JSES - 2026-05-19 - Journal Article
Preoperative Anti-remodeling Osteoporotic Therapy Is Associated with Increased Periprosthetic Humeral Fracture Risk.
Eisenberg MT, Wang K, Lederman E, Amini MH, Krohn K, Patel M
Topics
Key Takeaway
Preoperative anti-remodeling therapy (bisphosphonates) is independently associated with a 25% increased odds of one-year periprosthetic humeral fracture after shoulder arthroplasty (OR 1.25, 95% CI 1.06–1.46), with the effect driven primarily by the aTSA subgroup (OR 1.85).
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Summary
This study asked whether preoperative anti-remodeling or anabolic osteoporotic therapy affects one-year periprosthetic humeral fracture, acromial stress fracture, and all-cause revision after aTSA and rTSA. Using the PearlDiver Mariner database (2010–2025) with multivariate logistic regression adjusting for age, sex, and CCI, anti-remodeling therapy was independently associated with increased periprosthetic humeral fracture risk in the combined cohort (OR 1.25) and aTSA subgroup (OR 1.85), but not in the rTSA subgroup after adjustment (OR 1.11, p=0.220). Anabolic therapy showed no independent association with fracture in any cohort.
Key Limitation
Claims-based design cannot distinguish bisphosphonate duration, cumulative dose, or atypical femur fracture-equivalent bone suppression severity, which are the mechanistically relevant variables driving fracture risk.
Original Abstract
INTRODUCTION
Osteoporosis increases fracture risk and adversely affects outcomes after shoulder arthroplasty. Preoperative bisphosphonate use has been linked to higher rates of periprosthetic fracture after lower extremity total joint arthroplasty, but data in shoulder arthroplasty are limited. The purpose of this study was to evaluate whether anti-remodeling agents such as bisphosphonates or anabolic osteoporotic therapy influenced one-year outcomes, including periprosthetic humeral fracture, acromial stress fracture, and all-cause revision, following anatomic (aTSA) and reverse total shoulder arthroplasty (rTSA).
METHODS
A retrospective cohort study was performed using the PearlDiver Mariner Patient Claims Database (2010-2025). Adult patients with a documented diagnosis of osteoporosis undergoing first-time aTSA or rTSA with at least 12 months of pre- and postoperative continuous enrollment were included. Patients were stratified into anti-remodeling therapy, anabolic therapy, or no osteoporosis medication groups. Demographics, Charlson Comorbidity Index, and one-year postoperative outcomes were analyzed. Univariate and multivariate logistic regression was used to adjust for age, sex, and comorbidities.
RESULTS
A total of 18,922 patients were included (13,123 rTSA; 5,817 aTSA). In the combined aTSA/rTSA cohort, anti-remodeling therapy was independently associated with increased odds of one-year periprosthetic humeral fracture (OR 1.25, 95% CI 1.06-1.46, p = 0.006), whereas anabolic therapy was not. In the rTSA cohort, no independent association was observed between anti-remodeling therapy and one-year periprosthetic humeral fracture after multivariate adjustment (OR 1.11, 95% CI 0.94-1.32, p = 0.220), and anabolic therapy was not independently associated with fracture. In the aTSA cohort, anti-remodeling therapy was independently associated with increased odds of one-year periprosthetic humeral fracture (OR 1.85, 95% CI 1.20-2.83, p = 0.005), while anabolic therapy was not independently associated with fracture after adjustment.
DISCUSSION
Preoperative anti-remodeling osteoporotic therapy is independently associated with increased odds of one-year periprosthetic humeral fracture following shoulder arthroplasty. These findings may inform preoperative counseling and postoperative surveillance in osteoporotic patients undergoing shoulder arthroplasty.