and 25(OH)D values were assessed preoperatively (baseline) and repeated postoperatively at 1, 3, 5, 7, 9, and 12 months; alendronate was withdrawn when CTX-I and PINP reached the reference interval, and calcitriol and calcium were withdrawn when 25(OH)D reached the reference interval. The reference intervals in postmenopausal females were CTX-I < 1.008 ng/mL and PINP < 95 ng/mL [18]. In the control group, oral medication was implemented uniformly for 3 months, and no BTM values were assessed.

Assessment of bone turnover markers

The International Osteoporosis Foundation (IOF) and International Federation of Clinical Chemistry recommend C-telopeptide of type I collagen (CTX-I) as a serum bone resorption marker and N-terminal propeptide of type I procollagen (PINP) as a serum bone formation marker [14]. Serum CTX-I and PINP were assayed using an electrochemiluminescence immunoassay (Elecsys 1010 Analytics, Roche Diagnostics, Germany). Serum 25(OH)D was measured by chemiluminescence assay (Architect 1000, Abbott, USA). Fasting blood samples of patients were collected between 7 a.m. and 8 a.m. before the operation (baseline).

Tibial component fixation

Radiostereometric analysis (RSA) is a precise and highly accurate tool for the assessment of tibial component migration after TKA [19,20,21]. RSA was performed at 6 and 12 months postoperatively. An RSA parameter, the mean maximum total point motion (MTPM) was used to analyze the stability of the tibial component fixation. MTPM is defined as the largest three-dimensional translation of the tibial component [22]. The detailed RSA procedure referred to a previous study [21].

Bone mineral density

At 1 to 3 days pre-operation (baseline) and 12 months postoperatively, BMD (g/cm2) values of the lumbar spine or proximal femur were measured by DEXA using a densitometer (Discovery A; Hologic Inc., Bedford, USA). The T scores were calculated separately using the following formula: (measured BMD-young adult mean BMD)/young adult population SD [23]. A T score < − 2.5 was classified as osteoporosis [17].

Knee pain and function scores

At 1 to 3 days preoperatively (baseline) and 3, 6, and 12 months postoperatively, visual analog scale (VAS) [24], range of motion (ROM), and Oxford Knee Score (OKS) [25] were recorded for all patients. The range of motion was the active ROM of the knees. In the OKS, each question was scored from 1 to 5, and responses were then totaled to obtain a total score between 12 and 60 [25].

Statistical analysis

We calculated the sample size at a website (url: http://powerandsamplesize.com/Calculators/). We selected the power (1-β) as 0.80 and type I error rate (α) as 5%. The calculated sample size was 63.

All continuous variables are expressed as the mean ± SD. All data were managed through SPSS (IBM SPSS Statistics 19, USA). All continuous variables were analyzed by the normality test. When the variables were normally distributed, the independent t test was used; when the variables were not normally distributed, the Mann-Whitney U test was used. The χ2 test was used to compare the categorical variables. The level of significance was < 0.05 for all tests.

Results

Demographic results

A total of 64 patients were included, with 32 patients in each group. During the follow-up period, 4 patients in the monitoring group and 3 patients in the control group were lost to follow-up. Finally, there were data available for 28 patients in the monitoring group and 29 patients in the control group. The average age of the patients was 65.1 ± 6.0 years, the average BMI was 23.4 ± 4.6 kg/m2, and the average years since menopause was 13.4 ± 6.8 years. The age, BMI, years since operation time, and ambulation time in the two groups exhibited no significant differences (p < 0.05; Table 1).

Table 1 Characteristics of the patients in each group
Full size table

Medication duration

The alendronate duration, calcitriol + Ca duration, and total medication duration in the monitoring group were significantly higher than those in the control group (p < 0.05), but the adverse reaction rates between the two groups were not significantly different (p > 0.05). In addition, all the adverse reactions were mild and the patients could tolerate the adverse reactions (Table 2).

Table 2 Medication duration and adverse reactions of treatment in the BTM monitoring group and the control group
Full size table

Changes in BTMs in the monitoring group

The CTX-I level in the monitoring group gradually decreased after treatment and reached a plateau at approximately 150 days (Fig. 2a) However, the PINP level increased slightly before approximately 80 days and then gradually decreased until drug withdrawal at an average of 236 days (Fig. 2a). The level of 25(OH)D showed a trend of continuous increase after treatment until drug withdrawal at an average of 214 days (Fig. 2b).

Fig. 2
figure 2

Serum levels of CTX-I and PINP (a) and 25(OH)D (b) in the monitoring group. The green line is the drug withdrawal time (a alendronate, b calcitriol + Ca)

Full size image

Tibial component fixation and bone mineral density

At 6 and 12 months, the mean MTPM values in the monitoring groups were all significantly higher than those in the control group (p < 0.05). The BMD values before the operation in the two groups showed no significant difference (0.58 ± 0.06 vs. 0.59 ± 0.05; p > 0.05). At 12 m after the operation, the BMD value of the monitoring group increased by 9.7% compared to that before the operation, while the BMD value of the control group decreased by 3.2% compared to that before the operation. The changes in BMD at 12 m between the two groups exhibited an obviously statistical difference (p < 0.05) (Table 3).

Table 3 Comparison of mean MTPM and BMD during the 1-year follow-up
Full size table

Knee pain and function scores

There were no significant differences in VAS scores and ROM or OKS scores between the two groups before the operation (p > 0.05). The VAS score at 6 m in the monitoring group were significantly lower than those in the control group (p < 0.05), and the OKS scores at 6 and 12 months in the monitoring group were significantly higher than those in the control group (p < 0.05). There was no significant difference in the ROM values between the two groups at any time point (p > 0.05) (Table 4).

Table 4 Comparison of knee pain and function scores during the 1-year follow-up
Full size table

Discussion

Most postmenopausal females with osteoporosis appear to have some form of osteoarthritic impairment [26]. Postmenopausal bone loss is believed to occur as a result of an increase in the rate of bone turnover and a negative imbalance between bone formation and resorption [27], which may affect the surgical outcome of TKA and increase the incidence of prosthesis loosening [3]. Bone turnover markers provide timely bone turnover information that allows for earlier intervention in osteoporosis care [13]. As access to DXA scans is becoming more limited because of cost and insurance restrictions, BTM may become increasingly used in the therapeutic monitoring of osteoporosis [28]. To analyze the impact of BTM monitoring on improving osteoporosis treatment outcomes, prosthesis stability, and TKA surgical outcome, BTM monitoring was applied to guide osteoporosis treatment and compared with empirical treatment in postmenopausal osteoporosis females undergoing TKA.

In this study, the decrease in values of bone resorption marker (CTX-I) occurred rapidly after starting treatment with antiresorptive agents (alendronate). In contrast, the change in BMD occurs over months or years [15], so that BTM may provide earlier information on the response to anti-osteoporosis treatment than BMD. We observed a decrease in the bone resorption marker (CTX-I) earlier than in the bone formation marker (PINP) after treatment of postmenopausal osteoporosis, which has been reported by other studies [15, 29]. After 210 days of anti-osteoporosis treatment, CTX-I decreased by approximately 43% and PINP decreased by approximately 16%, indicating that bone resorption markers decreased by a greater magnitude than bone formation markers in response to bisphosphonate treatment. This phenomenon is caused by the pharmacological mechanism of alendronate, because alendronate directly inhibits bone resorption by osteoclasts and accordingly results in relatively rapid decreases in bone resorption markers; this causes a decrease in bone formation markers due to physiologic mechanisms linking osteoclast and osteoblast activity [13].

BTM can quickly and accurately reflect the state of bone resorption and bone formation, providing guidance and assistance when using bisphosphonate treatment. In this study, the treatment duration of the monitoring group was significantly extended, but the adverse reactions did not significantly increase. These results indicated that treatment under the monitoring of BTM was primarily safe. We measured BMD before and 1 year after TKA and found that the BMD values in the monitoring groups increased by 9.7%, while the BMD values in the control group decreased by 3.2%. This meant that the duration of the empirical treatment (3 months) was not long enough to achieve a long-term increase in BMD. The BMD reduction in the control group was probably attributed to the reduced mobility during rehabilitation [30]. BTM monitoring pays close attention to bone turnover in osteoporosis patients. When bone resorption and bone formation markers were within the reference intervals, bone turnover tended to be relatively balanced. Early decreases in bone turnover markers at 6–12 months of bisphosphonate treatment correlate with a long-term increase in bone mineral density [31].

Bone metabolism and bone quality are important for the initial stability of prostheses [3, 32, 33]. Bone loss in osteoporosis patients may have a negative effect on TKA, such as reduced stability, reduced lifetime of the prosthesis, and an increased rate of revision [3]. Reasons for periprosthetic bone loss include initial implant micromotion and migration [7]. This study placed emphasis on the initial migration of the prosthesis and used the mean MTPM of the tibial component to analyze prosthesis stability. Oral bisphosphonate significantly reduced early postoperative periprosthetic bone loss [11] and prevented osteolysis and aseptic loosening in TKA patients [7]. We found that the mean MTPM values at 6 and 12 months in the monitoring groups were all significantly higher than those in the control group. Under the monitoring of BTMs, patients might experience a more balanced bone turnover, a gradual increase in bone density, and a higher degree of prosthesis stability compared to the control.

Approximately one in five patients may be dissatisfied with their elective TKA, with dissatisfaction mainly focused on pain relief and function recovery [34]. The decrease in BMD in postmenopausal females with osteoporosis may affect the surgical results of TKA [3], particularly without effective and reasonable anti-osteoporosis treatment. Bisphosphonates improved the quality of life scores of postmenopausal females undergoing cementless THA [35]. In this study, we used the VAS score and ROM and OKS score to evaluate patient satisfaction with the surgical outcome, and the OKS score was mainly used to evaluate knee pain and daily function. We found that the VAS score at 6 months and OKS scores at 6 and 12 months after surgery in the BTM monitoring group were higher than those in the control group, indicating a higher satisfaction with the surgical outcome in the monitoring group. These results were likely because of the pain-reducing and stability-maintaining effects of alendronate treatment.

Although BTM monitoring prolonged the treatment duration of postmenopausal osteoporosis females undergoing TKA, it was still an effective way to guide osteoporosis treatment. Compared to empirical treatment, BTM monitoring treatment showed a valuable effect on improving the treatment outcomes of osteoporosis, thereby sustaining initial prosthesis stability. With lower pain scores and higher function scores, BTM monitoring treatment also achieved a satisfactory surgical outcome.

There were several limitations to this study. Firstly, the sample size was relatively small due to the specific requirements of patient recruitment in this study. Some patients refused to collect blood samples after operation. Second, the follow-up period (1 year) in this study was relatively short. The treatment of osteoporosis is a long-term procedure, and the bone mineral density is in a dynamic change after osteoporosis treatment. A prolonged follow-up period may supply more information after treatment and monitoring. Third, the sample may have selection bias. The female OA patients aged 55–75 years were selected, but increase of age (> 65 years) may also affect the BMD except for menopause. Our results need to be confirmed in larger sample sizes and with a longer follow-up period in the future.

Conclusion

The application of BTM monitoring to guide the treatment of osteoporosis in postmenopausal females can significantly improve bone density, prosthesis stability, and surgical outcomes after TKA, which may be of great significance in reducing the incidence of prosthesis loosening and improving surgical satisfaction in postmenopausal females with osteoporosis undergoing TKA.

Availability of data and materials

Data sharing not applicable to this article as no datasets were generated or analyzed during the current study.

Abbreviations

OP:

Osteoporosis

OA:

Osteoarthritis

TKA:

Total knee arthroplasty

BTM:

Bone turnover marker

CTX-I:

C-telopeptide of type I collagen

PINP:

N-terminal propeptide of type I procollagen

MTPM:

Maximum total point motion

BMD:

Bone mineral density

NICE:

National Institute for Health and Care Excellence

THA:

Total hip arthroplasty

DEXA:

Dual energy X-ray absorptiometry

RI:

Reference interval

SD:

Standard deviation

BMI:

Body weight index

Ca:

Calcium

IOF:

International Osteoporosis Foundation

RSA:

Radiostereometric analysis

VAS:

Visual analog scale

ROM:

Range of motion

OKS:

Oxford Knee Score

References

  1. Bultink IE, Lems WF. Osteoarthritis and osteoporosis: what is the overlap? Curr Rheumatol Rep. 2013;15(5):328. https://doi.org/10.1007/s11926-013-0328-0.

    Article  CAS  PubMed  Google Scholar 

  2. Sharma D, Larriera AI, Palacio-Mancheno PE, Gatti V, Fritton JC, Bromage TG, Cardoso L, Doty SB, Fritton SP. The effects of estrogen deficiency on cortical bone microporosity and mineralization. Bone. 2018;110:1–10. https://doi.org/10.1016/j.bone.2018.01.019.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  3. Huang CC, Jiang CC, Hsieh CH, Tsai CJ, Chiang H. Local bone quality affects the outcome of prosthetic total knee arthroplasty. J Orthop Res. 2016;34(2):240–8. https://doi.org/10.1002/jor.23003.

    Article  CAS  PubMed  Google Scholar 

  4. Valladares RD, Nich C, Zwingenberger S, Li C, Swank KR, Gibon E, Rao AJ, Yao Z, Goodman SB. Toll-like receptors-2 and 4 are overexpressed in an experimental model of particle-induced osteolysis. J Biomed Mater Res A. 2014;102(9):3004–11. https://doi.org/10.1002/jbm.a.34972.

    Article  CAS  PubMed  Google Scholar 

  5. Briem D, Strametz S, Ks O, Nm M, Lehmann W, Linhart W, et al. Effects of zoledronic acid on bone mineral density around prostheses and bone metabolism markers after primary total hip arthroplasty in females with postmenopausal osteoporosis. Osteoporos Int. 2019;30:1581–9.

    Article  Google Scholar 

  6. Licata AA. Discovery, clinical development, and therapeutic uses of bisphosphonates. Ann Pharmacother. 2005;39(4):668–77. https://doi.org/10.1345/aph.1E357.

    Article  CAS  PubMed  Google Scholar 

  7. Shanbhag AS. Use of bisphosphonates to improve the durability of total joint replacements. J AM Acad Orthop Sur. 2006;14(4):215–25. https://doi.org/10.5435/00124635-200604000-00003.

    Article  Google Scholar 

  8. Naylor KE, Jacques RM, Paggiosi M, Gossiel F, Peel NFA, McCloskey EV, et al. Response of bone turnover markers to three oral bisphosphonate therapies in postmenopausal osteoporosis: the TRIO study. Osteoporos Int. 2015;27:21–31.

    Article  Google Scholar 

  9. Fatoye F, Smith P, Gebrye T, Yeowell G. Real world persistence and adherence with oral bisphosphonates for osteoporosis - a systematic review. Value Health. 2018;21:S302–S3. https://doi.org/10.1016/j.jval.2018.09.1802.

    Article  Google Scholar 

  10. Shanbhag AS, Hasselman CT, Rubash HE. Inhibition of wear debris mediated osteolysis in a canine total hip arthroplasty model. Clin Orthop Relat Res. 1997;344:33–43.

    Article  Google Scholar 

  11. Soininvaara TA, Jurvelin JS, Miettinen HJ, Suomalainen OT, Alhava EM, Kroger PJ. Effect of alendronate on periprosthetic bone loss after total knee arthroplasty: a one-year, randomized, controlled trial of 19 patients. Calcif Tissue Int. 2002;71(6):472–7. https://doi.org/10.1007/s00223-002-1022-9.

    Article  CAS  PubMed  Google Scholar 

  12. Vasikaran SD, Chubb SA. The use of biochemical markers of bone turnover in the clinical management of primary and secondary osteoporosis. Endocrine. 2016;52(2):222–5. https://doi.org/10.1007/s12020-016-0900-2.

    Article  CAS  PubMed  Google Scholar 

  13. Greenblatt MB, Tsai JN, Wein MN. Bone turnover markers in the diagnosis and monitoring of metabolic bone disease. Clin Chem. 2017;63(2):464–74. https://doi.org/10.1373/clinchem.2016.259085.

    Article  CAS  PubMed  Google Scholar 

  14. Eastell R, Szulc P. Use of bone turnover markers in postmenopausal osteoporosis. Lancet Diabetes Endo. 2017;5(11):908–23. https://doi.org/10.1016/S2213-8587(17)30184-5.

    Article  Google Scholar 

  15. Vasikaran S, Eastell R, Bruyere O, Foldes AJ, Garnero P, Griesmacher A, et al. Markers of bone turnover for the prediction of fracture risk and monitoring of osteoporosis treatment: a need for international reference standards. Osteoporos Int. 2011;22(2):391–420. https://doi.org/10.1007/s00198-010-1501-1.

    Article  CAS  PubMed  Google Scholar 

  16. Naylor KE, McCloskey EV, Jacques RM, Peel NFA, Paggiosi MA, Gossiel F, et al. Clinical utility of bone turnover markers in monitoring the withdrawal of treatment with oral bisphosphonates in postmenopausal osteoporosis. Osteoporos Int. 2019;30(4):917–22. https://doi.org/10.1007/s00198-018-04823-5.

    Article  CAS  PubMed  Google Scholar 

  17. WHO. WHO scientific group on the assessment of osteoporosis at primary health care level. Summary Meeting Report. 2004; Brussels.

  18. Pollmann D, Siepmann S, Geppert R, Wernecke KD, Possinger K, Lüftner D. The amino-terminal propeptide (PINP) of type I collagen is a clinically valid indicator of bone turnover and extent of metastatic spread in osseous metastatic breast cancer. Anticancer Res. 2007;27(4A):1853–62.

    CAS  PubMed  Google Scholar 

  19. Valstar ER, Gill R, Ryd L, Flivik G, Börlin N, Kärrholm J. Guidelines for standardization of radiostereometry (RSA) of implants. Acta Orthop. 2005;76(4):563–72. https://doi.org/10.1080/17453670510041574.

    Article  PubMed  Google Scholar 

  20. Nilsson KG, Kirrholm J, Carlsson L, Dalén T. Hydroxyapatite coating versus cemented fixation of the tibial component in total knee arthroplasty. Prospective randomized comparison of hydroxyapatite-coated and cemented tibial components with 5-year follow-up using radiostereometry (RSA). J Arthroplasty. 1999;14:9–20.

    Article  CAS  Google Scholar 

  21. Linde KN, Madsen F, Puhakka KB, Langdahl BL, Soballe K, Krog-Mikkelsen I, et al. Preoperative systemic bone quality does not affect tibial component migration in knee arthroplasty: A 2-year radiostereometric analysis of a hundred consecutive patients. J Arthroplasty. 2019;34(10):2351–9. https://doi.org/10.1016/j.arth.2019.05.019.

    Article  PubMed  Google Scholar 

  22. Ryd L. Micromotion in Knee Arthroplasty. A roentgen stereophotogrammetric analysis of tibial component fixation. Acta Orthop Scand Suppl. 1986;220:1–80.

    CAS  PubMed  Google Scholar 

  23. Blake GM, Fogelman I. The role of DXA bone density scans in the diagnosis and treatment of osteoporosis. Postgrad Med J. 2007;83(982):509–17. https://doi.org/10.1136/pgmj.2007.057505.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Kooistra BW, Sprague S, Bhandari M, Schemitsch EH. Outcomes assessment in fracture healing trials: A primer. J Orthop Trauma. 2010;24(Suppl 1):S71–5. https://doi.org/10.1097/BOT.0b013e3181ca3fbd.

    Article  PubMed  Google Scholar 

  25. Meenan R, Gertman P, Mason J. Measuring heaIth status in arthritis: the arthritis impact measurement scales. Arthritis Rheum. 1980;23(2):146–52. https://doi.org/10.1002/art.1780230203.

    Article  CAS  PubMed  Google Scholar 

  26. Rizou S, Chronopoulos E, Ballas M, Lyritis GP. Clinical manifestations of osteoarthritis in osteoporotic and osteopenic postmenopausal women. J Musculoskelet Neuronal Interact. 2018;18(2):208–14.

    CAS  PubMed  PubMed Central  Google Scholar 

  27. Gossiel F, Altaher H, Reid DM, Roux C, Felsenberg D, Glüer C-C, Eastell R. Bone turnover markers after the menopause: T-score approach. Bone. 2018;111:44–8. https://doi.org/10.1016/j.bone.2018.03.016.

    Article  PubMed  Google Scholar 

  28. Jain S, Camacho P. Use of bone turnover markers in the management of osteoporosis. Curr Opin Endocrinol Diabetes Obes. 2018;25(6):366–72. https://doi.org/10.1097/MED.0000000000000446.

    Article  PubMed  Google Scholar 

  29. Riggs BL, Parfitt AM. Drugs used to treat osteoporosis: the critical need for a uniform nomenclature based on their action on bone remodeling. J Bone Miner Res. 2005;20(2):177–84. https://doi.org/10.1359/JBMR.041114.

    Article  CAS  PubMed  Google Scholar 

  30. Lee JK, Lee CH, Choi CH. QCT bone mineral density responses to 1 year of oral bisphosphonate after total knee replacement for knee osteoarthritis. Osteoporosis Int. 2012;24:287–92.

    Article  Google Scholar 

  31. Eastell R, Hannon RA, Garnero P, Campbell MJ, Delmas PD. Relationship of early changes in bone resorption to the reduction in fracture risk with risedronate: review of statistical analysis. J Bone Miner Res. 2007;22(11):1656–60. https://doi.org/10.1359/jbmr.07090b.

    Article  PubMed  Google Scholar 

  32. Aro HT, Alm JJ, Moritz N, Mäkinen TJ, Lankinen P. Low BMD affects initial stability and delays stem osseointegration in cementless total hip arthroplasty in women. Acta Orthop. 2012;83(2):107–14. https://doi.org/10.3109/17453674.2012.678798.

    Article  PubMed  PubMed Central  Google Scholar 

  33. Finnila S, Moritz N, Svedstro ME, Alm JJ, Aro HT. Increased migration of uncemented acetabular cups in female total hip arthroplasty patients with low systemic bone mineral density. A 2-year RSA and 8-year radiographic follow-up study of 34 patients. Acta Orthop. 2016;87(1):48–54. https://doi.org/10.3109/17453674.2015.1115312.

    Article  PubMed  Google Scholar 

  34. Kahlenberg CA, Nwachukwu BU, McLawhorn AS, Cross MB, Cornell CN, Padgett DE. Patient satisfaction after total knee replacement: A systematic review. HSSJ. 2018;14(2):192–201. https://doi.org/10.1007/s11420-018-9614-8.

    Article  Google Scholar 

  35. Muratore M, Quarta E, Quarta L, Calcagnile F, Grimaldi A, Orgiani MA, Marsilio A, Rollo G. Ibandronate and cementless total hip arthroplasty: densitometric measurement of periprosthetic bone mass and new therapeutic approach to the prevention of aseptic loosening. Clin Cases Miner Bone Metab. 2012;9(1):50–5.

    PubMed  PubMed Central  Google Scholar 

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Acknowledgements

The authors would like to thank American Journal Expert (AJE) for language polishing.

Funding

This research was supported by the National Natural Science Foundation of China (No. 81702130) and the Natural Science Foundation of Shaanxi Province (No. 2019JQ-143).

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Authors and Affiliations

  1. Department of Bone and Joint Surgery, The Second Affiliated Hospital of Xi’an Jiaotong University, NO. 157 Xiwu Road, Xi’an, 710004, Shaanxi, People’s Republic of China

    Rui Ma, Mengjun Wu, Yongwei Li, Jialin Wang, Pei Yang, Yuanyuan Chen, Wei Wang, Jinhui Song & Kunzheng Wang

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  3. Yongwei Li
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  4. Jialin Wang
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  5. Pei Yang
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  6. Yuanyuan Chen
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  7. Wei Wang
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  8. Jinhui Song
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  9. Kunzheng Wang
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Contributions

Conceptualization: Rui Ma, Kunzheng Wang. Data curation: Rui Ma, Mengjun Wu, Yongwei Li, Jialin Wang, Yuanyuan Chen. Formal analysis: Rui Ma, Pei Yang. Investigation: Mengjun Wu, Yongwei Li, Jialin Wang. Methodology: Wei Wang. Project administration: Kunzheng Wang. Resources: Kunzheng Wang, Jinhui Song, Pei Yang. Supervision: Kunzheng Wang. Writing – original draft: Rui Ma. Writing – review and editing: Rui Ma, Kunzheng Wang. The author(s) read and approved the final manuscript.

Corresponding author

Correspondence to Kunzheng Wang.

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This study was approved by the Medical Ethics Committee of the Second Affiliated Hospital of Xi’an Jiaotong University. All participants gave written informed consent and agreed for the publication.

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The authors declare that they have no competing interests.

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Ma, R., Wu, M., Li, Y. et al. The use of bone turnover markers for monitoring the treatment of osteoporosis in postmenopausal females undergoing total knee arthroplasty: a prospective randomized study. J Orthop Surg Res 16, 195 (2021). https://doi.org/10.1186/s13018-021-02343-3

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  • DOI: https://doi.org/10.1186/s13018-021-02343-3

Keywords

Journal of Orthopaedic Surgery and Research

ISSN: 1749-799X