Bisphosphonate use in patients undergoing total knee arthroplasty reduces overall and aseptic revisions and periprosthetic bone mineral density loss: A systematic review from the FP-UCBM Knee Study Group

Purpose: Bisphosphonates (BPs), widely used for osteoporosis management, have garnered attention in the context of total knee arthroplasty (TKA) for their potential to preserve periprosthetic bone mineral density (BMD) and mitigate risks such as aseptic loosening, periprosthetic fractures, and implant failure. This study systematically reviewed the current literature on the topic, hypothesising that BP therapy reduces the risk of postoperative adverse outcomes in patients undergoing TKA. Methods: A systematic literature search was conducted on 1 December 2024 using PubMed, Cochrane Library, Scopus and Google Scholar. Inclusion criteria were: English-language randomised controlled trials (RCTs), comparative prospective or retrospective studies, and studies evaluating postoperative outcomes (including all-cause and aseptic revisions, periprosthetic BMD loss, periprosthetic fractures and implant migration) in patients undergoing TKA who received BP treatment. Exclusion criteria were: computational studies; case reports; studies focusing uniquely on the surgical technique; studies reporting only cumulative data for total joint arthroplasty. Results: A total of 14 studies (480,294 patients) were included. Six studies focused exclusively on osteoporotic patients, six on non-osteoporotic patients and two on a mixed BMD population. The rate of all-cause and aseptic revisions was 1.5% and 1.1% respectively for BP users, and 2.3% and 2.5%, for non-BP users. Mean pre-/post-operative variation in BMD was –0.04 for BP users and –0.2 for non-BP users. The risk of bias was graded as low using the ROB 2 tool for RCTs and the Newcastle–Ottawa Scale for observational studies. Conclusion: Bisphosphonate use in patients undergoing total knee arthroplasty is associated with lower rates of overall and aseptic revisions, reduced periprosthetic BMD loss, and inconclusive effects on periprosthetic fractures and implant migration. Level of Evidence: Level IV.