Osteoporosis and Joint Replacement: New IOF Statement Urges Bone Testing Before Surgery

The International Osteoporosis Foundation has issued a new position statement calling for every patient over 65 to have their bone health assessed before a joint replacement or spinal fusion — and it warns that today, most are not. If you have a knee replacement, hip replacement, or spinal fusion coming up, your bone strength should be assessed before you reach the operating room — and in most cases today, it is not. The link between osteoporosis and joint replacement outcomes is stronger than most patients are told: between 60 and 80 percent of people undergoing knee replacement already have osteopenia or osteoporosis, and among hip replacement patients who have osteoporosis, nearly 75 percent go into surgery undiagnosed.

The statement comes from the Fracture Working Group of the Council of Scientific Advisors of the International Osteoporosis Foundation (IOF), and was published in Osteoporosis International on June 18, 2026. Its subject is implant fixation failure: what happens when an artificial joint or a spinal fusion construct is anchored into bone that cannot hold it.

Key takeaways

• 60–80 percent of knee replacement patients already have osteopenia or osteoporosis.
• Nearly 75 percent of hip replacement patients with osteoporosis are undiagnosed going into surgery.
• A periprosthetic fracture — a break in the bone around an implant — carries a one-year mortality rate of 11 to 18 percent, comparable to a hip fracture.
• The IOF now calls for systematic bone health assessment before joint replacement and spinal fusion for everyone aged 65 and older, and for younger patients with a previous fragility fracture or osteoporosis risk factors.
• Dr. Susan E. Brown, PhD, adds: vitamin D and calcium are a floor, not a plan. Full-spectrum bone nutrition belongs in surgical preparation.

What the position statement found about osteoporosis and joint replacement

The numbers are the striking part. Between 60 and 80 percent of people undergoing knee replacement already have osteopenia or osteoporosis. And among hip replacement patients who have osteoporosis, nearly 75 percent go into surgery undiagnosed.

That matters because the consequences are serious. A periprosthetic fracture is a break in the bone surrounding an implant. It carries a one-year mortality rate of 11 to 18 percent, which the authors note is comparable to a hip fracture itself. For periprosthetic fractures of the distal femur — the thigh bone just above the knee — the figure cited is 18.6 percent.

In other words: a large share of joint replacement patients have compromised bone, most of them do not know it, and the failures that follow are not minor complications.

Why osteoporosis puts a joint replacement at risk

An artificial joint is not free-floating. It is anchored into the bone around it, and that bone has to grip the implant and keep gripping it for years. When bone density is low, the working group notes, that anchorage is less secure — which is how implant fixation failure, loosening, and fractures around the hardware enter the picture. In instrumented spinal fusion, the same problem shows up as screws that lose their hold in weakened vertebrae.

This is why a DEXA scan and a clear reading of your bone density results matter well before a surgery date is set, and why bone density alone is not the whole picture of fracture risk.

What the statement recommends before joint replacement surgery

The working group calls for systematic bone health assessment before surgery for patients aged 65 and older having a joint replacement or an instrumented spinal fusion — and particularly for anyone with a previous fragility fracture, recognized osteoporosis risk factors, or a high-demand procedure such as revision surgery or a long-segment fusion.

Their specific recommendations include:

• Correcting vitamin D deficiency, with a target serum 25(OH)D of at least 50 nmol/L
• Calcium intake of 1,000 to 1,200 mg per day
• Bisphosphonates after surgery for arthroplasty patients who have osteoporosis
• Teriparatide for osteoporotic spinal fusion patients, started at least a month before surgery and continued for six to twelve months afterward
• Formal fall-risk assessment as part of perioperative care
• Coordination between the orthopedic surgeon and a bone specialist, rather than leaving bone health to chance

Who should have a bone density test before joint replacement?

Under this position statement, pre-surgical bone health assessment applies to:

• Anyone aged 65 or older scheduled for a hip replacement, knee replacement, or instrumented spinal fusion
• Anyone with a previous fragility fracture — a break from a fall at standing height or less
• Anyone with recognized osteoporosis risk factors, regardless of age
• Anyone facing a high-demand procedure such as revision surgery or a long-segment spinal fusion

Why this is worth your attention

Most bone health guidance is framed around preventing fractures from falls. This statement is about something different: whether your skeleton can hold the hardware that is about to be put into it, and whether anyone checked before the date was booked.

The practical takeaway is a question you can ask. If you have a joint replacement or spinal fusion scheduled, it is reasonable to ask your surgeon whether your bone density has been assessed, whether your vitamin D level has been measured and corrected, and whether a bone specialist has been consulted. Under this statement, for patients over 65, the answer should be yes.

Dr. Brown’s take: nutrition is the missing piece

For years I have encouraged people to think about bone health before orthopedic surgery, not after. If we are going to anchor an artificial joint, screws, rods, or other hardware into the skeleton, it makes sense to first ask whether that bone is strong enough to provide the support needed for successful healing and long-term stability.

What is particularly concerning in this report is how many people undergoing joint replacement already have osteopenia or osteoporosis without knowing it. A hip or knee replacement may be thought of primarily as a joint problem, but the success of that procedure also depends on the quality and strength of the bone surrounding the implant.

I am encouraged to see vitamin D assessment included in these recommendations, but I would take the preparation further. Bone healing and surgical recovery require much more than vitamin D and calcium. Adequate protein, magnesium, vitamin K, zinc, boron, vitamin C, and the full spectrum of bone-building nutrients all play roles in maintaining bone and supporting tissue repair. Identifying nutritional deficiencies and correcting them before surgery, when possible, gives the body a stronger foundation for recovery.

For patients with osteoporosis or very high fracture risk, medication may also be recommended as part of the surgical plan. Those decisions should be individualized and discussed with the orthopedic surgeon and a physician experienced in metabolic bone health. But medication should not replace a comprehensive look at why bone has become fragile in the first place.

I would like to see pre-surgical bone health assessment become a routine part of orthopedic planning, particularly for older adults and anyone with known risk factors for osteoporosis. We prepare the heart and other body systems for major surgery. We should give the skeleton that will actually hold the implant the same careful attention.

Questions to ask your surgeon before joint replacement surgery

• Has my bone density been assessed, and what did the DEXA scan show?
• Has my vitamin D level been measured, and is it above the recommended target?
• Do I have osteopenia or osteoporosis that could affect how well the implant is held?
• Should a bone specialist be involved in my surgical plan?
• Is there anything I should be doing nutritionally in the weeks before surgery to support healing?

Frequently asked questions

Can you have a knee replacement if you have osteoporosis?

Yes. Osteoporosis is not by itself a reason to rule out knee replacement, and 60 to 80 percent of knee replacement patients already have osteopenia or osteoporosis. The IOF position statement argues that it should be identified and treated before surgery, so the implant is anchored into the strongest bone possible.

Do you need a bone density test before joint replacement surgery?

The IOF position statement recommends bone health assessment before joint replacement or instrumented spinal fusion for all patients aged 65 and older, and for younger patients with a prior fragility fracture or osteoporosis risk factors. In current practice this is often skipped — nearly 75 percent of hip replacement patients with osteoporosis reach surgery undiagnosed.

What is a periprosthetic fracture?

A periprosthetic fracture is a break in the bone surrounding an implanted artificial joint. It is a serious complication: one-year mortality after a periprosthetic fracture runs 11 to 18 percent, and reaches 18.6 percent for fractures of the distal femur, comparable to the mortality that follows a hip fracture.

Should I take vitamin D before joint replacement surgery?

The position statement recommends correcting vitamin D deficiency before surgery, with a target serum 25(OH)D of at least 50 nmol/L, alongside 1,000 to 1,200 mg of calcium daily. Ask your physician to measure your level rather than guessing at a dose.

How far ahead of surgery should bone health be addressed?

As early as possible. The statement’s own timing guidance is instructive: teriparatide for osteoporotic spinal fusion patients is recommended starting at least one month before surgery and continuing for six to twelve months afterward. Correcting a vitamin D deficiency or a broader nutritional gap also takes time.

Sources

• Fracture Working Group of the Council of Scientific Advisors of the International Osteoporosis Foundation. “Osteoporosis and osteoporosis therapies as determinants of implant fixation failure in arthroplasty and spinal fusion constructs.” Osteoporosis International, June 18, 2026. PubMed
• International Osteoporosis Foundation. “New position statement calls for systematic bone health optimization before joint replacement and spinal fusion surgery.” Announcement

Reviewed by Dr. Susan E. Brown, PhD. This article is educational and is not medical advice. Decisions about surgery, medication, and supplementation belong to you and your physician.