Preoperative anti-remodeling osteoporotic therapy is associated with increased periprosthetic humeral fracture risk

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 1-year outcomes, including periprosthetic humeral fracture, acromial stress fracture, and all-cause revision, following anatomic total shoulder arthroplasty (aTSA) and reverse total shoulder arthroplasty (rTSA).

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 preoperative 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 1-year postoperative outcomes were analyzed. Univariate and multivariate logistic regressions were used to adjust for age, sex, and comorbidities.

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 1-year periprosthetic humeral fracture (odds ratio [OR] 1.25, 95% confidence interval [CI] 1.06-1.46, P = .006), whereas anabolic therapy was not. In the rTSA cohort, no independent association was observed between anti-remodeling therapy and 1-year periprosthetic humeral fracture after multivariate adjustment (OR 1.11, 95% CI 0.94-1.32, P = .220), and anabolic therapy was not independently associated with fracture. In the aTSA cohort, anti-remodeling therapy was independently associated with increased odds of 1-year periprosthetic humeral fracture (OR 1.85, 95% CI 1.20-2.83, P = .005), while anabolic therapy was not independently associated with fracture after adjustment.

Preoperative anti-remodeling osteoporotic therapy is independently associated with increased odds of 1-year periprosthetic humeral fracture following shoulder arthroplasty. These findings may inform preoperative counseling and postoperative surveillance in osteoporotic patients undergoing shoulder arthroplasty.