Preoperative bisphosphonates in total hip arthroplasty : safe regardless of treatment duration

Recent studies have suggested that preoperative bisphosphonate (BP) use increases complications after total hip arthroplasty (THA), compared with THA in BP-naive patients. This study aimed to determine whether preoperative BP is associated with adverse surgical outcomes in patients receiving perioperative BP therapy, and whether duration of preoperative BP affected complication risk.

Using a nationwide Korean claims database, patients aged ≥ 50 years undergoing unilateral THA with perioperative BP were analyzed. Patients were categorized into 'Pre & Post' (BP use before and after surgery), 'Post Only' (BP use only after surgery), or control groups (no BP use before and after THA). Propensity score-matching (PSM) was performed: 1:1 ratio between the Pre & Post and Post Only groups and 1:5 between each treatment group and their respective controls. The Pre & Post group was further stratified into three subgroups based on cumulative BP duration before THA (six months to one year; one to three years; and more than three years). Outcomes including periprosthetic fracture (PPF) and revision were analyzed.

After PSM balanced baseline characteristics, preoperative BP exposure was not a risk factor for PPF or revision compared with controls. Postoperative BP reduced revision risk after THA compared with the control group (hazard ratio (HR) 0.74 (95% CI 0.59 to 0.92); p = 0.008). Hip fracture was a risk factor for both PPF and revision, whereas older age and higher Charlson Comorbidity Index increased PPF risk, and diabetes increased revision risk. Sub-group analysis showed that the 'more than three-year' group showed a significantly lower risk of PPF (HR 0.39 (95% CI 0.14 to 0.96); p = 0.041) in the Pre & Post group.

Preoperative use of BP ≥ six months before THA does not increase the risk of PPF and revision, and may even lower such risk, supporting safety regardless of treatment duration. Patient-related factors, such as comorbidities and hip fracture, rather than BP use itself, was a key risk factor for periprosthetic complications after THA.