The Journal of Bone & Joint Surgery

The Journal of Bone & Joint Surgery, Volume 85, Issue 11

Scientific Articles | November 01, 2003

The Effect of Alendronate on Bone Mineral Density in the Distal Part of the Femur and Proximal Part of the Tibia After Total Knee Arthroplasty

Ching-Jen Wang, MD¹; Jun-Wen Wang, MD¹; Lin-Hsiu Weng, MD¹; Chia-Chen Hsu, MD¹; Chung-Cheng Huang, MD¹; Han-Shiang Chen, MD¹

¹ Department of Orthopedic Surgery (C.-J.W., J.-W.W., L.-H.W., C.-C. Hsu), Diagnostic Radiology (C.-C. Huang), and Surgery (H.-S.C.), Chang Gung Memorial Hospital, Kaohsiung Medical Center, 123 Ta-Pei Road, Niao-Sung Hsiang, Kaohsiung, Taiwan 833. E-mail address for C.-J. Wang: w281211@adm.cgmh.org.tw

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In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Chang Gung Research Fund (CMRP 1026). None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated. The local pharmaceutical distributor supplied the alendronate to the patients in this study free of charge.

Investigation performed at the Departments of Orthopedic Surgery, Diagnostic Radiology, and Surgery, Chang Gung Memorial Hospital, Kaohsiung Medical Center, Kaohsiung, Taiwan

The Journal of Bone and Joint Surgery, Incorporated

J Bone Joint Surg Am, 2003 Nov 01;85(11):2121-2126

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Abstract

Background: Bone mineral density around the knee is related to the mechanical properties of bone. Alendronate has been shown to be effective for the treatment of osteoporosis and for reducing the rate of osteoporotic fractures. The purpose of the present study was to investigate the effect of alendronate on bone mineral density in the distal part of the femur and proximal part of the tibia after total knee arthroplasty in women.

Methods: Ninety-six women with an average age of seventy years who were undergoing total knee arthroplasty were randomly divided into two groups. Patients in the study group received oral alendronate at a dose of 10 mg/day for six months, whereas patients in the control group did not. The bone mineral density in the distal part of the femur and proximal part of the tibia was determined preoperatively and at six and twelve months postoperatively.

Results: In the control group, the bone mineral density showed significant decreases of 13.8% (p < 0.001) and 7.8% (p = 0.003) in the distal part of the femur and of 6.5% (p = 0.002) and 3.6% (p = 0.141) in the proximal part of the tibia at six and twelve months, respectively. In the study group, however, the bone mineral density showed significant increases of 10.0% (p = 0.010) and 1.9% (p = 0.049) in the distal part of the femur and of 9.4% (p < 0.001) and 5.4% (p = 0.032) in the proximal part of the tibia at six and twelve months, respectively. The overall differences in bone mineral density between the study and control groups were significant (p = 0.011 for the proximal part of the tibia, and p = 0.033 for the distal part of the femur).

Conclusions: We found significant postoperative decreases in bone mineral density in the distal part of the femur and proximal part of the tibia in women who had undergone total knee arthroplasty. Oral administration of alendronate for six months postoperatively significantly improved the bone mineral density. While the clinical benefits of alendronate after total knee arthroplasty remain unproven and the duration of follow-up in the present study was quite short, the improvement in bone mineral density may have a clinically important effect on prosthetic fixation and the rate of periprosthetic fractures after total knee arthroplasty.

Level of Evidence: Therapeutic study, Level I-1a (randomized controlled trial [significant difference]). See Instructions to Authors for a complete description of levels of evidence.

Figures in this Article

Poor bone quality and bone stock are related to failure after total knee arthroplasty, including that due to periprosthetic fracture^1-5. The quality, and thus the mechanical properties, of the trabecular bone of the proximal part of the tibia and the distal part of the femur is considered to be an important predictor of failure after total knee arthroplasty^1,6,7. The bone mineral density of trabecular bone is directly related to the mechanical properties of the bone^1,2,6,8. Many studies have demonstrated a decrease in bone mineral density after total hip and total knee arthroplasty^8-15. After a cementless total knee replacement, bone loss in the proximal part of the tibia has been determined to be substantial as early as one month postoperatively and to last for more than three years¹⁶. However, to our knowledge, no study has identified an effective method of preventing bone loss after total knee arthroplasty.

Alendronate has been shown to be effective for the treatment of osteoporosis and for reduction of the rate of fractures associated with osteoporosis^17-19. We hypothesized that alendronate can decrease bone loss in the proximal part of the tibia and the distal part of the femur after total knee arthroplasty. The objectives of the present study were to evaluate the changes in bone mineral density in the proximal part of the tibia and the distal part of the femur and to investigate the effect of alendronate on bone mineral density after total knee arthroplasty in women.

Materials and Methods

Materials and Methods | Results | Discussion | References

The Institutional Review Board of our hospital approved this prospective clinical study. All female patients who were candidates for total knee arthroplasty were considered for inclusion in the study. Patients were excluded from the study if they had metabolic bone disease (including an established diagnosis of osteoporosis) and were receiving drug therapy (including hormone replacement), if they had a neuromuscular disorder, or if they had a history of infection of the ipsilateral knee or a history of a major operation on the ipsilateral or contralateral knee. All patients provided informed consent.

Between June 2000 and May 2001, 103 women undergoing total knee arthroplasty were initially recruited for this study. Seven patients were excluded for drug intolerance (three patients) or poor compliance (four patients). The remaining ninety-six patients constituted the study group. The patients were randomly divided into two groups on the basis of the sequence of admission to the hospital, with forty-eight patients in the study group and forty-eight patients in the control group (Table I). Patients in the study group received oral alendronate at a dose of 10 mg/day beginning on the second postoperative day and continuing for six months, whereas patients in the control group received no alendronate. During the course of treatment, three patients complained of mild dyspepsia when taking the alendronate. These symptoms resolved spontaneously.

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TABLE I Data on the Patients

	Study Group	Control Group
Number of patients	48	48
Age*(yr)	70.0 ± 7.0	71.0 ± 7.0
Female gender (no. of patients)	48	48
Right/left (no. of knees)	23/25	25/23
Diagnosis (no. of patients)
Osteoarthritis	45	46
Rheumatoid arthritis	2	2
Osteonecrosis	1	0

The values are expressed as the mean and the standard deviation.

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TABLE I Data on the Patients

	Study Group	Control Group
Number of patients	48	48
Age*(yr)	70.0 ± 7.0	71.0 ± 7.0
Female gender (no. of patients)	48	48
Right/left (no. of knees)	23/25	25/23
Diagnosis (no. of patients)
Osteoarthritis	45	46
Rheumatoid arthritis	2	2
Osteonecrosis	1	0

The values are expressed as the mean and the standard deviation.

Preoperative studies included measurement of the bone mineral density in the knee; determination of the serum levels of calcium, phosphate, and alkaline phosphatase; and determination of the twenty-four-hour urinary level of deoxypyridinoline (a measure of telopeptides of type-I collagen and a marker of bone resorption).

All patients received the same type of knee prosthesis (Advantim; Wright Medical, Arlington, Tennessee), and all prosthetic components were inserted with cement. All patients received the same postoperative management, including bedside continuous passive motion and physiotherapy for walking with partial weight-bearing and quadriceps and hamstring exercises starting on the second postoperative day. Patients were discharged from the hospital when they could walk independently with a walking aid and were able to do straightleg exercises. After discharge, physiotherapy was continued on an outpatient basis. Follow-up examinations were scheduled at one, six, and twelve months. Each evaluation involved a clinical examination; radiographs of the knee; determination of the bone mineral density in the knee; determination of the serum levels of calcium, phosphate, and alkaline phosphatase; and determination of the twenty-four-hour urinary level of deoxypyridinoline.

Bone Mineral Density

Dual energy x-ray absorptiometry (DEXA) was used to measure bone mineral density^9,20-28. The Hologic DEXA system (Hologic, Waltham, Massachusetts) was used in this study. The density in the distal part of the femur and proximal part of the tibia was measured in the anteroposterior and lateral projections at one week preoperatively and at six and twelve months postoperatively. In addition, the proximal part of the tibia was divided into three regions of interest (ROI): the lateral region (ROI 1), the medial region (ROI 2), and the center region (ROI 3) (Figs. 1-A and 1-B). Bone mineral density was measured in all three regions. The medial and lateral regions were located at 1.0 cm within the cortex and 1.0 cm distal to the prosthesisbone interface, and the center region was located at 1.0 cm distal to the prosthetic stem. These regions were chosen because they theoretically sustain the most stress-shielding and because changes in bone mineral density, if any, will most likely occur in these locations. The preoperative and postoperative bone mineral density values in the proximal part of the tibia and the distal part of the femur within the same group as well as the changes in bone mineral density values in the study group and the control group were compared statistically with use of the paired t test and the Mann-Whitney test, respectively, with the level of significance set at p < 0.05.

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The bone mineral density measurements in the distal part of the femur and proximal part of the tibia were performed in anteroposterior (1-A) and lateral (1-B) projections. In the anteroposterior projection, region of interest (ROI) 1 is 1.0 cm within the lateral cortex of the proximal part of the tibia and 1.0 cm distal to the prosthesis-bone interface, ROI 2 is 1.0 cm within the medial cortex of the proximal part of the tibia and 1.0 cm distal to the prosthesis-interface, and ROI 3 is 1.0 cm distal to the prosthetic stem.

Results

Materials and Methods | Results | Discussion | References

The bone mineral density values in the distal part of the femur are summarized in Table II. In the control group, there was a 13.8% decrease in mean bone mineral density at six months (p < 0.001) and a 7.8% decrease at twelve months (p = 0.003). In the study group, however, there was a 10.0% increase in mean bone mineral density at six months (p = 0.010) and a 1.9% increase at twelve months (p = 0.049).

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TABLE II Bone Mineral Density Values in the Distal Part of Femur

	Study Group		Control Group
Number of patients	48		48
Bone mineral density*
Preop.
Mean and standard deviation	0.5960 ± 0.1036		0.5413 ± 0.1274
Range	0.4200 to 0.8400		0.1670 to 0.9590
6 months
Mean and standard deviation	0.6397 ± 0.1385		0.4473 ± 0.1227
Range	0.2980 to 1.0730		0.2100 to 0.6750
P value†	0.010 (?)		<0.001 (?)
12 months
Mean and standard deviation	0.6005 ± 0.0994		0.4756 ± 0.1113
Range	0.4220 to 0.8240		0.2830 to 0.7380
P value†	0.049 (?)		0.003 (?)
Percent change in bone mineral density
Preop. compared with 6 months
Mean and standard deviation	10.0% ± 22.2%		-13.8% ± 17.4%
Range	-33.8% to 84.7%		-50.7% to 26.6%
P value‡		<0.001
Preop. compared with 12 months
Mean and standard deviation	1.9% ± 14.9%		-7.8% ± 20.9%
Range	-27.6% to 31.1%		-48.2% to 69.5%
P value‡		0.033

Bone mineral density is expressed in gm/cm². †Paired t test. ‡Mann-Whitney test.

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TABLE II Bone Mineral Density Values in the Distal Part of Femur

	Study Group		Control Group
Number of patients	48		48
Bone mineral density*
Preop.
Mean and standard deviation	0.5960 ± 0.1036		0.5413 ± 0.1274
Range	0.4200 to 0.8400		0.1670 to 0.9590
6 months
Mean and standard deviation	0.6397 ± 0.1385		0.4473 ± 0.1227
Range	0.2980 to 1.0730		0.2100 to 0.6750
P value†	0.010 (?)		<0.001 (?)
12 months
Mean and standard deviation	0.6005 ± 0.0994		0.4756 ± 0.1113
Range	0.4220 to 0.8240		0.2830 to 0.7380
P value†	0.049 (?)		0.003 (?)
Percent change in bone mineral density
Preop. compared with 6 months
Mean and standard deviation	10.0% ± 22.2%		-13.8% ± 17.4%
Range	-33.8% to 84.7%		-50.7% to 26.6%
P value‡		<0.001
Preop. compared with 12 months
Mean and standard deviation	1.9% ± 14.9%		-7.8% ± 20.9%
Range	-27.6% to 31.1%		-48.2% to 69.5%
P value‡		0.033

Bone mineral density is expressed in gm/cm². †Paired t test. ‡Mann-Whitney test.

The bone mineral density values in the proximal part of the tibia are summarized in Table III. In the control group, there was a 6.5% decrease in mean bone mineral density at six months (p = 0.002) and a 3.6% decrease at twelve months (p = 0.141). The changes in bone mineral density were more pronounced in the first six months. In the study group, however, there was a 9.4% increase in mean bone mineral density at six months (p < 0.001) and a 5.4% increase at twelve months (p = 0.032). Overall, the bone mineral density in the proximal part of the tibia (p = 0.011) and the distal part of the femur (p = 0.033) decreased significantly in the control group and increased significantly in the study group.

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TABLE III Bone Mineral Density Values in the Proximal Part of Tibia

	Study Group		Control Group
Number of patients	48		48
Bone mineral density*
Preop.
Mean and standard deviation	0.9030 ± 0.1599		0.8460 ± 0.1772
Range	0.5450 to 1.3890		0.4410 to 1.2870
6 months
Mean and standard deviation	0.9862 ± 0.1628		0.7937 ± 0.1856
Range	0.6890 to 1.3480		0.4400 to 1.1750
P value†	<0.001 (?)		0.002 (?)
12 months
Mean and standard deviation	0.9705 ± 0.1777		0.8286 ± 0.1909
Range	0.6170 to 1.4170		0.5190 to 1.2450
P value†	0.032 (?)		0.141 (?)
Percent change in bone mineral density
Preop. compared with 6 months
Mean and standard deviation	9.4% ± 10.2%		-6.5% ± 11.2%
Range	-6.2% to 37.1%		-30.9% to 14.8%
P value‡		<0.001
Preop. compared with 12 months
Mean and standard deviation	5.4% ± 12.7%		-3.6% ± 15.4%
Range	-18.5% to 36.5%		-41.2% to 27.7%
P value‡		0.011

Bone mineral density is expressed in gm/cm². †Paired t test. ‡Mann-Whitney test.

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TABLE III Bone Mineral Density Values in the Proximal Part of Tibia

	Study Group		Control Group
Number of patients	48		48
Bone mineral density*
Preop.
Mean and standard deviation	0.9030 ± 0.1599		0.8460 ± 0.1772
Range	0.5450 to 1.3890		0.4410 to 1.2870
6 months
Mean and standard deviation	0.9862 ± 0.1628		0.7937 ± 0.1856
Range	0.6890 to 1.3480		0.4400 to 1.1750
P value†	<0.001 (?)		0.002 (?)
12 months
Mean and standard deviation	0.9705 ± 0.1777		0.8286 ± 0.1909
Range	0.6170 to 1.4170		0.5190 to 1.2450
P value†	0.032 (?)		0.141 (?)
Percent change in bone mineral density
Preop. compared with 6 months
Mean and standard deviation	9.4% ± 10.2%		-6.5% ± 11.2%
Range	-6.2% to 37.1%		-30.9% to 14.8%
P value‡		<0.001
Preop. compared with 12 months
Mean and standard deviation	5.4% ± 12.7%		-3.6% ± 15.4%
Range	-18.5% to 36.5%		-41.2% to 27.7%
P value‡		0.011

Bone mineral density is expressed in gm/cm². †Paired t test. ‡Mann-Whitney test.

The changes in bone mineral density in the regions of interest in the proximal part of the tibia are summarized in Table IV. The changes that were noted in the regions of interest were consistent with the overall changes that were noted in the proximal part of the tibia at six and twelve months.

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TABLE IV Bone Mineral Density Changes in Regions of Interest in the Proximal Part of Tibia

Percent Change in Bone Mineral Density*	Study Group	Control Group	P Value†
Preop. compared with 6 months
ROI 1	14.6% ± 24.3%	1.3% ± 23.6%	0.018
ROI 2	-0.2% ± 17.7%	-13.8% ± 35.2%	0.033
ROI 3	12.0% ± 12.9%	-4.6% ± 12.9%	<0.001
Preop. compared with 12 months
ROI 1	15.6% ± 28.4%	3.2% ± 27.0%	0.072
ROI 2	3.5% ± 32.2%	-11.4% ± 28.7%	0.050
ROI 3	11.5% ± 12.9%	0.2% ± 17.5%	0.004

ROI = region of interest. †Mann-Whitney test.

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TABLE IV Bone Mineral Density Changes in Regions of Interest in the Proximal Part of Tibia

Percent Change in Bone Mineral Density*	Study Group	Control Group	P Value†
Preop. compared with 6 months
ROI 1	14.6% ± 24.3%	1.3% ± 23.6%	0.018
ROI 2	-0.2% ± 17.7%	-13.8% ± 35.2%	0.033
ROI 3	12.0% ± 12.9%	-4.6% ± 12.9%	<0.001
Preop. compared with 12 months
ROI 1	15.6% ± 28.4%	3.2% ± 27.0%	0.072
ROI 2	3.5% ± 32.2%	-11.4% ± 28.7%	0.050
ROI 3	11.5% ± 12.9%	0.2% ± 17.5%	0.004

ROI = region of interest. †Mann-Whitney test.

Anteroposterior, lateral, and Merchant weight-bearing radiographs were examined for the overall alignment of the knee, radiolucent lines, osteolysis, migration or sinking of the prosthetic components, and periprosthetic fracture. The results of the radiographic examination revealed no radiolucent lines, prosthetic migration, or periprosthetic fractures in either group during the short follow-up period.

The serum levels of calcium, phosphate, and alkaline phosphatase and the urinary level of deoxypyridinoline are summarized in Table V. At twelve months after total knee arthroplasty, the mean serum level of alkaline phosphatase and the mean urinary level of deoxypyridinoline were significantly lower in the study group than in the control group (p = 0.028 and 0.002, respectively), indicating that there was less bone resorption and bone turnover in the study group as compared with the control group.

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TABLE V Bone Markers

	Study Group*	Control Group*	P Value†
Urinary deoxypyridinoline (nmol)
Preop.	7.92 ± 3.07	9.01 ± 4.53	0.154
12 months	3.92 ± 1.82	5.73 ± 3.00	0.028
P value‡	<0.001 (?)	0.016 (?)
Serum calcium (mg/dL)
Preop.	8.13 ± 0.39	8.34 ± 0.57	0.475
12 months	9.32 ± 0.38	9.50 ± 0.37	0.084
P value‡	<0.001 (?)	<0.001 (?)
Serum phosphate (mg/dL)
Preop.	2.88 ± 0.88	2.87 ± 0.90	0.981
12 months	3.72 ± 0.46	3.68 ± 0.61	0.769
P value‡	<0.001 (?)	0.003 (?)
Serum alkaline phosphatase (IU/L)
Preop.	67.90 ± 21.84	67.79 ± 23.91	0.980
12 months	65.53 ± 20.32	83.77 ± 21.41	0.002
P value‡	0.582 (?)	<0.001 (?)

Bone marker data are given as the mean and the standard deviation. †The independent t test was used to compare the study and control groups. ‡The paired t test was used to compare the preoperative and postoperative data.

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TABLE V Bone Markers

	Study Group*	Control Group*	P Value†
Urinary deoxypyridinoline (nmol)
Preop.	7.92 ± 3.07	9.01 ± 4.53	0.154
12 months	3.92 ± 1.82	5.73 ± 3.00	0.028
P value‡	<0.001 (?)	0.016 (?)
Serum calcium (mg/dL)
Preop.	8.13 ± 0.39	8.34 ± 0.57	0.475
12 months	9.32 ± 0.38	9.50 ± 0.37	0.084
P value‡	<0.001 (?)	<0.001 (?)
Serum phosphate (mg/dL)
Preop.	2.88 ± 0.88	2.87 ± 0.90	0.981
12 months	3.72 ± 0.46	3.68 ± 0.61	0.769
P value‡	<0.001 (?)	0.003 (?)
Serum alkaline phosphatase (IU/L)
Preop.	67.90 ± 21.84	67.79 ± 23.91	0.980
12 months	65.53 ± 20.32	83.77 ± 21.41	0.002
P value‡	0.582 (?)	<0.001 (?)

Discussion

Materials and Methods | Results | Discussion | References

Petersen et al.²⁶ demonstrated a strong correlation between bone mineral density values and migration of the tibial component after total knee arthroplasty. The tibial component in the knees with higher bone mineral density showed less migration. Van Loon et al.⁵ described three types of femoral bone loss after total knee arthroplasty, including osteopenia caused by stress-shielding behind the anterior flange of the femoral component, osteolysis induced by wear particles, and a so-called "hollowing out" of the distal part of the femur around a stemmed total knee prosthesis. Many studies have demonstrated a decrease in bone mineral density in the proximal part of the tibia and the distal part of the femur after total knee arthroplasty^{2,3,5,8-14,16,19,24,29,30}. Several studies have demonstrated that the decrease in bone mineral density is most obvious during the first six months, and the magnitude of the decrease has been as high as 57%¹⁶. These decreases remain substantial, at an average of 5% per year, for as long as three years after total knee surgery^{8-14,16,24,25,27,29}. In the present study, the bone mineral density had decreased by as much as 13.8% in the control group at six months postoperatively. No prosthetic migration or periprosthetic fracture was noted during the short follow-up period of this study.

Alendronate sodium, an antiresorptive bisphosphonate, has been shown to be effective for the treatment of osteoporosis and the prevention of osteoporotic fractures^17-19. In addition, the administration of alendronate was found to effectively inhibit osteolysis in a canine total hip arthroplasty model³¹. However, the effect of alendronate on bone mineral density after total knee arthroplasty has not been established, to our knowledge. The results of the present study showed that women who had been treated with oral alendronate for six months after total knee arthroplasty had significantly improved bone mineral density in the distal part of the femur (p = 0.033) and proximal part of the tibia (p = 0.011) as compared with controls at one year postoperatively. The bone mineral density changes beyond one year are unknown at the present time, and additional studies are needed to determine the long-term effects of alendronate. The better bone density that was found after treatment with alendronate may lead to better fixation of prosthetic components, increased longevity of total knee prostheses, and a reduced risk of periprosthetic fracture. Additional research is needed to determine whether long-term clinical benefits are realized and to determine optimum treatment regimens.

References

Materials and Methods | Results | Discussion | References

Haddad FS, Masri BA, Garbuz DS, Duncan CP. The prevention of periprosthetic fractures in total hip and knee arthroplasty. Orthop Clin North Am.1999;30: 191-207.30191 1999 [PubMed][CrossRef]

Ishii Y, Yagisawa K, Ikezawa Y. Changes in bone mineral density of the proximal femur after total knee arthroplasty. J Arthroplasty.2000;15: 519-22.15519 2000 [PubMed][CrossRef]

Petersen MM, Nielsen PT, Lebech A, Toksvig-Larsen S, Lund B. Preoperative bone mineral density of the proximal tibia and migration of the tibial component after uncemented total knee arthroplasty. J Arthroplasty.1999;14: 77-81.1477 1999 [PubMed][CrossRef]

Sugita T, Umehara J, Sato K, Inoue H. Influence of tibial bone quality on loosening of the tibial component in total knee arthroplasty for rheumatoid arthritis: long-term results. Orthopedics.1999;22: 213-5.22213 1999 [PubMed]

van Loon CJ, de Waal Malefijt MC, Buma P, Verdonschot N, Veth RP. Femoral bone loss in total knee arthroplasty. A review. Acta Orthop Belg.1999;65: 154-63.65154 1999 [PubMed]

DiGioia AM 3rd, Rubash HE. Periprosthetic fractures of the femur after total knee arthroplasty. A literature review and treatment algorithm. Clin Orthop.1991;271: 135-42.271135 1991

Felix NA, Stuart MJ, Hanssen AD. Periprosthetic fractures of the tibia associated with total knee arthroplasty. Clin Orthop.1997;345: 113-24.345113 1997 [PubMed]

Karbowski A, Schwitalle M, Eckardt A, Heine J. Periprosthetic bone remodelling after total knee arthroplasty: early assessment by dual energy X-ray absorptiometry. Arch Orthop Trauma Surg.1999;119: 324-6.119324 1999 [CrossRef]

Kilgus DJ, Shimaoka EE, Tipton JS, Eberle RW. Dual-energy X-ray absorptiometry measurement of bone mineral density around porous-coated cementless femoral implants. Methods and preliminary results. J Bone Joint Surg Br.1993;75: 279-87.75279 1993 [PubMed]

Liu TK, Yang RS, Chieng PU, Shee BW. Periprosthetic bone mineral density of the distal femur after total knee arthroplasty. Int Orthop.1995;19: 346-51.19346 1995 [PubMed]

Petersen MM, Lauritzen JB, Pedersen JG, Lund B. Decreased bone density of the distal femur after uncemented knee arthroplasty. A 1-year follow-up of 29 knees. Acta Orthop Scand.1996;67: 339-44.67339 1996 [CrossRef]

Petersen MM, Olsen C, Lauritzen JB, Lund B. Changes in bone mineral density of the distal femur following uncemented total knee arthroplasty. J Arthroplasty.1995;10: 7-11.107 1995 [PubMed]

Rubash HE. Osteolysis: dealing with the consequences. Orthopedics.1998;21: 949-50.21949 1998 [PubMed]

van Loon CJ, Oyen WJ, de Waal Malefijt MC, Verdonschot N. Distal femoral bone mineral density after total knee arthroplasty: a comparison with general bone mineral density. Arch Orthop Trauma Surg.2001;121: 282-5.121282 2001 [PubMed][CrossRef]

Zerahn B, Storgaard M, Johansen T, Olsen C, Lausten G, Kanstrup IL. Changes in bone mineral density adjacent to two biomechanically different types of cementless femoral stems in total hip arthroplasty. Int Orthop.1998;22: 225-9.22225 1998 [PubMed][CrossRef]

Petersen MM, Nielsen PT, Lauritzen JB, Lund B. Changes in bone mineral density of the proximal tibia after uncemented total knee arthroplasty. A 3-year follow-up of 25 knees. Acta Orthop Scand.1995;66: 513-6.66513 1995 [PubMed][CrossRef]

Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC, Quandt SA, Reiss TF, Ensrud KE. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet.1996;348: 1535-41.3481535 1996 [PubMed][CrossRef]

Cummings SR, Black DM, Thompson DE, Applegate WB, Barrett-Connor E, Musliner TA, Palermo L, Prineas R, Rubin SM, Scott JC, Vogt T, Wallace R, Yates AJ, LaCroix AZ. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA.1998;280: 2077-82.2802077 1998 [PubMed][CrossRef]

Liberman UA, Weiss SR, Broll J, Minne HW, Quan H, Bell NH, Rodriguez-Portales J, Downs RW Jr, Dequeker J, Favus M. Effect of oral alendronate on bone mineral density and the incidence of fractures in postmenopausal osteoporosis. The Alendronate Phase III Osteoporosis Treatment Study Group. N Engl J Med.1995;333: 1437-43.3331437 1995 [PubMed][CrossRef]

Cohen B, Rushton N. Accuracy of DEXA measurement of bone mineral density after total hip arthroplasty. J Bone Joint Surg Br.1995;77: 479-83.77479 1995 [PubMed]

Kiratli BJ, Heiner JP, McBeath AA, Wilson MA. Determination of bone mineral density by dual x-ray absorptiometry in patients with uncemented total hip arthroplasty. J Orthop Res.1992;10: 836-44.10836 1992 [PubMed][CrossRef]

Korovessis P, Piperos G, Michael A, Baikousis A, Stamatakis M. Changes in bone mineral density around a stable uncemented total hip arthroplasty. Int Orthop.1997;21: 30-4.2130 1997 [PubMed][CrossRef]

Korovessis P, Piperos G, Michael A. Periprosthetic bone mineral density after Mueller and Zweymueller total hip arthroplasties. Clin Orthop.1994;309: 214-21.309214 1994 [PubMed]

Levitz CL, Lotke PA, Karp JS. Long-term changes in bone mineral density following total knee replacement. Clin Orthop.1995;321: 68-72.32168 1995 [PubMed]

Martini F, Lebherz C, Mayer F, Leichtle U, Kremling E, Sell S. Precision of the measurements of periprosthetic bone mineral density in hips with a custom-made femoral stem. J Bone Joint Surg Br.2000;82: 1065-71.821065 2000 [PubMed][CrossRef]

Petersen MM, Jensen NC, Gehrchen PM, Nielsen PK, Nielsen PT. The relation between trabecular bone strength and bone mineral density assessed by dual photon and dual energy X-ray absorptiometry in the proximal tibia. Calcif Tissue Int.1996;59: 311-4.59311 1996 [CrossRef]

Trevisan C, Bigoni M, Denti M, Marinoni EC, Ortolani S. Bone assessment after total knee arthroplasty by dual-energy X-ray absorptiometry: analysis protocol and reproducibility. Calcif Tissue Int.1998;62: 359-61.62359 1998 [PubMed][CrossRef]

Wilkinson JM, Peel NF, Elson RA, Stockley I, Eastell R. Measuring bone mineral density of the pelvis and proximal femur after total hip arthroplasty. J Bone Joint Surg Br.2001;83: 283-8.83283 2001 [CrossRef]

Li MG, Nilsson KG. Changes in bone mineral density at the proximal tibia after total knee arthroplasty: a 2-year follow-up of 28 knees using dual energy X-ray absorptiometry. J Orthop Res.2000;18: 40-7.1840 2000 [PubMed][CrossRef]

Seki T, Omori G, Koga Y, Suzuki Y, Ishii Y, Takahashi HE. Is bone density in the distal femur affected by use of cement and by femoral component design in total knee arthroplasty? J Orthop Sci.1999;4: 180-6.4180 1999 [PubMed][CrossRef]

Shanbhag AS, Hasselman CT, Rubash HE. The John Charnley Award. Inhibition of wear debris mediated osteolysis in a canine total hip arthroplasty model. Clin Orthop.1997;344: 33-43.34433 1997 [PubMed]

Topics

alendronate ; bone mineral density ; femur ; tibia ; knee replacement arthroplasty

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Chin-Jen Wang, M.D.

Posted on April 26, 2004

Dr Wang responds to Dr Alexandropoulos

Chang Gung Memorial Hospital, Dept., Orthopedic Surgery, Kaohsiung, Taiwan 833

We like to respond to the questions raised by Christos Alexandropoulos in reference to our recent article entitled "The effect of alendronate on bone mineral density ... after total knee arthroplasty" (2003;85:2121-6 Am). We did measure the BMD on the contralateral knee in this study. The BMD of the distal femur showed an increase of 11.6% +/- 22.2% in the alendronate group versus a decrease5.2% +/- 16.6% in the control group at 6 months. The BMD of the proximal tibia showed an increase of 6.3% +/- 26.5% in the alendronate group versus a decrease of 2.3% +/- 10/1% in the control group at 6 months. The data at one year postoperative were much lower.

We also analysed the BMD data on the contralateral knees into two groups; one group with prior TKA and the other had no surgery. The BMD changes with or without prior TKA were very similar. Therefore, the BMD changes on the contralteral knees were similar to those noted on the operated knees in our study. We did not include the data on the contralateral knees because they were irrevelant to the goal of our study. We hope that we have adequately answered the questions and addressed the concerns.

Ching-Jen Wang, M.D.

Posted on April 21, 2004

Dr. Wang responds:

Chang Gung Memorial Hospital, Department of Orthopedic Surgery, Kaohsiung, Taiwan 833

To the Editor:

We like to respond to the questions raised by Dr.Alexandropoulos in reference to our recent article entitled "The effect of alendronate on bone mineral density ... after total knee arthroplasty" (2003;85:2121-6 Am). We did measure the BMD on the contralateral knee in this study. The BMD of the distal femur showed an increase of 11.6% +/- 22.2% in the alendronate group versus a decrease5.2% +/- 16.6% in the control group at 6 months. The BMD of the proximal tibia showed an increase of 6.3% +/- 26.5% in the alendronate group versus a decrease of 2.3% +/- 10/1% in the control group at 6 months. The data at one year postoperative were much lower.

Christos Alexandropoulos

Posted on April 06, 2004

The Effect of Alendronate on Bone Mineral Density

Trikala General Hospital

To the Editor:

Regarding the article â€œ The Effect of Aledronate on Bone Mineral Density in the Distal Part of the Femur and Proximal Part of the Tibia After Total Knee Replacementâ€ (2003;85:2121-6) by CJ Wang et al, I would like to make some observations.

In this study aledronate was administered in non osteoporotic patients and the increased Bone Mineral Content (BMC) of the operated tibia and femur that measured, considered that possibly improves the prosthetic fixation of the Total Knee Arthroplasty. This would be good news.

But, surprisingly in this paper there are no data about the BMC increase of the non operated knee. Since aledronate has a systematic effect, one can expect an increased BMC in both knees and eventually on both hips. It is not clear how this iatrogenic alteration of BMC affects healthy major joints. For example, one can suppose that BMC increase may lead to subchondral sclerosis and rapid osteoarthritic degeneration of these joints.

MM Petersen et al(1), investigating the effect of nasal salmon calcitonin on post-traumatic osteopenia following ankle fracture measured the BMC in both operated and healthy tibiae and and found a statistically significant increase on BMC in the healthy leg tibia.

I believe that not only the improvement of the prosthetic components fixation but the effects of aledronate on the non osteoporotic patientsâ€™ major joints must be investigated in order the clinical importance of this study be evaluated. If the authors have obtained relative data the clinical follow up will be of great value.

Yours sincerely

Christos Alexandropoulos, MD Orthopaedic Department of Trikala General Hospital

Reference: 1. Petersen MM, Lauritzen JM, Schwarz P, Lund B. Effect of nasal salmon calcitonin on post traumatic osteopenia following ankle fracture. A randomized double-blind placebo-controlled study in 24 patients. Acta Orthop Scand. 1998 Aug; 69(4): 347-50

Corresponding address: Christos Alexandropoulos, MD 20, Triantafilou str., 42100 Trikala, Greece e-mail: alexand8@otenet.gr

Ching-Jen Wang

Posted on February 09, 2004

Dr Wang responds:

Chang Gung Memorial Hospital

Dear Editor, This is to acknowledge the receipt of the letter to Editor from Tarja A. Soininvaara regarding our article. We would like to congratulate them on their study showing favorable effect of alendronate on periprosthetic bone, findings that are similar to our study. In their study, patients treated with alendronate plus calcium maintained distal femur BMD values close to the baseline, while patients who received only calcium showed significant bone loss during the one-year post TKA.

The groups differed significantly in BMD in the metaphyseal and diaphyseal regions of interest. In their study, patients were allowed full weight bearing immediately after the operation, and the BMD was performed within one week, and at 3, 6, and 12 months postoperatively. In our study, the BMD was performed within one week preoperatively and at 6 and 12 months postoperatively. The geometries of the distal femur and the proximal tibia for BMD measurements were determined preoperatively. The same geometries were used for subsequent BMD measurements postoperatively. Thus, similar measurement areas can be secured and the values of measurement are reproducible.

We have noted a wide range of BMD values among the patients. Therefore, we analyzed the results based on the mean Â¡Ã“ SD values. In our study, patients were allowed to bear partial weight on the operated leg for 4 to 6 weeks before full weight bearing. In fact, the majority of patients were unable to bear full weight for approximately 4 weeks due to postoperative pain even though they were allowed to do so. Weight bearing may theoretically affect the BMD; however, short-term partial weight bearing (4 to 6 weeks) does not seem to cause any detrimental effect on BMD around the knee.

The BMD measurement of the proximal part of the tibia was divided into three regions of interest (ROI): the lateral region (ROI-1), the medial region (ROI-2), and the center region (ROI-3). The medial and lateral regions were located at 1.0 cm within the cortex and 1.0 cm distal to the prosthesis-bone interface, and the center region was located at 1.0 cm distal to the prosthetic stem. We only used one type of prosthesis in this study, and the prosthesis-bone interface in the medial and lateral regions can be fair precisely estimated preoperatively. Likewise, the tip of the prosthesis stem can be determined accordingly. Such measurements can minimize or eliminate the effect of cement mantle on BMD values.

The BMD values in the ROIs in Table IV are the average values of BMD measurement in anteroposterior and lateral projections. These regions were so chosen because they theoretically sustain the most stress shielding and the changes in BMD, if any, will most likely occur in these locations.

Overall, we agree with the writer's opinions that there is a favorable effect of alendronate on periprosthetic bone after TKA. We like to thank the writer for his valuable opinions and comments.

Ching-Jen Wang, M.D.

Tarja A Soininvaara

Posted on January 16, 2004

The Effect of Alendronate on Bone Mineral Density in the Distal Part of the Femur and Proximal Part

Savonlinna Central Hospital

To The Editor:

We read with great interest "The Effect of Alendronate on Bone Mineral Density in the Distal Part of the Femur and Proximal Part of the Tibia After Total Knee Arthroplasty" by Wang et al. (2003; 85-A:2121- 2126)(1).

We have previously shown the efficacy of oral alendronate with calcium for the inhibition of early BMD loss after TKA in a prospective, randomized, one-year follow-up study. Periprosthetic BMD changes were measured in 19 patients with knee osteoarthrosis with dual-energy X-ray absorptiometry within a week post-operatively and at 3, 6 and 12 months follow-up. Patients treated with alendronate+calcium maintained distal femoral BMD values close to the baseline (from 0.48% to â€“5.5, P > 0.04), while patients receiving only calcium showed significant bone loss during the one-year (from â€“14.3% to â€“23.6%, P <0.015). The groups differed significantly in metaphyseal and diaphyseal regions of interests (ROI)(2). These ROIs are reproducible, with an average precision error ranging from 1.3% to 3.1% (3). Full weight-bearing was allowed immediately after the operation(2-4).

The present study by Wang, et al., raises some questions. The authors used the preoperative BMD measurement as a baseline reference in their patients. We would like to know the reproducibility of their measurements. How did they verify that they measured the areas in the pre- and postoperative scans? What is the effect of the cement mantle and perioperative bone loss on these measurements? What was the duration and the effect of partial weight-bearing on BMD?

The ranges of BMDs and their percent changes are very wide. Although the BMD increase at 6 months is marked (10 %) in the study group, the 12 months change may not be significant (1.9 %).

According to both studies, alendronate treatment seems to prevent bone loss after TKA. The long-term effect of bisphosphonates in prevention of aseptic loosening needs to be investigated.

Tarja A Soininvaara, M.D. and Heikki KrÃ¶ger, M.D., Ph.D

Department of Surgery, Savonlinna Central Hospital, Savonlinna, Finland. Department of Surgery, Kuopio University Hospital, Kuopio, Finland. Bone and Cartilage Research Unit (BCRU), University of Kuopio, Kuopio, Finland. Tarja.Soininvaara@uku.fi

References

1. Ching-Jen Wang, Jun-Wen Wang, Lin-Hsiu Weng, Chia-Chen Hsu, Chung- Cheng Huang, Chen. H-S 2003 The Effect of Alendronate on Bone Mineral Density in the Distal Part of the Femur and Proximal Part of the Tibia After Total Knee Arthroplasty. J Bone Joint Surg Am 85:2121-2126. 2. Soininvaara TA, Jurvelin JS, Miettinen HJ, Suomalainen OT, Alhava EM, Kroger HPJ. 2002 Effect of alendronate on periprosthetic bone loss after total knee arthroplasty: a one-year, randomized, controlled trial of 19 patients. Calcif Tissue Int. Dec;71(6):472-7. 3. Soininvaara T, Kroger H, Jurvelin JS, Miettinen H, Suomalainen O, Alhava E 2000 Measurement of bone density around total knee arthroplasty using fan-beam dual energy X-ray absorptiometry. Calcif Tissue Int Sep 67(3):267-72. 4. Soininvaara TA, Miettinen HJA, Jurvelin JS, Suomalainen OT, Alhava EM, Kroger HPJ. Periprosthetic femoral bone loss after total knee arthroplasty: one-year follow-up study of 69 patients. The Knee (In press).

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Ching-Jen Wang, Jun-Wen Wang, Lin-Hsiu Weng, Chia-Chen Hsu, Chung-Cheng Huang, Han-Shiang Chen; The Effect of Alendronate on Bone Mineral Density in the Distal Part of the Femur and Proximal Part of the Tibia After Total Knee Arthroplasty. The Journal of Bone & Joint Surgery. 2003 Nov;85(11):2121-2126.

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