Call for systematic bone health optimization before joint replacement and spinal fusion surgery

A new position statement from the International Osteoporosis Foundation’s (IOF) Committee of Scientific Advisors Fracture Working Group urges orthopedic surgeons and bone health specialists to work together to assess and treat osteoporosis before and after joint replacement and spinal fusion surgery.

Bringing together expertise across multiple disciplines, the position paper published in Osteoporosis International presents a framework linking poor bone quality to complications across both types of procedures and provides evidence-informed recommendations to improve outcomes for the millions of patients undergoing these surgeries worldwide. It introduces the concept of implant fixation failure as a common endpoint, describing the progressive mechanical failure of bone–implant constructs resulting from compromised bone quality, specifically due to osteoporosis.

The problem: Osteoporosis is undermining surgical success

Each year, millions of hip replacements and spinal fusions are performed globally, with numbers continuing to rise as populations age. While these procedures are highly effective, a growing proportion of complications, including periprosthetic fractures, implant loosening, cage subsidence, pseudoarthrosis (nonunion) and junctional failure, arise from the interaction between osteoporotic bone and orthopedic implants.

Manju Chandran, lead author and co-chair of the IOF Fracture Working Group at Singapore General Hospital and clinical professor at Duke-NUS Medical School, Singapore, stated: “We urge the orthopedic and bone health communities to see implant failure and osteoporosis as two sides of the same coin. A hip replacement or spinal fusion is only as durable as the bone that supports it. We need to think about bone quality as a determinant of surgical durability, not just fracture risk. Identifying and treating osteoporosis before and after these operations is a practical, low-cost way to protect patients from painful, dangerous and expensive complications.”

Key findings

The position statement synthesizes evidence from randomized controlled trials, cohort studies, registry analyses, meta-analyses and systematic reviews. Among the key findings:

• Osteoporosis is highly prevalent and underdiagnosed in surgical candidates. Between 60–80% of patients presenting for knee replacement have osteopenia or osteoporosis, and nearly three-quarters of osteoporotic patients undergoing hip replacement are undiagnosed preoperatively.
• Low bone mineral density (BMD) is often associated with implant fixation failure across both arthroplasty and spinal fusion, including higher rates of periprosthetic fracture, screw loosening, cage subsidence and pseudoarthrosis.
• Periprosthetic fractures carry severe consequences. One-year mortality rates for periprosthetic femoral fractures after hip arthroplasty range from 11–18%, comparable to mortality after native hip fractures, and reach 18.6% for periprosthetic distal femur fractures.
• Osteoporosis therapies can improve surgical outcomes. In arthroplasty, bisphosphonates preserve peri-implant bone stock and may improve implant survival. In spinal fusion, anabolic therapies influence fixation-related parameters.
• Falls are the dominant trigger for postsurgical fractures. Most periprosthetic fractures follow low-energy falls from standing or sitting height, underscoring the importance of fall-prevention strategies in perioperative care.

Expert recommendations

Among the expert recommendations for perioperative bone health optimization are the following:

• Who should be assessed: Patients undergoing arthroplasty or instrumented spinal fusion who are age 65 or older, have a prior fragility fracture, have clinical risk factors for osteoporosis/secondary bone loss, or are undergoing high-demand procedures such as revision arthroplasty, long-segment spinal fusion or surgery after prior fixation/implant failure. (Strength of Recommendation: Strong | Moderate certainty of evidence)
• Surgery should not be delayed in acute fracture or spinal fusion settings (Strength of Recommendation: Strong | Moderate certainty of evidence), but bone health assessment should be initiated as early as possible in the perioperative period. (Strength of Recommendation: Conditional | Moderate certainty of evidence)
• Vitamin D and calcium status should be corrected perioperatively, with target serum 25(OH)D of at least 50 nmol/L (20 ng/ml) in patients with deficiency and total calcium intake of 1,000–1,200 mg/day, preferably through dietary sources. Calcium supplementation should be considered only where dietary intake is inadequate. (Strength of Recommendation: Conditional | Certainty of Evidence: Low)
• Fall-risk assessment and prevention should be integrated into perioperative care pathways. (Strength of Recommendation: Strong | Moderate certainty of evidence)
• Pharmacotherapy in arthroplasty: Bisphosphonates are recommended postoperatively in patients with osteoporosis or a high-risk bone phenotype. Denosumab is an alternative when bisphosphonates are contraindicated. (Strength of Recommendation: Strong | Moderate certainty of evidence)
• Pharmacotherapy in spinal fusion: Teriparatide is recommended in osteoporotic patients, ideally initiated at least one month preoperatively and continued for 6–12 months postoperatively. (Strength of Recommendation: Strong | Moderate certainty of evidence)
• Sequential therapy: Transition to antiresorptive therapy after completion of an anabolic course to maintain skeletal gains. (Strength of Recommendation: Conditional | Certainty of Evidence: Low)
• Multidisciplinary coordination between orthopedic surgeons and bone health specialists is essential. (Strength of Recommendation: Strong | Certainty of Evidence: Moderate)

A call for bone health optimization

The authors emphasize that bone health optimization should not be treated as an adjunct to surgical care but as an integral component of perioperative planning.

Eugene McCloskey, of the Mellanby Center for Musculoskeletal Research at the University of Sheffield, UK, and chair of the IOF Committee of Scientific Advisors, added: “This is a very important and timely position statement that calls for a fundamental shift in how orthopedic and metabolic bone specialists collaborate. I highly commend the Fracture Working Group for highlighting this important clinical gap and providing a roadmap for more integrated care.

“Every patient undergoing arthroplasty or spinal fusion who has or is at risk of poor bone quality deserves a structured assessment and, where indicated, targeted therapy. This would help improve surgical outcomes and reduce complications for patients worldwide.”

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Lisa Lock

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Andrew Zinin

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