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Denosumab vs. Oral Bisphosphonates: Impact on Osteoarthritis Risk

by Team SunilMadhavs World
written by Team SunilMadhavs World

Clinical Overview: Denosumab Versus Oral Bisphosphonates and Osteoarthritis Risk

A target trial emulation study published in the Journal of Bone and Mineral Research investigated whether older adults with osteoporosis initiating therapy with denosumab experience a decreased risk of osteoarthritis compared with those initiating oral bisphosphonates. The study also evaluated outcomes among patients switching from oral bisphosphonates to denosumab.

In the primary analysis of new medication users, adults initiating denosumab exhibited a 17% lower overall risk of new-onset osteoarthritis compared to those starting oral bisphosphonates. Commenting on these results, Masaki Hatano, MD, MPH, of the Department of Orthopedic Surgery at the Faculty of Medicine at the University of Tokyo, stated:

โ€œOur findings raise the possibility that denosumab may be associated with a lower observed risk of osteoarthritis in addition to its established role in osteoporosis treatment.โ€

Dr. Hatano added:

โ€œThey also suggest that this association may vary according to prior bisphosphonate exposure. Further evidence is needed before these findings can inform treatment decisions.โ€

Target Trial Emulation Design and Results

Researchers utilized administrative claims data from adults aged 50 years or older diagnosed with osteoporosis. Propensity score matching was implemented across two core analyses:

  • New User Cohort: 13,485 new denosumab users were matched 1:4 with 51,629 new oral bisphosphonate users. In a per-protocol analysis, denosumab initiation was associated with a lower risk for new-onset osteoarthritis (RR = 0.83; 95% CI, 0.73โ€“0.91; absolute risk reduction, 2%; 95% CI, 1.1%โ€“3.2%).
  • Switching Cohort: 4,309 adults who switched from an oral bisphosphonate to denosumab were matched 1:4 to 16,546 adults who continued using an oral bisphosphonate. There was no significant difference in overall osteoarthritis risk between patients who switched to denosumab and those who maintained continued bisphosphonate therapy.

When evaluating specific joint sites, denosumab initiation in new users reduced the risk of knee osteoarthritis (RR = 0.84; 95% CI, 0.71โ€“0.92; absolute risk reduction, 1.5%; 95% CI, 0.7%โ€“2.8%) and hip osteoarthritis (RR = 0.87; 95% CI, 0.52โ€“0.98; absolute risk reduction, 0.2%; 95% CI, 0%โ€“0.8%). No significant differences in hand osteoarthritis risk were observed between new users. Among patients who switched therapies, only knee osteoarthritis risk showed a reduction (RR = 0.85; 95% CI, 0.71โ€“1; absolute risk reduction, 1.3%; 95% CI, 0%โ€“2.8%), with no differences noted for hip or hand osteoarthritis.

Regarding the lack of overall risk reduction in patients who switched therapies, Dr. Hatano noted:

โ€œOne possible explanation is that prior bisphosphonate exposure may have altered the subchondral bone-remodeling environment.โ€

Furthermore, Dr. Hatano explained:

โ€œDifferences in treatment persistence and adherence-related characteristics between patients starting osteoporosis treatment for the first time and those already receiving oral bisphosphonates may also have contributed to this difference.โ€

Summary Tables of Osteoarthritis Risk Data

Table 1: New Users โ€” Denosumab vs. Oral Bisphosphonates

Clinical OutcomeRelative Risk (RR)95% Confidence Interval (CI)Absolute Risk Reduction95% CI (Absolute Risk)
Overall Osteoarthritis0.830.73 โ€“ 0.912.0%1.1% โ€“ 3.2%
Knee Osteoarthritis0.840.71 โ€“ 0.921.5%0.7% โ€“ 2.8%
Hip Osteoarthritis0.870.52 โ€“ 0.980.2%0% โ€“ 0.8%
Hand OsteoarthritisNo differenceN/AN/AN/A

Table 2: Treatment Switchers โ€” Switch to Denosumab vs. Continued Bisphosphonates

Clinical OutcomeRelative Risk (RR)95% Confidence Interval (CI)Absolute Risk Reduction95% CI (Absolute Risk)
Overall OsteoarthritisNo differenceN/AN/AN/A
Knee Osteoarthritis0.850.71 โ€“ 1.01.3%0% โ€“ 2.8%
Hip OsteoarthritisNo differenceN/AN/AN/A
Hand OsteoarthritisNo differenceN/AN/AN/A

Interactive Osteoarthritis Risk Explorer Widget (CLS-Optimized Code)

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<style>
  .osteo-risk-widget {
    box-sizing: border-box;
    width: 100%;
    max-width: 680px;
    min-height: 400px; /* Pre-allocated height to prevent Cumulative Layout Shift */
    margin: 20px auto;
    padding: 24px;
    background-color: #f8f9fa;
    border: 1px solid #ced4da;
    border-radius: 8px;
    font-family: -apple-system, BlinkMacSystemFont, "Segoe UI", Roboto, sans-serif;
    color: #212529;
    contain: layout style;
  }
  .osteo-risk-widget h4 {
    margin-top: 0;
    font-size: 1.2rem;
    color: #0f2537;
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  .orw-form-group {
    margin-bottom: 14px;
    display: flex;
    flex-direction: column;
    gap: 6px;
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  .orw-form-group label {
    font-size: 0.9rem;
    font-weight: 600;
  }
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    padding: 8px;
    font-size: 0.95rem;
    border: 1px solid #ccc;
    border-radius: 4px;
  }
  .orw-result-box {
    margin-top: 20px;
    padding: 14px;
    background: #e9ecef;
    border-left: 4px solid #0d6efd;
    border-radius: 4px;
    min-height: 70px;
  }
  .orw-result-title {
    font-size: 0.8rem;
    text-transform: uppercase;
    color: #495057;
    font-weight: 700;
    margin-bottom: 4px;
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  .orw-result-text {
    font-size: 0.95rem;
    font-weight: 600;
    color: #0d6efd;
  }
</style>

<div class="osteo-risk-widget">
  <h4>Osteoporosis Therapy & Osteoarthritis Risk Explorer</h4>
  <p style="font-size: 0.9rem; color: #666;">Select patient cohort and joint site to review comparative clinical outcomes from Hatano et al. (2026):</p>

  <div class="orw-form-group">
    <label for="cohortSelect">Patient Cohort:</label>
    <select id="cohortSelect" onchange="updateOsteoData()">
      <option value="new">New Treatment Users (Denosumab vs. Bisphosphonates)</option>
      <option value="switcher">Switchers (Switch to Denosumab vs. Continued Bisphosphonates)</option>
    </select>
  </div>

  <div class="orw-form-group">
    <label for="jointSite">Joint Site / Category:</label>
    <select id="jointSite" onchange="updateOsteoData()">
      <option value="overall">Overall Osteoarthritis Risk</option>
      <option value="knee">Knee Osteoarthritis Risk</option>
      <option value="hip">Hip Osteoarthritis Risk</option>
      <option value="hand">Hand Osteoarthritis Risk</option>
    </select>
  </div>

  <div class="orw-result-box">
    <div class="orw-result-title">Clinical Finding Summary</div>
    <div id="orwOutputText" class="orw-result-text">New denosumab users had a 17% lower overall osteoarthritis risk compared to new oral bisphosphonate users (RR = 0.83; 95% CI, 0.73-0.91).</div>
  </div>
</div>

<script>
  function updateOsteoData() {
    const cohort = document.getElementById('cohortSelect').value;
    const joint = document.getElementById('jointSite').value;
    const output = document.getElementById('orwOutputText');

    if (cohort === 'new') {
      if (joint === 'overall') {
        output.textContent = 'New denosumab users had a 17% lower overall osteoarthritis risk compared to new oral bisphosphonate users (RR = 0.83; 95% CI, 0.73-0.91; absolute risk reduction, 2%).';
      } else if (joint === 'knee') {
        output.textContent = 'Denosumab initiation was linked to reduced risk for knee osteoarthritis among new users (RR = 0.84; 95% CI, 0.71-0.92; absolute risk reduction, 1.5%).';
      } else if (joint === 'hip') {
        output.textContent = 'Denosumab initiation showed a reduced risk for hip osteoarthritis among new users (RR = 0.87; 95% CI, 0.52-0.98; absolute risk reduction, 0.2%).';
      } else {
        output.textContent = 'No significant difference in hand osteoarthritis risk was observed between new users of denosumab and oral bisphosphonates.';
      }
    } else {
      if (joint === 'overall') {
        output.textContent = 'Patients who switched from oral bisphosphonate to denosumab showed no significant difference in overall osteoarthritis risk compared to continued bisphosphonate users.';
      } else if (joint === 'knee') {
        output.textContent = 'Switchers had a lower risk for knee osteoarthritis than those who continued a bisphosphonate (RR = 0.85; 95% CI, 0.71-1; absolute risk reduction, 1.3%).';
      } else if (joint === 'hip') {
        output.textContent = 'No significant difference in hip osteoarthritis risk was observed between patients who switched therapies and those who continued bisphosphonates.';
      } else {
        output.textContent = 'No significant difference in hand osteoarthritis risk was observed between switchers and continued users.';
      }
    }
  }
</script>
<!-- END: CLS-Optimized Interactive Widget -->

Clinical Trials & Guidelines Resource Summary (CLS-Optimized HTML)

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    box-sizing: border-box;
    width: 100%;
    max-width: 680px;
    min-height: 260px; /* Pre-allocated height to prevent Cumulative Layout Shift */
    margin: 20px auto;
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    border: 1px solid #dee2e6;
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    text-align: center;
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    background-color: #e8f5e9;
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</style>

<div class="osteo-trials-card">
  <h3>Bone Mineral Research & Clinical Trials Hub</h3>
  <p>Access published literature, target trial emulation studies, and database resources concerning osteoporosis therapies and joint outcomes:</p>

  <div class="osteo-trials-grid">
    <a href="https://pubmed.ncbi.nlm.nih.gov/" target="_blank" rel="noopener" class="osteo-trial-link">PubMed Literature Database</a>
    <a href="https://clinicaltrials.gov/" target="_blank" rel="noopener" class="osteo-trial-link">ClinicalTrials.gov Registry</a>
    <a href="https://academic.oup.com/jbmr" target="_blank" rel="noopener" class="osteo-trial-link">Journal of Bone & Mineral Research</a>
    <a href="https://www.healio.com/" target="_blank" rel="noopener" class="osteo-trial-link">Healio Clinical News</a>
  </div>
</div>
<!-- END: CLS-Optimized Clinical Trials Component -->

Video Overview Container (CLS-Optimized Code)

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<style>
  .osteo-video-wrapper {
    position: relative;
    width: 100%;
    max-width: 680px;
    margin: 20px auto;
    aspect-ratio: 16 / 9; /* Reserves exact 16:9 vertical space to eliminate Cumulative Layout Shift */
    background-color: #000000;
    border-radius: 8px;
    overflow: hidden;
    contain: layout style;
  }
  .osteo-video-wrapper iframe {
    position: absolute;
    top: 0;
    left: 0;
    width: 100%;
    height: 100%;
    border: 0;
  }
</style>

<div class="osteo-video-wrapper">
  <iframe 
    src="https://www.youtube-nocookie.com/embed/dQw4w9WgXcQ" 
    title="Osteoporosis Therapy and Osteoarthritis Risk Discussion"
    loading="lazy"
    allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" 
    allowfullscreen>
  </iframe>
</div>
<!-- END: CLS-Optimized Video Container -->
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ORTHOPEDICSSPORTS MEDICINE

Weighted Vests and Bone Health During Weight Loss: Orthopedic Insights

by Team SunilMadhavs World
written by Team SunilMadhavs World

Clinical Overview: The Impact of Weighted Vests on Bone Health During Weight Loss

Intentional weight loss presents a distinct clinical dilemma for musculoskeletal providers. While reducing excess body weight improves overall health and decreases joint loading, it simultaneously diminishes the mechanical stimulus required to maintain bone mass. This reduction is particularly concerning for older adults, who face an elevated risk for osteoporosis and fragility fractures. Consequently, researchers and clinicians have explored whether weighted vests can substitute for lost mechanical loading and safeguard skeletal health during weight reduction.

Expert Perspectives and Evidence Analysis

Insights from Dr. Katherine J. Coyner

Katherine J. Coyner, MD, MBA, FAOAโ€”associate professor in the department of orthopaedic surgery, sports medicine fellowship director, orthopedic team physician for University of Connecticut Athletics, and director of the Women’s Center for Motion & Performance at UConn Healthโ€”notes that current evidence indicates weighted vests “may provide a modest benefit for bone health, particularly at the hip, by partially replacing the gravitational loading lost during weight loss”.
However, Dr. Coyner cautions against unrealistic expectations regarding body composition and weight reduction:
  • Clinicians should not expect weighted vests to accelerate or increase total weight loss volume.
  • Participants utilizing weighted vests achieve weight loss outcomes comparable to those undergoing dietary interventions alone.
  • Weighted vests do not consistently demonstrate meaningful preservation of lean muscle mass or improvements in muscle quality.
Emphasizing foundational exercise physiology, Dr. Coyner states that “progressive resistance training remains the most effective intervention for maintaining muscle mass and function during weight loss and should continue to be emphasized in any comprehensive weight management program”. Furthermore, emerging observations suggest that individuals utilizing weighted vests “appeared to maintain their weight loss more successfully over time than those who did not”.

Orthopedic Patient Selection and Contraindications

From an orthopedic standpoint, patient selection is critical because weighted vests elevate joint reaction forces throughout the spine and lower extremities. Dr. Coyner emphasizes that the decision to implement a weighted vest “should therefore be individualized based on a patientโ€™s underlying musculoskeletal health, functional status and exercise goals rather than applied as a blanket recommendation”.
Special pre-participation musculoskeletal evaluations are mandatory for individuals presenting with:
  • Symptomatic hip or knee osteoarthritis
  • Lower extremity stress injuries or significant pain
  • Spinal pathology or impaired functional mobility
  • Impaired balance, gait instability, or an elevated fall risk
Ultimately, orthopedic specialists should view weighted vests “as an adjunct rather than a replacement for established exercise recommendations”.

Insights from Dr. Sarah F. Eby

Sarah F. Eby, MD, PhDโ€”assistant professor in physical medicine and rehabilitation at Mass General Brigham Healthcare Centerโ€”points out that clinical data regarding weighted vests and weight loss remains mixed.
  • A 2018 investigation evaluated weighted vest utility and found that “weight loss, fat mass, lean mass and percentage body fat were equivalent between both groups” when compared to non-vest participants.
  • Conversely, a 2020 study observed “reduced body weight and reduced fat mass in folks using a heavier (11% of body weight) weighted vest when compared with those with lower (1% of body weight) weighted vest; however, the follow-up was very brief”.
  • Addressing long-term outcomes, a small 2025 study demonstrated that weighted vest use coupled with caloric restriction “may help to reduce weight gain for up to 2 years after the intervention when compared with caloric restriction alone,” though investigators noted a very small sample size.

Summary of Clinical Studies on Weighted Vests

Study Year / Reference Evaluated Intervention & Cohort Key Findings & Outcomes Clinical Implication
2018 Investigation Weighted vest use versus control during weight loss. Weight loss, fat mass, lean mass, and percentage body fat were equivalent between groups. Vests do not inherently accelerate weight loss or alter body composition compared to diet alone.
2020 Investigation Comparison between heavier (11% body weight) versus lighter (1% body weight) vests. Reduced body weight and reduced fat mass observed in the heavier vest cohort (brief follow-up). Higher load percentages may influence fat mass reduction, though long-term data is limited.
2025 Investigation Weighted vest use combined with caloric restriction. Helped reduce weight gain for up to 2 years post-intervention compared to caloric restriction alone (small sample size). May offer potential benefits for long-term weight maintenance after initial reduction.

Interactive Weighted Vest Patient Eligibility Widget (CLS-Optimized Code)

The following HTML and JavaScript widget includes explicit containment and dimensional properties (min-height, contain: layout style) to prevent Cumulative Layout Shift (CLS) when embedded in WordPress themes like Soledad.
HTML

<!-- START: CLS-Optimized Interactive Widget -->
<style>
  .vest-eligibility-widget {
    box-sizing: border-box;
    width: 100%;
    max-width: 680px;
    min-height: 400px;
    margin: 20px auto;
    padding: 24px;
    background-color: #fcfcfc;
    border: 1px solid #dcdcdc;
    border-radius: 8px;
    font-family: -apple-system, BlinkMacSystemFont, "Segoe UI", Roboto, sans-serif;
    color: #333333;
    contain: layout style;
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  .vest-eligibility-widget h4 {
    margin-top: 0;
    font-size: 1.2rem;
    color: #1a202c;
  }
  .vest-form-group {
    margin-bottom: 14px;
    display: flex;
    flex-direction: column;
    gap: 6px;
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  .vest-form-group label {
    font-size: 0.9rem;
    font-weight: 600;
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  .vest-form-group select {
    padding: 8px;
    font-size: 0.95rem;
    border: 1px solid #ccc;
    border-radius: 4px;
  }
  .vest-result-box {
    margin-top: 20px;
    padding: 14px;
    background: #edf2f7;
    border-left: 4px solid #3182ce;
    border-radius: 4px;
    min-height: 60px;
  }
  .vest-result-title {
    font-size: 0.8rem;
    text-transform: uppercase;
    color: #4a5568;
    font-weight: 700;
    margin-bottom: 4px;
  }
  .vest-result-text {
    font-size: 0.95rem;
    font-weight: 600;
    color: #2b6cb0;
  }
</style>

<div class="vest-eligibility-widget">
  <h4>Weighted Vest Patient Selection Tool</h4>
  <p style="font-size: 0.9rem; color: #666;">Evaluate clinical screening parameters before recommending weighted vest adjunct therapy:</p>
  
  <div class="vest-form-group">
    <label for="jointPathology">Lower Extremity / Spinal Pathology or Osteoarthritis:</label>
    <select id="jointPathology" onchange="evaluateVestSuitability()">
      <option value="no">None / Asymptomatic</option>
      <option value="yes">Symptomatic Hip/Knee OA or Spinal Pathology</option>
    </select>
  </div>

  <div class="vest-form-group">
    <label for="fallRisk">Balance Stability / Fall Risk:</label>
    <select id="fallRisk" onchange="evaluateVestSuitability()">
      <option value="stable">Stable Balance / Normal Gait</option>
      <option value="unstable">Impaired Balance / Gait Instability / Fall Risk</option>
    </select>
  </div>

  <div class="vest-result-box">
    <div class="vest-result-title">Screening Assessment Result</div>
    <div id="vestOutputText" class="vest-result-text">Patient appears suitable for a carefully monitored weighted vest adjunct program alongside progressive resistance training.</div>
  </div>
</div>

<script>
  function evaluateVestSuitability() {
    const pathology = document.getElementById('jointPathology').value;
    const stability = document.getElementById('fallRisk').value;
    const output = document.getElementById('vestOutputText');

    if (pathology === 'yes' || stability === 'unstable') {
      output.textContent = 'Caution / Contraindicated: Patient requires thorough musculoskeletal assessment. Additional loading may aggravate joint reaction forces or increase fall risk.';
      output.style.color = '#c53030';
    } else {
      output.textContent = 'Appropriate Candidate: Patient may be considered for a weighted vest program as a bone-loading adjunct, provided progressive resistance training is prioritized.';
      output.style.color = '#2b6cb0';
    }
  }
</script>
<!-- END: CLS-Optimized Interactive Widget -->

Clinical Trials & Guidelines Resource Summary (CLS-Optimized HTML)

HTML

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    border: 1px solid #e2e8f0;
    border-left: 5px solid #3182ce;
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<div class="trials-resource-card">
  <h3>Musculoskeletal Clinical Trials & Guidelines Hub</h3>
  <p>Access registered clinical trials, evidence databases, and orthopedic guidelines regarding bone mineral density and weight management:</p>
  
  <div class="trials-grid">
    <a href="https://pubmed.ncbi.nlm.nih.gov/" target="_blank" rel="noopener" class="trial-link-item">PubMed Bone Health Trials</a>
    <a href="https://clinicaltrials.gov/" target="_blank" rel="noopener" class="trial-link-item">ClinicalTrials.gov Registry</a>
    <a href="https://www.orthoinfo.org/" target="_blank" rel="noopener" class="trial-link-item">Orthopaedic Information Resources</a>
    <a href="https://www.aaos.org/" target="_blank" rel="noopener" class="trial-link-item">AAOS Clinical Practice Guidelines</a>
  </div>
</div>
<!-- END: CLS-Optimized Clinical Trials Component -->

Video Overview Container (CLS-Optimized Code)

HTML

<!-- START: CLS-Optimized Video Container -->
<style>
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    width: 100%;
    max-width: 680px;
    margin: 20px auto;
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    overflow: hidden;
    contain: layout style;
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    top: 0;
    left: 0;
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    height: 100%;
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<div class="video-container-wrapper">
  <iframe 
    src="https://www.youtube-nocookie.com/embed/dQw4w9WgXcQ" 
    title="Weighted Vests and Bone Health Presentation"
    loading="lazy"
    allow="accelerometer; autoplay; clipboard-write; encrypted-media; gyroscope; picture-in-picture" 
    allowfullscreen>
  </iframe>
</div>
<!-- END: CLS-Optimized Video Container -->

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ORTHOPEDICS

Acupuncture may improve pain, reduce opioid use after THA

by Team SunilMadhavs World
written by Team SunilMadhavs World

Efficacy of Intraoperative Acupuncture in Reducing Early Postoperative Opioid Consumption and Pain Following Total Hip Arthroplasty: A Randomized Clinical Trial

Importance

The integration of Enhanced Recovery After Surgery (ERAS) protocols has revolutionized the manaย  ย gement of patients undergoing total hip arthroplasty (THA), emphasizing early mobilization, reduced length of hospital stay, and the mitigation of postoperative complications. A central pillar of ERAS is multimodal analgesia designed to minimize reliance on systemic opioids, which are associated with adverse effects such as nausea, ileus, respiratory depression, and the potential for long-term dependency. Intraoperative auricular acupuncture presents a promising, non-pharmacologic adjunct to regional and systemic analgesia, yet large-scale, rigorous, triple-blinded clinical trials evaluating its efficacy within modern ERAS pathways remain scarce.ย 

Objective

To determine whether the administration of intraoperative acupuncture, as an adjunct to a standardized ERAS protocol, significantly reduces postoperative pain scores and oral morphine equivalent (OME) consumption in the immediate and short-term recovery periods following primary THA.

Design, Setting, and Participants

This triple-blind, randomized controlled clinical trial was conducted at the Hospital for Special Surgery. The findings were presented at the American Academy of Medical Acupuncture (AAMA) Annual Symposium in Denver, where the study was awarded first place in the annual research paper competition. The investigation enrolled 484 adult patients scheduled for primary total hip arthroplasty. Furthermore, a highly detailed subset analysis was performed on 185 patients who underwent the surgical procedure between January 2024 and March 2025 to evaluate secondary metrics including total length of hospital stay and absolute opioid avoidance.

Interventions

Participants were randomly assigned in a 1:1 ratio to receive either intraoperative auricular acupuncture in addition to the standard of care ERAS protocol or the standard of care alone without acupuncture. The auricular approach targets specific microsystem acupoints on the external ear, theorized to modulate central pain pathways via cranial and cervical nerve afferents.

Stephanie I. Cheng, MD, DABMA, FAAMA, explicitly highlighted the anatomical and clinical advantages of this specific intervention:

โ€œThis is something that is very, very safe. The safety profile is good. It is performed on the ear, it is away from the surgical site and you are not dealing with infection. Anything that can help us decrease opioid usage, increase patient satisfaction and decrease their length of stay is something that we should try.โ€

Main Outcomes and Measures

The primary clinical endpoints were postoperative pain intensity, measured utilizing standardized numerical rating scales (NRS), and cumulative opioid consumption, calculated in oral morphine equivalents (OME). Secondary outcomes assessed included the 77 hospital length of stay and the proportion of patients capable of entirely avoiding opioid medications during their inpatient recovery. Data were captured on postoperative day (POD) 0, POD 1, and at a 30-day follow-up.

Table 1. Trial Design and Cohort Allocation

Study Parameter Value / Description
Total Enrolled Cohort (N) 484 patients
Acupuncture Intervention Arm n = 242
Standard of Care Control Arm n = 242
Subset Analysis Cohort n = 185 (Procedures from Jan 2024 โ€“ Mar 2025)
Study Design Triple-blind, Randomized Controlled Trial

Results

The integration of intraoperative acupuncture yielded immediate and clinically significant postoperative benefits. Patients randomized to the acupuncture arm demonstrated a statistically significant reduction in both numerical pain scores and total opioid consumption on postoperative day 0 and postoperative day 1 when compared to the standard of care cohort. While these acute benefits were pronounced, longitudinal follow-up indicated that trends toward decreased opioid utilization at postoperative day 30 did not achieve statistical significance between the two groups.

The subset analysis of 185 patients provided deeper insights into the trajectory of inpatient recovery. Within this group, the acupuncture cohort experienced consistently lower pain scores and a significantly reduced length of hospital stay. Most notably, the intervention drastically increased the likelihood of a completely opioid-free hospital admission.

Table 2. Clinical Outcomes in the Subset Cohort (n = 185)

Clinical MetricIntraoperative AcupunctureStandard of Care (Control)Clinical Impact
Inpatient Opioid Avoidance14% of patients4% of patients3.5-fold increase in zero-opioid recoveries
Early Pain Scores (POD 0 & 1)Significantly LowerBaselineImproved immediate comfort
Length of Hospital StaySignificantly ShorterBaselineAccelerated discharge readiness

Conclusions and Relevance

Intraoperative auricular acupuncture is a safe, highly tolerable, and efficacious non-pharmacologic adjunct that significantly enhances the early postoperative pain profile for patients undergoing total hip arthroplasty. By effectively suppressing acute postoperative pain, the intervention drastically curbs early opioid demand and facilitates the achievement of rigorous ERAS milestones, including same-day or next-day discharge.

Addressing the systemic and economic implications of these findings, Dr. Cheng stated:

โ€œAcupuncture allows patients to get up and moving, and get out of the hospital within that 23-hour period instead of having a multiple day hospital stay that may not get paid by insurance. The helps hospitals, doctors and the patients not incur those costs of staying an extra couple of days because their pain is not controlled.โ€

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ORTHOPEDICSPHARMACOLOGY

Denosumab does not raise atypical femur fracture risk

by Team SunilMadhavs World
written by Team SunilMadhavs World

Interactive Data Explorer: Denosumab vs. Bisphosphonates

Osteoporosis Therapy Safety Comparison
Denosumab vs. Bisphosphonates (U.K. Population Study)
Bisphosphonates (1st Line) 161,839 Patients
Denosumab (Prolia) 2,310 Patients
Clinical Context: Denosumab is frequently utilized as a second-line therapy for patients who fail or are intolerant to bisphosphonates. Adjusting for this prior exposure is critical for accurate risk assessment.
0.82
Bisphosphonates
0.89
Denosumab
Subtrochanteric & Diaphyseal Femur Fractures
(Incidence per 1,000 person-years)
0.94
Adjusted Hazard Ratio
95% Confidence Interval: 0.62 – 1.43
1.0 (No Difference)
0.62
1.43
Not Statistically Significant: Because the confidence interval crosses 1.0, there is no evidence of an increased risk of atypical femur fractures associated with Denosumab compared to Bisphosphonates.
@sunilmadhavs.world

Denosumab Does Not Elevate Atypical Femur Fracture Risk Relative to Bisphosphonates in Real-World Study

The long-term administration of bisphosphonatesโ€”a widely utilized first-line pharmacological therapy for osteoporosis managementโ€”has been definitively correlated with a rare but profoundly morbid complication: atypical femur fractures (AFF). These subtrochanteric and diaphyseal fractures are characterized by significantly delayed union and considerable patient morbidity. Haolan Qi, MD, MSc, an epidemiology master’s student at McGill University, elaborated on the clinical response to this adverse event during a presentation at the American Association of Clinical Endocrinology Annual Scientific and Clinical Conference in Las Vegas:

โ€œTo mitigate this risk, a drug holiday was introduced for bisphosphonate treatment. Denosumab is another potent antiresorptive agent, but unlike bisphosphonates, denosumab is not retained in the bone matrix and does not exert residual activity after discontinuation. Its effects are highly reversible, and treatment cessation leads to a rebound phenomenon, where bone density rapidly drops and vertebral fracture risk spikes. Therefore, denosumab is technically administered without a drug holiday. Since it is also antiresorptive, there are concerns that it might also increase atypical femur fracture risk.โ€

To address this crucial safety concern, investigators conducted a large-scale, population-based active comparator study utilizing the U.K. Clinical Practice Research Datalink linked to Hospital Episode Statistics.

ย 

Study Design and Participant Demographics

The retrospective cohort study evaluated 272,834 adults diagnosed with osteoporosis. Participants with a documented history of atypical femur fractures or high-trauma fractures were rigorously excluded from the analysis. The cohort was predominantly female (81.5%) with a mean age of 73.7 years.

Participants were categorized into four distinct exposure groups: denosumab, bisphosphonates, alternative active therapies, and a supplement-only control group. The researchers employed multivariable models to adjust for critical covariates, including age, sex, race, body mass index (BMI), clinical comorbidity status, prior history of fracture, and historical bisphosphonate utilization (>5 years prior).

Table 1: Osteoporosis Treatment Exposure Cohorts

Treatment Group Number of Patients (N) Percentage of Total Cohort
Bisphosphonates (First-line) 161,839 59.3%
Calcium/Vitamin D Supplements Only 108,408 39.7%
Denosumab (Prolia, Amgen) 2,310 0.8%
Other Osteoporosis Therapies* 277 0.1%
Total Analyzed Cohort 272,834 100%

*Includes calcitonin, teriparatide, abaloparatide, and romosozumab.

Regarding baseline differences between the primary comparison groups, Dr. Qi noted, โ€œCompared to bisphosphonate users, denosumab users were generally older and had a higher prevalence of renal insufficiency and flare fractures. We accounted for these differences in our adjusted models.โ€

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Methodological Approach to Fracture Identification

The primary clinical outcome was the incidence of subtrochanteric and diaphyseal femur fractures. Because this was an analysis of administrative data, identifying true AFF events required a methodological proxy.

โ€œTo diagnose atypical femur fractures, according to the gold standard established by the American Society of Bone and Mineral Research, a blind review of X-ray images with radiographic features such as transverse fracture line, cortical thickening, etc, is required,โ€ Qi explained. โ€œTo extract and review individual X-ray images is not feasible within an administrative dataset. So, we used ICD-10 codes for subtrochanteric and diaphyseal femur fractures as proxies for atypical femur fractures.โ€

Clinical Outcomes and Risk Assessment

Over a mean follow-up duration of 4.3 years, the study recorded a total of 662 subtrochanteric and diaphyseal femur fracture events across the entire cohort, yielding an overall incidence rate of 0.8 per 1,000 person-years.

When comparing the two primary antiresorptive therapies, the incidence rates were remarkably similar, and the adjusted hazard ratio indicated no statistically significant difference in fracture risk.

Table 2: Incidence and Relative Risk of Subtrochanteric/Diaphyseal Femur Fractures

Outcome Metric Denosumab Users Bisphosphonate Users
Total Fracture Events 24 397
Incidence Rate (per 1,000 person-years) 0.89 0.82
Adjusted Hazard Ratio (HR) 0.94 (Reference Group)
95% Confidence Interval (CI) 0.62 – 1.43 N/A

The researchers emphasized that these findings remained consistent and did not vary significantly when stratified by patient age, sex, concomitant history of glucocorticoid use, or the total duration of the osteoporosis therapy.

The Impact of Sequential Therapy

A critical nuance in analyzing real-world pharmacological data in osteoporosis is the sequential nature of treatment. Dr. Qi highlighted the substantial crossover effect observed during the study period: at baseline, only 17% of denosumab users had prior exposure to bisphosphonates; however, by the 5-year mark, this figure had surged to 75%.

โ€œThis reflects the real-world sequence of osteoporotic management,โ€ stated Dr. Qi. โ€œDenosumab is often prescribed as a second-line therapy. Many patients who fail or who are intolerant of bisphosphonates transition to denosumab. Therefore, adjusting for prior bisphosphonate use was very crucial to estimate the true effect of denosumab.โ€

To validate their primary findings against this confounding factor, the research team conducted a rigorous sensitivity analysis that explicitly excluded patients with prior bisphosphonate utilization. This secondary analysis confirmed the primary results: prolonged denosumab therapy did not independently elevate the risk of atypical femoral fractures when compared to bisphosphonate therapy.

Conclusion

The findings from this large administrative dataset provide substantial reassurance regarding the long-term safety profile of denosumab.

โ€œWe found a reassuring safety profile, with no evidence of an increased risk associated with denosumab use in a real-world setting,โ€ Qi concluded. โ€œClinically, these results should be reassuring and support the use of denosumab as a vital therapy option for osteoporosis, with a risk profile similar to the standard of care.โ€

ย 

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ORTHOPEDICSTRIALS

Standardized protocol for PJI may lead to better outcomes

by Team SunilMadhavs World
written by Team SunilMadhavs World

 

A recent study presented at the Musculoskeletal Infection Society Annual Meeting (Aug. 1โ€“2, 2025, Jersey City, N.J.) highlighted the benefits of implementing a standardized protocol for managing periprosthetic joint infections (PJI) following total joint arthroplasty. Researchers found that using a structured approach to debridement, antibiotics, and implant retention (DAIR) resulted in significantly improved patient outcomes compared with non-standardized methods.

Study Overview

Alberto Carli, MD, a hip and knee replacement surgeon at the Hospital for Special Surgery, and colleagues conducted a retrospective review of patients who underwent DAIR procedures for PJI between October 2018 and January 2025. The study analyzed two patient cohorts:

  • Standardized DAIR group (n = 75): Procedures followed a defined protocol incorporating two antiseptic solutions โ€” 10% povidone-iodine and Bactisure (Zimmer Biomet).
  • Non-standardized DAIR group (n = 75): Procedures performed without a unified protocol, where the choice of antiseptic or steps varied by surgeon preference.

To ensure comparability, patients in both groups were matched by American Society of Anesthesiologists (ASA) scores, chronicity of infection, and whether their surgeries occurred within two years of each other.

Outcomes Measured

The researchers defined primary outcomes as the proportion of patients who avoided any subsequent surgery related to infection within two years of their DAIR procedure.
Secondary outcomes included:

  • Length of hospital stay, measured in admission days.
  • Rate of wound-related complications, broadly defined as wound dehiscence, requirement of postoperative antibiotics, or reoperation due to wound problems.

Results

Carli reported that patients treated under the standardized protocol had superior outcomes:

  • 85% of patients did not require additional infection-related surgery at two years post-procedure.
  • In contrast, only 65% of patients in the non-standardized group avoided further surgery.

This difference translated into a significantly higher implant survivorship rate for patients in the standardized DAIR group. The results suggest that the consistent use of antiseptic solutions and a structured, repeatable process can have a meaningful impact on long-term surgical outcomes.

Clinical Implications

Carli emphasized that the findings are less about proving the superiority of one antiseptic solution over another and more about demonstrating the value of systematic standardization. He noted that institutions without a formalized DAIR approach could achieve better patient outcomes by adopting standardized protocols and then tracking outcomes to evaluate effectiveness.

According to Carli, such protocols can help hospitals and surgical teams:

  • Deliver more efficient and cost-effective care, by reducing the need for repeat procedures.
  • Improve patient safety and satisfaction, through better implant survival and fewer complications.
  • Establish benchmarks that allow for continuous quality improvement in the treatment of periprosthetic joint infections.

Expert Recommendation

Dr. Carli concluded that orthopedic surgeons and institutions should actively implement standardized DAIR pathways. By formalizing these processes, healthcare providers may not only improve infection management but also optimize resource utilization and ultimately enhance the quality of patient care.

Source: Sculco P, et al. Paper 1507. Presented at: Musculoskeletal Infection Society Annual Meeting; Aug. 1โ€“2, 2025; Jersey City, N.J.
Disclosure: Dr. Alberto Carli reports consulting for Zimmer Biomet.

For further information, Dr. Carli can be reached via Robin Frank at frankr@hss.edu.

 

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