Bone quality used to be the problem orthopedic and spine surgeons dealt with after the hardware failed. In 2026, it moved to the front of the line.
Surgeons are ordering bone-density scans before they book the operating room. They also are establishing bone-optimization clinics and, in some cases, postponing elective procedures until a patient’s bone health improves. Medicare’s episode-based payment models are pushing the cost of fragility fractures and failed fixation back to hospitals and, soon, surgeons. Yet the infrastructure to find and treat at-risk patients still lags behind the clinical consensus.
Here are 10 things to know about bone health in orthopedics and spine in 2026:
1. Bone health is now a surgical prerequisite. Roughly 25% to 30% of patients presenting for spine surgery have osteoporosis, and many more have osteopenia, according to the National Spine Health Foundation. Becker’s named the shift one of 10 trends reshaping spine surgery in July. Surgeons at the Becker’s Spine, Orthopedic and Pain Management-Driven ASC + The Future of Spine Conference in June also ranked preoperative optimization and bone health among the themes defining the field’s next six months.
2. Some surgeons are pausing cases until the bone is treated. At New York City-based Hospital for Special Surgery, shoulder surgeon Gabriella Ode, MD, opens many surgical consultations by asking whether the patient has had a bone-density scan. Patients with untreated or unevaluated osteoporosis see the appropriate specialists before surgical planning resumes, she told Becker’s in June: “Bone health is a critical part of how we manage these patients.”
3. Bone-optimization clinics are showing up in outcomes data. Spine surgeons at Nashville, Tenn.-based Vanderbilt University Medical Center partnered with rheumatology and endocrinology to treat poor bone quality aggressively before complex deformity surgery. “Once we started the Bone Optimization Clinic, our complications significantly decreased,” Scott Zuckerman, MD, co-director of the Vanderbilt Spine Outcomes Lab, said.
4. Poor bone quality is being reframed as a driver of implant failure. A June 18 position statement in Osteoporosis International from the International Osteoporosis Foundation’s Fracture Working Group treats complications after joint replacement and spinal fusion as one outcome: implant fixation failure. It ties osteoporosis to periprosthetic fractures, loosening, subsidence, pseudarthrosis and junctional failure, and recommends routine perioperative bone assessment. Orthopedic surgeons Atahan Durbas, MD, and Sheeraz Qureshi, MD, made a similar case in the summer 2026 issue of Vertebral Columns, calling those complications costly and largely preventable.
5. The scope of the problem is bigger than the diagnosis rate suggests. One-third to one-half of patients presenting for instrumented spine procedures meet criteria for osteoporosis or osteopenia, Drs. Durbas and Qureshi wrote. Osteoporotic fractures occur more often in the spine than anywhere else, yet only about a third of vertebral fractures are ever clinically diagnosed, Rita Roy, MD, executive director of the National Spine Health Foundation, told Becker’s in September.
6. Screening is moving on to scans surgeons already order. Because dual-energy X-ray absorptiometry, or DEXA, scanners are not always available, some spine surgeons now assess bone quality using imaging collected for surgical planning. Dr. Durbas and Dr. Qureshi pointed to opportunistic CT, in which Hounsfield units at or below 110 to 120 are associated with osteoporosis, and MRI-based vertebral bone quality scores of 3.0 to 3.5 or higher, which signal elevated risk.
7. Anabolic drugs are the preferred preoperative approach. Agents that build bone — teriparatide, abaloparatide and romosozumab — are preferred before instrumented surgery, and teriparatide has the longest track record in spine fusion, Dr. Durbas and Dr. Qureshi wrote. They called pharmacologic treatment the most actionable step surgeons can take.
8. Most fracture patients still leave without a plan. Shannon Carpenter, MD, an orthopedic surgeon and founder of The Bone Health Clinic in Lenexa, Kan., estimated that 90% of patients leave the hospital after a fragility fracture “with no diagnosis and no follow-up.” A review in the Journal of Hand Surgery Global Online noted just 8% of Medicare beneficiaries with an osteoporotic fracture later received a bone mineral density test. Dr. Carpenter’s Demand the Scan campaign urges women to get a baseline scan around the time of their first mammogram, moving the conversation into midlife.
9. No department owns bone health — and that can create an operational bottleneck. Patients are referred among rheumatology, endocrinology, orthopedics and primary care, Dr. Roy said, and “these patients fall through the cracks. Pun intended.” Vincent Federico, MD, a spine surgeon with Bradenton, Fla.-based Coastal Orthopedics, said in October that endocrinology waits can exceed a year and many private orthopedic groups don’t offer bone optimization. Of roughly 20 hospitals he rotated through in training, only Rush University Medical Center in Chicago had a bone health program. Patients rarely know they have a problem until a wrist or hip breaks.
“It’s one of those diseases that’s silent until it’s not,” Dr. Federico said.
Programs that work, Dr. Durbas and Dr. Qureshi wrote, build a screening trigger into new-patient intake and a direct referral path to a bone health clinic, fracture liaison service or endocrinologist.
10. The business case is hardening as payment risk shifts. Under CMS’ Transforming Episode Accountability Model, mandatory for roughly 740 hospitals since Jan. 1, hospitals are accountable for the cost and quality of episodes including hip and femur fracture care. A new ambulatory specialty model will extend similar risk to individual spine and orthopedic surgeons starting in 2027. At Irvine, Calif.-based Hoag Orthopedic Institute, an American Orthopaedic Association Own the Bone Star Performer since 2015, CEO Kim Mikes, BSN, RN, said preventing repeat fragility fractures cuts readmissions and frees surgeon capacity for elective cases.
Policy is moving, too: In June, the American Medical Association adopted a policy backing physician education and broader insurance coverage for osteoporosis screening and treatment, citing an estimated 44 million Americans with low bone density.
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.
