Association between bisphosphonate use and implant survival after primary total arthroplasty of the knee or hip: population based retrospective cohort study

Abstract

Objectives To test whether bisphosphonate use is related to improved implant survival after total arthroplasty of the knee or hip.Design Population based retrospective cohort study. Setting Primary care data from the United Kingdom. Participants All patients undergoing primary total arthroplasty of the knee (n=18 726) or hip (n=23 269) in 1986-2006 within the United Kingdom’s General Practice Research Database. We excluded patients with a history of hip fracture before surgery or rheumatoid arthritis, and individuals younger than 40 years at surgery. Intervention Bisphosphonate users were classified as patients with at least six prescriptions of bisphosphonates or at least six months of prescribed bisphosphonate treatment with more than 80% adherence before revision surgery. Outcome measures Revision arthroplasties occurring after surgery, identified by READ and OXMIS codes. Parametric survival models were used to determine effects on implant survival with propensity score adjustment to account for confounding by indication. Results Of 41 995 patients undergoing primary hip or knee arthroplasty, we identified 1912 bisphosphonate users, who had a lower rate of revision at five years than non-users (0.93% (95% confidence interval 0.52% to 1.68%) v 1.96% (1.80% to 2.14%)). Implant survival was significantly longer in bisphosphonate users than in non-users in propensity adjusted models (hazard ratio 0.54 (0.29 to 0.99); P=0.047) and had an almost twofold increase in time to revision after hip or knee arthroplasty (time ratio 1.96 (1.01 to 3.82)). Assuming 2% failure over five years, we estimated that the number to treat to avoid one revision was 107 for oral bisphosphonates.Conclusions In patients undergoing lower limb arthroplasty, bisphosphonate use was associated with an almost twofold increase in implant survival time. These findings require replication and testing in experimental studies for confirmation.

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

“…Of note, the data on periprosthetic fracture outcomes were based on a smaller cohort of patients; fewer events occurred and therefore uncertainty (ie, wide CIs) surrounds our estimates. We acknowledge that there may have been changes in patient BMD from the time of the DEXA scan to actual THA; however, this time period has been previously used and our methodology was thus consistent with published data [28]. There may be a further change in BMD after initiation of a bisphosphonate but that change tends to be only 3% to 5%, even after 3 years of bisphosphonate treatment, and not likely to affect DEXA scores significantly [8].…”

“…All patients who underwent primary elective THA and were aged [ 40 years [28] with the primary diagnosis of osteoarthritis treated between April 2001 and December 2010 in the Southern California region of KP were included in the study (N = 12,878). During the course of the study, membership in the region was approximately three million people.…”

“…Bisphosphonate use was determined similarly to the criteria reported by PrietoAlhambra et al [28]. Patients were considered bisphosphonate users if they (1) had not had a revision procedure and had filled at least two medication prescriptions (each with three refills) at any time during the study period, indicating a minimum of 6 months of treatment with high adherence; and (2) had a revision and had been prescribed the medication for at least 6 months (two continuous prescriptions each with three refills) with high adherence 6 months before the revision.…”

“…Inadequate quantity or quality of the supporting bone can contribute to THA failure, including aseptic loosening and periprosthetic fracture [27,28]. Multiple studies have evaluated the effect of bisphosphonate use on bone mineral density (BMD) surrounding THA devices [1,2,5,12,15,16,29,32,37,38].…”

“…To our knowledge, three studies have examined fracture risk and revision arthroplasty after the use of bisphosphonates in patients who had undergone THA and TKA [27,28,31]. Although the studies revealed a lower risk of fracture and revision surgeries, it may be difficult to generalize these results because the samples were relatively homogenous populations and none of the studies quantified the degree of preoperative osteoporosis in the populations studied.…”