JBJS -- Letters to the Editor for Mochida et al., 84 (2) 226-235

JBJS welcomes reader comments on published articles. Letters to the Editor are reviewed by JBJS editors but are not peer-reviewed. To submit your letter, please follow the "submit a response" link that appears in the content box at the upper right of the full text of the article.

Letters to the Editor to:

Scientific Articles:
Yuichi Mochida, Thomas W. Bauer, Toshihiro Akisue, and Phillip R. Brown
Alendronate Does Not Inhibit Early Bone Apposition to Hydroxyapatite-Coated Total Joint Implants : A Preliminary Study
J Bone Joint Surg Am 2002; 84: 226-235 [Abstract] [Full text] [PDF]

Letters to the Editor: Submit a response to this article

Electronic letters published:

UPDATE: bisphosphonates and osteoporosis: Robert Poss (5 March 2002)

Bisphosphonates in Total Hip Arthroplasty--A Response to Dr. Cottrell: Thomas A. Einhorn, MD (4 March 2002)

Bone Density, ALN, Total Jt. Arthroplasty: William Cottrell (28 February 2002)

UPDATE: bisphosphonates and osteoporosis 5 March 2002

Robert Poss,
MD
deputy editor for electronic media, JBJS
Send letter to journal:
Re: UPDATE: bisphosphonates and osteoporosis

possr{at}jbjs.org Robert Poss

For a perspective on the status of using bisphsophonates to treat osteoporosis, see New England Journal of Medicine:346, page642, February 28, 2002.
In the same issue, there is a report on the use of a bisphosphonate, zoledronic acid, that when given intermittently via an intravenous route is effective in promoting increased bone density. (Reid, IR, et.al, Intravenous Zoledronic Acid In Postmenopausal Women With Low Bone Mineral Density, NEJM,346:653-661

Bisphosphonates in Total Hip Arthroplasty--A Response to Dr. Cottrell 4 March 2002

Thomas A. Einhorn, MD,
Chairman, Department of Orthopaedic Surgery
Boston University School of Medicine
Send letter to journal:
Re: Bisphosphonates in Total Hip Arthroplasty--A Response to Dr. Cottrell

thomas.einhorn{at}bmc.org Thomas A. Einhorn, MD

Although there have been no peer-reviewed reports demonstrating poor results of total joint arthroplasties performed in patients with documented osteoporosis, the notion that an individual should have healthy bone mass before undergoing such a procedure certainly makes sense. The best way to determine this is to perform a bone density examination. However, to my knowledge there is no consensus that all patients should undergo bone density testing prior to being indicated for total joint arthroplasty. Furthermore, I believe that if a patient has had radiographs taken with a standardized technique, and if there is neither visible evidence of osteopenia nor a medical history of metabolic disease, the measurement of bone mass is probably unnecessary.
The use of alendronate in the management of patients who have documented prosthetic loosening secondary to the presence of particulate wear debris is very intriguing. Several pre-clinical animal studies have addressed this question and all seem to support the concept that effective anti-osteoclastic therapy, using a bisphosphonate such as alendronate, could limit the resorption of bone in the vicinity of an implant. The pathophysiological basis for this concept is that wear debris elaborated from articulating prosthetic joint surfaces is phagocytized by synovial macrophages and these cells respond by secreting a variety of cytokines which activate osteoclastic activity. Alendronate, a bisphosphonate approved for the treatment of osteoporosis and Paget's disease, has a direct action on the osteoclast to inhibit its activity and possibly induce apoptosis(programmed cell death). Thus, without having to modify the wear-generating process or the production of cytokines, prosthetic loosening could potentially be managed by inhibiting the final step in the pathway to osteolysis, osteoclast-mediated bone resorption. Thus far, a handful of clinical studies have reported improved proximal femoral bone mass following total hip arthroplasty in patients treated with different bisphosphonates over the first twenty-four months after surgery. In addition, prospective studies are now underway to test the hypothesis that prosthetic loosening can be prevented or arrested in patients treated with alendronate. At this time, the use of these pharmaceutical agents in the management of patients with joint prostheses would be considered an off- label use. However, as new drugs become available for the treatment of bone diseases, there may be numerous ways that they can be used to enhance the results of orthopaedic surgery.

Bone Density, ALN, Total Jt. Arthroplasty 28 February 2002

William Cottrell,
orthopaedist
Send letter to journal:
Re: Bone Density, ALN, Total Jt. Arthroplasty

whc{at}innercite.com William Cottrell

The literature seems to support the concept that patients anticipating total joint arthroplasty should have a bone mineral density prior to surgery. If bone is osteoporotic, I would consider treating with alendronate for 1-2 years. The literature also supports the concept that prosthetic loosening secondary to the sequelae of particulate debris might be limited by alendronate also. I would appreciate comments from experts in the field.