Editor’s Spotlight/Take 5: Can Hip and Knee Arthroplasty Surgeons Help Address the Osteoporosis Epidemic?

The idea that I ought to “own the bone” [3] has always made me a little nervous, and I’m wondering if you feel the same way.

For sure, I don’t plan to prescribe bisphosphonates or other strong pharmacologic treatments for patients with osteoporosis. I don’t have the knowledge to manage the side effects and potential interactions, nor the clinical support to track the laboratory values and bone densitometry findings for the number of patients in my practice who might benefit from such therapy. I do feel, though, that when I treat patients with hip fractures and other sentinel events, I ought to make sure they receive at least a referral to someone who can order and follow-up on a dual energy x-ray absorptiometry (DEXA) test and prescribe pharmacotherapy as indicated.

But even with such a simple recipe—if we treat a patient for a sentinel event, we should arrange a suitable follow-up, even if we don’t provide it ourselves—the cracks in the complex system in which we practice sometimes look like crevasses. I’m mindful of how easy it is for patients not to get the care they need and ought to have. Large studies bear out this worry: Most patients who have a fragility fracture do not receive suitable follow-up, screening, or treatment [7]. This happens despite the concept of sentinel events being known since, well, not long after I learned how to walk. One study from 1970 found “a close connection between spinal osteoporosis and fracture of the neck of femur [5],” and countless more have replicated that finding since.

A study in this month’s Clinical Orthopaedics and Related Research® suggests that orthopaedic surgeons who treat patients in middle adulthood and beyond don’t have to—and perhaps ought not to—wait for the first fracture [2]. A multicenter group called the Orthopaedic Research Collaborative, led by Savyasachi C. Thakkar MD from Johns Hopkins University and Gregory J. Golladay MD from Virginia Commonwealth University, found that more than half of the patients who undergo THA or TKA were at high risk for developing osteoporosis based on established (and easily applied) criteria [4, 8]. These criteria were age over 65 years for women (70 for men) or a patient of either gender who was over 50 and who had one or more non-age-related risk factors such as cigarette smoking, alcohol abuse, being underweight (BMI < 18.5 kg/m²), a history of a fragility fracture, chronic systemic corticosteroid use, or having a metabolic or genetic condition affecting sex hormones or bone mineral density. Despite over 50% of patients meeting these criteria, 13% or fewer of them underwent a DEXA scan. And in even-worse news, patients who met one or more of those criteria for osteoporosis were approximately twice as likely to experience a fragility fracture or a periprosthetic fracture within 5 years of the arthroplasty than were patients who did not meet one of those criteria.

Although this study focused on patients who underwent arthroplasty, there is little reason to think it wouldn’t apply equally to patients in this age group undergoing other major elective procedures—shoulder replacement, wrist fusion, spine surgery, you get it.

We need to do better. I need to do better. Please join me in the Take 5 interview that follows with Dr. Thakkar to get some specific, practical suggestions that can help us do just that.

Savyasachi C. Thakkar MD

Take 5 Interview with Savyasachi C. Thakkar MD, senior author of “Can Hip and Knee Arthroplasty Surgeons Help Address the Osteoporosis Epidemic?”

Seth S. Leopold MD: Congratulations on this eye-opening study. To what degree can you empathize—or sympathize—with orthopaedic surgeons who are uneasy about taking the lead on identifying patients at risk for fragility fractures before they occur?

Savyasachi C. Thakkar MD:Thank you! I empathize completely with my orthopaedic surgery colleagues. In residency, there is little to no formal training regarding bone-health screening and treatment, so it is no surprise that surgeons feel uneasy initiating the screening process. Nonetheless, our study identified an opportunity and suggested a path for how hip and knee arthroplasty surgeons might help address the osteoporosis epidemic by engaging in surgeon-initiated screening. As medicine becomes more interdisciplinary, my co-authors and I challenge orthopaedic surgery residency programs to integrate bone health endocrinology rotations into the curriculum so future orthopaedic surgeons can feel more comfortable identifying patients at risk for this life-changing (and sometimes life-ending) diagnosis and initiating treatment.

Dr. Leopold: How practical is it in this context to refer every woman over 65 and every man over 70 for a DEXA scan? Do you order these tests yourself, or have you created a system that manages referrals to someone who does?

Dr. Thakkar: The screening process is not overly complicated. It is like normal preoperative clearance surgeons perform all the time in collaboration with primary care. Before each preoperative visit, I ask patients to fill out a form to identify whether they have at least one high-risk osteoporosis category (women 65 and older, men 70 and older, prior fragility fracture, or any of the other parameters listed in our paper). If they self-identify as having least one high-risk parameter, I ask patients in the clinic whether they have had a diagnosis for osteoporosis or have ever been screened. For those unscreened and identified to be at risk for osteoporosis, I order a DEXA scan and have them follow up with my endocrinology colleagues. What makes this program successful is having a robust connection with endocrinology. Building a network with any bone-health specialist fosters smooth communication, ensuring patients receive the care they need. Additionally, in the age of telehealth, visits with endocrinology need not be in-person, which relieves patients of the burden of travel to another healthcare professional. My coauthors and I have found that endocrinologists are often eager to collaborate with orthopaedic surgeons by way of the Orthopaedic Research Collaborative, which is our multi-institutional research group that strives to improve orthopaedic surgery outcomes by harnessing the power of high-quality data.

Dr. Leopold: Given how ineffective we’ve been in getting patients who’ve had major fractures and other sentinel events screened [7], why do you believe we might have more success if we intervene at the time of elective surgery in this patient population?

Dr. Thakkar: First, there is evidence noting the increased risk of surgical complications in patients with poor bone health following lower extremity arthroplasty [1, 9]. Thus, there is an incentive for surgeons to initiate bone-health screening and, ultimately, treatment (which can help prevent complications like periprosthetic fractures, as we found). Additionally, the problem is not only that current healthcare professionals are not screening patients, but also that patients may not opt to have screening depending on who orders it, and that surgeon involvement can help in this regard. Some evidence suggests that surgeon-initiated screening has led to more patients undergoing screening and eventually receiving treatment [6]. Thus, if patients see that surgeons care about their bone health, they may be more likely to get screened, and, ultimately, treated for this important diagnosis.

Dr. Leopold: A large proportion of the patients in your study were at risk for osteoporosis but only a small minority were tested for the possibility that they might have this diagnosis. This suggests that not just orthopaedic surgeons but also primary care professionals are missing the ball. Why do you see this as an “orthopaedic surgery thing”? It seems, on one hand, like the very definition of primary care.

Dr. Thakkar: Our study does not seek to assign blame to any specific specialty but rather shows on a national level that we all are missing the ball and that surgeons can help. As mentioned before, there is research showing patients will consider screening and treatment when surgeons initiate the pathway [6]. Thus, we recommend that surgeons join the process. At my institution, for example, surgeons are instrumental in identifying patients with anemia based on a simple complete blood count (CBC) lab test. If patients fall below a certain hemoglobin threshold, they are automatically referred to our hematology colleagues for anemia correction prior to elective joint replacement surgery. Collaborating with patients and other medical professionals, orthopaedic surgeons are able to demonstrate their commitment toward improving health and surgical outcomes. This is one of the integral goals of the Orthopaedic Research Collaborative and the like-minded individuals who make up our team.

On a related note, I recognize that many surgeons have limited resources for these kinds of interactions. The good thing is that taking care of osteoporosis screening is no harder than obtaining primary care clearance before elective surgery. The processes can be related, and it may help to engage the primary care team on this topic. Showing that you, as the surgeon, have an interest in a patient’s bone health for postoperative outcomes may incentivize the primary care physician to focus more on a bone-health assessment.

Dr. Leopold: At the end of your study, you mention the issue of cost-effectiveness. Why do you question that since, presumably, the nationally accepted screening criteria you used were developed at least to some degree with that issue in mind? How concerned are you that if your suggestions were widely applied, we could wind up on the wrong side of the cost-benefit ratio?

Dr. Thakkar: I agree with your comment that nationally accepted screening criteria are usually developed keeping cost-effectiveness in mind. However, I also realize that there may be resource allocation concerns at certain institutions and orthopaedic surgery practices, which can make preoperative medical management pathways challenging from the expense side. Generally speaking, an improvement in outcomes such as reducing periprosthetic fractures using cost-effective screening criteria should enable cost savings for our healthcare system in the long run.