High Prevalence of Osteopenia and Osteoporosis in Total Hip and Total Knee Arthroplasty Patients and Effects of Anti-Resorptive Agents on Bone Health Optimization: A Systematic Review and Meta-Analysis

Abstract

Background: Osteoarthritis is a leading cause of chronic pain and long-term disability in adults, which commonly affects the hip and knee joints. Joint arthroplasties are one of the management strategies for end-stage osteoarthritis. Periprosthetic fractures after hip or knee arthroplasties have mortality rates comparable to hip fractures. Recent studies assessed bone health optimization and the use of anti-osteoporotic agents in elective hip and knee arthroplasty surgeries. This systematic review and meta-analysis aimed to determine the prevalence of osteoporosis before surgery and the effect of bone health optimization on periprosthetic fractures and revisions. Methods: A systematic search was carried out on three databases, including PubMed, Embase, and Web of Science. The keywords used were (Revision or Periprosthetic fracture) AND (osteop*) and (Total Knee* or Total Hip*). Studies that included subjects aged >50 years with investigated outcomes were included in the review. The quality of selected randomized controlled trials was assessed using the Cochrane Collaboration tool, and non-randomized studies were assessed using the Newcastle–Ottawa Scale. The review was not registered with the International Prospective Register of Systematic Reviews (PROSPERO). Results: A total of 2482 records were identified. Twenty-three studies were included, and eighteen were used for quantitative analysis. Pooled overall prevalence of osteopenia in patients undergoing total knee arthroplasty (TKA)/total hip arthroplasty (THA) surgery was 42.87% (95% confidence interval (CI) 32.65 to 53.09). Pooled overall prevalence of osteoporosis in patients undergoing TKA/THA surgery was 23.99% (95% CI 15.72 to 32.26). The overall mean difference was in favor of anti-resorptive treatment on periprosthetic BMD of the medial calcar region (Gruen zone 7) after THA (12.16% (95% CI 8.78 to 15.53, p < 0.00001). Pooled odds ratio of periprosthetic fracture was 1.27 (95% CI 1.08 to 1.48, p = 0.003) in favor of the control group compared to bisphosphonate treatment. The pooled hazard ratio for all-cause revisions after TKA/THA for both osteopenia and osteoporotic patients was 0.26 (95% CI 0.13 to 0.51, p = 0.0001, I² 76%), signifying an improvement with bisphosphonates. Limitations of this study include the heterogeneity and retrospective nature of the included studies, with the average level of evidence subject to bias. Conclusions: There was a high prevalence of osteopenia/osteoporosis amongst patients undergoing total knee and total hip arthroplasty at 66.86%. Whilst bone health optimization with bisphosphonates may decrease the risk of revisions, the risk of periprosthetic fracture appeared to increase. Further research will be required to evaluate the effects of bone health optimization on the risk of periprosthetic fracture and revisions, and the effects of anabolic agents on periprosthetic fractures.