A Novel Osteoporosis Screening Protocol to Identify Orthopedic Surgery Patients for Preoperative Bone Health Optimization

Authors: Elliot Chang, BA et al. (2022)

Link: https://doi.org/10.1177/21514593221116413

Background Information:

Osteoporosis—a condition where bones become fragile—is surprisingly common among people undergoing elective orthopedic surgeries like knee, hip, shoulder replacements, or spinal fusions. Weak bones can increase the risk of serious complications during and after surgery, including fractures, loose implants, and implant failure, potentially leading to longer hospital stays and even higher risk of death. Despite these risks, bone health checks are rarely routine before surgery—even though treatments like bisphosphonates have been shown to halve revision rates in arthroplasty patients by strengthening bone beforehand.

Purpose of the Study:

The researchers developed and tested a straightforward screening protocol to identify which elective surgery patients should receive a bone density scan (DXA) before surgery. Their goal was to catch patients at high risk of osteoporosis early—so that doctors can treat bone weakness before surgery and reduce the chance of poor outcomes related to weak bones.

Methods and Data Analysis:

This was a retrospective cohort study involving 628 patients aged 40 and older undergoing primary elective procedures (knee, hip, shoulder arthroplasty or thoracolumbar fusion). The screening criteria to warrant a DXA scan were simple: women aged 65 or older, men aged 70 or older, a history of non-traumatic fracture after age 50, or a FRAX-calculated risk of a major osteoporotic fracture of 8.4% or higher (without bone density). Osteoporosis was diagnosed based on World Health Organization criteria (T-score ≤ −2.5), clinical guidelines (NOF), and a modified clinical definition. For the 209 patients who had DXA results, the team calculated how well the protocol identified true cases (sensitivity) and excluded non-cases (specificity).

Key Findings and Conclusions:

The screening protocol proved excellent at identifying osteoporosis risk: sensitivity was 96% for T-score osteoporosis and 99% for clinically defined osteoporosis, meaning almost all patients with poor bone health would be flagged for DXA scans. Specificity—correctly ruling out those without the condition—was lower, at 19% for T-score and 61% for clinical osteoporosis, resulting in some false positives. Despite this, the authors argue prioritizing sensitivity over specificity is appropriate in this case, since missing osteoporosis poses greater surgical risks. They concluded that this very simple, information-based screening method works well for deciding who should have preoperative bone density testing.

Applications & Limitations:

This protocol can be easily used in any orthopedic clinic—without extra imaging or cost—by simply recording basic patient information and calculating FRAX. It helps surgeons identify patients who may benefit from preoperative bone optimization, like bisphosphonates or other treatments, and may even inform choices around implant types and surgical timing. Limitations include its retrospective, single-center design with predominantly Caucasian patients and those already likely to have DXA scans, which might bias sensitivity estimates. Also, the protocol wasn’t tested on patients undergoing revision surgeries. The authors recommend a prospective, broader study to confirm effectiveness in a wider population.