Osteoporosis is the most commonly reported metabolic bone disease in the USA and worldwide, affecting both males and females of all races¹⁾. As the estimated total economic burden for direct treatment of osteoporosis in the US, Canada, and the European Union alone was between 5,000 and 6,500 billion USD, projections of increasing prevalence of osteoporosis will lead to an exponential increase in financial burden on healthcare systems²⁾. Coexistence of osteoarthritis with osteoporosis, a common geriatric musculoskeletal condition, has been frequently reported³⁾ and the incidence has shown a continuous increase^4,5). Total hip arthroplasty (THA) can be regarded as a suitable treatment option in cases involving end stage arthritic changes, and when conservative non-operative management of the condition has failed⁶⁾.

THA is included in the top five most commonly performed procedures across all disciplines in the United States, and in the top five procedures showing a rapid increase each year^7,8). With the increasing number of THA procedures performed, it is expected that the number of associated perioperative complications such as periprosthetic fractures (PPFs), aseptic loosening, and periprosthetic joint infection will also increase^9,10). In addition, several studies have reported that osteoporosis is commonly diagnosed among THA candidates, particularly elderly patients^11-13). In addition, osteoporosis has been reported as a potential risk factor for failure of THA¹⁴⁾. Thus, osteoporosis can have a substantial impact on the outcomes following THA and attaining a better understanding of the prevalence and management of the condition among patients included in this population remains critical.

Thus, in this manuscript the objective is to provide a critical review of the literature as an attempt to better clarify the prevalence of osteoporosis and osteopenia among THA recipients, provide an in-depth estimation of the impact on outcomes, and highlight potential relevant medical and surgical considerations in the effort to minimize potential complications and improve outcomes.

Higher prevalence of osteopenia and osteoporosis, degenerative bone disorders, has been reported in the geriatric population^15,16). With the estimated number of THA procedures performed annually reaching 572,000 by 2030¹⁷⁾, an increase in the number of patients undergoing osteopenic and osteoporotic THA is also expected. A large meta-analysis conducted by Xiao et al.¹⁸⁾ reported that 64% of candidates for total knee or hip arthroplasty had osteopenia/osteoporosis. In addition, a retrospective study conducted by Delsmann et al.¹⁹⁾ reported that 18% and 41% of patients who underwent THA were diagnosed with osteoporosis and osteopenia, respectively. Of particular interest, the authors reported that 73% of patients with osteoporosis were undiagnosed prior to surgery, and therefore did not receive appropriate treatment or optimization¹⁹⁾. Similarly, Watanabe et al.¹³⁾ reported an osteoporosis rate of 13.3% and a rate of 61.3% for osteopenia or osteoporosis with only 22.1% receiving pharmacologic treatment in a cohort of 398 THA recipients.

As osteoporosis could increase the risk of revision THA with an increased rate of aseptic loosening, implant migration, and PPFs^20-25), and as the number of revision procedures is projected to increase by 70% in 2030 from numbers reported in 2014^8,17), proper screening, management, and treatment of osteoporosis before the procedure remains critical. Multiple methods and scoring systems have been developed for osteoporosis screening, including the use of tools designed to account for patient-specific and demographic factors such as the osteoporosis screening tool for Asians²⁶⁾. While the Qfracture and Garvan fracture risk calculator are both validated tools for prediction of osteoporotic fracture risk²⁷⁾, the fracture risk assessment tool (FRAX) score is still the most commonly used tool. In a recent retrospective analysis, Wang et al.²⁸⁾ examined the relationship between the type of osteoporosis treatment and fracture risk among patients undergoing total joint arthroplasty. The authors reported that 90% of high-risk patients received no pharmacological treatment and 88% of the cohort did not undergo adequate perioperative bone density testing²⁸⁾. Dual energy X-ray absorptiometry (DXA) is still regarded as the gold standard for screening high-risk patients, including females aged 65 and older, males aged 70 and older, and individuals with previous fragility fractures²⁹⁾ and a diagnosis of osteoporosis³⁰⁾. However, with the increased incidence of osteoporosis in young adults³¹⁾, screening may sometimes be required for males and females younger than 65. The importance of performing a thorough preoperative assessment for osteoporosis using tools for screening osteoporosis such as DXA before applying tools for predicting the risk of osteoporotic fracture such as FRAX should be noted.

Low bone mineral density (BMD) has been reported to affect postoperative outcomes in patients undergoing THA. Commonly studied complications include the risk of PPFs and revision rates. Fiedler et al.³²⁾, who compared these complications in osteoporotic and non-osteoporotic patients, reported an increased rate of PPFs (6.5% vs. 1.0%; P=0.04) as well as a higher revision rate (7.5% vs. 1.5%; P=0.04) in patients with low BMD. Similarly, Holzer et al.³³⁾ reported a significant correlation between the FRAX and PPFs after THA. Other studies reported higher rates of revision, as well as postoperative surgical and medical complications, aseptic loosening, perioperative fracture, and implant migration in osteoporotic patients undergoing THA^20-25). In addition, Zhu et al.³⁴⁾ reported a positive correlation of intraoperative blood loss with the BMD of the greater trochanter. Fragility fractures, which are considered the main clinical consequence of osteoporosis, can have a substantial impact on outcomes of THA. Ross et al.³⁵⁾, who examined outcomes for patients with a fragility fracture sustained within three years prior to undergoing THA, reported an increased risk of PPFs, additional fragility fractures, and all-cause revision THA at one and two years postoperatively compared to a control cohort.

Consequently, considering the substantial cost burden, complications, morbidity, and mortality of these conditions, perioperative optimization of osteoporosis and osteopenia should be a priority.

Radiographic assessment of the appearance of bone around the prosthesis, in the Gruen zones, can be performed to determine the loss of BMD (Fig. 1)³⁶⁾. A suboptimal periprosthetic BMD may contribute to development of postoperative complications such as PPF and aseptic loosening, subsequently leading to increased revision rates and affecting functional outcomes. Therefore, the incidence of complications can be minimized with appropriate medical and surgical management.

Figure 1. Gruen zones used in DXA analysis of periprosthetic BMD. Adapted from the article of Alm et al.³⁶⁾ (Acta Orthop. 2009;80:531-7) under the terms of the Creative Commons Attribution NonCommercial NoDerivatives 4.0 International (CC BY-NC-ND 4.0) license. DXA: X-ray absorptiometry, BMD: bone mineral density.

1. Medical Considerations (Table 1)

Table 1 . Studies Exploring the Use of Medical Therapy in Osteoporotic Patients Undergoing Total Hip Arthroplasty.

Drug	Study	Cohort/study design	Timing of the drug	Results
Zoledronate	Scott et al.38) (2013)	Randomized controlled trial 51 patients undergoing cementless THA. 27 received an intravenous infusion of zoledronate 5 mg. 24 received saline.	14 days and at 1 year postoperatively	Postoperative zoledronate reduced BMD loss, in all Gruen zones at 6 weeks, 6 months, 1 year, and 2 years postoperatively.
	Gao et al.39) (2017)	Meta-analysis of 4 studies		Postoperative zoledronate reduced BMD loss in Gruen zones 1, 2, 4, 6, and 7.
	Zhou et al.37) (2019)	Randomized controlled trial 32 patients undergoing cementless THA. 16 patients received only basic treatment (oral calcium carbonate 1,200 mg/day and calcitriol 0.50 μg/day). 16 patients received an intravenous infusion of 5 mg zoledronic acid in addition to the basic treatment.	5-7 days postoperatively	Postoperative zoledronate can reduce BMD loss in Gruen zones 1, 4, 6, and 7 at 6 months and in zones 1, 2, 4, 6, and 7 at 12 months postoperatively.
	Liu et al.40) (2021)	Meta-analysis of 6 studies		Postoperative zoledronate reduced BMD loss in Gruen zone 7 at 3, 6, and 12 months postoperatively, increased the Harris hip score at 6 months and 12 months.
Risedronate	Li et al.48) (2018)	Meta-analysis of 5 studies		Postoperative risedronate increased BMD in Gruen zones 1, 2, 3, and 7, and improved Harris hip score.
	Su et al.47) (2018)	Meta-analysis of 6 studies		Postoperative risedronate increased BMD in Gruen zones 1, 2, 6, and 7 at 3 months postoperatively, in all Gruen zones at 6 and 12 months postoperatively, and the Harris hip score.
Denosumab vs. risedronate	Nakura et al.49) (2023)	Randomized controlled trial 51 patients undergoing cementless THA. 40 patients received 60 mg of subcutaneous denosumab. 42 patients received 17.5 mg of oral risedronate.	Denosumab: postoperative day 1 and every 6 months for 2 years Risedronate: postoperative day 3 and weekly thereafter for 2 years	Higher BMD in Gruen zones 1, 2, 6, and 7 at all the studied timepoints in the denosumab group.
Alendronate vs. alendronate+vitamin D	Iwamoto et al.50) (2014)	Randomized controlled trial 64 patients undergoing cementless THA. 20 patients received alendronate 5 mg/day. 22 patients did not receive anything. 22 patients received both alendronate (5 mg/day) and alfacalcidol (1 mg/day).	Postoperative day 1	Both effective in preventing periprosthetic BMD loss especially in the proximal femur with no difference between the cohorts.
Alendronate vs. teriparatide	Kobayashi et al.51) (2016)	Randomized controlled trial 46 patients undergoing cementless THA. 16 patients received subcutaneous daily injection of teriparatide (Forteo 20 μg/day). 14 patients received oral weekly administration of alendronate (Bonalon 35 mg/week). 16 patients received nothing.	Postoperative week 2 and continuing until week 48	No difference in BMD loss prevention was seen between both groups.
Alendronate+teriparatide	Morita et al.46) (2020)	Randomized controlled trial 48 patients undergoing cementless THA. 14 patients received daily injections of 20 μg/day teriparatide (Forteo; Eli Lilly Japan K.K.), beginning 2 weeks after THA and continuing for 1 year. These patients were subsequently switched to oral administration of ALD (35 mg/week) continuously for 1 year. 12 patients received oral weekly administration of alendronate (35 mg/week) for 2 years. 15 patients received nothing.	2 weeks postoperatively	Switching therapy had a significant effect on BMD of the lumbar spine and zones 1 and 7 at 2 years postoperatively. At zone 1 in particular, it was found to be more effective than ALD alone.
Preoperative anti-osteoporotic drugs	Prieto-Alhambra et al.54) (2014)	A retrospective cohort study was conducted within the Danish nationwide registries.		Preoperative bisphosphonates decreased revision rate and showed better implant integration when compared to a drug-naïve control group.
	Ross et al.35) (2021)	A propensity score-matched retrospective cohort study was conducted using a commercially available database.		No difference in postoperative outcomes whether or not anti-osteoporosis drugs were used.
	Jeong et al.52) (2023)	A retrospective review of a national administrative claims database was conducted.		Preoperative bisphosphonates increased risk of periprosthetic fractures and revision rates when compared to a drug-naïve control group.

THA: total hip arthroplasty, BMD: bone mineral density, ALD: alendronate..

Antiresorptive drugs such as bisphosphonates are beneficial in management of osteoporosis and prevention of fragility fractures, and multiple studies analyzing their impact on prevention of periprosthetic decline of BMD have been reported. Zhou et al.³⁷⁾, who compared periprosthetic BMD in patients who received postoperative zoledronate with a control group of patients who received calcitriol, reported slowing of the decline of BMD in Gruen zones 1, 4, 6, and 7 at six months postoperatively and in zones 1, 2, 4, 6, and 7 at 12 months in the study group compared with control. Scott et al.³⁸⁾ reported similar findings demonstrating reduced BMD loss, with improvement in all Gruen zones at six weeks, six months, one year, and two years. In a meta-analysis that included four studies, Gao et al.³⁹⁾ reported a reduction of BMD loss in Gruen zones 1, 2, 4 ,6, and 7 with administration of zoledronate. In addition, in a more recent meta-analysis analyzing six randomized controlled trials, Liu et al.⁴⁰⁾ reported a reduction in BMD loss in Gruen zone 7 at three, six, and 12 months postoperatively and an increase in the Harris hip score at six and 12 months with administration of zoledronate. Lee et al.⁴¹⁾ conducted a retrospective study that included 167 patients who underwent cementless hip arthroplasty, 68 of whom were treated with zoledronate while the other 99 were not, as an attempt to examine the impact of zoledronate on stem subsidence. Their findings showed no difference in occurrence rates of stem subsidence between the two groups⁴¹⁾. By contrast, Friedl et al.⁴²⁾ reported that a single infusion of zoledronate was effective in reducing the migration of cups in both the transverse and vertical directions, while only a trend toward decreased stem subsidence was observed. In their review, Karachalios et al.⁴³⁾ also reported that local treatment with alendronate prior to implant insertion resulted in increased osseointegration (at four weeks)^43,44), and that administration of a single systematic intravenous dose of zoledronic acid resulted in increased bone ingrowth (six weeks) within the pores of tantalum implants in a canine ulnar model^43,45). In addition, Morita et al.⁴⁶⁾ reported that administration of teriparatide postoperatively and switching to alendronate one year postoperatively resulted in increased BMD around the implant in zones 1 and 7.

While extensive assessment of zoledronate has been conducted, and given that associated flu-like symptoms are a known side effect of the medication, the impact of other bisphosphonates on BMD has been examined. In a meta-analysis of six randomized controlled trials, Su et al.⁴⁷⁾, who compared periprosthetic loss of BMD with risedronate, observed increased BMD in Gruen zones 1, 2, 6, and 7 at three months and in all Gruen zones at six and 12 months postoperatively. The authors also reported a significant increase in the Harris hip score when compared with the control group⁴⁷⁾. Similar findings were reported in another meta-analysis, with aa significant increase in BMD in Gruen zone 3 instead of 6⁴⁸⁾. Nakura et al.⁴⁹⁾, who compared another antiresorptive drug, denosumab, with risedronate, reported higher BMD in Gruen zones 1, 2, 6, and 7 at all studied timepoints in the denosumab group. Iwamoto et al.⁵⁰⁾ evaluated the addition of vitamin D to anti-osteoporotic medication to determine the effectiveness of alendronate when combined with active vitamin D. The authors reported on the effectiveness of alendronate, whether alone or in combination with vitamin D, in preventing periprosthetic loss of BMD, particularly in the proximal femur, and no significant difference was observed between the groups⁵⁰⁾. In addition, a study comparing teriparatide, an anabolic anti-osteoporotic agent, with alendronate reported no difference in their efficacy in reducing periprosthetic loss of BMD⁵¹⁾.

Fewer studies have examined the impact of preoperative bisphosphonates in elective THA on outcomes, and the literature remains controversial. Jeong et al.⁵²⁾ reported a significant increase in the risk of PPFs and revision rates with intake of preoperative bisphosphonates when compared with a naïve-control group. In a meta-analysis, Shi et al.⁵³⁾ reported that significant long-term efficacy was achieved in preservation of periprosthetic BMD after joint arthroplasty with use of bisphosphonates. However, Prieto-Alhambra et al.⁵⁴⁾ reported that use of bisphosphonates preoperatively resulted in a lower revision rate and better implant integration. Another study by Ross et al.³⁵⁾ reported no difference in postoperative outcomes with preoperative administration of anti-osteoporotic medication.

Therefore, comparable effectiveness of postoperative anti-osteoporotic drugs in prevention of periprosthetic loss of BMD has been reported throughout the literature. Thus, administration of these antiresorptive drugs after THA can be recommended for osteoporotic patients. Clear recommendations regarding preoperative treatment with bisphosphonates remains controversial based on currently available evidence. With bone remodeling and the known risk of subsequent femoral pathologic fractures associated with extended duration of bisphosphonate treatment, conduct of additional study will be required in order to determine the optimal timing and duration of preoperative treatment prior to THA.

2. Surgical Considerations (Table 2)

Table 2 . Studies Exploring the Use of Surgical Techniques in Osteoporotic Patients Undergoing Total Hip Arthroplasty.

	Study	Cohort/study design	Results
Cement	Yang et al.60) (2019)	Retrospective analysis with 5-year follow-up of prospectively gathered data eligible for study: 306 (184 cemented vs. 182 uncemented) After follow-up: 104 cemented vs. 85 uncemented analyzed	Uncemented femoral implants had higher rates of prosthetic loosening (P=0.027) and revision rate (P=0.028) when compared to cemented stems.
Stem design	Li et al.72) (2007)	Retrospective analysis of patients from 3 prospective studies 83 patients with cemented THAs	Cobalt-chrome stems are associated with more periprosthetic BMD loss than titanium-composed stems.
	Sano et al.70) (2008)	Retrospective analysis 62 patients (65 hips) in whom surgery was performed at least two years before the present study.	A straight tapered stem with porous plasma spray coating on the proximal quarter was shown to produce minimal stress shielding with an early decrease in BMD that was recovered at 12 months postoperatively when compared to a fluted, tri-slot stem with porous hydroxyapatite coating on the proximal third where BMD loss was not recovered.
	Wu et al.69) (2019)	Prospective analysis 41 patients who had undergone primary unilateral THA with the Ribbed anatomic cementless stem	The ribbed anatomic stem shows BMD loss in Gruen zones 4 and 5. However no BMD decline in the proximal region was reported.
	Djebara et al.71) (2022)	Prospective analysis 93 patients who underwent THA with a short stem (46 patients, Vitae stem; 47 patients, Optimys)	OptimysTM stem had higher BMD in Gruen zones 2, 6, and 7 when compared to the VitaeTM stem. In overall BMD, there was no difference between the 2 designs.
	Liu et al.73) (2022)	Retrospective cohort study 138 patients who underwent THA (45, 49, and 44 Summit, Trilock, and Corail stems resp.)	No difference between the Summit, Trilock, and Corail stems in terms of periprosthetic BMD loss.
Stem alignment	Fujita et al.74) (2023)	Retrospective study 42 patients (50 hips) who underwent total hip arthroplasty using a cementless Polarstem	Stems in varus position leads to a BMD loss in Gruen zone 1 higher to non-varus placed stems.
Stemless hip implant	Munting et al.75) (1997)	Prospective longitudinal study 32 hips in 31 patients who underwent THA	Increased BMD due to absent stress shielding phenomenon.
Acetabular liner	Kim et al.77) (2017)	Prospective study 50 patients (100 hips) who had undergone bilateral simultaneous primary total hip replacement	No difference in periprosthetic BMD loss between alumina ceramic liners and ultra-high-molecular-weight polyethylene liners.
Press-fit Acetabular cup	Pakvis et al.78) (2016)	Single-center prospective cohort 25 patients (18 females) in whom a cementless elastic press-fit socket was implanted	Press-fit acetabular cup does not prevent stress shielding and results in acetabular periprosthetic BMD loss.
Femoral rasping	El-Daly et al.76) (2020)	Prospective study Four cadaveric femurs were selected to undergo a rasping procedure.	In cadaveric femurs, femoral rasping increased BMD in the applied areas.
Stem-coating with zoledronate	Peter et al.79) (2006)	Prospective study Twenty-five female 6-month-old Wistar rats were ovariectomized 6 weeks before the implantation to induce osteoporosis.	Zoledronate-coated implants showed significantly higher maximal pullout force when compared to non-coated implants.
	Gao et al.80) (2009)	Prospective study 40 rats randomly assigned into four groups (control, pamidronate, ibandronate, and zoledronic acid)
Stem-coating with calcium phosphate with platelet rich plasma	Sun et al.81) (2021)	In vivo study	Increased maximal push-out force in the group treated with calcium phosphate with platelet rich plasma compared to the control group.
Stem melted with large area electron beam	Goriainov et al.82) (2018)	In vivo study	When compared to the control group, the group with the treated stem showed a significant increase in osteogenic activity which correlated with a higher surface roughness.
Stem-coated with Hydroxyapatite	Tezuka et al.83) (2020)	Randomized controlled trial 52 patients who underwent primary THA were randomly allocated to HA and non-HA groups.	No effect on periprosthetic BMD loss prevention was seen when stems coated with hydroxyapatite when compared with non-coated stems.

THA: total hip arthroplasty, BMD: bone mineral density..

Given the higher risk of PPFs in cases of osteoporosis and osteopenia, and with uncemented stems considered a risk factor for PPFs, there is renewed interest in use of cemented femoral components within the arthroplasty community^55,56). Preparation of the femoral canal for stems that rely on cementless fixation requires successive broaching for achievement of a tight fit, imposing a high risk of intraoperative fracture of the osteoporotic bone. In addition, insertion of a cementless stem with a tight fit places high stress on the receiving brittle osteoporotic bone, increasing the potential for development of intraoperative fractures. Similarly, as cementless fixation is dependent on osseointegration of the femoral component, osteoporotic patients have a theoretical disadvantage, although this has not been confirmed in the literature^57-59). By contrast, preparation of the canal and stem insertion for a cemented femoral component requires less aggressive broaching and lower generation of hoop stress during the insertion process, and thereby theoretically poses a lower risk of intraoperative PPF. Therefore, current general recommendations support utilization of cemented femoral stems in treatment of osteoporotic and elderly patients. In addition, Yang et al.⁶⁰⁾, who compared cemented to cementless THA, reported higher rates of prosthetic loosening (P=0.027) and revision surgery (P=0.028) for the cementless prosthesis.

By contrast, a recent retrospective cohort study reported an association of cemented femoral fixation with significantly fewer short-term PPFs; however, the numbers of unplanned readmissions, deaths, and postoperative complications were greater compared with cementless femoral fixation in patients undergoing elective THA⁶¹⁾. A prospective study on THA in patients over 80 years with a fracture of the neck of the femur reported an association of cementless THA with significantly less surgical time, blood loss, transfusion rates, and hospital stay. By contrast, a significantly high number of deaths was observed during the perioperative period in patients undergoing cemented THA. However, the two groups showed similar overall mortality rates, complications, and functional and radiological results⁶²⁾. In addition, a recent prospective cohort study reported an association of cemented femoral stems with a higher risk of pulmonary embolism, particularly among patients with a high body mass index⁶³⁾. Some cases of delayed osteotomy union due to leakage of cement into the osteotomy gap have also been reported⁶⁴⁾. Such complications should be considered when selecting the appropriate implant.

Given the continued progress and evolution in development and design of cementless femoral stems, conduct of future research to examine the long-term outcomes and revision rates for these components in comparison with cemented femoral stems will be needed. Following primary THA, bone remodeling around the prosthesis can lead to loss of BMD, a phenomenon reported with use of various stem designs. The degree of periprosthetic decrease of BMD is impacted by stem and patient specific factors, thus there is wide variability^65-67). In addition, a continuous impact on fracture risk must be assumed as bone loss can continue into the third decade postoperatively⁶⁸⁾. Thus, to avoid potential complications, critical consideration of prosthesis design and intraoperative techniques is required in treatment of osteoporotic patients.

Regarding stemmed prosthesis, stem designs can be modified to reduce the likelihood of decreasing periprosthetic bone density. Wu et al.⁶⁹⁾, who assessed the ribbed anatomic stem, reported loss of BMD in Gruen zones 4 and 5 with no decline of BMD in the proximal region when compared with the contralateral non-operative side. The authors ascribe this finding to the expected stress shielding caused by the design of the prosthesis. Sano et al.⁷⁰⁾ compared BMD loss between a straight tapered stem with a porous plasma spray coating on the proximal quarter and a fluted, tri-slot stem with a porous hydroxyapatite coating on the proximal third aspect. Use of the straight tapered stem resulted in minimal stress shielding with an early decrease in BMD that was recovered at 12 months postoperatively compared with the other stem where loss of BMD was not recovered, which was explained by distal fixation⁷⁰⁾. Another study by Djebara et al.⁷¹⁾ examining the Optimys^TM (Mathys) stem with an anatomical medial curvature designed to rest against the calcar, reported minimal stress shielding when compared with the Vitae^TM (Adler Ortho) stem with no medial cortical contact. The authors reported a higher BMD in Gruen zones 2, 6, and 7 when using the Optimys^TM stem; however, no difference in the overall BMD was observed between the two stems⁷¹⁾. Regarding stem composition, cobalt-chrome stems were found to be stiffer and therefore associated with greater periprosthetic loss of BMD than titanium-composed stems⁷²⁾. In addition, Liu et al.⁷³⁾, who compared periprosthetic loss of BMD using three different stems, reported no difference between the Summit (DePuy Orthopedics), Trilock (DePuy Orthopedics), and Corail stems (DePuy Orthopedics). Stem alignment is also important and a varus position could lead to a decrease of BMD in Gruen zone 1 due to a shift of the mechanical loading to the medial calcar sparing the lateral femoral aspect⁷⁴⁾. However, the stem choice depends primarily on the shape of the intra-medullary canal and thickness of cortical bone.

Other prosthetic designs can also affect periprosthetic decline of BMD. Munting et al.⁷⁵⁾, who studied the change of BMD around stemless hip implants, reported increased BMD due to the absence of stress shielding in these stems. In addition, in a cadaveric study, El-Daly et al.⁷⁶⁾ assessed femoral rasping using a micro-computed tomography scanner and BMD values were measured before and after rasping. The authors reported an increase in BMD in areas where rasping was applied. Another study examining the effect of acetabular liners on loss of BMD in the femur and acetabulum reported that no difference was observed between alumina ceramic liners and ultra-high-molecular-weight polyethylene liners⁷⁷⁾. In addition, Pakvis et al.⁷⁸⁾ reported that usage of a press-fit acetabular cup would not prevent stress shielding and could therefore result in acetabular periprosthetic loss of BMD. However, given the high rate of success reported with use of cementless acetabular components, with rare occurrence of acetabular PPFs, press-fit acetabular components are still regarded as the gold standard.

Stem coating with different products is another method for improving prosthesis stability and reducing postoperative complications in osteoporotic patients undergoing THA. In fact, stem-coating with zoledronate^79,80), platelet-rich-plasma and calcium phosphate⁸¹⁾, and large area electron beam melted stems⁸²⁾ was reported to increase maximal push-out force^79-81) and surface roughness⁸²⁾. However, no benefit with regard to postoperative periprosthetic loss of BMD was reported with use of coating with hydroxyapatite⁸³⁾.

In a frail population, preoperative screening is recommended for high-risk osteoporotic candidates in order to minimize the risk of complications such as aseptic loosening and PPFs and for subsequent avoidance of complex revisions. Once diagnosed, pharmacological management with postoperative administration of anti-osteoporotic agents is recommended. Surgical considerations include the selection of an appropriate stem design and fixation techniques.

No funding to declare.

No potential conflict of interest relevant to this article was reported.