Assessing Bone Health Before Joint Replacement Surgery
—Adherence to the guidelines for osteoporosis screening in this study was poor, although the study did not demonstrate this leading to more adverse events for total joint surgery vs the national average.
The number of total hip arthroplasties (THAs) and total knee arthroplasties (TKAs) is expected to increase significantly by 2040. Because the average age of patients undergoing these procedures is between 65 and 67 years, osteoporosis is likely to be present. However, unlike other screening and preoperative testing that is done before elective arthroplasty (blood pressure, glucose, smoking history), osteoporosis is not routinely screened for. This is despite the possible complications associated with osteoporosis in arthroplasty, including altered component positioning, aseptic loosening, and periprosthetic fractures.1 There are several possible reasons for the poor compliance with osteoporosis screening. Because it is a silent disease, it is often not recognized until there is a fracture. Additionally, there are often time constraints during healthcare visits and providers may not be knowledgeable regarding the diagnosis and treatment of osteoporosis.1
Who gets screened and who does not
To look at osteoporosis screening compliance in more detail, Samuel Shepard, DO, of the Department of Orthopedic Surgery, Kettering Health Dayton, Ohio, and David J. Houserman, DO, Orthopedic Surgery Fellow, Hip, Knee, and Shoulder Arthroplasty, Minnesota Center for Orthopaedics, Cuyuna Regional Medical Center, and their colleagues, assessed how many patients who have undergone total joint surgery (TJS) (either THA or TKA, or both) had undergone the proper screening for osteoporosis with a dual X-ray absorptiometry (DXA) scan (as recommended by the United States Preventive Services Task Force and the National Osteoporosis Foundation [NOF]).
Their hypothesis was that a significant percentage of patients did have screening and that those who did not may not have been aware of the screening, or may have had other barriers to compliance.1
They did a retrospective chart review of patients, aged ≥ 65, who had undergone elective THA or TKA between 2019 and 2023. They looked at these factors:
- Age at the time of surgery (average age was 74 years)
- Sex (61.3% were female)
- Race (88% were White individuals)
- Osteoporosis status
- Eligible patients > 65 years old who had a DXA scan prior to surgery (24.1%
- Number of primary hip/knee replacements
- Occurrence of a periprosthetic femur fracture (PPFx) within 6 months to 4 years after surgery.1
Most of the adults screened for osteoporosis were female (94.6%) (P < .0001); most were White individuals (89.6%) and 7.1% were Black individuals (P < .0001).
Of the total number of patients, 9.03% had osteoporosis; 45.3% of those patients were diagnosed because of an insufficiency fracture (vertebral, pelvis, hip, distal radius); 54.7% were diagnosed by DXA.1 Of all the patients, 2.1% were diagnosed with a PPFx in the time frame mentioned above. Of these, 75.6% did not have a workup for osteoporosis before their TJS. There was no significant association between whether they had osteoporosis or had a DXA scan preoperatively and the occurrence of PPFxs (P > .253).1
Integrating bone health into preoperative care and future research
In an interview with MedPageToday, Dr Houserman discussed the clinical implications of their study and future research that needs to be done. He said, “Advancing patient outcomes in orthopedic surgery demands a deeper focus on the foundational role of bone health in joint replacement success. The concept that strong, healthy bones are essential for optimal outcomes is still emerging. Rigorous research is needed to explore how pharmacotherapy can reduce the risk of complications, such as periprosthetic fractures, and reshape the future of joint replacement care.”
The authors also stated that they agreed with prior researchers who recommended, that “If patients have not had DXA testing in the past 2 years, [the NOF criteria should be applied] to determine if such evaluation is indicated.” Additionally, they recommended that patients with osteopenia or osteoporosis be referred “…to a bone health/fracture liaison service, primary-care provider, or further evaluation by the orthopedic clinic. In patients with a confirmed diagnosis of osteoporosis, preoperative medical therapy should be considered for 3-6 months if elective surgery can be delayed.”1,2
Study limitations
The investigators mentioned the following limitations to their study1):
- As it is retrospective, causality between osteoporosis screening and PPFxs cannot be shown.
- There may be data missing from the electronic health record.
- As the study population was comprised of 88% White individuals, the outcomes may not be generalizable to other populations.
The last word
In conclusion, the authors said, “Our study finds that screening adherence based on nationally accepted recommendations and guidelines for osteoporosis screening is poor within our single health network. Our sample of patients did not experience adverse events at higher rates than the national average despite our reduced adherence to screening recommendations. Bone health screening and compliance within our at-risk elective total joint patients should be further prioritized to reduce potential adverse events.”1
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