SLR - July 2020 - Jordan W. Crafton

Bone Health Optimization in Orthopaedic Surgery

Reference: Kadri A, Binkley N, Hare KJ, Anderson PA. Bone Health Optimization in Orthopaedic Surgery. J Bone Joint Surg Am. 2020; 102:574-81.

Scientific Literature Review

Reviewed By: Jordan W. Crafton, DPM
Residency Program: Mount Auburn Hospital – Cambridge, MA

Podiatric Relevance: Fifty-four million Americans have low bone mass or osteoporosis which naturally will continue to increase with aging. Osteoporosis and poor bone health is associated with adverse outcomes in orthopaedic surgery. In a survey of 465 joint arthroplasties, 77 percent of surgeons stated that osteoporosis affected the type of implant used but only 5 percent actually assessed bone density before procedures. Given that osteoporosis is linked to increased fracture risk and poor surgical outcomes it behooves the foot and ankle surgeon to optimize at risk patients to mitigate these adverse affects. The purpose of this study was to characterize a patient population referred for bone health optimization before elective orthopaedic surgery.

Methods: A retrospective review of 124 patients was performed for patients referred for bone health optimization by their surgeon who were  > 50 years of age and candidates for arthroplasty or thoracolumbar surgery. Fracture Risk Assessment Tool (FRAX) and dual x-ray absorptiometry (DXA) results were collected. The World Health Organization (WHO) diagnostic and National Osteoporosis Foundation (NOF) treatment guidelines were also used and, when available, CT imaging and trabecular bone score were evaluated. 

Results: Mean age was 69.2 years and 83 percent of the population was female with menopause occurring before age 45 in 27 percent. Prior fractures were identified in 56 percent of patients with 51 percent having multiple fractures and 67 percent occurring after age 50. 44 percent of patients were identified to have one or more secondary causes of osteoporosis. At the time of consultation anticonvulsants (excluding gabapentin) were reported in 6 percent, high-dose glucocorticoids (> 5mg) in 14 percent, opioids in 22 percent, proton pump inhibitors in 40 percent, and selective serotonin reuptake inhibitors in 23 percent. Forty-five percent of women and 20 percent of men met WHO criteria for osteoporosis and only 3 percent of women and 10 percent of men had normal bone mineral density. There was no difference in T-score between men and women. CT showed 60 percent of patients met criteria for osteoporosis and 34 percent were shown to have degraded bone microarchitecture. High FRAX risk of major osteoporotic fracture > 20 percent or hip > 3 percent was present in 82 percent. Using WHO criteria, 41 percent met threshold for medical treatment and using NOF guidelines 91 percent met threshold. All patients referred were instructed to take 2000-5000 IU of vitamin D3 and 1200mg of calcium daily. Forty-five percent were prescribed anabolic therapy  (abaloparatide or teriparatide) and 30 percent were prescribed antiresorptive therapy (alendronate, risedronate, zoledronic acid or denosumab).

Conclusions: Osteoporosis is common in a foot and ankle surgery practice and complications from even the simplest bony procedure can be devastating. Although this data included hip and knee arthroplasty it is easily extrapolated to include total ankle arthroplasty where optimal results require bony on-growth to the implant for stability long-term. Those patients suspected to have osteoporosis would benefit from a consultation for bone health optimization. For those patients found to be at risk, delaying surgery two to three months while medical management is initiated may be beneficial especially those undergoing total ankle arthroplasty. At the very least prescribing 2000-5000 IU of Vitamin D3 at the time of procedure scheduling appears to be beneficial.

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