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Use of Bone Health Evaluation in Orthopedic Surgery: The 2019 ISCD Official Positions.

Abstract

This position development conference (PDC) Task Force examined the assessment of bone status in orthopedic surgery patients. Key questions included which orthopedic surgery patients should be evaluated for poor bone health prior to surgery and which subsets of patients are at high risk for poor bone health and adverse outcomes. Second, the reliability and validity of using bone densitometry techniques and measurement of specific geometries around the hip and knee before and after arthroplasty was determined. Finally, the use of computed tomography (CT) attenuation coefficients (Hounsfield units) to estimate bone quality at anatomic locations where orthopedic surgery is performed including femur, tibia, shoulder, wrist, and ankle were reviewed. The literature review identified 665 articles of which 198 met inclusion exclusion criteria and were selected based on reporting of methodology, reliability, or validity results. We recommend that the orthopedic surgeon be aware of established ISCD guidelines for determining who should have additional screening for osteoporosis. Patients with inflammatory arthritis, chronic corticosteroid use, chronic renal disease, and those with history of fracture after age 50 are at high risk of osteoporosis and adverse events from surgery and should have dual energy X-ray absorptiometry (DXA) screening before surgery. In addition to standard DXA, bone mineral density (BMD) measurement along the femur and proximal tibia is reliable and valid around implants and can provide valuable information regarding bone remodeling and identification of loosening. Attention to positioning, selection of regions of interest, and use of special techniques and software is required. Plain radiographs and CT provide simple, reliable methods to classify the shape of the proximal femur and to predict osteoporosis; these include the Dorr Classification, Cortical Index, and critical thickness. Correlation of these indices to central BMD is moderate to good. Many patients undergoing orthopedic surgery have had preoperative CT which can be utilized to assess regional quality of bone. The simplest method available on most picture archiving and communications systems is to simply measure a regions of interest and determine the mean Hounsfield units. This method has excellent reliability throughout the skeleton and has moderate correlation to DXA based on BMD. The prediction of outcome and correlation to mechanical strength of fixation of a screw or implant is unknown.

Authors+Show Affiliations

Department of Orthopedics Surgery & Rehabilitation, University of Wisconsin UWMF Centennial Building, Madison, WI, USA. Electronic address: anderson@ortho.wisc.edu.UAB Osteoporosis Prevention and Treatment Clinic, University of Alabama Birmingham, Birmingham, AL, USA.University of Wisconsin, Osteoporosis Clinical Research Program, Madison, WI, USA.Radius Health Inc, Boston, MA, USA.Division Rheumatology, Vanderbilt University, Nashville, TN, USA.Greenville Health System, Deparment of Orthopaedic Surgery, Greenville, SC, USA.Core Institute, Phoenix, AR, USA.Department of Orthopedic Surgery, Hospital for Special surgery, New York, USA.University of Malaysia, Kuala Lumpur, Malaysia.Swedish Medical Center, Seattle, WA, USA.University of Hawaii Cancer Center, University of Hawaii, Honolulu, HI, USA.

Pub Type(s)

Journal Article

Language

eng

PubMed ID

31519473

Citation

Anderson, Paul A., et al. "Use of Bone Health Evaluation in Orthopedic Surgery: the 2019 ISCD Official Positions." Journal of Clinical Densitometry : the Official Journal of the International Society for Clinical Densitometry, 2019.
Anderson PA, Morgan SL, Kreuger D, et al. Use of Bone Health Evaluation in Orthopedic Surgery: The 2019 ISCD Official Positions. J Clin Densitom. 2019.
Anderson, P. A., Morgan, S. L., Kreuger, D., Zapalowski, C., Tanner, B., Jeray, K. J., ... Shepherd, J. (2019). Use of Bone Health Evaluation in Orthopedic Surgery: The 2019 ISCD Official Positions. Journal of Clinical Densitometry : the Official Journal of the International Society for Clinical Densitometry, doi:10.1016/j.jocd.2019.07.013.
Anderson PA, et al. Use of Bone Health Evaluation in Orthopedic Surgery: the 2019 ISCD Official Positions. J Clin Densitom. 2019 Aug 16; PubMed PMID: 31519473.
* Article titles in AMA citation format should be in sentence-case
TY - JOUR T1 - Use of Bone Health Evaluation in Orthopedic Surgery: The 2019 ISCD Official Positions. AU - Anderson,Paul A, AU - Morgan,Sarah L, AU - Kreuger,Diane, AU - Zapalowski,Carol, AU - Tanner,Bobo, AU - Jeray,Kyle J, AU - Krohn,Kelly D, AU - Lane,Joseph P, AU - Yeap,Swan Sim, AU - Shuhart,Christopher R, AU - Shepherd,John, Y1 - 2019/08/16/ PY - 2019/07/16/received PY - 2019/07/16/accepted PY - 2019/9/15/entrez KW - Dual energy X-ray absorptiometry KW - Orthopedic surgery KW - Osteoporosis KW - Position statements KW - Screening criteria JF - Journal of clinical densitometry : the official journal of the International Society for Clinical Densitometry JO - J Clin Densitom N2 - This position development conference (PDC) Task Force examined the assessment of bone status in orthopedic surgery patients. Key questions included which orthopedic surgery patients should be evaluated for poor bone health prior to surgery and which subsets of patients are at high risk for poor bone health and adverse outcomes. Second, the reliability and validity of using bone densitometry techniques and measurement of specific geometries around the hip and knee before and after arthroplasty was determined. Finally, the use of computed tomography (CT) attenuation coefficients (Hounsfield units) to estimate bone quality at anatomic locations where orthopedic surgery is performed including femur, tibia, shoulder, wrist, and ankle were reviewed. The literature review identified 665 articles of which 198 met inclusion exclusion criteria and were selected based on reporting of methodology, reliability, or validity results. We recommend that the orthopedic surgeon be aware of established ISCD guidelines for determining who should have additional screening for osteoporosis. Patients with inflammatory arthritis, chronic corticosteroid use, chronic renal disease, and those with history of fracture after age 50 are at high risk of osteoporosis and adverse events from surgery and should have dual energy X-ray absorptiometry (DXA) screening before surgery. In addition to standard DXA, bone mineral density (BMD) measurement along the femur and proximal tibia is reliable and valid around implants and can provide valuable information regarding bone remodeling and identification of loosening. Attention to positioning, selection of regions of interest, and use of special techniques and software is required. Plain radiographs and CT provide simple, reliable methods to classify the shape of the proximal femur and to predict osteoporosis; these include the Dorr Classification, Cortical Index, and critical thickness. Correlation of these indices to central BMD is moderate to good. Many patients undergoing orthopedic surgery have had preoperative CT which can be utilized to assess regional quality of bone. The simplest method available on most picture archiving and communications systems is to simply measure a regions of interest and determine the mean Hounsfield units. This method has excellent reliability throughout the skeleton and has moderate correlation to DXA based on BMD. The prediction of outcome and correlation to mechanical strength of fixation of a screw or implant is unknown. SN - 1094-6950 UR - https://www.unboundmedicine.com/medline/citation/31519473/Use_of_Bone_Health_Evaluation_in_Orthopedic_Surgery:_The_2019_ISCD_Official_Positions L2 - https://linkinghub.elsevier.com/retrieve/pii/S1094-6950(19)30130-1 DB - PRIME DP - Unbound Medicine ER -