Does radiopaque cement conceal periprosthetic bone loss around femoral stems?

Background: Periprosthetic bone remodelling may increase fracture risk and deplete bone stock around hip implants. These changes are in part caused by implant design, advocating an early evaluation of bone remodelling properties of new implants. This can be done by repeated dual-energy x-ray absorptiometry (DXA) measurements. We know that radiopaque cement falsely elevates bone mineral density (BMD) in single measurements, however, its impact on repeated measurements, i.e. BMD changes is unexplored. We have therefore investigated whether the presence of radiopaque cement affect repeated BMD measurements. Methods: 33 patients eligible for total hip replacement were randomly assigned to either radiopaque or radiolucent cement. BMD changes up to 12 months were measured by DXA, in addition to Harris Hip Score, plain radiographs and radiostereometric analysis (RSA). Results: Periprosthetic BMD declined during the first 3–6 months in all zones in both groups. The greatest reduction (14%) was seen in the proximal Gruen zones (1 and 7). We found a significant difference in Gruen zones 1 and 2, where the measured bone loss was higher in the radiolucent cement group. Conclusions: The presence of radiopaque agents in bone cement may influence DXA measurements of bone remodelling. ClinicalTrials.gov identifier NCT00473421.

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Long-term bone remodelling around ‘legendary’ cementless femoral stems

EFORT Open Reviews ◽

10.1302/2058-5241.3.170024 ◽

2018 ◽

Vol 3 (2) ◽

pp. 45-57 ◽

Cited By ~ 16

Author(s):

Charles Rivière ◽

Guido Grappiolo ◽

Charles A. Engh ◽

Jean-Pierre Vidalain ◽

Antonia-F. Chen ◽

...

Keyword(s):

Bone Loss ◽

Bone Remodelling ◽

Bone Ingrowth ◽

Stress Shielding ◽

Implant Design ◽

Periprosthetic Bone ◽

Femoral Stems ◽

Periprosthetic Bone Loss ◽

Load Pattern

Bone remodelling around a stem is an unavoidable long-term physiological process highly related to implant design. For some predisposed patients, it can lead to periprosthetic bone loss secondary to severe stress-shielding, which is thought to be detrimental by contributing to late loosening, late periprosthetic fracture, and thus rendering revision surgery more complicated. However, these concerns remain theoretical, since late loosening has yet to be documented among bone ingrowth cementless stems demonstrating periprosthetic bone loss associated with stress-shielding. Because none of the stems replicate the physiological load pattern on the proximal femur, each stem design is associated with a specific load pattern leading to specific adaptive periprosthetic bone remodelling. In their daily practice, orthopaedic surgeons need to differentiate physiological long-term bone remodelling patterns from pathological conditions such as loosening, sepsis or osteolysis. To aid in that process, we decided to clarify the behaviour of the five most used femoral stems. In order to provide translational knowledge, we decided to gather the designers’ and experts’ knowledge and experience related to the design rationale and the long-term bone remodelling of the following femoral stems we deemed ‘legendary’ and still commonly used: Corail (Depuy); Taperloc (Biomet); AML (Depuy); Alloclassic (Zimmer); and CLS-Spotorno (Zimmer).Cite this article: EFORT Open Rev 2018;3:45-57. DOI: 10.1302/2058-5241.3.170024

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Randomized Controlled Trial of Annual Zoledronic Acid to Prevent Gonadotropin-Releasing Hormone Agonist–Induced Bone Loss in Men With Prostate Cancer

Journal of Clinical Oncology ◽

10.1200/jco.2006.07.3361 ◽

2007 ◽

Vol 25 (9) ◽

pp. 1038-1042 ◽

Cited By ~ 224

Author(s):

M. Dror Michaelson ◽

Donald S. Kaufman ◽

Hang Lee ◽

Francis J. McGovern ◽

Philip W. Kantoff ◽

...

Keyword(s):

Prostate Cancer ◽

Lumbar Spine ◽

Zoledronic Acid ◽

Bone Loss ◽

Gnrh Agonist ◽

Controlled Trial ◽

Gonadotropin Releasing Hormone ◽

Mineral Density ◽

Releasing Hormone ◽

Increase Fracture Risk

Purpose Gonadotropin-releasing hormone (GnRH) agonists decrease bone mineral density (BMD) and increase fracture risk in men with prostate cancer. Annual zoledronic acid increases BMD in postmenopausal women, but its efficacy in hypogonadal men is not known. Patients and Methods In a 12-month study, 40 men with nonmetastatic prostate cancer who were receiving a GnRH agonist and had T scores more than −2.5 were randomly assigned to zoledronic acid (4 mg intravenously on day 1 only) or placebo. BMD of the posteroanterior lumbar spine and proximal femur were measured by dual-energy x-ray absorptiometry. Results Mean (± SE) BMD of the posteroanterior lumbar spine decreased by 3.1% ± 1.0% in men assigned to placebo and increased by 4.0% ± 1.0% in men assigned to zoledronic acid (P < .001). BMD of the total hip decreased by 1.9% ± 0.7% in men assigned to placebo and increased by 0.7% ± 0.5% in men assigned to zoledronic acid (P = .004). Similar between-group differences were observed for the femoral neck and trochanter. Serum N-telopeptide, a marker of osteoclast activity, decreased significantly after zoledronic acid treatment. Conclusion In men receiving a GnRH agonist, a single treatment with zoledronic acid significantly increased BMD and durably suppressed serum N-telopeptide levels for 12 months. Annual zoledronic acid may be a convenient and effective strategy to prevent bone loss in hypogonadal men.

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Advantages of lateral BMD DEXA measurement and concomitant lateral spinal imaging at the point of service over conventional PA measurement in the estimation of BMD

South African Journal of Radiology ◽

10.4102/sajr.v7i2.1400 ◽

2003 ◽

Vol 7 (2) ◽

pp. 29-35

Author(s):

Paul Sneider

Keyword(s):

Lumbar Spine ◽

Bone Loss ◽

Treatment Protocol ◽

Visual Image ◽

Mineral Density ◽

Spinal Imaging ◽

Appropriate Treatment ◽

Significant Difference ◽

Serious Disease ◽

Bone Density Loss

This study examined 144 sequentially selected female patients with a mean age of 53.4 years. The purpose was to assess whether instant vertebral assessment (IVA) and lateral DEXA bone mineral density (BMD) measurement in the lumbar spine would render a significant difference in the assessment of bone loss compared with the older conventional PA measurement only. Thirty-five per cent of our patients' bone loss had to be upgraded because of the lower BMDs found on lateral DEXA scanning of the lumbar spine than was shown on PADEXA studies. Using the Genant classification, asymptomatic vertebral fractures were found in 10% of osteopaenic patients and in 26% who had osteoporosis with lateral IVA assessment. It was therefore concluded that both of these modalities were useful and made a greater contribution in the assessment of bone density loss, therefore enabling a more appropriate treatment protocol to be instituted and also improving patient compliance. The latter occurred because patients would rather accept a visual image of their illness such as a spine fracture or BMD value visually displayed on a graph than a verbal explanation for their asymptomatic but serious disease.

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Zoledronic Acid Increases Bone Mineral Density in Patients with Thalassemia Intermedia-Induced Osteoporosis Regardless of the Incessant Bone Marrow Expansion.

Blood ◽

10.1182/blood.v110.11.3813.3813 ◽

2007 ◽

Vol 110 (11) ◽

pp. 3813-3813

Author(s):

Ersi Voskaridou ◽

Dimitrios Christoulas ◽

Lito Antoniadou ◽

Panagiotis Tsaftaridis ◽

Eleni Plata ◽

...

Keyword(s):

Bone Mineral Density ◽

Bone Marrow ◽

Placebo Group ◽

Zoledronic Acid ◽

Bone Loss ◽

Bone Pain ◽

Bone Remodelling ◽

Erythropoietic Activity ◽

Mineral Density ◽

Marrow Expansion

Abstract Osteoporosis represents an important cause of morbidity in adult patients with thalassemia. Its pathogenesis is multifactorial, and includes mainly bone marrow expansion, endocrine dysfunction and iron overload. Patients with thalassaemia intermedia (TI) seem to have a more expanded bone marrow with pressure on cortical bone, which causes pain and bone loss in several cases. The measurement of soluble transferrin receptor (sTfR) and erythropoietin (Epo) in the serum is considered as accurate marker of erythropoietic activity in thalassemia. Bisphosphonates are potent inhibitors of osteoclast activity and have been used for the management of thalassemia-induced osteoporosis. The aim of this study was to evaluate the effect of zoledronic acid, the most potent aminobisphosphonate, on bone mineral density (BMD) of patients with TI and explore possible correlations with bone marrow expansion and erythropoietic activity. Thirty-five patients with TI and osteopenia or osteoporosis (13M/22F, median age 45 years) were evaluated. Twenty-three were randomized to receive zoledronic acid, 4 mg, IV, every 3 months (n=12) or every 6 months (n=11) for one year, while 12 patients received placebo every 3 months. There was no difference in terms of the presence of gonadal dysfunction between the three studied groups. BMD of the lumbar spine (L), femoral neck and forearm was determined in all patients, using DEXA, before and 12 months after treatment. Bone marrow expansion was assessed by the measurement of sTfR and Epo serum levels, using an ELISA methodology (R&D Systems, Minneapolis, MN, USA), before and 12 months post zoledronic acid or placebo administration. In all patients markers of bone remodelling, such as C-telopeptide of collagen type-I (CTX) and bone specific alkaline phosphatase (bALP) were also measured by ELISA (Nordic Bioscience Diagnostics, Herlev, Denmark, and Quidel, San Diego, CA, USA, respectively). Patients were asked to quantify their degree of bone pain on Huskisson’s visual analogue scale and the McGill-Melzack scoring system before and 12 months post-therapy. All patients had increased values of sTfR, Epo, CTX, and bALP compared with 40 controls of similar age and gender (p<0.001). Patients who received zoledronic acid showed a significant increase in their L-BMD (p=0.01), which was accompanied by a dramatic reduction in CTX and bALP values ((p<0.001). There was no difference in terms of L-BMD changes between zoledronic acid groups. Placebo group showed an aggravation of L-BMD (p=0.041) and markers of bone remodelling at 12 months. No other changes were observed in the BMD of other sites. Zoledronic acid reduced bone pain, which remained stable in placebo group during the study period. There was only weak correlation between baseline sTfR levels and L-BMD, while there was no correlation between Epo or hemolytic parameters (indirect bilirubin, reticulocytes counts, and LDH) with BMD of all studied sites. Serum sTfR and Epo values showed a significant elevation after 12 months of therapy in all studied groups (p<0.01, p<0.02, and p<0.01, respectively); this elevation was irrespective of the L-BMD changes. This study suggests that the increase of BMD produced by zoledronic acid in TI is irrespective of the continuous increase of bone marrow expansion, which is considered a major cause of bone loss in this hemoglobinopathy.

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Modulation and Predictors of Periprosthetic Bone Mineral Density following Total Knee Arthroplasty

BioMed Research International ◽

10.1155/2015/418168 ◽

2015 ◽

Vol 2015 ◽

pp. 1-10 ◽

Cited By ~ 8

Author(s):

Anett Mau-Moeller ◽

Martin Behrens ◽

Sabine Felser ◽

Sven Bruhn ◽

Wolfram Mittelmeier ◽

...

Keyword(s):

Bone Mineral Density ◽

Total Knee Arthroplasty ◽

Bone Loss ◽

Muscle Mass ◽

Knee Arthroplasty ◽

Lean Mass ◽

Mineral Density ◽

Periprosthetic Bone ◽

Periprosthetic Bone Mineral Density ◽

Total Knee

Total knee arthroplasty (TKA) leads to a loss of periprosthetic bone mineral density (BMD). Great importance is attached to the prevention of periprosthetic bone loss with a view to ensuring a long service life of the prosthesis. In order to provide appropriate recommendations for preventive movement therapy measures to combat peri-implant bone loss, it is necessary to know the predictors of periprosthetic BMD. The aim of this study was (1) to determine the change of periprosthetic BMD of the femur and tibia and (2) to analyse the effects of different predictors on periprosthetic BMD. Twenty-three patients with primary TKA were evaluated 10 days and 3 months postoperatively. The data analysis comprised (1) the change in periprosthetic BMD from pretest to posttest and (2) the correlations between BMD and the variables isometric maximum voluntary force, lean mass, physical activity (step count), and BMI using multiple linear regression and structural equation modelling (SEM). BMD of the distal femur was significantly reduced by 19.7% (P = 0.008) 3 months after surgery, while no changes were found in BMD of the tibia. The results of SEM demonstrate that 55% of the BMD variance was explained by the model (χ2=0.002;df=1;P=0.96;χ2/df=0.002;RMSEA<0.01;TLI=1.5;CFI=1.0). A significant direct effect was only evidenced by the variable lean mass (β=0.38;b=0.15;SE=0.07;C.R.=2.0;P=0.046). It can be assumed that a large muscle mass with accompanying distribution of high mechanical load in the bones can contribute to local changes of periprosthetic BMD. Concrete recommendations for preventing peri-implant bone loss therefore include exercises which have the aim of maintaining or building up muscle mass.

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Influence of alendronate therapy on the results of densitometric examination after implantation of total hip endoprosthesis

Archives of Public Health ◽

10.3889/aph.2021.5994 ◽

2021 ◽

Vol 13 (1) ◽

pp. 32-38

Author(s):

Ilir Shabani ◽

Antonio Gavrilovski ◽

Vilijam Velkovski ◽

Nenad Atanasov ◽

Shaban Memeti ◽

...

Keyword(s):

Bone Resorption ◽

Bone Loss ◽

Bone Mass ◽

Bone Mineral ◽

Mineral Content ◽

Mineral Density ◽

Periprosthetic Bone ◽

Hip Endoprosthesis ◽

Periprosthetic Bone Loss ◽

Post Implantation

The development of aloarthroplasty of the hip is continuously rising. After implantation of a total cement-free hip endoprosthesis, often there is a periprosthetic femoral bone loss. Alendronate has been shown to be a potent inhibitor of bone resorption activity; it inhibits osteoclastic bone resorption, increases bone mass, and plays a significant role in post-implantation stabilization of the femur. The aim of this study was to determine the effect of alendronate on osteointegration of hip endoprosthesis.Material and methods: The study analyzed 10 patients operated on with implantation of a total cement-free hip endoprosthesis (THP). The included patients were examined by a radiographic method at 6 and 12 months and DXA method at 6 and 12 months. Results: The study showed differences in the values of bone mineral density and bone mineral content in the interval between 6 and 12 months in patients undergoing THP, and hence we can conclude that alendronate therapy after THP implantation reduced periprosthetic loss of bone mass and implant stiffening. Alendronate is a proven inhibitor of periprosthetic bone loss that occurs after prirmary impantation of a total cement-free hip endoprosthesis.

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Predicting Bone Remodeling in Response to Orthopedic Implantations: Computational Study Using a Mechano-Biochemical Model

10.32920/ryerson.14653821 ◽

2021 ◽

Author(s):

Pouria Tavakkoli Avval

Keyword(s):

Bone Density ◽

Bone Loss ◽

Bone Remodeling ◽

Bone Fracture ◽

Mineral Density ◽

Periprosthetic Bone ◽

Premature Failure ◽

Gruen Zone ◽

Periprosthetic Bone Loss

Periprosthetic bone loss following orthopedic implantations is a serious concern leading to the premature failure of the implants. Therefore, investigating bone remodeling in response to orthopedic implantations is of paramount importance for the purpose of designing long lasting prostheses. In this study, a predictive bone remodeling model (Thermodynamic-based model) was employed to simulate the long-term response of femoral density to total hip arthroplasty (THA), bone fracture plating and intramedullary (IM) nailing. The ability of the model in considering the coupling effect between mechanical loading and bone biochemistry is its unique characteristic. This research provided quantitative data for monitoring bone density changes throughout the femoral bone. The results obtained by the thermodynamic-based model agreed well with the bone morphology and the literature. The study revealed that the most significant periprosthetic bone loss in response to THA occurred in calcar region (Gruen zone 7). Conversely, the region beneath the hip stem (Gruen zone 4) experienced the lowest bone mineral density (BMD) changes. It was found that the composite hip implant and IM nail were more advantageous over the metallic ones as they induced less stress shielding and provided more uniform bone density changes following the surgery. The research study also showed that, due to plating, the areas beneath the bone fracture plate experienced severe bone loss. However, some level of bone formation was observed at the vicinity of the most proximal and distal screw holes in both lateral and anterior plated femurs. Furthermore, in terms of long-term density distributions, the anterior plating was not superior to the lateral plating.

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Intra-operative Clodronate Rinsing Improves the Integration of the Femoral Stem in a Prospective, Double-blinded, Randomized, Placebo-controlled Clinical RSA-study

The Open Orthopaedics Journal ◽

10.2174/1874325002115010001 ◽

2021 ◽

Vol 15 (1) ◽

pp. 1-12

Author(s):

Jukka Kiuttu ◽

Petri Lehenkari ◽

Hannu-Ville Leskelä ◽

Olli Yrjämä ◽

Pasi Ohtonen ◽

...

Keyword(s):

Placebo Group ◽

Bone Loss ◽

Femoral Stem ◽

Harris Hip Score ◽

Periprosthetic Bone ◽

Point Motion ◽

Periprosthetic Bone Loss ◽

Total Point ◽

Double Blinded

Background: Periprosthetic bone loss after Total Hip Arthroplasty (THA), detected as an early migration of the prosthesis may predict later loosening of the implant. Objective: We hypothesized that intra-operative bisphosphonate rinsing would reduce bone resorption after THA. It might therefore be possible to achieve better early fixation of the implant. Methods: Nineteen patients suffering from arthrosis were recruited in a prospective, double-blinded, randomized, placebo-controlled clinical pilot trial. Patients were operated with an uncemented Bimetric stem using tantalum markers. The femoral proximal intramedullary canal was rinsed with 1mM clodronate in nine patients and with saline in 10 patients. These patients were followed for two years using radiostereometric analysis (RSA), dual energy x-ray absorptiometry (DXA) and the Harris Hip Score (HHS). Results: We did not found any significant differences between the study groups with regards to the primary output measures (maximum total point motion, MTPM). However, there was evidence that clodronate could affect periprosthetic bone quality; a beneficial effect in BMD in Gruen zone 3 during the two-year follow-up was observed, BMD decreased less in the clodronate group (p = 0.02). The maximal x-translation of the stem at 3-24 months was significantly two-fold, being higher in the placebo group (p = 0.02). The baseline BMD and the maximal total point motion (MTPM) at 3-24 months showed a positive correlation in the clodronate group and a negative correlation in the placebo group. Conclusion: In conclusion, further studies with larger patient groups and longer follow-up periods are needed to estimate the clinical importance of these findings and further to prove if an intraoperative clodronate rinsing prior to application of femoral stem during THA can prevent periprosthetic bone loss. Clinical Trial Registration No.: NCT03803839

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Perioperative Patient-specific Factors-based Nomograms Predict Short-term Periprosthetic Bone Loss After Total Hip Arthroplasty

10.21203/rs.3.rs-35547/v1 ◽

2020 ◽

Author(s):

Guangtao Fu ◽

Mengyuan Li ◽

Yunlian Xue ◽

Qingtian Li ◽

Zhantao Deng ◽

...

Keyword(s):

Total Hip Arthroplasty ◽

Bone Loss ◽

Hip Arthroplasty ◽

Postoperative Period ◽

Patient Specific ◽

Mineral Density ◽

Periprosthetic Bone ◽

Gruen Zone ◽

Total Hip ◽

Periprosthetic Bone Loss

Abstract Background Although medical intervention of periprosthetic bone loss in the immediate postoperative period was recommended, not all the patients experienced periprosthetic bone loss after total hip arthroplasty (THA). Prediction toolsthat enrolledallpotential risk factors to calculate an individualized prediction of postoperative periprosthetic bone loss were strongly needed for clinical decision-making.MethodsData of the patients underwent primary unilateral cementless THA between April 2015 and October 2017 in our center were retrospectively collected. Candidate variables included demographic data and bone mineral density (BMD) in spine, hip and periprosthetic regions that measured 1 week after THA. Outcomes of interest included the risk of postoperative periprosthetic bone loss in Gruen zone 1, 7 and total zones in the 1st postoperative year. Nomograms were presented based on multiple logistic regressions via R language.Bootstrap was used for internal validation. Results 427 patients (195 male and 232 female) were included in this study.The mean BMD of Gruen zone 1, 7,and total were decreased by 4.1%, 6.4%, and 1.7% at the 1st year after THA, respectively. 61.1% of the patients (261/427) experienced bone loss in Gruen zone 1 at the 1st postoperative year, while there were 58.1% (248/427) in Gruen zone 7 and 63.0% (269/427) in Gruen zone total. Bias-corrected c-index for risk of postoperative bone lossin Gruen zone 1, 7 and total zones in the 1st postoperative year were 0.700, 0.785, and 0.696, respectively. The most highly influential factor for the postoperative periprosthetic bone loss was the BMD in the corresponding Gruen zones at the baseline.ConclusionsThe present study presented the perioperative factors-based nomograms for predicting periprosthetic bone loss after THA with adequate predictive discrimination and calibration.Those tools would helpsurgeons to identify high-risk patients who may benefit from anti-bone-resorptive treatment on the early postoperative period effectively. Such prediction model could also provide patients with reasonable expectations following surgery, which may improve satisfaction and patient compliance.

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The Risk of Fracture in Patients Undergoing Androgen Deprivation May Be Overstated: Analysis of an Unselected Cohort of Patients

Einstein Journal of Biology and Medicine ◽

10.23861/ejbm20112720 ◽

2016 ◽

Vol 27 (2) ◽

pp. 51

Author(s):

Kevin J. Clerkin ◽

Seth M. Cohen ◽

Ronald D. Ennis

Keyword(s):

Prostate Cancer ◽

Bone Loss ◽

Medical Center ◽

Academic Medical Center ◽

Androgen Deprivation ◽

Mineral Density ◽

Dual Emission ◽

Cancer Disease ◽

Normal Bone Mineral Density ◽

Significant Difference

Objective: In this study we examined the prevalence of fracture among men undergoing ADT for prostate cancer to determine if the fracture risk was increased among this population.Background: Androgen deprivation therapy (ADT) is a therapeutic approach for men with various prostate cancer disease states. Treatment-related side effects of ADT include rapid bone loss. Previous studies have found that the bone loss related to ADT leads to the development of fractures. Methods: This is a retrospective cohort study of patients treated with ADT in a radiation oncology and medical oncology practice at an urban academic medical center from 2005 to 2010. Patients with evidence of bone metastases responsive to ADT were included. Those with androgen-independent prostate cancer were excluded. Results: One hundred thirty patients met the inclusion criteria and among them only three fractures occurred during 373 person-years of follow-up. The fracture-free survival (FFS) rate at three years for all was 97.7%. Excluding fractures occurring within six months of ADT initiation, the FFS rate was 100% at three years. No significant difference was demonstrated in those screened with a pretreatment dual-emission X-ray absorptiometry (DEXA) scan; there was no relationship between the number of ADT cycles, recovery of testosterone to normal, or total time on ADT. Older patients, surprisingly, had a lower risk (p = 0.054). Patients with normal bone mineral density (BMD) had an FFS rate of 93.8% at three years, osteopenic patients had 94.7%, and patients with osteoporosis and hormone-responsive metastases had 100%. Conclusion: The prevalence of fracture among this group is significantly less than what has previously been reported for men receiving ADT, potentially suggesting an overstatement of risk in the literature to date. Further prospective study with a larger sample size is needed.

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