Bone status in primary hyperparathyroidism

Traditional bone involvement, such as osteoitis fibrosa, has become very rare (< 1%) in primary hyperparathyroidism (PHPT); nevertheless, fractures seem more frequent than in controls, with a predilection for fractures of the distal extremity of the radius, pelvis, ribs and vertebrae, and a relative modest incidence of fractures of the upper extremity of the femur. Histo-morphometric studies have stressed a discrepancy between cortical and trabecular bone with an increase of bone remodeling. The cortical width is constantly diminished and the cortical porosity is increased whereas trabecular volume is normal and micro-architecture preserved. Bone mineral density (BMD) allows an early diagnosis of bone disease and takes a growing place in the management of patients. Since the consensus conference in 1991, the measurement of BMD has been incorporated in the surgical decision with a threshold: Z-score < -2. The demineralisation predominates on sites rich in cortical bone (1/3 proximal of the distal radius); the radius, which was the first site evaluated for technical reasons, is also the most discriminating one. Spine demineralisation is met in more severe forms and BMD measurement of the whole body is promising but requires more studies. In the absence of a radical processing, moderate forms remain stable, whereas more severe forms have a tendency to deteriorate. The evaluation of spine and femoral BMD is useful for the follow-up because the bone gain after parathyroidectomy is significant early on at these sites (rich in trabecular bone with high bone turnover), whereas the BMD of radius is relatively stable.