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Tomasz Poboży

Osteopenia before joint replacement and increased reoperation risk

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Tomasz Poboży

Polish version: Osteopenia przed endoprotezoplastyką — większe ryzyko reoperacji

A cohort of 3,302 primary hip and knee arthroplasty patients found progressively higher reoperation rates as bone mineral density declined, including at the osteopenic stage. This may inform risk assessment, but observational data cannot show that routine DXA or treating osteopenia reduces complications.

Why this study matters

Osteoporosis is a recognised risk factor for problems after joint replacement, particularly periprosthetic fracture. Osteopenia is often considered merely a result that has not reached osteoporosis. A study published online in The Journal of Arthroplasty on 24 August 2026 examined whether that distinction understates operative risk.

The primary endpoint was reoperation within 2 years, with additional assessment of periprosthetic fracture, infection, readmission and mortality. The question was whether low BMD marks a broader adverse prognosis after primary arthroplasty.

Study design

This retrospective single-centre study included consecutive patients treated during 2015–2023 who had DXA within 1 year before surgery: 1,111 total hip arthroplasties (THAs) and 2,191 total knee arthroplasties (TKAs), totalling 3,302 patients.

Classification used the lowest T-score: normal BMD above −1.0, osteopenia from −1.0 to −2.5, and osteoporosis below −2.5. Separate multivariable logistic regressions were performed for hip and knee procedures. The public abstract did not provide full adjusted odds ratios, so interpretation is limited to reported event rates and significance of adjusted associations.

Main results

  • After THA, 2-year reoperation rates were 0.4% with normal BMD, 4.4% with osteopenia and 6.8% with osteoporosis.
  • After TKA, corresponding rates were 0.3%, 1.7% and 3.5%.
  • Differences across the three groups were significant for both procedures (P < 0.001).
  • Both osteopenia and osteoporosis remained associated with reoperation after covariate adjustment.
  • Additional analyses showed similar graded patterns for periprosthetic fracture, infection, readmission and mortality.

Clinical interpretation for an orthopaedic surgeon

The important signal is that risk may increase progressively rather than abruptly at a T-score of −2.5. BMD can be considered a continuous component of the overall risk profile, beyond a binary osteoporosis diagnosis. This does not imply automatic DXA for every arthroplasty candidate: inclusion only of patients already scanned may select a particular age, comorbidity or bone-risk profile.

Systemic preoperative BMD should also be distinguished from local remodelling around an implant. The randomized comparison of bone preservation with different hip stems addresses the latter question; this cohort concerns baseline bone health as a prognostic marker.

Limitations

  • The retrospective single-centre design establishes association, not causation.
  • Selection was restricted to patients with preoperative DXA.
  • Residual confounding may involve age, frailty, comorbidity, malnutrition, medication and other factors linked to both low BMD and complications.
  • The abstract does not provide all model variables or adjusted odds-ratio estimates.
  • The study did not test whether identifying or treating low BMD reduces reoperation.

Implications for practice

Bone health deserves attention even when formal osteoporosis criteria are not met, particularly in older patients, those with fragility fractures, long-term steroid exposure or other risks. Osteopenia should not automatically be regarded as clinically neutral. The study does not establish grounds for delaying arthroplasty, a contraindicating T-score or a complication-reducing effect of preoperative medication. Prospective screening and intervention studies are needed.

References

  1. Chen WC, Shen PH, Wu CC, Pan RY, Lin LC, Wang SH. Graded Association Between Preoperative Bone Mineral Density and Two-Year Postoperative Complications After Primary Total Hip and Knee Arthroplasty. J Arthroplasty. Published online August 24, 2026. DOI: 10.1016/j.arth.2026.08.032. PMID 42637029.

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Content prepared by: Tomasz Poboży - orthopaedic surgeon.

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