Metabolic Bone Diseases and Total Hip Arthroplasty: Preventing Complications

Joaquin Moya-Angeler, MD, PhD; Joseph M. Lane, MD; Jose A. Rodriguez, MD


J Am Acad Orthop Surg. 2017;25(11):725-735. 

In This Article

Biologic Options to Enhance Periprosthetic Bone Mass

The optimization of bone quality and strength is imperative to promote successful outcomes in the treatment of patients with MBDs undergoing hip arthroplasty. Implant fixation and periprosthetic bone mass have the potential to be enhanced with pharmacologic agents, such as diphosphonates, denosumab, and parathyroid hormone (PTH), to prevent early implant failure and periprosthetic fractures.[39]


Diphosphonates are US FDA-approved drugs used for the prevention and management of osteoporosis. They inhibit bone resorption, increase bone density, and reduce the risk of fractures. Ibandronate, alendronate, risedronate, pamidronate, and zoledronic acid have all been shown to decrease periprosthetic bone loss after noncemented joint arthroplasty.[39] Therefore, the use of diphosphonates should not be stopped perioperatively in patients undergoing hip arthroplasty.[12,15] Prior studies have demonstrated the ability of locally delivered diphosphonates to enhance bone formation around implants in animal models.[39] More recently, Bobyn et al[40] demonstrated that the local elution of alendronic acid causes a dose-dependent net increase in peri-implant bone formation in an animal model. This concept has potential to improve the biologic fixation of porous reconstructive implants.


Denosumab is an FDA-approved drug that is widely used for the prevention and management of osteoporosis. Its mechanism of action is different from that of diphosphonates. Denosumab is a human monoclonal antibody (IgG2) that prevents bone resorption by inhibiting osteoclast differentiation in the interaction between receptor activator of nuclear factor-[kappa] B (RANK) and RANK ligand.[39] This drug has the theoretical potential to prevent and manage osteolysis, which can result in aseptic implant loosening. However, the effect of denosumab on patients undergoing joint arthroplasty has not yet been studied.

Parathyroid Hormone

PTH is a bone anabolic agent that directly stimulates bone formation and bone mineral density in patients with osteoporosis. PTH acts in a dose- and time-dependent manner, and when administered as a daily 20-μg subcutaneous injection, it has been shown to reduce the risk of fractures in postmenopausal women with osteoporosis.[39] PTH stimulates bone formation on all bone surfaces, including trabecular, endosteal, and periosteal bone. The use of PTH in joint arthroplasty is currently being investigated. Studies in animals suggest that PTH has the potential to increase the density of regenerating bone and improve the fixation of steel implants in a dose- and time-dependent manner.[41] These preliminary findings indicate that PTH could be investigated further as an agent to increase periprosthetic bone mass.