September 07, 2021

Periprosthetic Fractures: The New Osteoporotic Fragility Epidemic

Posted By: Richard S. Pope, PA-C, MPAS

Periprosthetic fracture, defined as a post-operative fracture around or near a prosthesis, has become increasingly common. This was shown in a study published in BMJ in 2020. The study period took place over 3.5 years, from April 2015 to December 2018, and used the International Classification of Diseases 10th (ICD-10) Revision code M96.6 (fracture of bone following insertion of orthopedic implant, joint prosthesis, or bone plate) to identify these fractures in England's national database. This showed a 13% annual rise in these fracture types. It has now come to the attention of orthopedists and others who have studied this phenomenon that this type of fragility fracture is most commonly due to osteoporosis.

In 2016 a team from the Mayo Clinic did a retrospective review of periprosthetic fractures and noted a 3.5% incidence of post-operative periprosthetic fracture extending to 20 years among the 32,644 total hip arthroplasties reviewed. Notably, the risk of this fracture was 10 times more likely in the 30 days following the procedure with an uncemented prosthesis vs those who received a cemented prosthesis.

In a review of femoral periprosthetic fractures in Italy, Caruso et al reviewed functional and radiological outcomes of these fractures and determined risk factors included osteoporosis (63%), osteolysis (26%), and loosening of the prosthesis (8.2%). Since there is an association (and suggested causality) of these types of fractures with osteoporosis, it would be helpful if surgeons knew the state of the "bone stock" prior to surgery so that they might change their plans preoperatively.

The University of Wisconsin's orthopedic unit has asked the question, "What percent of patients have osteoporosis prior to undergoing orthopedic joint replacement or spine surgery?" The results showed that only 20% of patients undergoing elective joint surgery had bone mineral density (BMD) measured prior to surgery at their institution. They also calculated that, of those with osteoporosis, only 18% had ever been treated for that disease. Additionally, a metanalysis by Prince et al, also from the University of Wisconsin's orthopedic unit, using BMD showed local bone loss around the prosthesis of 20% of patients, due to a combination of local inflammatory processes, wear particles, and activation of osteoclasts.

As primary care providers, we are asked to medically evaluate our patients prior to elective surgery. Patients with diseases such as heart disease, hypertension, diabetes, and the like must have these disorders optimized prior to surgery—this is considered standard of care. However, with a 13% year-over-year increase in periprosthetic fracture as seen in England, and its association with osteoporosis now causing it to be recognized as a fragility fracture, shouldn't we consider evaluating for osteoporosis and ordering a DXA scan as part of our pre-surgical workup? There is a wide gap in recognition that these fractures are osteoporotic. Further, there is an increasing body of knowledge that would suggest evaluation and treatment for osteoporosis, prior to prosthesis placement, with the goal of minimizing these serious and often life-changing fractures.

References

Anderson P, et al. Bone health optimization to prevent periprosthetic fracture. Presented at: Santa Fe Annual Bone Symposium; August 2021.
Abdel MP, et al. Epidemiology of periprosthetic fracture of the femur in 32,644 primary total hip arthroplasties: A 40-year experience. Bone Joint J. 2016;98-B:461.
Bottle A, et al. Periprosthetic fractures: the next fragility fracture epidemic? A national observational study. BMJ Open. 2020;10:e042371.
Caruso G, et al. Surgical treatment of periprosthetic femoral fractures: a retrospective study with functional and radiological outcomes from 2010 to 2016. European Journal of Orthopaedic Surgery & Traumatology. 2018;28:931.
Prince JM, et al. Changes in femoral bone mineral density after total knee arthroplasty: a systematic review and meta-analysis. Arch Osteoporos. 2019;14:23.

Filed under: Orthopedics , Rheumatology