Elsevier

Bone

Volume 45, Issue 3, September 2009, Pages 499-504
Bone

Use of diuretics and risk of implant failure after primary total hip arthroplasty: A nationwide population-based study

https://doi.org/10.1016/j.bone.2009.04.247Get rights and content

Abstract

Introduction

Thiazid and loop diuretics have been associated with changes in bone mineral density and fracture risk. However, data on survival of prosthesis implants are lacking. We evaluated the association between diuretic use and the risk of revision after primary total hip arthroplasty (THA).

Materials and methods

We conducted a nationwide population-based case-control study using medical databases in Denmark. In the Danish Hip Arthroplasty Registry, we identified 2491 cases that were revised after primary THA in the period 1995–2005 and who could be matched on age, gender and year of primary operation with 4943 non-revised THA controls. By means of conditional logistic regression, we estimated the relative risk (RR) of revision due to all causes and due to specific causes according to postoperative use of thiazid and loop diuretic, respectively.

Results

The 10-year cumulated implant revision rate in the underlying cohort of 57,575 THA procedures from the Danish Hip Arthroplasty Registry was 8.9% (95% CI: 8.4–9.4). Postoperative thiazid diuretic use was not associated with neither the overall risk of revision nor revision due to specific causes compared to non-use. Postoperative loop diuretic use was associated with an adjusted RR of revision of 1.14 (95% CI; 0.98–1.32) compared with non-use. The adjusted RR of revision due to deep infection and periprosthetic fracture in loop diuretic users was 1.71 (1.15–2.55) and 6.39 (1.84–22.21), respectively. Loop diuretic use was not associated with risk of revision due to aseptic loosening, dislocation or miscellaneous causes.

Discussion

Loop diuretics but not thiazides may be associated with an increased risk of revision following primary THA. Further studies are warranted in order to confirm this finding and clarify the nature of the association.

Introduction

Diuretics, including thiazid and loop diuretics, are widely used drugs for treatment of hypertension and congestive heart failure. Thiazid diuretics reduce, whereas loop diuretics increase the renal calcium excretion and thereby alter bone metabolism [1]. Previous randomized controlled trials and observational studies have indicated that treatment with thiazides may exert positive effects on bone with an increased bone mineral density (BMD) and decreased risk of fractures [2], [3], [4], [5]. In contrast, loop diuretics have been associated with an increased bone turnover, decreased BMD and increased risk of fractures [4], [6], [7], [8].

Primary total hip arthroplasty (THA) is a well documented treatment of hip joint arthritis providing pain relief and improved function. Various patient related predictors for implant survival after primary THA surgery have been described, e.g., age, gender, co-morbidity, indication for THA, smoking and alcohol [9], [10], [11]. However, information on potential effects of drugs on the implant survival after primary THA is yet sparse [10]. Knowing that diuretics interfere with calcium homeostasis and thus bone metabolism, we hypothesized that thiazides and loop diuretics may influence the implant survival after primary THA surgery. We therefore conducted a nested case-control study of the association between thiazides and loop diuretic use and the risk of revision after primary THA surgery using population-based nationwide medical databases in Denmark. To our knowledge, this is the first epidemiological study to evaluate the effect of diuretic use on the risk of revision after primary THA.

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

Cases and controls were well matched on gender, age and year of operation and distribution of 25 covariates was equal between cases and controls, whereas distribution of 12 covariates, including county of residence, NSAID use, cerebrovascular disease, peripheral vascular disease, ulcer disease, liver disease, diabetes I and II, diabetes with organ disability, renal disease, Charlson co-morbidity index, implant fixation technique, and diagnosis for primary THA surgery, differed between cases and

Discussion

We report that thiazid users did not have an overall increased risk of revision, except for an increased risk of revision due to miscellaneous causes including pain, implant failure, anisomelia, ectopic bone formation and technical problems. In contrast, loop diuretic users had an overall greater risk of revision after primary THA compared to non-users. In particular, loop diuretic users had an increased risk of revision due to deep infection and periprosthetic fracture. However, the overall

Acknowledgments

This study was supported by the Danish Rheumatism Association and the Augustinus Foundation. The authors thank Anne Hjelm, secretary of the Danish Hip Arthroplasty Registry.

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