A new position statement from the International Osteoporosis Foundation argues that failing hip replacements and collapsing spinal fusions share a common, overlooked cause: brittle bone. Published in Osteoporosis International on 18 June 2026, the paper urges surgeons and bone specialists to screen and treat osteoporosis before and after these operations, treating implant failure as a bone-health problem rather than a purely mechanical one.
Every year, millions of people undergo hip and knee replacements or spinal fusion surgery. Most of these operations succeed. But a growing number fail – not because the surgery itself was flawed, but because the bone anchoring the metal gave way beneath it. A new position statement from the Fracture Working Group of the International Osteoporosis Foundation’s (IOF) Committee of Scientific Advisors, published in Osteoporosis International, makes the case that osteoporosis and orthopaedic implant failure are, in the authors’ words, “two sides of the same coin.”
A call to build bone screening into routine surgical pathways
Patients aged 65 and over, those with a prior fragility fracture, or those undergoing high-demand procedures such as revision arthroplasty or long-segment spinal fusion should have their bone health assessed before surgery wherever feasible, and treated with antiresorptive or anabolic osteoporosis therapy according to the dominant failure risk anticipated. Surgery should never be delayed to accommodate this assessment – that recommendation is rated strong even though the certainty of evidence behind it is only moderate, resting on registry and observational data rather than trials. The working group is explicit that bone health optimisation “should not be treated as an adjunct to surgical care, but as an integral component of peri-operative planning.” For clinicians running joint replacement or spinal fusion services, this amounts to a call to build routine bone health screening into pre-operative pathways, alongside cardiac and anaesthetic workups that are already standard.
Lead author Professor Manju Chandran, of Singapore General Hospital and Duke-NUS Medical School, noted: “We urge the orthopaedic and bone health communities to see implant failure and osteoporosis as two sides of the same coin. A hip replacement, or a spinal fusion, is only as durable as the bone that supports it. We need to think about bone quality as a determinant of surgical durability, not just fracture risk. Identifying and treating osteoporosis before and after these operations is a practical, low-cost way to protect patients from painful, dangerous, and expensive complications.”
A shared mechanical failure
The paper’s central conceptual move is to introduce “implant fixation failure” as a unifying construct-level outcome spanning arthroplasty and spinal fusion alike. This is defined as “loss of mechanical integrity of the bone-implant unit over time,” encompassing periprosthetic fracture, aseptic loosening, cage subsidence, pseudarthrosis and junctional failure. The working group treats these as expressions of one underlying problem, rather than as separate, procedure-specific complications: bone that cannot sustain the altered loading a metal implant imposes on it.
The numbers underpinning this argument are striking. Between 60 and 80 per cent of patients presenting for knee replacement have osteopenia or osteoporosis, and nearly three-quarters of osteoporotic patients undergoing hip replacement go undiagnosed pre-operatively. Periprosthetic femoral fractures carry one-year mortality rates of 11 to 18 per cent – comparable to native hip fractures – rising to
18.6 per cent for periprosthetic distal femur fractures. In the spine, a systematic review of 71 studies covering more than 12,000 patients found low bone mineral density (BMD) was associated not only with cage subsidence and screw loosening, but also with proximal junctional kyphosis due to fracture.
Falls remain the dominant trigger for these injuries: most periprosthetic fractures follow low-energy falls from standing or sitting height, which is why fall-risk assessment features as a strong recommendation alongside pharmacological treatment.
What the drugs do
The position statement synthesises evidence across bisphosphonates, denosumab, teriparatide, abaloparatide and romosozumab. As the authors summarise in their results: “In arthroplasty, randomized trials demonstrate preservation of periprosthetic BMD with bisphosphonates, while registry analyses suggest improved implant survival. In spinal fusion, antiresorptive and anabolic therapies influence fixation-related parameters, with anabolic agents showing the most consistent evidence for enhanced fusion mass and earlier union.”
In practical terms, bisphosphonates are recommended postoperatively for arthroplasty patients with osteoporosis or a high-risk bone phenotype, with denosumab as an alternative where bisphosphonates are contraindicated – though discontinuing denosumab without transitioning to further antiresorptive therapy risks a rebound in bone turnover and vertebral fracture, a point the working group flags as a strong recommendation in its own right. For spinal fusion, teriparatide carries the strongest evidence base, typically started at least a month before surgery and continued for six to twelve months, with trial data showing higher and earlier fusion rates and markedly fewer instances of pedicle screw loosening. Romosozumab, evaluated mostly in retrospective and preclinical work, shows promise specifically against fracture-related junctional failure in high-risk deformity constructs, though its use is time-limited and should feed into a broader osteoporosis treatment strategy rather than replace one.
The authors are careful not to overstate what these drugs can do: bisphosphonates, they write, “should not be considered universal prophylaxis against all forms of arthroplasty failure” – they stabilise the peri-implant environment and bone stock, but the evidence for directly reducing periprosthetic fracture itself remains limited and heterogeneous, and much of it is confounded by indication.
Diagnosis lags behind the evidence
Standard central DXA (dual-energy X-ray absorptiometry) scanning, while remaining the diagnostic reference standard, misses much of what matters mechanically. Bone loss around an implant is intensely regional – the paper cites a roughly 15 per cent reduction in distal femoral bone density within six months of knee replacement, concentrated at the implant interface rather than distributed generally, though the authors note the studies behind this figure were heterogeneous in methodology, so the true magnitude of loss remains incompletely defined. Opportunistic CT-derived Hounsfield units, obtained from scans already taken for surgical planning, and Gruen-zone specific DXA analysis after hip replacement, are highlighted as more clinically relevant, if not yet universally available, alternatives.
The evidence base
The authors note the limits of what can be concluded from the literature they reviewed. As they state in their conclusions: “Systematic peri-operative bone health optimization may improve construct longevity, although more definitive outcome-driven trials are needed. Closer integration between orthopaedic surgeons and osteoporosis specialists will be central to advancing peri-operative bone health care.” Much of the supporting literature relies on radiographic or biomechanical surrogate endpoints – bone density change, screw pull-out strength, fusion mass volume – rather than hard outcomes like revision surgery or fracture, a limitation the working group attributes to the near-total absence of dedicated fracture-reduction trials in the periprosthetic and peri-fusion setting.
Professor Eugene McCloskey, of the University of Sheffield and chair of the IOF Committee of Scientific Advisors, described the paper as “a very important and timely position statement which calls for a fundamental shift in how orthopaedic and metabolic bone specialists collaborate,” adding that “every patient undergoing arthroplasty or spinal fusion who has or is at risk of poor bone quality deserves a structured assessment and, where indicated, targeted therapy. This would help improve surgical outcomes and reduce complications for patients worldwide.”
Reference:
Chandran, M., Anastasilakis, A. D., Blank, R. D., et al. (2026). Osteoporosis and osteoporosis therapies as determinants of implant fixation failure in arthroplasty and spinal fusion constructs: a position statement from the Fracture Working Group of the Council of Scientific Advisors of the International Osteoporosis Foundation. Osteoporosis International. https://doi.org/10.1007/s00198-026-08086-3
