Review article
Osteoporosis and shoulder osteoarthritis: incidence, risk factors, and surgical implications

https://doi.org/10.1016/j.jse.2012.05.029Get rights and content

Background

Patients with osteoarthritis undergoing shoulder arthroplasty may suffer from osteoporosis. The purpose of this study was to determine whether computed tomography (CT)-derived Hounsfield unit (HU) measurements correlate with bone mineral density (BMD) and whether these data could predict implant size and fixation choice.

Materials and methods

The study analyzed preoperative dual energy x-ray absorptiometry and shoulder CT scans for 230 patients who underwent total shoulder arthroplasty. Hip BMD and T scores and HU attenuation in the humerus were correlated. HU cutoff values were developed to aid in differentiating patients whose BMD values were within normal reference ranges from patients with osteopenia or osteoporosis. Risk factors associated with low BMD were correlated, and the effect of BMD on humeral stem size, and fixation method was investigated.

Results

Significant correlations between HU and hip BMD and T score were identified (P < .001). HU value ranges were identified that may alert the surgeon of metabolic bone disease. Significant correlation (P < 0.05) was found between low BMD and certain osteoporosis risk factors. Age at time of surgery was a predictor of cemented stem fixation (P = .024). Patients with a lower BMD were statistically more likely to receive a larger-diameter humeral stem (P = .016).

Conclusions

Orthopedic surgeons may be able to use data obtained from shoulder CT scans to predict the need for larger stem size or cement fixation during shoulder arthroplasty. In combination with the risk factor profile, these data may be useful in predicting the need for an osteoporosis workup and treatment.

Section snippets

Materials and methods

Data from 2004 to 2010 were prospectively collected for 230 patients undergoing anatomic TSA at our institution. Patients who had undergone TSA for primary osteoarthritis of the shoulder and had preoperative DEXA and shoulder CT scans were candidates for inclusion in the study. Patient informed consent was waived.

Previously described radiographic criteria were used for the diagnosis of shoulder osteoarthritis, including joint space narrowing with osteophytes, subchondral sclerosis, and cyst

Results

Our 230 patients (155 men, 75 women) were a mean age of 68.2 years (range, 27.5-86.7 years). BMD values were significantly lower in women (0.89 ± 0.14 g/cm2 [mean ± standard deviation]) than in men (0.98 ± 0.14 g/cm2; P < 0.001). Bone density was classified as normal in 104 patients (45%). Of the 126 who exhibited abnormal bone density, 98 were osteopenic (43.6%) and 28 were osteoporotic (12.2%). Only 7 of the 28 osteoporotic patients (25%) were aware of their diagnosis and undergoing treatment

Discussion

Osteoporosis and shoulder arthritis can coexist,1, 4, 8, 11, 16, 20 and many of these patients are not aware of their coexisting diagnosis and risk for fragility fractures.7, 19, 21, 28 This point is made clear by our study findings: 75% of the osteoporotic patients were unaware of their coexisting metabolic disease and were subsequently referred for treatment after their preoperative workup. A number of additional studies have shown that osteoporosis is under-diagnosed and under-treated.6, 9

Conclusion

The present study suggests that orthopedic surgeons may be able to apply readily available data obtained from shoulder CT scans to predict the stability of humeral stems in patients diagnosed with osteoarthritis and undergoing TSA. In addition to preoperative planning, study results indicate that shoulder CTs may be of diagnostic value because they can be used to screen patients for metabolic bone diseases, such as osteoporosis, at no additional cost to the patient. These data, as well as the

Acknowledgment

The authors thank Rachel Clark and Chris Williams for their assistance with this project.

Disclaimer

The research foundation that employs Dr Santoni (Foundation for Orthopaedic Research and Education) received research support from DJO Surgical in the form of a research grant. Dr Frankle is a consultant for DJO Surgical and has received payment for lectures, including service on speaker's bureaus. Dr. Frankle has patents with DJO Surgical from which he has received royalties that are related to the subject of this work. The other authors, their immediate families, and any research foundations

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      In addition, implant information (anatomic vs. reverse, stemless vs. regular stem, need for cement, etc), intraoperative complications, and any alterations to standard surgical technique due to bone quality were recorded. At the conclusion of the study period, a blinded reviewer measured bone quality via Hounsfield Units (HUs) from the preoperative CT scans in a method previously described by Pervaiz11. First, the distance from the superior humeral head to surgical neck was measured on coronal images using SECTRA PACS (Linkoping, Sweden).

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    The Western Institutional Review Board, 3535 7th Ave SW, P.O. Box 12029, Olympia, WA 98502-5010, USA, approved this study (Study No.: 1129467) on Jan 6, 2012.

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