Orthopedic and spine surgeons have spent the last decade tightening preoperative protocols for nearly every modifiable risk factor that affects surgical outcomes: diabetes control, smoking cessation, cardiac clearance and weight optimization. Some surgical risk-optimization programs now screen for as many as 13 separate conditions before clearing a patient for elective surgery.
Bone health is not yet reliably one of them, despite bone being, as Paul Anderson, MD, an orthopedic surgeon at the University of Wisconsin School of Medicine and Public Health in Madison put it, “our primary substrate we’re operating on.”
“It’s not inconceivable that poor quality bone is going to negatively impact our results, and that’s what the data certainly shows,” Dr. Anderson said. Studies on osteoporosis-related complications bear this out across orthopedic subspecialties — spine fusion, joint arthroplasty and even rotator cuff repair all show elevated complication rates in patients with poor bone quality, complications that can often be mitigated with treatment beforehand.
“You significantly reduce complications and improve outcomes when you treat patients in spine surgery for their osteoporosis preop,” Dr. Anderson said.
Yet unlike smoking or glycemic control, bone health optimization hasn’t become routine. According to Dr. Anderson, that’s going to change.
The barriers are structural, not just behavioral
Smoking cessation is “a binary thing,” Dr. Anderson said: A patient either quits or doesn’t. Bone health optimization is slower and more complicated, and several structural gaps are standing in the way.
Surgeons aren’t trained for it, Dr. Anderson said. Orthopedics is built around treating acute conditions, not managing chronic disease with prolonged treatment.
“We’re not used to treating medical conditions long term with medications,” Dr. Anderson said.
There aren’t enough specialists to refer patients to. Without an in-house bone health program, patients are typically referred to endocrinology or rheumatology — a process Dr. Anderson said takes six to nine months just to get an appointment, on top of another three to six months of treatment to reach a surgery-ready bone state. Compare that with diabetes, where blood sugar can often be brought under control in about three weeks.
Economics also discourages bone health optimization, he said. Osteoporosis medications, particularly injectable options, require prior authorization, a process Dr. Anderson said drives physicians away from prescribing altogether.
“There’s nothing that makes physicians hate medicine more than dealing with pre-authorization,” Dr. Anderson said.
Bone treatment can also disrupt high-volume workflows. Especially in arthroplasty, where practices are built around efficiency and case volume, adding a multimonth bone optimization pathway “throws a hiccup” into standard care flow, Dr. Anderson said.
Spine surgery got there first — arthroplasty is catching up
Bone health screening has become far more common in spine surgery than in joint replacement, and the reason comes down to the math on complications.
“Complication rates are magnified tenfold in the spine,” Dr. Anderson said. About 30% of the multilevel fusions his practice performs involve seven or more levels, and a meaningful share of the complications in those cases trace back to poor bone quality. That risk was stark enough that spine surgeons largely bought in and built dedicated programs.
Arthroplasty’s complication rates are lower in comparison, which has allowed many joint replacement practices to deprioritize bone screening. Arthroplasty’s high case volume makes adoption difficult, but Dr. Anderson expects bone health screening will eventually take hold within the field, pointing to the adoption of diabetes screening.
“It’d be almost malpractice to operate on somebody with out-of-control blood sugars,” he said. “So, we were able to adopt that, and [bone health screening] will be slowly adopted too.”
Two forces are likely to accelerate that shift. The first is sheer volume: An estimated 4 million patients per year will need hip and knee replacements by 2030, and studies show that a growing share of that population is expected to be osteoporotic. The second is growing awareness of periprosthetic fractures — breaks that occur around existing joint replacements. Dr. Anderson’s team studied 150 such fractures and found 97% of those patients met osteoporosis criteria, with most going undiagnosed and untreated for years before fracturing.
He said the cost of each fracture lands hard on hospitals operating under bundled payment models that penalize complications and readmissions within 90 days.
The model that works — and why it hasn’t scaled
The most effective delivery mechanism, according to Dr. Anderson, is the fracture liaison service, a dedicated bone health unit typically staffed by physician assistants and nurse practitioners, and embedded directly within an orthopedic department. Fracture liaison services were originally built to treat patients after a fragility fracture but have since expanded to preoperative optimization ahead of elective surgery.
Embedding the service inside orthopedics — rather than relying on outside referrals — gives it direct access to the patients who need it most and dramatically shortens the referral-to-treatment timeline. Dr. Anderson runs one such program at the University of Wisconsin.
Where a dedicated fracture liaison service isn’t feasible, some institutions have built alternative models. Rochester, Minn.-based Mayo Clinic, for instance, embeds endocrinologists directly inside orthopedic and spine clinics.
But fracture liaison services remain rare nationally, largely because they’re expensive to run and difficult to reimburse.
“The fracture liaison service, which would fix a lot of the osteoporotic access problems, [has] to be justified financially,” Dr. Anderson said.
At the Becker’s 32nd Annual Meeting: The Business and Operations of ASCs, taking place October 29-31 in Chicago, ASC leaders, surgeons and healthcare executives will explore strategies to drive growth, enhance operational performance, navigate reimbursement challenges and prepare for the future of ambulatory surgery. Apply for complimentary registration now.
