บทถอดความฉบับเต็มของ Fixated on Bone: Orthopaedic Bone Health Optimization

bad outcomes in spine surgery, revision surgeries, and that perhaps we need to change the paradigm where we identify the osteoporosis early enough, perhaps do treatment for it to try to reduce the risk of those osteoportic bone-related complications. 00:03:00.240 --> 00:03:06.960 Well, we're fortunate that you've taken this uh path and uh we can learn from your expertise. 00:03:07.680 --> 00:03:14.080 So to make sure that we're all on the same page, can you give us a working and operational definition of osteoporosis? 00:03:14.159 --> 00:03:16.080 What is osteoporosis in your mind? 00:03:16.400 --> 00:03:16.560 Yeah. 00:03:16.879 --> 00:03:31.680 Osteoporosis is in general the diminished bone mineral density and bone quality that results in increased bone fragility with a higher risk of fracture. 00:03:31.919 --> 00:03:37.120 Unfortunately, that is not a very good operational definition, but it's conceptually excellent. 00:03:37.360 --> 00:03:50.800 But for operational, uh, the definition really uh began to be important with the development of the T-score based on bone marrow density obtained from DEXA scans. 00:03:51.039 --> 00:03:57.199 And that's what most orthopedic surgeons would have learned is that we use a T-score. 00:03:57.360 --> 00:04:10.560 Unfortunately, that that misses many patients who have bone fragility and high risk for fractures, or what we're going to talk about later is high risk for poor outcomes from elective surgery. 00:04:10.879 --> 00:04:34.240 And so, more recently, uh a better definition has been developed that includes not only diminished bone mineral density as measured by DEXA T scores, but also a fracture history, because a fracture history of a fragility type fracture is indicative of bone fragility. 00:04:34.480 --> 00:04:44.240 And if it's involving the hip or spine, most guidelines automatically say you have osteoporosis, regardless of what your DEXA T score. 00:04:44.800 --> 00:04:52.240 And the third thing after bone mineral density and uh fracture history is your future fracture risk. 00:04:52.480 --> 00:05:08.399 Like any tool, it's hard to uh uh develop paradigms to measure fracture risk, but there has been one that's well accepted in the United States and worldwide, something called the FRAX, which is FRAX. 00:05:08.879 --> 00:05:15.839 And this gives you the 10-year probability of sustaining a hip or a major osteoportic fracture. 00:05:16.079 --> 00:05:28.879 And if you combine the uh T-score, the fracture history, and FRACS, then you have what's called a diagnosis of clinical osteoporosis. 00:05:29.120 --> 00:05:34.639 This is going to be much more operational for orthopedic surgeons to utilize. 00:05:34.800 --> 00:05:41.519 So we need to move off of the fact that uh a patient needs a T-score to make this diagnosis. 00:05:41.680 --> 00:05:42.399 That's not true. 00:05:42.639 --> 00:05:51.120 They need to show evidence of bone fragility based on their fracture history or have a high fracture risk based

on this calculator. 00:05:51.920 --> 00:05:52.959 Well, that's excellent. 00:05:53.040 --> 00:05:53.279 Thank you. 00:05:53.360 --> 00:05:57.680 And a very helpful way to approach uh osteoporosis for the orthopedic surgeon. 00:05:57.920 --> 00:06:03.120 So, how would you describe the overall concept of bone health optimization? 00:06:03.759 --> 00:06:16.399 Yeah, the idea of bone health optimization is to identify and correct uh skeletal health before and after elective orthopedic surgery. 00:06:16.560 --> 00:06:20.879 And what we're trying to do is a three-step process. 00:06:21.199 --> 00:06:26.399 First is to screen a patient to determine if they might have this disease. 00:06:26.800 --> 00:06:31.600 Second, to see if the disease is in as optimized condition as possible. 00:06:32.000 --> 00:06:45.439 And third, if it's not in an optimized condition, then get it optimized with the use of supplements, exercise programs, smoking secession, and ultimately medications. 00:06:45.600 --> 00:06:59.839 So again, it's the idea to identify people with uh deficits in their skeletal health, uh, uh evaluate how severe those deficits are and how they and estimate how they might affect your surgical results. 00:07:00.000 --> 00:07:11.120 And then finally, those patients who are at high risk uh get those people treated, hopefully before, and then uh the treatment would always continue after surgery as well. 00:07:12.000 --> 00:07:18.399 And what's the rationale behind bone health optimization prior to elective orthopedic surgery? 00:07:18.560 --> 00:07:23.439 I think this is based on research that you can give us some examples of. 00:07:23.920 --> 00:07:51.759 Yeah, in the spine surgery, the uh odds ratio of having an osteoportic bone-related complication, such as pseudoarthrosis, revision surgery, uh fracture, hardware failure, kyphosis, uh, any of those complications, the odds ratio if you're osteoprotic compared to non-osteoporosis ranged two to five fold. 00:07:51.920 --> 00:07:54.560 So you have two to five times chance. 00:07:54.800 --> 00:08:12.800 If you look at things like periposthetic fracture after total hip or total knee replacement, then the odds ratios are about 1.5 to 2 that an osteoprotic patient will have one of those complications relative to the non-osteoprotic patient. 00:08:13.040 --> 00:08:17.680 And you're controlling for medical comorbidities, age, and gender as well. 00:08:17.839 --> 00:08:20.959 So it's it does have a profound effect on our outcome. 00:08:21.120 --> 00:08:24.160 It also may change what our surgical plan is. 00:08:24.319 --> 00:08:36.080 For example, in the spine, if somebody has really poor bone quality, uh, I may alter my surgical technique, either not do as complicated a surgery. 00:08:36.240 --> 00:08:42.320 If I'm using hardware, maybe put more screws in, or cement augment the screws. 00:08:42.559 --> 00:08:57.360 The same way, if you have an osteoprotic patient who you're doing a total hip replacement on, it's probably gonna be prudent to use cement rather than a cementless technique to reduce the risk of periprostotic fracture and revision surgery. 00:09:00.000 --> 00:09:04.320 I'd like to just emphasize uh the importance of what you uh just spoke about. 00:09:04.559 --> 00:09:26.639 You know, nowadays we're thinking so much about outcomes of surgery, and we focus so much on you know patient-reported outcomes, surveys that we ask the patients, but really this bone health optimization can help not only our patients have better outcomes, but the surgeons themselves have outcomes that are more improved in the surgeries that we perform. 00:09:26.720 --> 00:09:28.799 So that's a it's a really important concept. 00:09:31.519 --> 00:09:51.519 Yeah, and it's uh it's across all of orthopedic disciplines, it's not just spine and maybe arthroplasty, whose patients tend to be older, but even sports medicine such as yourself, uh, you see that a lot of the complications that you have are are oftentimes related to poor bone quality. 00:09:51.679 --> 00:09:58.559 For instance, um rotator cuff repairs, where there's just literally no bone in the proximal humerus. 00:09:58.720 --> 00:10:08.000 There are studies that show optimizing bone health in that patient population will improve your fixation of your rotator cuff in the bone. 00:10:08.240 --> 00:10:23.919 The same way uh in total shoulder replacements, one of the complications they're seeing more and more with the reverse technique are acromial stress fractures, which are clearly related to the severity of the osteoporosis. 00:10:24.159 --> 00:10:42.639 And even in your field uh of hip preservation surgery, where you're talking about osteotomies, uh, you may have more hip failures or other stress type fractures that uh are going to be much more likely in the osteoportic than non-osteoprotic patient. 00:10:43.360 --> 00:11:03.919 And I think it's important you you mentioned some of these surgeries because you know, in sports medicine in particular, most of our patients are younger than the typical patient we think of having bone fragility, and yet it is a very uh pertinent, uh, you know, it's a very prevalent problem in uh in the surgeries that you mentioned. 00:11:06.399 --> 00:11:15.120 Uh so Paul, can you give us a step-by-step approach to how the orthopaedic surgeon can optimize bone health prior to surgery? 00:11:15.279 --> 00:11:20.320 So, how should practicing surgeons integrate this concept into their practice? 00:11:20.559 --> 00:11:25.039 How should we identify these patients who could benefit from bone health optimization? 00:11:26.080 --> 00:11:29.519 Okay, you need to look at this as a quality improvement program. 00:11:29.679 --> 00:11:43.200 So this is it needs to be attacked at a system uh process in your own facility, hopefully within your own clinic, if it's a small clinic or if it's a bigger group, and then you have to engage more people. 00:11:43.519 --> 00:11:49.840 But it has to uh start with

how do you identify the patient by screening? 00:11:50.159 --> 00:12:02.480 And uh a lot of people misconstrue this as I'm not saying that every patient needs to have a bone density test or see an endocrinologist before uh orthopedic surgery. 00:12:02.559 --> 00:12:05.360 Uh that's just an overuse of resources. 00:12:05.519 --> 00:12:18.080 But you can take a history, and if there is a history of fragility fractures after the age of 50, that is a red flag, and that patient probably would benefit from having a DEXA scan. 00:12:18.480 --> 00:12:28.559 There are already screening criteria that are used by primary care as well as a bone specialist for who should get a DEXA scan. 00:12:28.639 --> 00:12:29.519 It's very easy. 00:12:29.679 --> 00:12:36.559 It's women over the age of 65, men over the age of 70, history of a fragility fracture. 00:12:36.960 --> 00:12:45.279 If you have one of those three things, then you probably should think about their bone quality before attacking them surgically. 00:12:45.440 --> 00:12:53.519 Uh, and then finally, uh, I think uh trying to incorporate fracture risk using this fracks tool. 00:12:53.600 --> 00:13:12.080 It's a much more nuanced kind of approach, uh, but it uh can be done pretty easily in the office, uh, perhaps with uh MA or RN who works with you could calculate this for you and add that into your ARM inventarium of screening. 00:13:12.320 --> 00:13:19.519 Then finally, uh, we're used to looking at imaging studies like CT scans, MRIs, and plain x-rays. 00:13:19.679 --> 00:13:25.279 And you can look at these and try to assess yourself: does this look like the patient's osteoprotic? 00:13:25.679 --> 00:13:34.399 Plain x-rays, some of the key findings, for instance, around the pelvis is the door classification, which most orthopedic surgeons should be aware of. 00:13:34.559 --> 00:13:51.039 And those DOR-C patients who have large capacious canals with very thin cortices, those patients uh have about an 80% chance of being osteoprotic and would probably benefit from uh this process of pre-op optimization. 00:13:51.200 --> 00:13:52.720 That's just one example. 00:13:52.879 --> 00:14:12.480 There are other examples using CT, something called Hounsfeld units, which is uh most surgeons now are available are used to this, but you can do a region of interest on a CT scan and calculate how much uh the x-ray, it's called the x-ray attenuation coefficient, which is Hounsfeld units. 00:14:12.639 --> 00:14:21.519 And if that Hounsfeld units in the spine is less than 110, patient probably has osteoporosis and you should uh assess them. 00:14:21.679 --> 00:14:27.200 So that's the first step is get a process of screening that's going to work for you. 00:14:27.519 --> 00:14:33.679 Uh secondly, those patients who screen positive, go ahead and order a DEXA scan. 00:14:33.840 --> 00:14:38.480 Orthopedic surgeons should feel empowered to order a DEXA scan. 00:14:38.720 --> 00:14:41.840 We should be able to interpret DEXA scans. 00:14:41.919 --> 00:14:49.519 And if you don't feel comfortable as an orthopedic surgeon interpreting DEXA scans, then I would urge you to get more education about that. 00:14:49.759 --> 00:15:02.320 I realize it's not taught as part of our residency to the degree that we learn how to read, interpret CT or MRI, but it's something that is pretty easy to learn. 00:15:02.559 --> 00:15:18.960 And uh orthopedic surgeons should be facile in knowing the indications, interpreting, and interpretation of the results so that we can communicate to the patient and also would act as a red flag that we need to maybe get something done. 00:15:19.279 --> 00:15:27.759 And then finally, uh we need to be able to uh have a referral source to take care of those patients. 00:15:27.840 --> 00:15:47.120 I realize most orthopedic surgeons are not going to take care of the management of the bone health, but we should be developing relationships either within our community or our group where we have personnel who are available to take care of this. 00:15:47.360 --> 00:16:00.159 The AOA Own the Bone has really promoted this to get orthopedic practice groups to develop uh services called the fracture liaison service that can take this process on. 00:16:00.639 --> 00:16:17.759 And that would be a great source for anybody who has a group of orthopedic surgeons, probably 10 or more, could easily uh have someone like a physician's assistant or an APP in the practice group taking care of osteoporosis. 00:16:17.840 --> 00:16:24.480 That's what we have, and it's grown from one person, now we have like five people doing that uh at our university. 00:16:24.879 --> 00:16:35.519 So it's and it's very successful at providing the care needed to help the elective orthopedic patients aside from uh the fracture patients. 00:16:36.639 --> 00:16:36.960 Dr. 00:16:37.039 --> 00:16:46.159 Anderson, there are so many different options for treatment once a patient's been identified as at risk for bone health issues. 00:16:46.320 --> 00:16:54.720 So, how do you decide what type of medication or what treatment a patient should be uh given after they've been identified as at risk? 00:16:55.360 --> 00:16:55.679 Yeah. 00:16:56.000 --> 00:17:11.920 Well, there's general measures that that would be useful for all patients, such as uh making sure they have adequate vitamin D, calcium nutrition, protein, that type of things, avoiding harmful things like smoking. 00:17:12.160 --> 00:17:16.960 But in terms of the medications, remember there are two types of medications. 00:17:17.039 --> 00:17:24.720 There's the antiresorptives that prevent bone loss, and then there's the anabolics that promote bone formation. 00:17:25.279 --> 00:17:37.119 In the idea of bone health optimization, the anabolics are much faster at building up bone, so that they would be our preferred drugs for most of these patients. 00:17:38.000 --> 00:17:49.920 And uh how we decide that though is really based on accepted criteria, and

it's due to uh it's it's uh determined by risk stratification. 00:17:50.079 --> 00:18:03.440 And we can risk stratify patients into low risk, which means they have uh bone marrow density that is greater than minus 2.5 T scores, they've not had fracture histories. 00:18:03.839 --> 00:18:08.720 Those patients don't need anything, uh no antiosteoproduct drugs. 00:18:08.880 --> 00:18:38.079 Then you have the osteopenic, or then you have, I'm sorry, the high-risk patients, and these are patients who've already had fragility fractures, uh, or they've had remote hip or spine fractures, let's say years ago, or they have a T-score less than minus 2.5, and those patients would be uh probably given as a first drug of choice would be an anti-resorptive type of medication. 00:18:38.240 --> 00:18:47.119 Although if the surgery is complex or they've already shown failure from hardware-related complications, then maybe an anabolic. 00:18:47.279 --> 00:18:53.440 And then there's the group that we really want to try to identify and get treated is the very high risk. 00:18:53.599 --> 00:18:58.799 And these are patients who have multiple fragility fractures in the past. 00:18:59.039 --> 00:19:05.279 They're on bone-harming drugs such as corticosteroids, anticonvulsants are the common ones. 00:19:05.599 --> 00:19:37.920 They have very low T-scores or less T-scores less than minus 3.0, very high fracture risk, let's say a major osteoporic fracture risk greater than 30, or a hip fracture risk greater than 5%, uh, or they're frequently falling because of underlying debilitation or degenerative neurologic diseases, then those patients would be definitely given an anabolic and have a delay of surgery. 00:19:40.079 --> 00:19:43.519 Paul, you mentioned fragility fractures a number of times. 00:19:43.680 --> 00:19:49.599 When you think about a patient's history of a fragility fracture, which fractures, which fractures are you referring to? 00:19:50.000 --> 00:19:50.400 Yeah. 00:19:50.720 --> 00:19:56.640 So first of all, uh this were the uh the language is uh undergoing a lot of changes. 00:19:56.880 --> 00:20:01.839 I go to bone meetings, there's a lot of controversy about using the word fragility. 00:20:02.079 --> 00:20:04.000 What exactly does that mean? 00:20:04.319 --> 00:20:12.160 And I think in simplest terms, it's low energy fractures where you wouldn't expect the patient to sustain a fracture. 00:20:12.319 --> 00:20:15.279 So this is most typically it's ground level falls. 00:20:15.519 --> 00:20:24.400 In the case of spines, many of those patients get it from coughing, sneezing, valsalving, or bending and lifting, and they'll they'll get a spine fracture. 00:20:24.559 --> 00:20:32.000 So those are low energy mechanisms, uh, is what we mean by fragility type fractures. 00:20:32.240 --> 00:20:48.640 Where uh I think it could be almost anywhere, I would kind of exclude the digits, but outside of that, uh it it could be obviously it's hip and spine are the predominant ones, but also proximal humerus, distal radius. 00:20:48.880 --> 00:20:55.920 But we're also seeing many more femoral shaft and particularly suprachondyl or the femur type fractures. 00:20:56.079 --> 00:21:16.559 And in fact, uh a lot of ankle fractures in older patients are uh the when we get in there to do surgery on them, I think we all remember trying to put a screw in a severe ankle fracture with uh bad osteoporosis is a challenging uh procedure to say the least. 00:21:18.079 --> 00:21:29.039 And when we recommend these patients get DEXA scans, what is the patient experience of a DEXA scan compared to, say, a CT or an MRI? 00:21:29.359 --> 00:21:29.519 Yeah. 00:21:29.839 --> 00:21:32.400 So a DEXA scan is a radiation. 00:21:32.559 --> 00:21:33.920 It's very low dose. 00:21:34.000 --> 00:21:44.079 There's less radiation in a DEXA machine or a DEXA in study than you get if you fly across the country. 00:21:44.240 --> 00:21:50.960 Uh and uh it's it's uh aligns with one day of our natural radiation dosage. 00:21:51.039 --> 00:22:00.880 So it's extremely low radiation, so the it's virtually harmless to the patient, and uh it takes about 20 minutes, uh To do. 00:22:01.119 --> 00:22:03.920 Most of it is getting the patient positioned correctly. 00:22:04.000 --> 00:22:07.440 The scans themselves only take 20 or 30 seconds. 00:22:08.559 --> 00:22:15.839 So, from their perspective, it's a pretty easy task, painless, of course, and safe. 00:22:16.640 --> 00:22:29.200 The problems with DEXA are they're not always reimbursed, and that's why you need to have justification when you order one that will suit whatever their insurance carrier is. 00:22:29.519 --> 00:22:35.759 And also there are a lot of errors in interpretation and the technologist, how they are done. 00:22:36.000 --> 00:22:44.799 And that's why you need to learn how to interpret every your own patient's DEXA scan, because there are quite a lot of errors. 00:22:45.279 --> 00:22:56.960 At our institution, we have a variety of practitioners who read DEXA, and our nuclear radiologists read them, and they average 30 seconds. 00:22:57.119 --> 00:23:10.319 And consequently, their error rate is much higher than other people's because they're just getting the work done based on pure numbers rather than looking at the images to make sure they're appropriately positioned. 00:23:11.359 --> 00:23:22.000 So it's again the onus is on orthopedic surgeons to learn how to interpret and read their own patients' DEXA scans. 00:23:23.519 --> 00:23:32.319 And you know, this I could see as a potential barrier to an orthopedic surgeon who's trying to optimize bone health for his or her patients. 00:23:32.480 --> 00:23:44.960 But what other barriers can you foresee that a surgeon who is attempting to go through these steps that you've outlined to, you know, include bone health optimization in their practice? 00:23:45.039 --> 00:23:48.079 Uh, what are some of those other barriers that they might encounter?

00:23:48.480 --> 00:23:48.880 Yeah. 00:23:49.200 --> 00:23:55.039 Well, um, the biggest one is frankly lack of uh personnel to refer to. 00:23:55.839 --> 00:24:09.920 Uh most patients, as I go around the country giving grand rounds at different universities and training centers, and I always ask, you know, how long does it get you, does it take to get a bone health consult in? 00:24:10.079 --> 00:24:12.319 It's like six to nine months on average. 00:24:12.480 --> 00:24:18.240 So we just do not have a uh uh an adequate number of practitioners. 00:24:18.400 --> 00:24:32.960 For instance, uh endocrinologists, uh, they're they're uh I think they're only at like 3,000 in the country, and um they're greatly understaffed, and uh they're just not available, particularly now. 00:24:33.039 --> 00:24:36.640 They're spending most of their time prescribing weight loss drugs. 00:24:36.960 --> 00:24:39.599 Uh, so it's even getting worse. 00:24:39.680 --> 00:24:44.240 Uh, and that's why I say uh you need to kind of build your own program. 00:24:45.440 --> 00:24:53.839 The uh other one is it is disruptive to your practice in that you have somebody who needs a hip replacement, but they have lousy bone. 00:24:54.240 --> 00:25:05.039 Uh, if you're gonna delay that for three months to improve their bone health, how's that gonna affect your case mix uh or your uh cases? 00:25:05.359 --> 00:25:18.400 A lot of surgeons are worried that by delaying surgery you're gonna be losing patients and uh having inadequate uh scheduling of cases for your um OR list. 00:25:19.039 --> 00:25:21.359 But those are a couple of biggest barriers. 00:25:21.599 --> 00:25:30.079 Then there's pre-authorization hassles if you if they do need medications, uh, which are uh very painful to say the least. 00:25:30.799 --> 00:25:41.359 So for the orthopedic surgeon who's listening to this podcast right now and is thinking they'd like to incorporate this into their practice, they're worried about some of these barriers you've just discussed. 00:25:41.599 --> 00:25:50.000 What resources do the AOA have to help them uh expedite the implementation of this into their practice? 00:25:50.400 --> 00:26:09.759 Yeah, the Own the Bone Program has invested a lot of time and resources into developing a website with a lot of learning modules, in particular, how to develop fracture liaison service programs and bone health optimization programs. 00:26:10.400 --> 00:26:26.559 Uh, they also have a APP boot camp who are really for those people who are utilizing fracture liaison service, these are the people, the boots on the ground, who are oftentimes going to deliver care. 00:26:26.720 --> 00:26:36.640 So they have a lot of educational material and a place where people can ask questions about how to do best practices. 00:26:36.960 --> 00:26:52.880 In addition, they have uh algorithms available on uh how to screen patients, how to work up patients, what kind of drugs you would use, under which condition, and they have

even order sets that could be adopted. 00:26:53.039 --> 00:26:56.799 So there's a whole gamut of material that the AOA has. 00:26:56.960 --> 00:27:29.279 And then they have educational conferences such as webinars, and uh we have a monthly Echo conference, which is a educational format that uh is attended by many orthopedic surgeons and uh APPs who work in orthopedics for educational, and then they have a yearly symposium, and uh now bone health optimization is always one of the areas that is discussed at these kind of conferences. 00:27:30.079 --> 00:27:35.759 So a lot of resources, which is excellent, um, which leads into my next question. 00:27:36.079 --> 00:27:44.480 Do we have a sense of how widespread adoption of bone health optimization in orthopedics has affected the financial bottom line? 00:27:47.359 --> 00:28:08.240 Um well, uh that I can't, I don't know about the financial aspects in terms of are we saving money by doing this, by reducing complications, particularly in the first 30 days, where a lot of the reimbursement, particularly for hip and knee replacement, is in bundled care programs. 00:28:08.480 --> 00:28:11.920 So we haven't been able to tease that out. 00:28:12.400 --> 00:28:22.559 But we do know that if you can save a periprosthetic fracture from happening, uh, I think we can save like$15,000 per case. 00:28:22.799 --> 00:28:36.160 And obviously a periprosthetic fracture that requires reoperation hospitalization in the first 30 days is going to be big negative for those in a in these alternative payment plan programs. 00:28:36.480 --> 00:28:41.599 Exact numbers I I don't have uh at my fingertips. 00:28:41.759 --> 00:28:46.640 They're a little hard to get because so much depends on what your payer mix is. 00:28:46.880 --> 00:28:56.640 Uh, like at the University of Wisconsin, like half our patients are capitated, and so it's hard to calculate cost savings in a capitated system. 00:28:57.200 --> 00:28:57.759 Absolutely. 00:28:58.000 --> 00:29:08.240 But presumably, as you mentioned, I mean, if we're preventing a lot of these complications, then you know it it not only helps our patients, but also helps the financial bottom line, which is excellent. 00:29:08.640 --> 00:29:16.160 Yeah, I can give you an example of a study that was done out of Columbia and New York of major spine surgery. 00:29:16.480 --> 00:29:20.799 These were deformity patients, had seven or more levels fused. 00:29:21.599 --> 00:29:32.720 Uh, and they studied 544 patients, all of them had DEXA scans with a diagnosis of either osteoporosis, osteopenia, or normal. 00:29:32.880 --> 00:29:36.880 And then they looked at how many people had complications within two years. 00:29:37.039 --> 00:29:45.920 The osteoprotic patients were given six months of an anabolic type of drug, a PTH analog drug before surgery. 00:29:46.079 --> 00:29:51.200 The osteopenic were not given anything, and the normals, of course, were not given anything. 00:29:51.359 --> 00:30:00.160 But

basically, the complication rate was normalized by the anabolic drug in the osteoprotic group. 00:30:00.240 --> 00:30:19.759 That means that the osteoprotic patients who were given pteraperitite had the same complication rates as the patients who had normal bone mineral density, whereas the osteopenic patients had twice to three times as high various complications compared to even the osteoprotic patients, but the osteoprotic patients were treated. 00:30:20.000 --> 00:30:24.720 So in spine surgery, you probably can easily show its benefit. 00:30:25.039 --> 00:30:46.400 The complications and total hip and knee again are going to be related to periposthetic fractures and revision surgery because these drugs do help incorporation of the porous ingrowth surface, and you might get better and faster incorporation and therefore less likely for loosening, things like that. 00:30:46.880 --> 00:30:51.599 But nobody's done a systematic study of the cost benefits of those. 00:30:52.319 --> 00:30:55.519 That's an impressive result from that spine study. 00:30:55.839 --> 00:30:56.480 Yeah. 00:30:57.599 --> 00:31:03.759 Now, you're seen as a leader on this topic, and you've given presentations all over the world on bone health optimization. 00:31:04.000 --> 00:31:09.839 So, in your experience, how has this concept been perceived among other orthopedic surgeons? 00:31:10.079 --> 00:31:14.960 And recently have you noticed a shift in the collective thinking on this issue? 00:31:15.519 --> 00:31:26.400 Yeah, I think the spine world, and this includes the neurosurgeons, and actually, the neurosurgeons buy into this even more than the orthopedic spine surgeons, to be honest, have really bought into this. 00:31:26.559 --> 00:31:42.319 And it is getting very common that uh patients are getting evaluated for their bone health and getting preoperative treatment before major fusion type surgeries, particularly those bigger uh multi-level type of fusions. 00:31:42.720 --> 00:31:48.480 Uh, it's been less well accepted by the total joint replacement uh community. 00:31:48.960 --> 00:31:51.519 Uh, they still have a ways to go. 00:31:51.920 --> 00:32:07.759 Uh they are uh you know very streamlined in trying to produce a consistent result and have had difficulty fitting bone health assessment and treatment into their optimization programs. 00:32:08.160 --> 00:32:19.359 They've done a great job of optimizing you know 10 to 15 conditions before you get a total joint, but it's been hard to get them to add in bone health. 00:32:19.599 --> 00:32:24.079 Uh well, uh Dr. 00:32:24.240 --> 00:32:33.599 Anderson, as we wrap up, do you have any final thoughts on the topic of bone health optimization as it applies to orthopedic surgeons' practices? 00:32:34.559 --> 00:32:53.440 Yeah, uh the one thing uh to mention is uh the big concern of surgeons is okay, if I'm going to do something like this, uh if a patient needs treatment, how long does that patient need to be treated before surgery uh to try to reduce the risk of complications? 00:32:54.240 --> 00:33:05.759 And this is uh a little bit of evidence-free zone here, but it is based on what we know about fracture risk after instituting these drugs. 00:33:06.079 --> 00:33:15.279 And we're starting, you see, a pretty rapid uh decrease in fracture risk at three months with these drugs, particularly the anabolic type drugs. 00:33:15.680 --> 00:33:20.880 So mechanically, it looks like we're beginning to see an effect at three months. 00:33:21.119 --> 00:33:26.480 Uh, and so I would say the delay, a good delay rule of thumb, is three months. 00:33:26.640 --> 00:33:37.519 However, if you're doing a higher risk type of surgery, like those multi-level spine fusions, six months clearly is probably going to be better. 00:33:37.839 --> 00:33:47.359 In the arthroplasty world, probably three months would be sufficient for most of those uh patients. 00:33:47.519 --> 00:33:59.119 But also you can modify the techniques, such as if you've identified somebody's got pretty bad osteoporosis, you really need to think about using cement, for instance, rather than a cementless technique. 00:33:59.759 --> 00:34:00.240 Well, Dr. 00:34:00.319 --> 00:34:04.240 Anderson, thank you so much for being a guest on the Fixated on Bone Podcast. 00:34:04.480 --> 00:34:12.400 It's truly been an honor having you, and we really appreciate you sharing your expertise on bone health optimization with us today. 00:34:12.960 --> 00:34:13.280 Yeah. 00:34:13.440 --> 00:34:14.079 Well, thank you. 00:34:14.159 --> 00:34:16.880 It's been a pleasure talking to everybody. 00:34:17.039 --> 00:34:23.199 And uh uh remember, bone health is part of uh what we need to assess. 00:34:23.360 --> 00:34:45.039 It's not just looking at the disease we're treating, such as arthritis or spinal stenosis, but we also have to include assessment of what their bone health is in all of our patients, not pr not even just our operative ones, but we can really help a patient even if we're not going to operate on them by getting their bone health addressed if needed. 00:34:47.360 --> 00:34:48.480 Well, thank you again. 00:34:49.280 --> 00:34:56.000 Thank you for joining us, and we hope you'll tune in to our next episode of the AOA Own the Bones Fixated on Bone Podcast.