Is bisphosphonate use a risk factor for atypical periprosthetic/peri-implant fractures?-A metanalysis of retrospective cohort studies and systematic review of the current evidence

Introduction: Atypical periprosthetic/peri-implant fractures are not recognised in any widely used clas-sification and therefore little focus is given to them. Multiple case reports and case series demonstrate these fractures exist and are related to bisphosphonate (BP) use.Hypothesis: Are patients taking long-term BPs at an increased risk of developing an atypical periprosthetic/peri-implant fracture? Is a particular BP drug causing an increased risk of fracture? Is there a correlation between the time of BP use and the incidence of fractures? Do vitamin D analogues or parathyroid hormones reduce the time to union?Material and methods: Systematic review of all available evidence on the existence of periprosthetic/peri-implant atypical fractures in patients taking long-term BPs and metanalysis of available retrospective cohort studies. Selected 1 systematic review, 7 retrospective cohort studies (5 used for metanalysis) and 32 case reports.Results: Metanalysis reported a risk ratio of 14.1, p = 0.25, suggesting bisphosphonates are a risk factor in the development of periprosthetic/peri-implant atypical fractures. The secondary outcomes couldn't be reliably identified due to the small size of available studies and risk of significant bias.Discussion: Atypical periprosthetic/peri-implant fractures are an entity and seem to be associated with the use of bisphosphonates. The benefits of bisphosphonates use outweigh the risks, but clinicians should be aware of atypical fractures and actively search for them when patients on long-term bisphosphonates attend with non-specific pain close to the implant/prosthesis or reduced mobility. Level of evidence: II, Systematic review and metanalysis. (c) 2022 Elsevier Masson SAS. All rights reserved.

Automated summary

This study conducted a systematic review and meta-analysis of patients taking long-term bisphosphonates, and found an association between bisphosphonate use and atypical periprosthetic/peri-implant fractures. Although there is limited research on these fractures, clinicians should be vigilant and actively search for atypical fractures in patients on long-term bisphosphonates.