Bone 46 (2010) 14361441

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Bone
j o u r n a l h o m e p a g e : w w w. e l s e v i e r. c o m / l o c a t e / b o n e

Strontium ranelate improves implant osseointegration

Laurent Mamoun, Tara C. Brennan, Isabelle Badoud, Victor Dubois-Ferriere, Ren Rizzoli, Patrick Ammann
Division of Bone Diseases [WHO Collaborating Center for Osteoporosis Prevention], Department of Rehabilitation and Geriatrics and Faculty of Medicine, University Hospital of Geneva, CH-1211 Geneva 14, Switzerland

a r t i c l e

i n f o

a b s t r a c t
Introduction: Endosseous implantation is a frequent procedure in orthopaedics and dentistry, particularly in the aging population. The incidence of implant failure, however, is high in situations where the bone at the site of implantation is not of optimal quality and quantity. Alterations of bone turnover and changes in intrinsic bone tissue quality have potentially negative effects on optimal osseointegration. Strontium ranelate, which acts on both resorption and formation, and improves biomaterial properties, is hypothesized to improve osseointegration and this hypothesis was tested here. Materials and methods: Titanium implants were inserted into the proximal tibias of thirty 6-month-old SpragueDawley female rats. During the 8 weeks following implantation, animals received orally strontium ranelate (SrRan) 5 days a week (625 mg/kg/day) or saline vehicle. Pull-out strength, CT and nanoindentation were assessed on the implanted tibias. Results: SrRan signicantly increased pull-out strength compared to controls (+ 34%). This was associated with a signicant improvement of bone microarchitecture around the implant (BV/TV + 36%; Tb.Th + 13%; Conn.D + 23%) with a more plate-shape structure and an increase in bone-to-implant contact (+ 19%). Finally, strontium ranelate had a signicant benecial effect on parameters of bone biomaterial properties at both cortical (modulus + 11.6%; hardness + 13%) and trabecular areas (modulus + 7%; hardness + 16.5%). Conclusions: SrRan is an antiosteoporotic agent that increased mechanical xation of the implant. The improvement of pull-out strength was associated with an improvement of implant osseointegration with both a positive effect on bone microarchitecture and on bone biomaterial properties in the vicinity of the implant. These current results may support potential benets of strontium ranelate in orthopaedic and dental surgery to enhance osseointegration. 2010 Elsevier Inc. All rights reserved.

Article history: Received 10 November 2009 Revised 21 January 2010 Accepted 21 January 2010 Available online 29 January 2010 Edited by: R. Baron Keywords: Rodent Implants Osseointegration Strontium ranelate

Introduction Endosseous implantation is a common procedure in orthopaedics and periodontics. In addition, due to an ever expanding aging population, there is also an increasing need for total joint replacements. Successful implant osseointegration and its clinical longevity depends upon the way mechanical stresses are transferred to the surrounding bone or tissue which are themselves inuenced by the type of load that occurs, the boneimplant interface (direct contact or a gap interface), the characteristics of the implant (dimensions, shape, surface texture), and quality and quantity of the surrounding bone (osteoporosis).

This study was supported by a grant from Servier. Corresponding author. Service of Bone Diseases, Department of Rehabilitation and Geriatrics, University Hospital, CH-1211 Geneva 14, Switzerland. Fax: + 41 22 382 99 73. E-mail addresses: laurent.maimoun@laposte.net (L. Mamoun), Tara.Brennan@unige.ch (T.C. Brennan), Isabelle.Badoud@unige.ch (I. Badoud), victor.Dubois-Ferriere@unige.ch (V. Dubois-Ferriere), Rene.Rizzoli@unige.ch (R. Rizzoli), Patrick.Ammann@unige.ch, patrick.ammann@medecine.unige.ch (P. Ammann). 8756-3282/$ see front matter 2010 Elsevier Inc. All rights reserved. doi:10.1016/j.bone.2010.01.379

The process of implant osseointegration begins with a phase of bone resorption around the implant, with bleeding and inammation, and is followed by a phase of bone formation. The major problem with these procedures is the possibility of implant failure. Aseptic loosening, caused by periprosthetic osteolysis, is the most common cause of implant failure [1,2]. Osteolysis in patients with failed orthopaedic prostheses is commonly due to multiple factors, including biological and physical components. Implant-derived wear particles are often generated and cause increased bone resorption around the implant [3,4]. In particular, local inammatory mediators such as cytokines (IL-1, IL-6, TNF-) are produced by macrophages following phagocytosis, leading to the recruitment and the activation of osteoclasts at the bone implant interface [5,6]. Stress shielding is also considered as a potent stimulator of bone resorption [7]. Finally, both alteration of bone turnover and intrinsic bone tissue quality in pathologies like osteoporosis could potentially preclude an optimal osseointegration [8,9]. The signs and symptoms of implant failure are often not clinically apparent until the late stages of failure and therefore the development of pharmacological strategies which minimize the severity and

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progression of periprosthetic bone loss and, as such, improve the durability of implants is essential. The time necessary to obtain successful osseointegration is also essentially important for the clinical evolution and outcome of such procedures and the investigation of stimulators of this process of initial implant xation would be of signicant clinical relevance. There is a potential for the use of pharmaceutical agents to enhance periprosthetic bone quality, thus preventing early implant failure [1013]. One therapeutic approach involves the use of bisphosphonates which inhibit osteoclast function and induce osteoclastic apoptosis. Using an experimental rat model developed in our group, we recently demonstrated that one bisphosphonate, pamidronate improves the mechanical xation of titanium implants in rats fed both normal protein or isocaloric low-protein diets [14]. Clinical studies also reported that bisphosphonates prevented periprosthetic bone loss following total hip arthroplasty [15,16]. Bone ingrowth into the etched surface of the implant is an important determinant of the strength of implantation as demonstrated by the improvement of osseointegration using sand-blasted, large grit, acid-etched (SLA) implants [17] capable of stimulating this process. Stimulators of bone formation, such as PTH, have also shown potential benecial effects [14,18]. In untreated control animals, the strength of implantation also appears to be directly proportional to the percentage of bone in the vicinity of the implant [19], yet this relationship was not found in those rats treated with PTH or pamidronate [14,18]. However, linear regression analysis indicates that there is a strong relationship between implantation strength and structure model index (SMI) [18], where decreased SMI values indicate a more plate-like trabecular network and are associated with increased force necessary to loosen the implant [18]. This suggests that treatments modify different parameters which improve the quality of osseointegration. Another antiosteoporotic treatment, strontium ranelate (SrRan), is also of considerable interest in investigations looking to improve implant osseointegration. The benecial effects of SrRan have previously been reported in various animal models, where it has been shown to prevent bone loss by maintaining bone formation at a high level and inhibiting bone resorption [2024]. These in vivo results were consistent with in vitro data where SrRan has been shown to reduce bone resorption by osteoclasts and to increase bone formation by osteoblasts [2527]. Furthermore, we demonstrated that SrRan is able to improve biomechanical and structural properties of the bone [28]. All these data strongly suggest that strontium ranelate would have the potential to improve peri-implant bone structure. Furthermore, treatment with strontium ranelate is not associated with osteonecrosis of the jaw (ONJ). This represents a distinct advantage compared to biphosphonates as, despite the poor evidence, many dentists or oral surgeons are reluctant to administer bisphosphonates due to the possibility of ONJ development. Moreover, a potential link between the use of biphosphonates and low energy fractures of the femur has been recently shown [29]. As a consequence, there is a justied call for alternatives to bisphosphonates regarding the improvement of osseointegration in implant patients with a compromised nutritional status. The aim of this study was to evaluate whether the administration of strontium ranelate could improve osseointegration of titanium implants in rats after 8 weeks of treatment. In addition, the mechanisms by which strontium ranelate affects the process of osseointegration were also evaluated. Specically, the individual parameters which affect this process, including changes in microarchitecture and bone biomaterial properties were assessed. The results indicate that strontium ranelate improves osseointegration, with a signicant increase in the pull-out strength necessary to completely loosen the implant associated with an improvement of bone microarchitecture around the implant. In addition, strontium ranelate was particularly able to improve the biomaterial properties of the surrounding trabecular and cortical bone as analyzed by nanoindentation.

Materials and methods Animals and diet All experimental designs and procedures have received approval of the Animal Ethics Committee of the Geneva University Faculty of Medicine. Thirty 6-month-old SpragueDawley female rats (Charles River Laboratories, L'Arbresle, France), were acclimatized to the study conditions for a period of 14 days before the implantation. The animals were housed individually at 25 C. They were strictly pairfed a laboratory diet provided by Provimi Kliba AG (Kaiseraugst, Switzerland) containing 15% casein, 0.8% phosphorus, 1% calcium, 70 80% carbohydrates, and 5% fat throughout the experimental period. Demineralized water was available ad libitum. For a period of 8 weeks following implantation, one group of 15 rats was treated with strontium ranelate by gavage at a dose 625 mg/kg, 5 days/week. This dose leads to a blood strontium concentration close to the human exposure after a therapeutic dose of 2 g/day [30]. The control group (n = 15) received 0.5% carboxymethylcellulose aqueous solution by gavage 5 days a week with volumes corresponding to those administered in the strontium ranelate-treated group. Implants design and preparation Pure titanium implants with dimensions of 1.0 mm diameter and 4.1 mm length, with a threaded end of 1.25 mm (type M1), were sandblasted and acid-etched on the non-threaded section (Institut Straumann AG, Waldenburg, Switzerland). The threaded section remained outside of the bone, allowing for prehension during the pull-out test. We selected this type of implant as titanium is well tolerated by bone tissue. The rough surface produced by sandblasting and acid-etching ensures good osseointegration. The implants were cleaned in phosphate-free Deconex (Borer Chemie AG, Zuchwil, Switzerland), rinsed in pure water in an ultrasonic bath, and sterilized with ethylene oxide. Implantation technique Animals were anesthetized by abdominal injection of ketamine (100 mg/kg) and xylazine (10 mg/kg). The skin of the bilateral tibial region was shaved and cleaned with 70% ethanol. Under aseptic conditions, an anterior approach with a 10-mm incision was made to gain access to the proximal medial aspect of the tibia metaphysis. The periosteum was reected medially. A 1-mm diameter hole was drilled through one of the cortices using a hand-held drill, and the implant was inserted. Rotary speed did not exceed 2000 rpm, and drilling was accompanied by profuse saline irrigation to avoid thermal bone necrosis. The proximal limit of the entry point was delimited by a virtual line perpendicular to the long axis of the tibia and crossing the anterior edge of the growth plate centrally, which is curved in this central region anteriorly and inferiorly. A second anatomical landmark was a virtual line going from the inferior border of the tendinous insertion on the proximal anterior tibial crest to a medial tendinous insertion probably corresponding to the pes anserinus in humans; the point of implantation was mid-way between these two tendinous insertions. With such landmarks X-ray examination demonstrated the implant to be in contact with trabecular bone of the proximal tibial metaphysis [19], at a distance of 2 mm from the growth plate proximally along the great axis of the tibia. The implant was inserted strictly perpendicularly to the surface of the cortical bone on the medial part of the proximal tibia. The depth of the inserted part of the implant into the bone corresponded to the length of the non-threaded part of the implant (2.85 mm). Only the threaded part remained outside the bone. The implants were specically designed, taking into account the X-ray determined dimensions of the proximal tibia in adult female SpragueDawley rats. After insertion of the implant, the skin was sutured using a 30 resorbable polyglatic suture (Vycril;

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Ethicon, Spreintenbach, Switzerland). Postoperative analgesia was ensured by subcutaneous injection of buprenorphine (0.06 mg/kg) twice a day for 3 days. CT analysis The tibias were excised immediately after death and individually wrapped in saline soaked gauze and frozen at 20 C in plastic bags. The night before -CT analysis, the bones were thawed slowly at 7 and maintained at room temperature. During the whole analysis, bones were immersed in saline solution. Parameters of mass, architecture and percentage of implant surface in direct contact with trabecular bone (percentage of attachment, bone-to-implant contact) were studied by CT morphometry using a high-resolution CT system (CT 40; Scanco Medical AG, Bruettisellen, Switzerland). The voxel size was 20 m in all spatial directions. For penetrating radio-opaque titanium and improving signal-to-noise ratio, the system was set to 70 kEV and 350-ms integration time. The number of tomographic projections was 1000 projections per 360. Images were ltered with a 3-D Gauss lter with sigma 1.5 voxels, and then segmented with threshold 1.4 cm 1 for bone (25% of maximal gray scale, visually chosen), and threshold 5.8 cm 1 for titanium (attenuation coefcient). Trabecular bone was analysed on a circular band of 0.5 mm around the implant. Relative bone volume (BV/TV), trabecular number (Tb.N), trabecular thickness (Tb.Th), and trabecular separation (Tb.Sp) were calculated by measuring directly the 3-D distances in the trabecular network. Connectivity density based on Euler number (Conn.D) and the structure model index (SMI) were calculated. When a bone voxel was in the vicinity (60-m boundary) of a titanium voxel, this titanium voxel was classied as attached surface. With a distance of 3 voxels (=60 m) from the detected titanium surface, the presence or absence of bone can be accurately determined (IPL, image processing language software, available in the CT 40; Scanco Medical AG, Bassersdorf, Switzerland). The artefacts of the titanium in the CT image prevented us from analyzing bone presence at any shorter distances from the implant [14]. The number of attached surface voxels divided by the total number of titanium surface voxels yielded the percentage bone-to-implant contact. The three-dimensional reconstructions obtained were always veried against the original grey scale images. Pull-out test Following CT analysis, one tibia of each rat was subjected to a pull-out test. The tibiae were xed with a metal device specically designed for this purpose, with two at supports set at a distance of 5.6 mm from each other on which the medial zone of the proximal tibae were laid, and another metal piece was screwed onto the threaded part of the implant. The pull-out strength was determined as the peak force applied to fully loosen the implant from the bone as measured with a servo-controlled electromechanical system (Instron 5566; Instron Corp., High Wycombe, UK) with the actuator displaced at 2 mm/min. Reproducibility was 9.4%, as evaluated as the CV of paired sample measurements (left/right). A preliminary study showed that the freezing procedure did not alter pull-out strength values. Regression between values obtained before or after freezing procedure was characterized by an r2 coefcient of 0.96. Nanoindentation test Nanoindentation tests evaluated the biomaterial properties of bone tissue. In this test, forcedisplacement data of a pyramidal diamond indenter that was pressed into the bone material were recorded. Measurements were performed with a nano-hardness tester (NHT, CSM Instruments, Peseux Switzerland). This technique has been described in detail elsewhere [28,31]. The tibia which was not sub-

jected to the pull-out test was used for nanoindentation and histology. The tibia was cut transversally using a diamond wire saw (Well Mod 3242-3, Well Diamond Wire Saws SA, Le Locle, Suisse) close to the level of the implant (3 mm from the implant). Samples were then washed in 2% detergent to remove any soft tissue. Tibias were then embedded in

Fig. 1. Pull-out strength. (A) CT image of a titanium implant inserted in the medial part of the rat proximal tibia metaphysis image includes a schematic depiction of pull-out apparatus positioning. (B) Pull-out apparatus. (C) Effects of strontium ranelate (625 mg/kg 5/7 days) or vehicle control on pull-out strength (N) of titanium implant inserted in the proximal tibia. Values are means SEM. *p < 0.05 compared to control.

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PMMA (8.00590.2500 Merk) and the blocks were cut into two pieces transversally through the middle of the implant using the diamond wire saw. The face of one half of the transverse cuts was polished and nished with a 0.25-m diamond solution. Following this, the specimens were kept at 4 C. Specimens were slowly thawed at 7 C overnight and then warmed to room temperature prior to nanomechanical testing. The tests included 5 indents on the trabecular bone situated around the implant and 5 indents on the trabecular bone situated at 200 m from the implant. Cortical bone next to the implant was also tested, with 5 indents performed on the cortical bone next to the implant. For a schematic of the implanted zones, see Fig. 2. Specimens were kept in a saline solution before and after the testing. Indents were set to a 900 nm depth with an approximate strain rate of = 0.066 1/s for both loading and unloading. At maximal load, a 5-s holding period was applied. The limit of the maximum allowable thermal drift was set to 0.1 nm/s. Statistical analysis All results are expressed as means SEM. For continuous variables, the distribution of variables was tested with the ShapiroWilk statistic and was found normal. Signicance of difference between the 2 groups was evaluated with a Student t-test. Results Effect of strontium ranelate on pull-out strength Strontium ranelate induced signicantly higher pull-out strength values (+33.9%, p < 0.05) compared to control (Fig. 1C). Effect of strontium ranelate on trabecular bone microarchitecture surrounding the implant and bone-to-implant contact Trabecular bone microarchitecture around the titanium implant and the bone-to-implant contact were signicantly improved in groups treated with strontium ranelate compared to control group (Table 1 and Fig. 3). BV/TV was increased by 36% (p < 0.05), Tb.Th by + 13.0% (p < 0.05) and the bone-to-implant contact (BIC) was increased by + 19.2% (p < 0.05). We also observed a change in the trabecular structure, as demonstrated by the negative values of SMI in animals treated with strontium ranelate ( 166%, p < 0.05), indicating a more plateshaped structure. Finally, connectivity density was signicantly increased compared to controls in the strontium-treated group (+23%,
Fig. 2. Location of nanoindents in reference to the implants. (A) Typical implant insertion into the rat proximal tibia. (B) A schematic plan of the location of the indentation of the diamond indenter tip with reference to the implant, the cortical and the trabecular bone. Closed white triangles represent indents performed in the cortical zone, open white triangles represent indents performed in the trabecular zone, and dashed white lines depict the distance of 200 m from the implant surface.

p < 0.05). Tb.N and Tb.Sp surrounding the implant were unaffected by the treatment. Bone biomaterial properties Trabecular zone In the trabecular area next to the implant, tissue hardness was increased by strontium ranelate compared to control (+ 10.2%, p < 0.05, Table 2), but no other biomaterial properties were altered. We investigated these same biomaterial properties at the trabecular zone at a distance of 200 m from the implant and found that all of the parameters were signicantly increased by strontium ranelate. Specically, elastic modulus (+7.2%, p < 0.05), tissue hardness (+16.5%, p < 0.001) and working energy (+9.4%, p < 0.01) were all signicantly increased by strontium ranelate when compared to control (Table 2). Cortical zone Nanoindentation was also performed at the level of the cortical bone situated next to the implant. Strontium ranelate increased elastic modulus (+11.6%, p < 0.05), tissue hardness (+ 13.2%, p < 0.001) and working energy (+9.6%, p < 0.01) compared to control (Table 2).

Table 1 Effects of strontium ranelate (625 mg/kg 5/7 days) or vehicle control on bone microarchitecture and on bone-to-implant contact around the titanium implant. Control BV/TV (%) Tb.N (1/mm) Tb.Th (mm) Tb.Sp (mm) SMI Conn.D. % Bone-to-implant contact 34.3 3.0 6.245 0.930 0.123 0.004 0.200 0.016 0.859 0.274 54.30 4.36 66.2 3.3 SrRan 625 46.7 3.2 5.878 0.217 0.139 0.004 0.178 0.010 0.571 0.457 66.83 3.43 78.9 3.2

Results are bone volume to total volume (BV/TV), trabecular number (Tb.N), trabecular thickness (Tb.Th), trabecular separation (Tb.Sp), structure model index (SMI) and connectivity density based on Euler number (Conn.D.). SMI is an estimate of the rod characteristics of trabecular bone (0 value = purely plate-shaped bone, 3 value =purely rod-like bone, negative value indicates a solid mass with only a few holes in it). When a bone voxel was in the vicinity (60 m boundary) of a titanium voxel, this titanium voxel was classied as attached surface and the number of attached surface voxels divided by the total number of titanium surface voxels yielded the percentage bone-to-implant contact. Values are means SEM. p < 0.05, compared to control.

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Table 2 Effects of strontium ranelate (625 mg/kg 5/7 days) or vehicle control on trabecular and cortical intrinsic biomaterial properties surrounding the titanium implant. Area of evaluation Trabecular: next to the implant Parameters Modulus (GPa) Hardness (MPa) Working energy (mN nm) Modulus (GPa) Hardness (MPa) Working energy (mN nm) Modulus (GPa) Hardness (MPa) Working energy (mN nm) Control 14.60 0.30 576.40 14.23 4969.76 104.37 14.53 0.27 606.75 17.56 5008.16 88.13 13.40 0.28 438.10 11.95 3912.69 97.56 Strontium ranelate 14.26 0.35 634.93 19.62 4835.23 109.73 15.57 0.34 706.72 21.27 5479.64 118.97 14.96 0.31 495.75 14.49 4287.12 107.28

Trabecular: 200 m distance from implant

Cortical: next to the implant

Values are means SEM. p < 0.05 vs. control group. p < 0.01 vs. control group. p < 0.001 vs. control group.

Discussion The present study demonstrates that strontium ranelate is able to improve the osseointegration of titanium implants at a dose leading to a blood strontium concentration close to the human exposure after a therapeutic dose of 2 g/day. This was illustrated by the increased force necessary to completely loosen the implant (pull-out strength) in treated animals. These observed increases in pull-out values were seen alongside an improvement of trabecular bone microarchitecture, bone-to-implant contact and an augmentation of biomaterial properties of bone tissue around the implant. The evaluation of pull-out strength allows for the assessment of functional implant osseointegration into the surrounding bone and is dependent on several factors including bone mass or volume, threedimensional bone distribution around the implant [19], ingrowth into the etched surface of the implant and the quality of bone tissue in the vicinity of the implant. Here we demonstrate, for the rst time, that treatment with strontium ranelate, which has proven its efcacy in reducing the risk of vertebral, non-vertebral and hip fracture in women with post-menopausal osteoporosis [3234], promotes osseointegration. In the current study, strontium ranelate increased pull-out strength and modied microstructure, increased relative bone volume and trabecular thickness, and induced more plate-like bone, as measured by SMI, than animals from the control group. Strontium ranelate also improved the connective density surrounding the implants. These data highlight the important role played by the surrounding microarchi-

Fig. 3. Micro-computed tomography (CT). Microtomographic tridimensional reconstruction of the trabecular bone around the titanium implant at 8 weeks after implantation in control (A) and strontium ranelate (B) treated animals.

tecture in the process of osseointegration, and the importance of maintaining, if not improving, this surrounding microstructure. This is the rst time that benecial effects of strontium ranelate on peri-implant bone microarchitecture have been reported, and is consistent with results obtained at other non-implanted sites such as the vertebrae and tibia in rats [20,28]. We have previously reported that strontium ranelate positively inuences biomaterial properties of bone in a rat model [28], and it is therefore plausible that this treatment is able to improve this tissue quality in the vicinity of the titanium implant. To investigate this hypothesis, biomaterial parameters (i.e. elastic modulus, hardness, and working energy) were assessed by nanoindentation as previously described [28,31]. The results demonstrate that strontium ranelate has a benecial action on bone tissue quality. Indeed, all nanoindentation parameters at the trabecular and cortical levels in animals from the strontium-treated group were improved compared to control. This positive effect of strontium ranelate might be explained by the fact that the newly formed bone structures around the implants could be inuenced by the strontium ranelate effects since extensive bone modelling and remodelling occurred in this area. The improvement of these biomaterial properties following treatment with strontium ranelate may be the result of a modication of the bone matrix, which is mainly constituted of type-1 collagen and it has previously been shown that strontium ranelate stimulates the synthesis of bone collagen in vitro [26]. Finally, the differences observed in the strontium ranelate effect depending on the studied zone around the implant (close or distant) may be linked to a difference in the maturity of the newly bone formed but this requires further investigations. In order to fully understand the mechanism of osseointegration, the bony ingrowth on the surface of the SLA implant surface needs to be taken into account. It has been demonstrated that this process plays an important role in the process of osseointegration [17]. Strontium ranelate, which was demonstrated to stimulate bone formation, may be benecial for osseointegration for this reason. It has also been reported that strontium ranelate treatment is able to stimulate preosteoblastic and osteoblastic cell replication and synthesis of collagenous matrix [26,3537] and to promote the differentiation of osteoblast precursors into mature osteoblasts [36]. This effect of strontium ranelate may induce an ingrowth of bone into the etched surface of the implants, an important factor for their integration, as well as an improvement of the microarchitecture around the implant as described above. Finally, it is known that following implantation, bone undergoes an initial phase of remodelling which is characterized by an increase in osteoclast activity [16]. Strontium ranelate is known to decrease markers of bone resorption in human studies [38], reduce osteoclastic bone resorption [25,27,36] and decrease osteoclast formation [36] as well as induce osteoclast apoptosis [39] in vitro. It is likely, therefore, that this action of strontium ranelate also contributes to the improved osseointegration seen in the present study.

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Strontium ranelate increased mechanical xation of implants when compared with controls, and improved the microarchitecture of the bone surrounding the implant. Additional effects of strontium ranelate on biomaterial properties of bone tissue, at both trabecular and cortical levels, allowed for excellent osseointegration. A longerterm follow-up investigation is necessary to further discriminate the specic effects on pull-out strength of strontium ranelate. These current results, that need to be conrmed by clinical studies, may support potential benets of strontium ranelate in orthopaedic and dental surgery. Acknowledgments We thank S. Clement for animal management and S. Vouillamoz for technical assistance. References
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