Fixated on Bone: Orthopaedic Bone Health Optimization

We sit down with Dr. Paul Anderson, a nationally recognized orthopaedic spine surgeon and longtime leader in bone health, to explain how bone fragility quietly drives pseudoarthrosis, hardware failure, periprosthetic fracture, and revision surgery across orthopaedics, including spine fusion, total hip and knee arthroplasty, shoulder procedures, and sports medicine repairs. Our goal is simple: help you make bone health optimization a normal part of elective surgical planning, not an extra task that never fits the schedule. 

We start by clearing up a common trap: relying on a DEXA T-score alone. Dr. Anderson walks us through a more operational definition of clinical osteoporosis that combines bone mineral density, fragility fracture history, and the FRAX 10-year fracture risk calculator. That broader view catches the patients who “do not look osteoporotic” on paper but still have fragile bone and higher risk of poor outcomes after surgery. 

From there, we lay out a step-by-step workflow you can actually run in clinic: who to screen, when to order DEXA, how to use imaging clues like CT Hounsfield units, and why orthopaedic surgeons should feel confident interpreting DEXA quality and results. We also cover how to build referral pathways using fracture liaison services, how to think about antiresorptive vs anabolic medications, and what timing looks like when you decide to delay surgery to improve bone strength. 

If you want fewer failures, fewer fractures, and more predictable fixation, bone health has to be part of the plan. Subscribe and share this with a colleague.

Transcript

Why Bone Health Is Now Urgent

SPEAKER_00 0:06

Many orthopedic traumatologists recognized early on that osteoporosis and poor bone health have devastating impacts on patients. Today, this is increasingly clear to spine, total joint, and even sports medicine orthopedic surgeons, all of whom are seeing increasing numbers of complications, including periprosthetic fractures and insufficiency fractures. That's why we're convening some of the leading voices in the bone health world to talk to orthopedists and their teams about the rationale for the orthopedic surgeon's growing interest in bone health, including tips and tricks for getting bone health programs integrated into practice and the evidence behind it all. I'm Andrea Spiker, a sports medicine and hip preservation surgeon at the University of Wisconsin, and I'll be your host for a special news series of the AOA Lessons in Orthopedic Leadership podcast called Fixated on Bone, which is brought to you by the AOA's Own the Bone Program. I'd like to introduce today's guest, Dr. Paul Anderson, one of the nation's leading orthopedic spine surgeons and longtime professor at the University of Wisconsin. He is a past president of both the Cervical Spine Research Society and the Lumbar Spine Research Society, and has been recognized with numerous national honors for his research, teaching, and leadership in spine surgery. Dr. Anderson has authored hundreds of scientific publications, contributed to major clinical guidelines, and is a frequent keynote speaker on surgical innovation, biomechanics, and quality improvement in spine care and bone health. We are thrilled to welcome Dr. Paul Anderson to the podcast. Well, Paul, welcome. Our episode today will focus on bone health optimization prior to elective orthopedic surgeries, which is something you've been a leading voice on for a very long time. So just to start our discussion today, can you please begin by giving a brief background on how you developed your passion for advocacy of orthopedic surgeons to take ownership of bone health?

SPEAKER_01 1:59

Well, like many things in my career, it started with research back in the 1980s. Actually, began to do research in how to improve stabilization of implants in osteoprotic bone. And then as new diagnostics became available, and more importantly, new treatments, I began to try to see how orthopedic surgeons could utilize these new tools to help our patients. Also, as a spine surgeon, uh it was clear to me that osteoporosis led to many bad outcomes in spine surgery, revision surgeries, and that perhaps we need to change the paradigm where we identify the osteoporosis early enough, perhaps do treatment for it to try to reduce the risk of those osteoportic bone-related complications.

Defining Osteoporosis Beyond DEXA

SPEAKER_00 3:00

Well, we're fortunate that you've taken this uh path and uh we can learn from your expertise. So to make sure that we're all on the same page, can you give us a working and operational definition of osteoporosis? What is osteoporosis in your mind?

SPEAKER_01 3:16

Yeah. Osteoporosis is in general the diminished bone mineral density and bone quality that results in increased bone fragility with a higher risk of fracture. Unfortunately, that is not a very good operational definition, but it's conceptually excellent. But for operational, uh, the definition really uh began to be important with the development of the T-score based on bone marrow density obtained from DEXA scans. And that's what most orthopedic surgeons would have learned is that we use a T-score. Unfortunately, that that misses many patients who have bone fragility and high risk for fractures, or what we're going to talk about later is high risk for poor outcomes from elective surgery. And so, more recently, uh a better definition has been developed that includes not only diminished bone mineral density as measured by DEXA T scores, but also a fracture history, because a fracture history of a fragility type fracture is indicative of bone fragility. And if it's involving the hip or spine, most guidelines automatically say you have osteoporosis, regardless of what your DEXA T score. And the third thing after bone mineral density and uh fracture history is your future fracture risk. Like any tool, it's hard to uh uh develop paradigms to measure fracture risk, but there has been one that's well accepted in the United States and worldwide, something called the FRAX, which is FRAX. And this gives you the 10-year probability of sustaining a hip or a major osteoportic fracture. And if you combine the uh T-score, the fracture history, and FRACS, then you have what's called a diagnosis of clinical osteoporosis. This is going to be much more operational for orthopedic surgeons to utilize. So we need to move off of the fact that uh a patient needs a T-score to make this diagnosis. That's not true. They need to show evidence of bone fragility based on their fracture history or have a high fracture risk based on this calculator.

SPEAKER_00 5:51

Well, that's excellent. Thank you. And a very helpful way to approach uh osteoporosis for the orthopedic surgeon. So, how would you describe the overall concept of bone health optimization?

What Bone Health Optimization Means

SPEAKER_01 6:03

Yeah, the idea of bone health optimization is to identify and correct uh skeletal health before and after elective orthopedic surgery. And what we're trying to do is a three-step process. First is to screen a patient to determine if they might have this disease. Second, to see if the disease is in as optimized condition as possible. And third, if it's not in an optimized condition, then get it optimized with the use of supplements, exercise programs, smoking secession, and ultimately medications. So again, it's the idea to identify people with uh deficits in their skeletal health, uh, uh evaluate how severe those deficits are and how they and estimate how they might affect your surgical results. And then finally, those patients who are at high risk uh get those people treated, hopefully before, and then uh the treatment would always continue after surgery as well.

SPEAKER_00 7:12

And what's the rationale behind bone health optimization prior to elective orthopedic surgery? I think this is based on research that you can give us some examples of.

SPEAKER_01 7:23

Yeah, in the spine surgery, the uh odds ratio of having an osteoportic bone-related complication, such as pseudoarthrosis, revision surgery, uh fracture, hardware failure, kyphosis, uh, any of those complications, the odds ratio if you're osteoprotic compared to non-osteoporosis ranged two to five fold. So you have two to five times chance. If you look at things like periposthetic fracture after total hip or total knee replacement, then the odds ratios are about 1.5 to 2 that an osteoprotic patient will have one of those complications relative to the non-osteoprotic patient. And you're controlling for medical comorbidities, age, and gender as well. So it's it does have a profound effect on our outcome. It also may change what our surgical plan is. For example, in the spine, if somebody has really poor bone quality, uh, I may alter my surgical technique, either not do as complicated a surgery. If I'm using hardware, maybe put more screws in, or cement augment the screws. The same way, if you have an osteoprotic patient who you're doing a total hip replacement on, it's probably gonna be prudent to use cement rather than a cementless technique to reduce the risk of periprostotic fracture and revision surgery.

How Poor Bone Drives Complications

SPEAKER_00 9:00

I'd like to just emphasize uh the importance of what you uh just spoke about. You know, nowadays we're thinking so much about outcomes of surgery, and we focus so much on you know patient-reported outcomes, surveys that we ask the patients, but really this bone health optimization can help not only our patients have better outcomes, but the surgeons themselves have outcomes that are more improved in the surgeries that we perform. So that's a it's a really important concept.

SPEAKER_01 9:31

Yeah, and it's uh it's across all of orthopedic disciplines, it's not just spine and maybe arthroplasty, whose patients tend to be older, but even sports medicine such as yourself, uh, you see that a lot of the complications that you have are are oftentimes related to poor bone quality. For instance, um rotator cuff repairs, where there's just literally no bone in the proximal humerus. There are studies that show optimizing bone health in that patient population will improve your fixation of your rotator cuff in the bone. The same way uh in total shoulder replacements, one of the complications they're seeing more and more with the reverse technique are acromial stress fractures, which are clearly related to the severity of the osteoporosis. And even in your field uh of hip preservation surgery, where you're talking about osteotomies, uh, you may have more hip failures or other stress type fractures that uh are going to be much more likely in the osteoportic than non-osteoprotic patient.

SPEAKER_00 10:43

And I think it's important you you mentioned some of these surgeries because you know, in sports medicine in particular, most of our patients are younger than the typical patient we think of having bone fragility, and yet it is a very uh pertinent, uh, you know, it's a very prevalent problem in uh in the surgeries that you mentioned. Uh so Paul, can you give us a step-by-step approach to how the orthopaedic surgeon can optimize bone health prior to surgery? So, how should practicing surgeons integrate this concept into their practice? How should we identify these patients who could benefit from bone health optimization?

Practical Screening With FRAX And Imaging

SPEAKER_01 11:26

Okay, you need to look at this as a quality improvement program. So this is it needs to be attacked at a system uh process in your own facility, hopefully within your own clinic, if it's a small clinic or if it's a bigger group, and then you have to engage more people. But it has to uh start with how do you identify the patient by screening? And uh a lot of people misconstrue this as I'm not saying that every patient needs to have a bone density test or see an endocrinologist before uh orthopedic surgery. Uh that's just an overuse of resources. But you can take a history, and if there is a history of fragility fractures after the age of 50, that is a red flag, and that patient probably would benefit from having a DEXA scan. There are already screening criteria that are used by primary care as well as a bone specialist for who should get a DEXA scan. It's very easy. It's women over the age of 65, men over the age of 70, history of a fragility fracture. If you have one of those three things, then you probably should think about their bone quality before attacking them surgically. Uh, and then finally, uh, I think uh trying to incorporate fracture risk using this fracks tool. It's a much more nuanced kind of approach, uh, but it uh can be done pretty easily in the office, uh, perhaps with uh MA or RN who works with you could calculate this for you and add that into your ARM inventarium of screening. Then finally, uh, we're used to looking at imaging studies like CT scans, MRIs, and plain x-rays. And you can look at these and try to assess yourself: does this look like the patient's osteoprotic? Plain x-rays, some of the key findings, for instance, around the pelvis is the door classification, which most orthopedic surgeons should be aware of. And those DOR-C patients who have large capacious canals with very thin cortices, those patients uh have about an 80% chance of being osteoprotic and would probably benefit from uh this process of pre-op optimization. That's just one example. There are other examples using CT, something called Hounsfeld units, which is uh most surgeons now are available are used to this, but you can do a region of interest on a CT scan and calculate how much uh the x-ray, it's called the x-ray attenuation coefficient, which is Hounsfeld units. And if that Hounsfeld units in the spine is less than 110, patient probably has osteoporosis and you should uh assess them. So that's the first step is get a process of screening that's going to work for you. Uh secondly, those patients who screen positive, go ahead and order a DEXA scan. Orthopedic surgeons should feel empowered to order a DEXA scan. We should be able to interpret DEXA scans. And if you don't feel comfortable as an orthopedic surgeon interpreting DEXA scans, then I would urge you to get more education about that. I realize it's not taught as part of our residency to the degree that we learn how to read, interpret CT or MRI, but it's something that is pretty easy to learn. And uh orthopedic surgeons should be facile in knowing the indications, interpreting, and interpretation of the results so that we can communicate to the patient and also would act as a red flag that we need to maybe get something done. And then finally, uh we need to be able to uh have a referral source to take care of those patients. I realize most orthopedic surgeons are not going to take care of the management of the bone health, but we should be developing relationships either within our community or our group where we have personnel who are available to take care of this. The AOA Own the Bone has really promoted this to get orthopedic practice groups to develop uh services called the fracture liaison service that can take this process on. And that would be a great source for anybody who has a group of orthopedic surgeons, probably 10 or more, could easily uh have someone like a physician's assistant or an APP in the practice group taking care of osteoporosis. That's what we have, and it's grown from one person, now we have like five people doing that uh at our university. So it's and it's very successful at providing the care needed to help the elective orthopedic patients aside from uh the fracture patients.

SPEAKER_00 16:36

Dr. Anderson, there are so many different options for treatment once a patient's been identified as at risk for bone health issues. So, how do you decide what type of medication or what treatment a patient should be uh given after they've been identified as at risk?

DEXA Skills And Referral Pathways

SPEAKER_01 16:55

Yeah. Well, there's general measures that that would be useful for all patients, such as uh making sure they have adequate vitamin D, calcium nutrition, protein, that type of things, avoiding harmful things like smoking. But in terms of the medications, remember there are two types of medications. There's the antiresorptives that prevent bone loss, and then there's the anabolics that promote bone formation. In the idea of bone health optimization, the anabolics are much faster at building up bone, so that they would be our preferred drugs for most of these patients. And uh how we decide that though is really based on accepted criteria, and it's due to uh it's it's uh determined by risk stratification. And we can risk stratify patients into low risk, which means they have uh bone marrow density that is greater than minus 2.5 T scores, they've not had fracture histories. Those patients don't need anything, uh no antiosteoproduct drugs. Then you have the osteopenic, or then you have, I'm sorry, the high-risk patients, and these are patients who've already had fragility fractures, uh, or they've had remote hip or spine fractures, let's say years ago, or they have a T-score less than minus 2.5, and those patients would be uh probably given as a first drug of choice would be an anti-resorptive type of medication. Although if the surgery is complex or they've already shown failure from hardware-related complications, then maybe an anabolic. And then there's the group that we really want to try to identify and get treated is the very high risk. And these are patients who have multiple fragility fractures in the past. They're on bone-harming drugs such as corticosteroids, anticonvulsants are the common ones. They have very low T-scores or less T-scores less than minus 3.0, very high fracture risk, let's say a major osteoporic fracture risk greater than 30, or a hip fracture risk greater than 5%, uh, or they're frequently falling because of underlying debilitation or degenerative neurologic diseases, then those patients would be definitely given an anabolic and have a delay of surgery.

SPEAKER_00 19:40

Paul, you mentioned fragility fractures a number of times. When you think about a patient's history of a fragility fracture, which fractures, which fractures are you referring to?

Choosing Medications By Risk Level

SPEAKER_01 19:50

Yeah. So first of all, uh this were the uh the language is uh undergoing a lot of changes. I go to bone meetings, there's a lot of controversy about using the word fragility. What exactly does that mean? And I think in simplest terms, it's low energy fractures where you wouldn't expect the patient to sustain a fracture. So this is most typically it's ground level falls. In the case of spines, many of those patients get it from coughing, sneezing, valsalving, or bending and lifting, and they'll they'll get a spine fracture. So those are low energy mechanisms, uh, is what we mean by fragility type fractures. Where uh I think it could be almost anywhere, I would kind of exclude the digits, but outside of that, uh it it could be obviously it's hip and spine are the predominant ones, but also proximal humerus, distal radius. But we're also seeing many more femoral shaft and particularly suprachondyl or the femur type fractures. And in fact, uh a lot of ankle fractures in older patients are uh the when we get in there to do surgery on them, I think we all remember trying to put a screw in a severe ankle fracture with uh bad osteoporosis is a challenging uh procedure to say the least.

SPEAKER_00 21:18

And when we recommend these patients get DEXA scans, what is the patient experience of a DEXA scan compared to, say, a CT or an MRI?

SPEAKER_01 21:29

Yeah. So a DEXA scan is a radiation. It's very low dose. There's less radiation in a DEXA machine or a DEXA in study than you get if you fly across the country. Uh and uh it's it's uh aligns with one day of our natural radiation dosage. So it's extremely low radiation, so the it's virtually harmless to the patient, and uh it takes about 20 minutes, uh To do. Most of it is getting the patient positioned correctly. The scans themselves only take 20 or 30 seconds. So, from their perspective, it's a pretty easy task, painless, of course, and safe. The problems with DEXA are they're not always reimbursed, and that's why you need to have justification when you order one that will suit whatever their insurance carrier is. And also there are a lot of errors in interpretation and the technologist, how they are done. And that's why you need to learn how to interpret every your own patient's DEXA scan, because there are quite a lot of errors. At our institution, we have a variety of practitioners who read DEXA, and our nuclear radiologists read them, and they average 30 seconds. And consequently, their error rate is much higher than other people's because they're just getting the work done based on pure numbers rather than looking at the images to make sure they're appropriately positioned. So it's again the onus is on orthopedic surgeons to learn how to interpret and read their own patients' DEXA scans.

SPEAKER_00 23:23

And you know, this I could see as a potential barrier to an orthopedic surgeon who's trying to optimize bone health for his or her patients. But what other barriers can you foresee that a surgeon who is attempting to go through these steps that you've outlined to, you know, include bone health optimization in their practice? Uh, what are some of those other barriers that they might encounter?

Barriers And Building A Bone Program

SPEAKER_01 23:48

Yeah. Well, um, the biggest one is frankly lack of uh personnel to refer to. Uh most patients, as I go around the country giving grand rounds at different universities and training centers, and I always ask, you know, how long does it get you, does it take to get a bone health consult in? It's like six to nine months on average. So we just do not have a uh uh an adequate number of practitioners. For instance, uh endocrinologists, uh, they're they're uh I think they're only at like 3,000 in the country, and um they're greatly understaffed, and uh they're just not available, particularly now. They're spending most of their time prescribing weight loss drugs. Uh, so it's even getting worse. Uh, and that's why I say uh you need to kind of build your own program. The uh other one is it is disruptive to your practice in that you have somebody who needs a hip replacement, but they have lousy bone. Uh, if you're gonna delay that for three months to improve their bone health, how's that gonna affect your case mix uh or your uh cases? A lot of surgeons are worried that by delaying surgery you're gonna be losing patients and uh having inadequate uh scheduling of cases for your um OR list. But those are a couple of biggest barriers. Then there's pre-authorization hassles if you if they do need medications, uh, which are uh very painful to say the least.

SPEAKER_00 25:30

So for the orthopedic surgeon who's listening to this podcast right now and is thinking they'd like to incorporate this into their practice, they're worried about some of these barriers you've just discussed. What resources do the AOA have to help them uh expedite the implementation of this into their practice?

SPEAKER_01 25:50

Yeah, the Own the Bone Program has invested a lot of time and resources into developing a website with a lot of learning modules, in particular, how to develop fracture liaison service programs and bone health optimization programs. Uh, they also have a APP boot camp who are really for those people who are utilizing fracture liaison service, these are the people, the boots on the ground, who are oftentimes going to deliver care. So they have a lot of educational material and a place where people can ask questions about how to do best practices. In addition, they have uh algorithms available on uh how to screen patients, how to work up patients, what kind of drugs you would use, under which condition, and they have even order sets that could be adopted. So there's a whole gamut of material that the AOA has. And then they have educational conferences such as webinars, and uh we have a monthly Echo conference, which is a educational format that uh is attended by many orthopedic surgeons and uh APPs who work in orthopedics for educational, and then they have a yearly symposium, and uh now bone health optimization is always one of the areas that is discussed at these kind of conferences.

SPEAKER_00 27:30

So a lot of resources, which is excellent, um, which leads into my next question. Do we have a sense of how widespread adoption of bone health optimization in orthopedics has affected the financial bottom line?

SPEAKER_01 27:47

Um well, uh that I can't, I don't know about the financial aspects in terms of are we saving money by doing this, by reducing complications, particularly in the first 30 days, where a lot of the reimbursement, particularly for hip and knee replacement, is in bundled care programs. So we haven't been able to tease that out. But we do know that if you can save a periprosthetic fracture from happening, uh, I think we can save like$15,000 per case. And obviously a periprosthetic fracture that requires reoperation hospitalization in the first 30 days is going to be big negative for those in a in these alternative payment plan programs. Exact numbers I I don't have uh at my fingertips. They're a little hard to get because so much depends on what your payer mix is. Uh, like at the University of Wisconsin, like half our patients are capitated, and so it's hard to calculate cost savings in a capitated system.

SPEAKER_00 28:57

Absolutely. But presumably, as you mentioned, I mean, if we're preventing a lot of these complications, then you know it it not only helps our patients, but also helps the financial bottom line, which is excellent.

SPEAKER_01 29:08

Yeah, I can give you an example of a study that was done out of Columbia and New York of major spine surgery. These were deformity patients, had seven or more levels fused. Uh, and they studied 544 patients, all of them had DEXA scans with a diagnosis of either osteoporosis, osteopenia, or normal. And then they looked at how many people had complications within two years. The osteoprotic patients were given six months of an anabolic type of drug, a PTH analog drug before surgery. The osteopenic were not given anything, and the normals, of course, were not given anything. But basically, the complication rate was normalized by the anabolic drug in the osteoprotic group. That means that the osteoprotic patients who were given pteraperitite had the same complication rates as the patients who had normal bone mineral density, whereas the osteopenic patients had twice to three times as high various complications compared to even the osteoprotic patients, but the osteoprotic patients were treated. So in spine surgery, you probably can easily show its benefit. The complications and total hip and knee again are going to be related to periposthetic fractures and revision surgery because these drugs do help incorporation of the porous ingrowth surface, and you might get better and faster incorporation and therefore less likely for loosening, things like that. But nobody's done a systematic study of the cost benefits of those.

SPEAKER_00 30:52

That's an impressive result from that spine study.

SPEAKER_01 30:55

Yeah.

SPEAKER_00 30:57

Now, you're seen as a leader on this topic, and you've given presentations all over the world on bone health optimization. So, in your experience, how has this concept been perceived among other orthopedic surgeons? And recently have you noticed a shift in the collective thinking on this issue?

SPEAKER_01 31:15

Yeah, I think the spine world, and this includes the neurosurgeons, and actually, the neurosurgeons buy into this even more than the orthopedic spine surgeons, to be honest, have really bought into this. And it is getting very common that uh patients are getting evaluated for their bone health and getting preoperative treatment before major fusion type surgeries, particularly those bigger uh multi-level type of fusions. Uh, it's been less well accepted by the total joint replacement uh community. Uh, they still have a ways to go. Uh they are uh you know very streamlined in trying to produce a consistent result and have had difficulty fitting bone health assessment and treatment into their optimization programs. They've done a great job of optimizing you know 10 to 15 conditions before you get a total joint, but it's been hard to get them to add in bone health.

SPEAKER_00 32:19

Uh well, uh Dr. Anderson, as we wrap up, do you have any final thoughts on the topic of bone health optimization as it applies to orthopedic surgeons' practices?

SPEAKER_01 32:34

Yeah, uh the one thing uh to mention is uh the big concern of surgeons is okay, if I'm going to do something like this, uh if a patient needs treatment, how long does that patient need to be treated before surgery uh to try to reduce the risk of complications? And this is uh a little bit of evidence-free zone here, but it is based on what we know about fracture risk after instituting these drugs. And we're starting, you see, a pretty rapid uh decrease in fracture risk at three months with these drugs, particularly the anabolic type drugs. So mechanically, it looks like we're beginning to see an effect at three months. Uh, and so I would say the delay, a good delay rule of thumb, is three months. However, if you're doing a higher risk type of surgery, like those multi-level spine fusions, six months clearly is probably going to be better. In the arthroplasty world, probably three months would be sufficient for most of those uh patients. But also you can modify the techniques, such as if you've identified somebody's got pretty bad osteoporosis, you really need to think about using cement, for instance, rather than a cementless technique.

SPEAKER_00 33:59

Well, Dr. Anderson, thank you so much for being a guest on the Fixated on Bone Podcast. It's truly been an honor having you, and we really appreciate you sharing your expertise on bone health optimization with us today.

SPEAKER_01 34:12

Yeah. Well, thank you. It's been a pleasure talking to everybody. And uh uh remember, bone health is part of uh what we need to assess. It's not just looking at the disease we're treating, such as arthritis or spinal stenosis, but we also have to include assessment of what their bone health is in all of our patients, not pr not even just our operative ones, but we can really help a patient even if we're not going to operate on them by getting their bone health addressed if needed.

SPEAKER_00 34:47

Well, thank you again. Thank you for joining us, and we hope you'll tune in to our next episode of the AOA Own the Bones Fixated on Bone Podcast.