A call to "own the bone": osteoporosis is a predictor for adverse two-year outcomes following total hip and knee arthroplasty

Enhanced risk of 90-day medical and 2-year implant-related complications in total shoulder arthroplasty patients with osteoporosis

BACKGROUND

As the average age of patients undergoing shoulder arthroplasty (SA) increases, the frequency of SA patients with osteoporosis is expected to rise. While the effects of osteoporosis have been described in the broader orthopedic literature, it is presently unclear how osteoporosis affects SA postoperative medical and implant-related outcomes.

METHODS

A multicenter database TriNetX was queried for patients between 2011 and 2021 who underwent SA with and without osteoporosis. Patients with less than 2 years of follow-up and those with a prior shoulder hemiarthroplasty were excluded. Primary outcomes included 2-year periprosthetic joint infection, prosthesis dislocation, periprosthetic fracture, and revision surgery. Secondary outcomes included 90-day medical complications and readmissions. Osteoporotic and control patient cohorts were propensity matched in a 1:1 ratio.

RESULTS

Seven thousand eight hundred forty-two patients were included after matching in each cohort. Baseline demographic variables were similar between groups, except osteoporotic patients had a lower body mass index (28.6 vs. 31.0 kg/m2; P < .001). Osteoporotic patients undergoing SA were more likely to experience wound disruptions, stroke, pulmonary embolism, deep vein thrombosis, myocardial infarction, anemia, pneumonia, renal failure, transfusion, and readmission within 90 days after surgery. At 2 years postoperative, osteoporotic SA patients experienced an elevated risk of mechanical loosening, periprosthetic joint infection, dislocation, periprosthetic fracture, and required revision surgery at a higher rate than control patients.

CONCLUSIONS

Osteoporotic patients undergoing SA are at greater risk for medical complications within the 90 days perioperative period as well as implant-related complications within 2 years of surgery. Patients and surgeons should be aware of the potential higher risk of complications in osteoporotic patients following SA, and further investigation into benefits of preoperative management and treatment of osteoporosis is necessary.

Is surgeon assessed bone quality during total knee arthroplasty a valid tool to diagnose osteoporosis?

Osteoporosis continues to have a high prevalence amongst people undergoing total knee arthroplasty (TKA). The surgeon assessed intraoperative bone quality using a visual analogue scale has a strong correlation with bone mineral density. Surgeon assessment of bone quality has a high specificity(100%) and positive predictive value(100%) in diagnosing osteoporosis and osteopenia.

BACKGROUND

Patients undergoing TKA have a high prevalence of osteoporosis. Our aim is to study (a) the correlation of intraoperative surgeon assessed bone quality with bone mineral density(BMD) as measured by dual-energy x-ray absorptiometry(DEXA) and (b) the diagnostic strength of intraoperative surgeon assessment of bone quality in diagnosing osteoporosis and osteopenia, in patients undergoing TKA.

METHODS

We prospectively recruited 31 patients undergoing TKA. Patients were classified into normal, osteopenia or osteoporosis based on preoperative DEXA. Intraoperatively, the senior surgeon by visual and tactile assessment, graded the bone quality(BQ) using a visual analogue scale(VAS) from 0 to 10, with 10 being the strongest bone. Using the VAS score, we classified patients as normal(≥ 8), osteopenia(5-7) and osteoporosis(≤ 4).

RESULTS

The Spearman's rho correlation between BMD and VAS was 0.954.(p < 0.001). VAS < 8 to diagnose osteopenia and osteoporosis had a sensitivity of 70.83%, specificity of 100%, positive predictive value of 100% and diagnostic accuracy of 77.42%(p = 0.001). VAS ≤ 4 to diagnose osteoporosis had a sensitivity of 71.43%, specificity of 100%, positive predictive value of 100% and diagnostic accuracy of 93.55%(p < 0.001).

CONCLUSION

The surgeon assessed intraoperative bone quality using a VAS during TKA has a strong correlation with the gold standard BMD as measured by DEXA scan. VAS ≤ 4 can help diagnose osteoporosis, allowing surgeons to augment implant fixation with stem and cement as well as guide osteoporosis treatment postoperatively. VAS < 8 can identify osteopenic or osteoporotic bone, thus allowing the surgeon to better identify weaker bone and help titrate implant choice.

Finely controlled bioceramic granules and sonoporation for osteogenic bone defect repair and reconstruction

Osteoporotic fractures caused by imbalance in bone homeostasis like chemotherapy, loss of ovarian function，glucocorticoid use and aging require special surgical procedure to treat and restore anatomical function. However, due to escalating bone weakness and impairment, it remains a clinical challenge to treat these types of fracture defects through conventional means. Herein, we fabricated a novel calcium silicate‑strontium (CS-Sr35) bioceramic granules with high biological properties and combined it with ultrasound aided sonoporation (sono) in augmenting osteoporotic critical-sized bone defect. The use of sonoporation mediated by microbubble was to influence efficient response for tissue permeability and delivery of bioactive ions from the bioceramic scaffold. The graded robust granule with adjustable microstructure exhibited physiochemical and biointegration properties favorable for ion release in vitro and osteogenic related activities in vivo. Herein, we compared the treatment of bone defect repair using (i) no scaffold (ii) CS-Sr35 only and (iii) CS-Sr35 + sono. The gradual bone repair process was elucidated by X-ray, histology and micro-CT analyses. Overall, our results showed that the CS-Sr35 + sono exhibited a tailored biodissolution behavior with complete defect repair and reconstruction. Meanwhile, the group with only CS-Sr35 granules had less osteoblastic healing while the blank group showed inadequate critical-sized defect repair throughout the study. Our study suggests that, the synergistic technique of combining bioceramic granule with sonoporation significantly optimizes osteogenic activity and biomineralization ability of the bioceramic granule for new bone growth in osteoporotic pathology and also this tailored technique provides versatile approach for improving the biological effect for next generation reconstruction and repair of diseased bone defect.

Total Hip Arthroplasty in Patients with Hip Osteoporosis: A Narrative Review

Osteoporosis and osteopenia can affect patients undergoing arthroplasty of the hip, which is typically recommended for patients with severe osteoarthritis or elderly patients with a femoral neck fracture. Preoperative screening for this type of bone loss could be helpful to patients and prevent poor outcomes due to the rate of underdiagnosis of osteoporosis, which can reach 73% in patients undergoing hip arthroplasty. Complications associated with low bone mineral density include periprosthetic fractures as well as an increased revision rate. Although the benefit of antiresorptive medications postoperatively has been demonstrated, when administered preoperatively, worse outcomes were reported compared to its non-usage. Surgical management is as important as pre-medication. According to general recommendations, cemented implants provide greater benefit in osteoporotic patients. However, when using cementless implants, ribbed stems, straight tapered stems, stems with medial calcar contact, and titanium-composed stems can be used to prevent periprosthetic loss of bone mineral density; however, they should not be placed in a varus position. These stems can also be coated with zoledronate and other products.

Osteoporosis in the setting of knee arthroplasty: a narrative review

Patients undergoing knee replacement, which is mainly indicated in severe osteoarthritis, are frequently co-affected by osteoporosis and osteopenia. With a prevalence standing at around 20% in patients receiving knee arthroplasty, osteoporosis could lead to poor outcomes postoperatively. Some of these complications include periprosthetic fractures and an increased revision rate. Antiresorptive medications have been shown to be beneficial postoperatively. However, no studies have been conducted on whether they had any benefits if given preoperatively. Surgical management may also be beneficial, but this area remains full of controversy.

Patients with Periprosthetic Femoral Hip Fractures are Commonly Classified as Having Osteoporosis Based on DXA Measurements

Periprosthetic femoral hip fractures are subject to an increasing incidence and are often considered to be related to osteoporosis. However, there are no available studies that have determined the frequency of osteoporosis in affected patients using gold standard dual-energy X-ray absorptiometry (DXA). In this retrospective comparative study, we analyzed the DXA results of 40 patients with periprosthetic femoral hip fractures who were treated surgically in our department. DXA measurements were performed at the total hip and the lumbar spine to determine bone mineral density T-scores. Data were compared to two age-, sex-, and BMI-matched control groups in which patients underwent DXA prior to aseptic revision surgery for other causes or primary THA (consisting of 40 patients each). The mean T-score in the periprosthetic fracture cohort was significantly lower (- 1.78 ± 1.78) than that of the aseptic revision (- 0.65 ± 1.58, mean difference - 1.13 [95% CI - 1.88 to - 0.37]; p = 0.001) and the primary THA cohort (- 0.77 ± 1.34, mean difference - 1.01 [95% CI - 1.77 to - 0.26]; p = 0.005). Accordingly, osteoporosis was detected more frequently (45%) in the fracture cohort compared to patients undergoing aseptic revision (12.5%) and primary THA (10%). In conclusion, almost half of the patients with periprosthetic femoral hip fractures have osteoporosis according to DXA measurements. A regular assessment of bone health in THA enables identification of patients with osteoporosis who likely benefit from initiation of osteoporosis medication and cemented stem fixation.

Comprehensive evaluation of risk factors for aseptic loosening in cemented total knee arthroplasty: A systematic review and meta-analysis

Purpose

Aseptic loosening is the most common cause for revisions after total knee arthroplasty (TKA). Despite many studies exploring various risk factors associated with aseptic loosening, findings often present inconsistencies. To address this, we conducted a thorough review of the literature to identify and analyse these risk factors in cemented TKA. Additionally, we performed a meta-analysis to reconcile the divergent conclusions observed across studies.

Methods

We searched PubMed, Web of Science and Embase from 1996 up to 2024 and evaluated the quality of the included literature. Seventy-four studies were included to assess the association of BMI, diabetes, high physical activity (HPA), osteoporosis, rheumatoid arthritis (RA), cement material and implant design. Twenty-nine studies were used to calculate relative risk and CIs (using the random effects theory) and study heterogeneity for six different risk factors (BMI, diabetes, HPA level, cement material, polyethylene and implant design).

Results

Patients with diabetes are eight times more likely to experience aseptic loosening compared to those without diabetes (RR = 9.18, 95% CI: 1.80-46.77, p < 0.01). The use of tibial stem extension or highly crosslinked polyethylene can help reduce the incidence of aseptic loosening. However, we did not identify BMI, HPA, osteoporosis, RA, the use of high-viscosity cement and the utilization of mobile-bearing designs as risk factors for aseptic loosening post-cemented TKA.

Conclusions

Patients with diabetes undergoing TKA should be counselled regarding their potential increased risk of aseptic loosening. The use of tibial stem extensions and HXLPE can mitigate the incidence of aseptic loosening in cemented TKA. However, given a limited number of studies were included in the meta-analysis, we believe that higher-level studies are necessary to clearly identify other risk factors.

Level of Evidence

Level III.

Osteoporosis and Total Knee Arthroplasty: Higher 5-Year Implant-Related Complications

BACKGROUND

The risk of revision surgery in patients who have osteoporosis after total knee arthroplasty (TKA) is understudied. Our aim was to compare the 5-year cumulative risk of revision surgery after TKA in patients who have preoperative osteoporosis.

METHODS

A national administrative claims database was queried for patients undergoing primary TKA from 2010 to 2021. There were 418,054 patients included, and 41,760 (10%) had osteoporosis. The 5-year incidence of revision surgery was examined for all-causes, periprosthetic fracture (PPF), aseptic loosening, and periprosthetic joint infection (PJI). A multivariable analysis was conducted using Cox proportional hazards models. Hazards ratios (HRs) were reported with 95% confidence intervals (CIs).

RESULTS

The 5-year rate of all-cause revision surgery was higher for patients who had osteoporosis (HR 1.1, 95% CI: 1.0 to 1.2), however, the highest risk of revision surgery was seen for PPF (HR 1.8, 95% CI: 1.6 to 2.1). Patients who had osteoporosis also had elevated risk of revision surgery for PJI (HR 1.2, 95% CI: 1.1 to 1.3) and aseptic loosening (HR 1.2, 95% CI: 1.1 to 1.3). Osteoporosis was independently associated with PJI and aseptic loosening at a higher rate in obese patients.

CONCLUSIONS

In unadjusted survival analysis, those who had osteoporosis have a marginally lower risk of all-cause revision surgery. However, after controlling for age, sex and comorbidities, patients who had osteoporosis have a nearly 2-fold increased risk of 5-year revision for PPF after TKA, and mildly increased risk of revision for all causes, aseptic loosening, and PJI. Obesity may also modulate this association. Future studies should determine the extent to which treatment of osteoporosis modifies these postoperative outcomes.

Team Approach: Bone Health Optimization in Orthopaedic Surgery

» Bone health optimization (BHO) has become an increasingly important consideration in orthopaedic surgery because deterioration of bone tissue and low bone density are associated with poor outcomes after orthopaedic surgeries.» Management of patients with compromised bone health requires numerous healthcare professionals including orthopaedic surgeons, primary care physicians, nutritionists, and metabolic bone specialists in endocrinology, rheumatology, or obstetrics and gynecology. Therefore, achieving optimal bone health before orthopaedic surgery necessitates a collaborative and synchronized effort among healthcare professionals.» Patients with poor bone health are often asymptomatic and may present to the orthopaedic surgeon for reasons other than poor bone health. Therefore, it is imperative to recognize risk factors such as old age, female sex, and low body mass index, which predispose to decreased bone density.» Workup of suspected poor bone health entails bone density evaluation. For patients without dual-energy x-ray absorptiometry (DXA) scan results within the past 2 years, perform DXA scan in all women aged 65 years and older, all men aged 70 years and older, and women younger than 65 years or men younger than 70 years with concurrent risk factors for poor bone health. All women and men presenting with a fracture secondary to low-energy trauma should receive DXA scan and bone health workup; for fractures secondary to high-energy trauma, perform DXA scan and further workup in women aged 65 years and older and men aged 70 years and older.» Failure to recognize and treat poor bone health can result in poor surgical outcomes including implant failure, periprosthetic infection, and nonunion after fracture fixation. However, collaborative healthcare teams can create personalized care plans involving nutritional supplements, antiresorptive or anabolic treatment, and weight-bearing exercise programs, resulting in BHO before surgery. Ultimately, this coordinated approach can enhance the success rate of surgical interventions, minimize complications, and improve patients' overall quality of life.