Aug 2026· Arthroplasty· Vol 8· 0 citations· 38 references
Medicine
TL;DR
Preoperative radiographic evaluation of VF may improve bone fragility assessment, particularly in older patients, and DXA alone underestimated clinically relevant bone fragility in patients undergoing THA.
Abstract
Bone fragility assessment prior to total hip arthroplasty (THA) is typically based on bone mineral density (BMD) measured by dual-energy X-ray absorptiometry (DXA). Meanwhile, prevalent vertebral fracture (VF), an important indicator of bone fragility, may be present even when BMD does not meet the diagnostic criteria for osteoporosis. Although preoperative bone health assessment has become crucial in patients undergoing THA, VFs remain insufficiently evaluated. This study aimed to investigate the prevalence and distribution of DXA-defined osteoporosis and VFs in patients undergoing THA and to evaluate how often DXA alone fails to detect clinically relevant bone fragility. This retrospective observational study included all consecutive patients aged ≥ 45 years who underwent primary THA between January 2021 and December 2025. Those undergoing THA for non-osteoarthritis etiologies were excluded. BMD was measured at the lumbar spine and femoral neck using DXA, and prevalent VFs were assessed on preoperative lateral thoracolumbar radiographs using Genant’s semi-quantitative method. DXA-defined osteoporosis was defined as a T-score ≤ − 2.5 at any measured site. Clinical osteoporosis was defined as DXA-defined osteoporosis and/or VF. The prevalence and distribution of DXA-defined osteoporosis, VF, and their overlap were assessed. Multivariable logistic regression analysis adjusted for age, sex, body mass index, and contralateral hip status was performed to identify factors associated with VF without DXA-defined osteoporosis. Among the 352 included patients, DXA-defined osteoporosis was identified in 84 (23.9%) and VFs in 59 (16.8%). Clinical osteoporosis was observed in 118 patients (33.5%). Of these, 34 patients (9.7% of the total cohort; 28.8% of those with clinical osteoporosis) had VFs without DXA-defined osteoporosis and would not have been identified using DXA alone. Advanced age was independently associated with VF without DXA-defined osteoporosis (adjusted odds ratio, 2.65 per 10-year increase; 95% confidence interval, 1.65–4.24). In patients aged 80 years or older, the prevalence of VF without DXA-defined osteoporosis was 30.6%, and that of clinical osteoporosis was 58.3%. DXA alone underestimated clinically relevant bone fragility in patients undergoing THA. Preoperative radiographic evaluation of VF may improve bone fragility assessment, particularly in older patients.
Osteoporosis in patients awaiting total hip arthroplasty remains undiagnosed. Although hip radiographic indices have been proposed for screening, they have not been compared. We compared the diagnostic accuracy of eight indices for osteoporosis. The canal–bone ratio measured 7 cm below the lesser trochanter may be a useful screening tool. Osteoporosis increases the risk of perioperative and postoperative fractures in patients undergoing total hip arthroplasty (THA). However, osteoporosis remains undiagnosed and untreated preoperatively. Several indices measured on hip anteroposterior radiographs have been proposed to screen for osteoporosis. Nevertheless, few studies have compared these indices, necessitating investigations to identify a practical and effective radiographic index. Osteoporosis prevalence was assessed in 317 female patients who underwent dual-energy X-ray absorptiometry before primary THA. The screening performance of eight radiographic indices was evaluated using anteroposterior hip radiographs for patients without previous diagnosis or treatment of osteoporosis: canal flare index (CFI), morphological cortical index (MCI), canal–bone ratio (CBR) at 2, 7, and 10 cm below the lesser trochanter and canal–bone area ratio (CBAR) measured at 2–7, 2–10, and 7–10 cm segments. Receiver operating characteristic analyses were performed, and the areas under the curve (AUCs) were calculated and compared among indices. Osteoporosis was identified in 129 patients (40.7%), of whom only 48 (37.2%) received treatment. The highest AUC values were observed for CBAR2–7 (0.801), CBAR7–10 (0.798), and CBR7 (0.798), followed by CBAR2–10 (0.785), CBR10 (0.766), CBR2 (0.740), CFI (0.696), and MCI (0.654). CBAR and CBR7 exhibited higher screening accuracy than other indices. The osteoporosis prevalence and treatment rates were 40.7% and 37.2%, respectively. Among the radiographic indices, CBR7 and CBARs demonstrated favorable screening performance, with CBR7 offering comparable accuracy and greater simplicity. CBR7 may serve as a practical and efficient screening tool for osteoporosis.
Ryo Higuchi, K. Uemura, Tomoki Asano et al.· Archives of Osteoporosis· 0 citations
Study Design
Retrospective sex- and age-matched case-control study.
Purpose
To assess bone mineral density (BMD)-trabecular bone score (TBS) discordance and high-burden abdominal aortic calcification (AAC) in patients with radiographically confirmed osteoporotic vertebral compression fracture (OVCF).
Overview of Literature
Conventional BMD thresholds may fail to identify all patients with vertebral skeletal fragility, as vertebral fractures can occur despite nonosteoporotic BMD. TBS complements BMD by evaluating trabecular microarchitecture, while AAC may serve as a marker of systemic bone-vascular health associated with skeletal fragility.
Methods
This retrospective sex- and age-matched case-control study enrolled patients aged ≥50 years who underwent dual-energy X-ray absorptiometry (DXA) with TBS assessment and vertebral imaging. OVCF was defined as a Genant grade 2 or 3 vertebral fracture. The primary cohort included 47 OVCF patients and 188 matched controls. BMD T-scores at the lumbar spine, femoral neck, total hip, TBS, and AAC-24 were evaluated. Matched conditional logistic regression was used to determine associations with OVCF.
Results
More than half of OVCF patients did not demonstrate osteoporotic BMD at any measured DXA site (53.2%). Among those with nonosteoporotic BMD, low TBS was more common in cases than in controls (48.0% vs. 22.7%). Low TBS remained independently associated with OVCF after adjusting for the lowest BMD T-score and high-burden AAC (odds ratio, 2.66; 95% confidence interval, 1.25-5.63; p =0.011). High-burden AAC was more frequent among cases, although its association was attenuated after adjustment.
Conclusions
Low TBS may aid in identifying vertebral skeletal fragility in OVCF patients with nonosteoporotic BMD on conventional DXA. High-burden AAC may provide vascular information, although its incremental association beyond BMD and TBS was attenuated.
Background Osteoporosis is a well-established risk factor for early femoral failure following cementless total hip arthroplasty (THA). The performance of cementless collared triple-taper stems (CTTSs) in patients with a confirmed diagnosis of osteoporosis remains poorly defined. This study aimed to evaluate early clinico-radiographic outcomes of CTTS in osteoporotic patients undergoing elective THA. Methods We retrospectively reviewed 96 patients (87.5% women; mean age 69.5 ± 7.4 years) who underwent elective THA with a CTTS between 2018 and 2025. Osteoporosis was confirmed by either dual-energy x-ray absorptiometry T-score ≤ −2.5 or history of fragility fracture. Preoperative morphology and postoperative canal fill ratios, alignment, and subsidence (>3 mm) were assessed. Femoral failure was defined as periprosthetic fracture or aseptic loosening. Results Preoperative morphology demonstrated a predominance of wide canals (Dorr B: 67.5%, Dorr C: 26%) and a mean morphological cortical index of 2.55. Postoperatively, high mean canal fill ratios were achieved (Z1: 0.66; Z2: 0.79; Z3: 0.76; Z4: 0.74), indicating reliable metaphyseal and diaphyseal fit. Despite osteoporotic bone quality, no cases of measurable subsidence were observed. Prominent collars occurred in 34.4% and neocortex formation in 5.2%, with no associated complications. At a mean follow-up of 2 years (range 1–7), the primary outcome of femoral failure was 0% at 90 days, 1 year, and final follow-up. Conclusions Cementless CTTS demonstrated reliable early fixation with no femoral failures in a rigorously defined osteoporotic cohort. These findings suggest that cementless CTTS may be a viable option for femoral fixation in osteoporotic patients undergoing elective THA. Level of Evidence Level III, Therapeutic study.
Ahmad M. Zedan, Jessica L. Abrolat, Maithily Diaz et al.· Arthroplasty Today· 0 citations
BACKGROUND
Osteoporosis is a recognized risk factor for adverse events after total joint arthroplasty, whereas osteopenia is often considered a borderline or lower-risk condition. This study evaluated whether osteopenia is associated with increased two-year reoperation after primary total hip arthroplasty (THA) and total knee arthroplasty (TKA) and whether decreasing bone mineral density (BMD) is associated with a graded postoperative risk.
METHODS
We retrospectively reviewed a single-center cohort of consecutive patients who underwent primary THA or TKA between 2015 and 2023 and had dual-energy X-ray absorptiometry within one year preoperatively. Patients were categorized by lowest T-score as normal (greater than -1.0), osteopenia (-1.0 to -2.5), or osteoporosis (less than -2.5). The primary outcome was reoperation within two years after surgery. The secondary outcomes included periprosthetic fracture, periprosthetic joint infection (PJI), readmission, all-cause mortality, and dislocation in the THA cohort. Aseptic loosening was reviewed descriptively as a reason for reoperation. Separate multivariable logistic regression analyses were performed for THA and TKA.
RESULTS
A total of 3,302 patients were included, including 1,111 THA and 2,191 TKA patients. Reoperation rates increased from 0.4% in normal BMD to 4.4% in osteopenia and 6.8% in osteoporosis after THA, and from 0.3 to 1.7 to 3.5% after TKA (all P < 0.001). In adjusted models, osteopenia and osteoporosis were associated with higher odds of reoperation after both THA and TKA compared with normal BMD. The secondary analyses showed similar graded increases in periprosthetic fracture, periprosthetic joint infection, readmission, and mortality.
CONCLUSION
Osteopenia was associated with increased two-year reoperation after primary THA and TKA and may represent an intermediate-risk state between normal BMD and osteoporosis. Decreasing preoperative BMD was associated with graded postoperative risk.
Wei-Chin Chen, Pei-Hung Shen, Chia-Chun Wu et al.· Journal of Arthroplasty· 0 citations
INTRODUCTION
Periprosthetic fracture following total shoulder arthroplasty (TSA) is a devastating complication. Metabolic bone disease has been shown to increase the incidence of fracture. However, the state of metabolic bone care in this population is poorly studied. The purpose of this study is to elucidate the state of metabolic bone care in patients undergoing TSA. We also aim to study the association between computed tomography (CT) derived Hounsfield unit (HU) measurements and Fracture Risk Assessment Tool (FRAX) scores in this population.
METHOD AND MATERIALS
Consecutive adult patients who underwent primary TSA between 01/01/2019 and 12/31/2023 at a single institution were included in the study. Demographic variables, medical and surgical history, medications, pre-operative and post-operative DEXA scans, and post-operative follow up data were collected retrospectively. FRAX scores were calculated for each patient. Patients with FRAX major score > 20 or FRAX hip score >3 were classified as "high-risk" for metabolic bone disease related complications. HU measurements for the humeral head and glenoid from pre-operative CT were collected for patients with available CT scans. T-tests were used to compare high-risk versus low-risk patients. Logistic and linear regression was used to examine factors associated with higher metabolic bone disease associated risk.
RESULTS
Overall, 831 patients were included in the study, with 577 of them having a pre-operative shoulder CT scan. 632 patients were classified as low-risk while 199 classified as high-risk. For high-risk patients, 50% and 16% received preoperative and 1-year post-operative DEXA respectively. Of these, 60% were on vitamin D and calcium, and only 13% are taking osteoporosis medications. High-risk patients were significantly more likely to be older, female, obese, and have a higher comorbidity index. Average humeral head HU measurement was significantly lower for high-risk patients (28.5 HU vs 50.14 HU, p <0.001) and patients with diagnosed osteoporosis (23.6 HU vs 44.4 HU, p = 0.005. Univariate regression demonstrated strong correlation between humerus HU measurement and metabolic bone disease risk.
DISCUSSION
Metabolic bone disease is under screened and under treated in patients undergoing shoulder arthroplasty with a large proportion of high-risk patients not receiving indicated care. There are significant missed opportunities to improve metabolic bone care for these patients during the peri-operative period, indicating barriers to care. High-risk patients and patients with diagnosed osteoporosis have significantly lower humerus HU on pre-op CT.
Zhaorui Wang, Jesse King, Anthony Prentice et al.· Journal of shoulder and elbo...· 0 citations
Background: Osteoporosis poses a significant challenge to spinal instrumentation because compromised bone quality may predispose patients to screw loosening, implant failure, and reoperation. However, in resource-limited settings where dual-energy X-ray absorptiometry (DEXA) is unavailable, clinicians must rely on clinical and radiographic indicators of poor bone quality.
Aim: This study evaluated the outcomes of pedicle screw fixation in patients with clinically suspected osteoporosis at a Nigerian tertiary hospital and identified factors associated with adverse outcomes.
Methods: A retrospective cohort study was conducted among 61 patients older than 55 years who underwent pedicle screw fixation at the National Orthopaedic Hospital Dala, Kano, from January 2018 to December 2024. Clinically suspected osteoporosis was identified using age, sex, low body mass index (BMI), fragility fractures, and radiographic osteopenia. DEXA was unavailable. Outcomes included screw loosening at one year, reoperation, pain (VAS), neurological status (ASIA grade), disability (ODI), fusion status, quality of life (EQ-5D), and complications. Univariate analysis was used to examine factors associated with adverse outcomes.
Results: Of the 61 patients (47 women and 14 men), screw loosening at one year occurred in 14 (22.9%): 11 women (23.4% of women) and 3 men (21.4% of men). Reoperation was required in 5 patients (8.2%): 4 women (8.5%) and 1 man (7.1%). Univariate analysis showed no statistically significant association between sex and screw loosening (p = 1.00) or reoperation (p = 1.00). Patients older than 75 years had a higher loosening rate (44.4% vs 14.3–25.0%), although the difference was not statistically significant (p = 0.17). Multilevel fusion (≥3 levels) was associated with a higher loosening rate (50.0% vs 9.1–20.0%; p = 0.02). VAS improved from 7.2 ± 1.5 to 3.1 ± 1.8 (p < 0.001), and ODI improved from 58.4 ± 14.2 to 32.5 ± 16.5 (p < 0.001). Complications occurred in 18 patients (29.5%).
Conclusions: Pedicle screw fixation in patients with clinically suspected osteoporosis was accompanied by screw loosening in 22.9% and reoperation in 8.2%. Multilevel fusion was associated with screw loosening. The absence of DEXA screening, cement augmentation, and pharmacological treatment indicates a gap in care. Improved diagnostic capacity and access to appropriate augmentation strategies may support surgical planning in resource-limited Nigerian settings.
Kawu Ahidjo Abdulkadiri, Misbahu Ahmad, Oderinde Gbadebo Afeez et al.· Asian Journal of Medicine an...· 0 citations
