Effect of Preoperative Bisphosphonate Treatment on Fracture Healing after Internal Fixation Treatment of Intertrochanteric Femoral Fractures

Does Preoperative Bisphosphonate Use Impact the Risk of Periprosthetic Fracture Following Total Hip Arthroplasty?

BACKGROUND

Bisphosphonate (BP) use is not uncommon among total hip arthroplasty (THA) candidates. While the impact of BP therapy post-THA has been investigated, there is a paucity of literature discussing the impact of BP therapy pre-THA. Using a national dataset, we aimed to study the association between preoperative BP use and surgical outcomes in primary THA recipients.

METHODS

This retrospective cohort study used a commercial claims and Medicare Supplemental database to identify adults aged ≥ 18 years who had an index nonfracture-related primary THA from 2016 to 2020. The use of BP was defined as ≥ 6 months of BP therapy in the year prior to THA. Outcomes were 90-day all-cause readmission, 90-day readmission related to periprosthetic fracture (PPF), 90-day and 1-year all-cause revision, 1-year PPF-related revision, and 1-year diagnosis of PPF. In a 1:5 propensity score-matched analysis, each THA patient who had preoperative BP use was matched to five THA patients who did not have preoperative BP use. Logistic regression models were fitted; we report odds ratios (ORs) and 95% confidence intervals (CIs).

RESULTS

Of 91,907 THA patients, 1,018 (1.1%) used BP preoperatively. In the propensity score-matched cohort (1,018 preoperative BP users and 5,090 controls), preoperative BP use was significantly associated with increased odds of 90-day all-cause revision surgery (OR 1.67; 95% CI 1.10 to 2.53; P = 0.02), 1-year PPF-related revision (OR 2.23; 95% CI 1.21 to 4.10; P = 0.01), and 1-year PPF diagnosis (OR 1.88; 95% CI 1.10 to 3.20; P = 0.02). There were no statistically significant associations between preoperative BP use and the other outcomes in the matched cohort.

CONCLUSIONS

These findings suggest that preoperative BP use is associated with an increased risk of revision surgery and PPF in both the short and long term. This information can help in preoperative planning and patient counseling, potentially leading to improved surgical outcomes and reduced complication rates.

Does early administration of denosumab delay bone healing after intertrochanteric femoral fractures?

INTRODUCTION

Hip fractures are commonly associated with osteoporosis and pose a risk for secondary fractures. Although the administration of anti-osteoporotic drugs is recommended after fractures to mitigate this risk, the potential effect of strong anti-resorptive drugs (e.g., denosumab) on fracture healing processes have not been extensively studied. This prospective study aimed to evaluate the feasibility of early denosumab administration after femoral intertrochanteric fracture surgery and to compare its effect on fracture healing to that of bisphosphonate-treated patients.

MATERIALS AND METHODS

Patients who underwent surgery for intertrochanteric femoral fragility fractures between November 2018 and November 2020 were prospectively examined. Patients were randomized into two groups (denosumab [DSM] and ibandronate [IBN] groups) using a simple randomization procedure. Physical findings, plain radiographs, and computed tomography (CT) were used to evaluate fracture healing at 3 months postoperatively.

RESULTS

Physical findings showed no significant differences between the two groups in pain on loading, tenderness at fracture site, or walking ability. There were inter-rater differences in radiological fracture healing rate: plain radiographs, 57.5%-81.8% in the DSM group and 51.5%-90.9% in the IBN group; CT, 51.5%-72.7% in the DSM group and 45.4%-81.8% in the IBN group. Although there were variations, there were no significant differences in the fracture healing rate between groups on plain radiographs or CT among all three raters.

CONCLUSIONS

Early administration of denosumab after intertrochanteric femoral fracture surgery did not delay radiological or clinical fracture healing times when compared with ibandronate administration.

Initiation of Bisphosphonates Prior to Total Joint Arthroplasty Does Not Lower Periprosthetic Fracture Risk

BACKGROUND

Many patients are diagnosed with osteoporosis shortly prior to scheduling total joint arthroplasty (TJA). The purpose of this study was to determine if initiation of bisphosphonates prior to TJA decreased the risks of periprosthetic fractures (PPFx).

METHODS

A national database was used to identify all patients diagnosed with osteoporosis prior to primary TJA. Patients who had osteoporosis without preoperative bisphosphonate use were designated as our control group. Patients on preoperative bisphosphonates were stratified based on duration and timing of bisphosphonate use: long-term preoperative users (initiation 3 to 5 years preoperatively), intermediate-term preoperative users (initiation 1 to 3 years preoperatively), and short-term preoperative users (initiation 0 to 1 year preoperatively). Rates of PPFx at 90-day and 2-year follow-up were compared between groups.

RESULTS

In patients undergoing primary total hip arthroplasty, there was no difference in PPFx rate between our control group and preoperative bisphosphonate users of all durations at 90-day (P = .12) and 2-year follow-up (P = .22). In patients undergoing primary total knee arthroplasty, there was no difference in PPFx rate between our control group and preoperative bisphosphonate users of all durations at 90-day (P = .76) and 2-year follow-up (P = .39).

CONCLUSIONS

In patients undergoing primary TJA, preoperative bisphosphonate users did not have a decreased PPFx rate compared to our control group at 90-day and 2-year follow-up. Our findings suggest that preoperative bisphosphonate use, regardless of the duration of treatment, does not confer protective benefits against PPFx in patients undergoing TJA.

LEVEL OF EVIDENCE

Prognostic Level III.

The Effect of Preoperative Bisphosphonate Use on Total Hip Arthroplasty Outcomes

BACKGROUND

Patients undergoing total hip arthroplasty (THA) commonly have osteoporosis for which bisphosphonates (BPs) are Food and Drug Administration (FDA)-approved for treatment. Bisphosphonate use post-THA is associated with decreased periprosthetic bone loss or revisions, and increased longevity of implants. However, evidence is lacking for preoperative bisphosphonate use in THA recipients. This study investigated the association between bisphosphonate use pre-THA and outcomes.

METHODS

A retrospective review of a national administrative claims database was conducted. Among THA recipients who had a prior diagnosis of hip osteoarthritis and osteoporosis/osteopenia, the treatment group (BP-exposed) consisted of patients who had a history of bisphosphonate use at least 1 year before THA; controls (BP-naive) comprised patients who did not have preoperative bisphosphonate use. The BP-exposed were matched to BP-naive in a 1:4 ratio by age, sex, and comorbidities. Logistic regressions were used to calculate the odds ratio for intraoperative and 1-year postoperative complications.

RESULTS

The BP-exposed group had significantly higher rates of intraoperative and 1-year postoperative periprosthetic fractures (odds ratio (OR): 1.39, 95% confidence interval (CI): 1.23, 1.57) and revisions (OR: 1.14, 95% CI: 1.04, 1.25) compared with the BP-naive controls. BP-exposed also experienced higher rates of aseptic loosening, dislocation, periprosthetic osteolysis, and stress fracture of the femur or hip/pelvis compared to the BP-naive controls, but these values were not statistically significant.

CONCLUSION

The use of bisphosphonates in THA patients preoperatively is associated with higher rates of intraoperative and 1-year postoperative complications. These findings may impact the management of patients undergoing THA who have a prior diagnosis of osteoporosis/osteopenia and use of bisphosphonates.

LEVEL OF EVIDENCE

Retrospective Cohort Study (Level 3).

Study on the Mechanism of Qigu Capsule in Upregulating NF-κB/HIF-1α Pathway to Improve the Quality of Bone Callus in Mice at Different Stages of Osteoporotic Fracture Healing

Objective

The present study intends to investigate the effects and underlying molecular mechanism of Qigu Capsule (QG) on fracture healing in mice with osteoporosis.

Methods

Ten-week-old female C57BL/6 mice were ovariectomized and three weeks later were evaluated for successful modeling. Then, all mice were prepared into models of transverse fracture in the right middle femoral shaft. Mice were treated daily using a gavage with normal saline (the NS group), Qigu Capsule (the QG group), or alendronate (the ALN group) postoperatively. Fracture callus tissues were collected and analyzed by X-ray, micro-CT, western blot (WB), and transmission electron microscope (TEM) on postoperation Day 14 (POD14), POD28, and POD42.

Results

(1) X-ray results showed that on POD14, the QG group had the fracture healing score significantly higher than the NS and ALN groups, and on POD28, it had the fracture healing score higher than the NS group, suggesting that QG could promote fracture healing. (2) Micro-CT results showed that on POD14, the QG group had tissue bone density (TMD) significantly higher than the NS and ALN groups, and on POD28 and POD42, it had bone volume fraction, trabecular number, and TMD significantly higher than the NS group. (3) WB results showed that, compared with the NS group, the QG group had significantly increased expression of nuclear factor kappa-B (NF-κB), hypoxia-inducible factor-1α (HIF-1α), bone alkaline phosphatase (BALP), runt-related transcription factor 2 (Runx2), bone Gla protein (BGP) and collagen Iα1 (COLIα1) on POD14, significantly increased expression of NF-κB, HIF-1α, BALP and COLIα1 on POD28, and significantly increased expression of NF-κB, HIF-1α, and Runx2 on POD42. (4) TEM scanning results showed that, compared with the NS and ALN groups, the QG group had significantly increased numbers of autophagic vacuoles (AVs) in osteocytes on POD14, POD28, and POD42.

Conclusion

QG could accelerate osteoporotic fracture healing by promoting bone formation and osteocyte autophagy, possibly through upregulating the NF-κB/HIF-1α signaling pathway.

The effect of osteoporosis and its treatment on fracture healing a systematic review of animal and clinical studies

Introduction

Osteoporosis is characterised by low bone mass and micro-architectural deterioration of bone structure. Its treatment is directed at the processes of bone formation or resorption, that are of utmost importance in fracture healing. We provide a comprehensive review of the literature aiming to summarize and clarify the effects of osteoporosis and its treatment on fracture healing.

Material and methods

A literature search was conducted in PubMed and Embase (OVID version). In vivo animal and human studies on long bone fractures were included. A total of 93 articles were included for this review; 23 studies on the effect of osteoporosis (18 animal and 5 clinical studies) and 70 studies on the effect of osteoporosis treatment (41 animal, 26 clinical studies and 3 meta-analyses) on fracture healing.

Results

In animal fracture models osteoporosis was associated with decreased callus formation and bone growth, bone mineral density, biomechanical strength and delayed cellular and differentiation processes during fracture healing. Two large databases identified osteoporosis as a risk factor for non-union whereas three other studies did not. One of those three studies however found a prolonged healing time in patients with osteoporosis. Anti-osteoporosis medication showed inconsistent effects on fracture healing in both non-osteoporotic and osteoporotic animal models. Only the parathyroid hormone and anti-resorption medication were related to improved fracture healing and delayed remodelling respectively. Clinical studies performed in predominantly hip and distal radius fracture patients showed no effect of bisphosphonates on fracture healing. Parathyroid hormone reduced time to union in several clinical trials performed in mainly hip fracture patients, but this did not result in decreased delayed or non-union rates.

Conclusion

Evidence that substantiates the negative influence of osteoporosis on fracture healing is predominantly from animal studies and to a lesser extent from clinical studies, since convincing clinical evidence lacks. Bisphosphonates and parathyroid hormone may be used during fracture healing, since no clear negative effect has been shown. Parathyroid hormone might even decrease time to fracture union, without decreasing union rate.

•

Osteoporosis negatively influences fracture healing in animal models.

•

There is no convincing evidence for a similar effect in humans.

•

In animals, bisphosphonates delay bone remodelling

•

In animals, parathyroid hormone improves fracture healing

•

In humans, anti-osteoporotic drugs do not interfere with fracture healing.

Effect of Osteoporosis Medication on Fracture Healing: An Evidence Based Review

A systematic search was conducted and relevant studies that evaluated the influence of osteoporosis medications (bisphosphonates [BPs], denosumab, selective estrogen receptor modulators [SERMs], recombinant human parathyroid hormone teriparatide [TPTD], and strontium ranelate [SrR]) on wrist, hip, and spine fracture healing, were selected. BPs administration did not influence fracture healing and clinical outcomes after distal radius fracture (DRF). Similar results were observed in hip fracture, but evidence is lacking for spine fracture. Denosumab did not delay the non-vertebral fractures healing in one well-designed study. No studies evaluated the effect of SERMs on fracture healing in humans. One study reported shorter fracture healing times in TPTD treated DRF patients, which was not clinically meaningful. In hip fracture, recent studies reported better pain and functional outcomes in TPTD treated patients. However, in spine fracture, recent studies found no significant differences in fracture stability between TPTD treated patients and controls. Evidence is lacking for SrR, but it did not influence wrist fracture healing in one study. In comparisons between TPTD and BPs, fracture healing and physical scores were not significantly different in hip fracture by 1 study. In spine fracture, controversy exists for the role of each medication to the fracture stability, but several studies reported that fracture site pain was better in TPTD treated patients than BPs treated patients. Considering no clinical data of negative fracture healing of the antiresorptive medication and the danger of subsequent fracture after initial osteoporotic fracture, there is no evidence to delay initiation of osteoporosis medications after fracture.