Elsevier

Bone

Volume 46, Issue 4, April 2010, Pages 946-951
Bone

Postoperative use of bisphosphonates and risk of revision after primary total hip arthroplasty: A nationwide population-based study

https://doi.org/10.1016/j.bone.2010.01.377Get rights and content

Abstract

Background

Recently, bisphosphonates have been linked with mechanisms that may influence longevity of orthopedic implants. We therefore evaluated the association between the use of bisphosphonates and the risk of revision after primary total hip arthroplasty (THA).

Methods

We conducted a nationwide population-based nested case–control study using medical databases in Denmark. From the Danish Hip Arthroplasty Register (DHR) we included primary THA patients diagnosed with either osteoporosis or a previous osteoporotic fracture (n = 16,145). Among these patients we identified 632 cases that were revised after primary THA in the period 1995–2006. The cases were matched on gender, age and year of primary THA surgery with 1262 non-revised osteoporotic THA controls. Using conditional logistic regression we estimated the risk of revision due to all causes and due to specific causes according to postoperative bisphosphonate use.

Results

The 10-year cumulated implant revision rate in the underlying cohort of 16,145 primary THA procedures among osteoporotic patients was 8.3% (95% confidence interval (CI): 7.3–9.3). The use of bisphosphonates was associated with an adjusted relative risk of revision due to deep infections of 2.59 (95% CI; 1.30–6.53). Further, the duration of bisphosphonates use up to 120 days, 120 and 240 days, and more than 240 days was associated with adjusted relative risks of revision due to all causes of 2.77 (95% CI; 1.65–4.64), 1.33 (95% CI; 0.63–2.72), and 0.58 (95% CI; 0.32–1.05) respectively.

Conclusions

The use of bisphosphonates following primary THA was associated with an increased risk of revision due to deep infection. However, long-term use was associated with a reduced risk of revision of any type. Further research is warranted in order to clarify whether these associations are truly causal.

Introduction

Primary total hip arthroplasty (THA) is a well-documented treatment of hip joint arthritis providing pain relief and improved function. The most frequent reasons for revision are aseptic loosening of the components, deep infections, and dislocation [1]. As revision surgery is associated with increased rates of complications and morbidity every effort should be directed at identifying factors that could increase the longevity of primary THA.

Bisphosphonates are widely used for the treatment of osteoporosis. They inhibit bone resorption, increase bone density and reduce the risk of fractures [2]. Further, according to experimental and clinical studies bisphosphonates have been associated with increased implant fixation, decreased prosthetic migration [3], [4], [5], decreased periprosthetic bone loss, and reduced particle induced bone resorption [6]. It has therefore been proposed that bisphosphonates may improve the longevity of total joint replacements [6]. However, so far there have been a lack of large-scale epidemiological studies and it is therefore uncertain if the proposed effects of bisphosphonates really translate into clinically relevant improvements in implant durability.

We therefore conducted this nested case–control study to examine the association between the use of bisphosphonates and the risk of revision after primary THA using comprehensive data from population-based nationwide medical databases in Denmark.

Section snippets

Materials and methods

In Denmark, the National Health Service provides tax-supported healthcare for all inhabitants, allowing free access to general practitioners and hospitals. In addition, part of the costs of prescribed drugs is covered by the healthcare system.

Results

The distribution of covariates among matched cases and controls are presented in Table 1. Statistical significant differences were found for a number of covariates including region of residence, congestive heart failure, chronic pulmonary disease, liver disease, Charlson comorbidity index score, implant fixation technique, diagnosis for primary THA surgery, and previous diagnosis of osteoporosis or osteoporotic fracture.

The 10-year THA failure rate for the underlying cohort of osteoporosis

Discussion

In this first large-scale epidemiological study on bisphosphonates use and revision risk following primary THA, we found an increased risk of revision due to deep infection in postoperative users of bisphosphonates. However, long-term use of bisphosphonates was not associated with the risk of revision due to deep infections. Further, we found evidence of an increased risk of revision in short-term postoperative users whereas; the risk of revision was reduced among long-term postoperative users

Acknowledgments

The authors thank the Danish Rheumatism Association, the Korning Foundation and the Augustinus Foundation for their financial support. The funding sources did not play a role in the study. The authors thank Anne Hjelm, secretary for the Danish Hip Arthroplasty Registry.

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