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Preclinical Evaluation of Zoledronate to Maintain Bone Allograft and Improve Implant Fixation in Revision Joint Replacement
Mette Sørensen, MD, PhD1; Jeppe Barckman, MD, PhD1; Joan E. Bechtold, PhD2; Kjeld Søballe, MD, DMSc3; Jørgen Baas, MD, PhD1
1 Orthopaedic Research Laboratory, Aarhus University Hospital, Norrebrogade 44, Building 1A, Aarhus C, 8000, Denmark. E-mail address for M. Sørensen: mette.sorensen@ki.au.dk
2 Orthopaedic Biomechanics Laboratory, University of Minnesota, Minneapolis Medical Research Foundation, Excelen Center for Bone and Joint Research and Education, 700 South 10th Avenue, Minneapolis, MN 55415
3 Aarhus University Hospital, Tage-Hansens Gade 2, Cuilding 9A, Aarhus C, 8000, Denmark
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Investigation performed at the Orthopaedic Research Laboratory and Department of Orthopaedics, Aarhus University Hospital, Aarhus, Denmark, and the Orthopaedic Biomechanics Laboratory, Minneapolis Medical Research Foundation, Minneapolis, Minnesota

Disclosure: One or more of the authors received payments or services, either directly or indirectly (i.e., via his or her institution), from a third party in support of an aspect of this work. In addition, one or more of the authors, or his or her institution, has had a financial relationship, in the thirty-six months prior to submission of this work, with an entity in the biomedical arena that could be perceived to influence or have the potential to influence what is written in this work. No author has had any other relationships, or has engaged in any other activities, that could be perceived to influence or have the potential to influence what is written in this work. The complete Disclosures of Potential Conflicts of Interest submitted by authors are always provided with the online version of the article.

Copyright © 2013 by The Journal of Bone and Joint Surgery, Inc.
J Bone Joint Surg Am, 2013 Oct 16;95(20):1862-1868. doi: 10.2106/JBJS.L.00641
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Revision arthroplasty surgery is often complicated by loss of bone stock that can be managed by the use of bone allograft. The allograft provides immediate stability for the revision implant but may be resorbed, impairing subsequent implant stability. Bisphosphonates can delay allograft resorption. We hypothesized that zoledronate-impregnated allograft impacted around revision implants would improve implant fixation as characterized by mechanical push-out testing and histomorphometry.


Twenty-four axially pistoning micromotion devices were inserted bilaterally into the knees of twelve dogs according to our revision protocol. This produced a standardized revision cavity with a loose implant, fibrous tissue, and a sclerotic bone rim. Revision surgery was performed eight weeks later; after stable titanium revision components were implanted, saline solution-soaked allograft was impacted around the component on the control side and allograft soaked in 0.005 mg/mL zoledronate was impacted on the intervention side. The results were evaluated after four weeks.


The zoledronate treatment resulted in a 30% increase in ultimate shear strength (p = 0.023), a 54% increase in apparent shear stiffness (p = 0.002), and a 12% increase in total energy absorption (p = 0.444). The quantity of allograft in the gap was three times greater in the zoledronate group compared with the control group (p < 0.001). The volume fraction of new bone in the zoledronate group (25%; 95% confidence interval [CI], 22% to 28%) was similar to that in the control group (23%; 95% CI, 19% to 26%) (p = 0.311).


The data obtained in this canine model suggest that pretreating allograft with zoledronate may be beneficial for early stability of grafted revision arthroplasty implants, without any adverse effect on bone formation. Clinical studies are warranted.

Clinical Relevance: 

The zoledronate treatment is simple to apply in the clinical setting. The treatment could increase early stability of revision joint replacements without impairing new bone formation. In the long term, this can potentially improve the longevity of revision joint replacements and reduce the number of subsequent revisions.

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    These activities have been planned and implemented in accordance with the Essential Areas and policies of the Accreditation Council for Continuing Medical Education (ACCME) through the joint sponsorship of the American Academy of Orthopaedic Surgeons and The Journal of Bone and Joint Surgery, Inc. The American Academy of Orthopaedic Surgeons is accredited by the ACCME to provide continuing medical education for physicians.
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