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Article

Prevalence of Osteoporosis and Vitamin D Levels in Patients Undergoing Total Hip Arthroplasty: Insights from a Single-Center Experience in Italy

by
Amarildo Smakaj
1,2,3,
Riccardo Iundusi
2,3,4,*,
Angela Chiavoghilefu
2,4,
Tommaso Cardelli
2,4,
Danilo Rossi
2,4,
Claudio Raso
2,4,
Umberto Tarantino
3 and
Elena Gasbarra
2,3,4
1
Department of Biomedicine and Prevention, “Tor Vergata” University of Rome, 00133 Rome, Italy
2
Department of Orthopaedics and Traumatology, “Policlinico Tor Vergata” Foundation, 00133 Rome, Italy
3
Catholic University “Our Lady of Good Counsel”, 1026 Tirana, Albania
4
Department of Clinical Sciences and Translational Medicine, “Tor Vergata” University of Rome, 00133 Rome, Italy
*
Author to whom correspondence should be addressed.
Prosthesis 2025, 7(4), 73; https://doi.org/10.3390/prosthesis7040073 (registering DOI)
Submission received: 30 March 2025 / Revised: 18 June 2025 / Accepted: 24 June 2025 / Published: 26 June 2025
(This article belongs to the Special Issue State of Art in Hip, Knee and Shoulder Replacement (Volume 2))
Browse Figure
Versions Notes

Abstract

Background: Patients awaiting total hip arthroplasty (THA), particularly those with hip osteoarthritis (OA), face an elevated risk of osteoporosis due to age and gender-related factors. Osteoporosis, indicated by low bone mineral density (BMD), can affect implant osteointegration, long-term stability, and increase the likelihood of periprosthetic fractures. Despite these risks, osteoporosis is often underdiagnosed and undertreated in THA candidates. While several studies have addressed this issue in Northern populations, data on Southern European cohorts, particularly Italian patients, remain limited. This study aims to evaluate the prevalence of osteoporosis and vitamin D deficiency, as well as the rates of related treatments, in patients with hip osteoarthritis scheduled for THA. Methods: This single-center, retrospective study was conducted at Policlinico Universitario di TorVergata, Italy, involving 66 hip OA patients (35 men, 31 women; mean age 67.5 years). BMD was assessed at the femoral neck, total femur, and lumbar spine via DEXA, alongside vitamin D and PTH levels. Demographic data, ongoing anti-osteoporotic therapies, Harris Hip Score (HHS), and handgrip strength were recorded. Statistical analysis included t-tests and Pearson’s correlation. Osteoporosis was defined per WHO criteria, with significance set at p < 0.05. Results: In this study of 66 patients with hip osteoarthritis (35 men, 31 women; mean age 67.5 years), women exhibited significantly lower bone mineral density (BMD) at the total femur (−0.98 ± 1.42 vs. −0.08 ± 1.04; p < 0.05) and lumbar spine (−0.66 ± 1.74 vs. 0.67 ± 1.59; p < 0.05) compared to men. Handgrip strength was also significantly reduced in females (17.1 ± 8.2 kg) versus males (27.3 ± 10.3 kg; p < 0.05). Vitamin D levels were below 30 ng/mL in 89.4% of patients, and 63.6% had levels below 20 ng/mL; PTH levels were elevated (>65 pg/mL) in 54.5% of cases, indicating frequent secondary hyperparathyroidism. Only 9 patients were receiving vitamin D supplementation and none were on anti-osteoporotic treatment. Conclusions: These findings highlight the frequent coexistence of low BMD, vitamin D deficiency, and reduced muscle strength in THA candidates, suggesting a pattern of musculoskeletal vulnerability that warrants clinical attention.

1. Introduction

Patients awaiting hip arthroplasty (THA) present an elevated risk of osteoporosis due to factors related to age and gender [1]. Low bone mineral density (BMD) represents a significant risk factor for implant osseointegration and long-term fixation stability [2,3]. Reduced BMD has been shown to impair the initial mechanical stability of cementless implants, which is critical for early bone ingrowth. Aro et al. demonstrated that women with low BMD undergoing cementless total hip arthroplasty (THA) experienced delayed stem osseointegration and reduced fixation stability over a two-year period, as assessed by radiostereometric analysis (RSA) [3]. Inadequate mechanical anchorage at the implant–bone interface can result in micromotion, ultimately leading to fibrous tissue formation instead of osseous integration. Furthermore, compromised bone quality increases the risk of periprosthetic fractures, especially under physiological loading or minor trauma. A systematic review by Yan et al. highlighted how poor bone remodeling capacity in osteoporotic bone may predispose to implant migration and bone loss in short-stem THA [4]. Despite the recognized benefits of osteoporosis management in reducing these risks, studies show that osteoporosis is frequently underdiagnosed and undertreated in patients undergoing total joint arthroplasty (TJA) [5,6]. Bernatz et al. reported that over 75% of patients scheduled for total joint arthroplasty met diagnostic criteria for osteopenia or osteoporosis based on bone mineral density (BMD) or history of fragility fractures, yet fewer than 20% were receiving pharmacologic treatment for bone health prior to surgery [5]. Similarly, Delsmann et al. found that a substantial proportion of elderly patients undergoing total hip arthroplasty (THA) exhibited unrecognized osteoporosis, with limited application of both DEXA scanning and anti-osteoporotic therapy during the perioperative period [6]. This undertreatment persists despite well-established guidelines recommending screening and management of osteoporosis in older adults, particularly those undergoing major orthopedic procedures.
The evaluation of bone health through dual-energy X-ray absorptiometry (DEXA) is essential for diagnosing osteopenia and osteoporosis preoperatively [7]. In addition to BMD, the biomarkers vitamin D and parathyroid hormone (PTH) levels provide valuable parameters of bone metabolism and quality, potentially influencing surgical outcomes and guiding osteoporosis management in THA candidates [8,9,10]. In fact, Vitamin D deficiency has been associated with both reduced BMD and impaired functional recovery after surgery [8]. Makinen et al. highlighted that a significant proportion of women scheduled for cementless total joint replacement had undiagnosed osteopenia or osteoporosis, with suboptimal vitamin D status potentially contributing to compromised perioperative bone health [9]. More recently, Watanabe et al. demonstrated that biochemical markers of bone turnover, including vitamin D and PTH, were not only common but often insufficiently addressed in patients undergoing THA, despite their potential utility in identifying those at greater risk of poor osseointegration or periprosthetic complications [10]. Although osteoporosis-related biomarkers have been linked to fracture risk in the general population [11,12], their role in predicting outcomes for THA patients requires further exploration [13,14].
This study aims to investigate the prevalence and treatment rates of osteoporosis in THA candidates with hip osteoarthritis (OA), assessing DEXA-derived BMD values and biomarkers levels of vitamin D and PTH. Correlating these aspects of clinical and surgical management, this research seeks to emphasize the importance of osteoporosis management in improving THA outcomes and the need for increased awareness and standardization of preoperative osteoporosis screening and treatment in this high-risk patient group. This study provides new insight into the prevalence of untreated osteoporosis and vitamin D deficiency in THA candidates, focusing on an under-investigated Italian cohort, as few studies have addressed Southern European populations.

2. Material and Methods

This single-center, retrospective study was conducted at the Policlinico Universitario di TorVergata, Lazio, Italy, in accordance with the ethical guidelines of the 2013 revision of the Declaration of Helsinki [15]. Each experimental procedure was conducted with the approval of the Lazio Area 2 Territorial Ethics Committee (CET) (approval reference number #25/23). All patients included provided written informed consent for the collection, analysis and publication of clinical data. The study included a total of 66 patients diagnosed with hip OA, comprising 35 men and 31 women, with a mean age of 67.55 years. The data were retrospectively collected from medical records between October 2023 and June 2024. Inclusion criteria required patients to have a confirmed diagnosis of hip OA and to have undergone bone mineral density (BMD) assessment via dual-energy X-ray absorptiometry (DEXA). No distinction was made based on prior contralateral hip surgeries, as these were not considered to influence the systemic metabolic parameters under investigation. The diagnosis of hip osteoarthritis was based on clinical symptoms and radiographic evidence of joint degeneration, in accordance with standard orthopedic criteria, although formal ACR classification criteria were not explicitly applied. Patients with metabolic bone disorders other than osteoporosis, high-energy trauma history, or psychiatric conditions affecting treatment adherence were excluded.
BMD was measured at three anatomical sites within two weeks preoperatively: femoral neck, total femur, and lumbar spine, using a Lunar iDXA system (GE Healthcare, Milwaukee, WI, USA). Results were expressed in T-scores, with osteoporosis defined as a T-score ≤ −2.5 and osteopenia as a T-score between −1 and −2.5, according to the World Health Organization (WHO) criteria [16]. In addition to BMD, laboratory biomarkers related to bone metabolism were evaluated, including vitamin D and intact parathyroid hormone (PTH) levels. Serum levels of 25-hydroxyvitamin D [25(OH)D] were measured as part of the biochemical evaluation.
Patient demographic data, including age, sex, height, weight, and BMI, were recorded. The study also considered vitamin D deficiency as a potential contributing factor to variations in BMD. Additionally, data on ongoing anti-osteoporotic therapies were collected. Preoperative functional assessments were performed, including the Harris Hip Score (HHS) to evaluate hip function and handgrip strength measurements to assess overall muscle strength. Handgrip strength was measured using a hand dynamometer, with the patient in a seated position, shoulder adducted and neutrally rotated, elbow flexed at 90°, forearm in a neutral position, and wrist positioned between 0° and 30° of extension, according to standardized protocol recommendations. All measurements were performed by two trained assessors (A.C., C.R.) to ensure consistency and minimize inter-operator variability.
Statistical analyses were conducted using Prism v10.4.1 (GraphPad, Boston, MA, USA). Continuous variables were expressed as mean ± standard deviation (SD) and compared between male and female patients using independent-samples t-tests assuming unequal variance. Variables assessed included age, BMD values at the femoral neck, total femur and lumbar spine, serum vitamin D and PTH levels, Harris Hip Score (HHS), and handgrip strength. Categorical variables, such as sex distribution and vitamin D supplementation status, were analyzed using chi-square tests. Pearson’s correlation coefficient was used to explore linear relationships between vitamin D, PTH, and BMD parameters. A p-value of less than 0.05 was considered statistically significant.

3. Results

In this study, a total of 66 patients with hip osteoarthritis (OA) were evaluated, including 35 men and 31 women. The mean age of the cohort was 67.5 years (Table 1), with women being slightly older (69.0 ± 9.3 years) than men (64.1 ± 9.2 years; p = 0.07) (Table 2). Bone mineral density (BMD) values were lower in women across all DEXA-assessed sites, although the degree of significance varied depending on the anatomical region. At the femoral neck, women showed a mean BMD T-score of −0.99 ± 1.29 compared to −0.55 ± 1.28 in men (p = 0.26), while at the total femur, BMD was statistically significantly lower in females (−0.98 ± 1.42) versus males (−0.08 ± 1.04; p < 0.05) (Table 2, Figure 1A). The lumbar spine also revealed a statistically significant reduction in BMD for women (−0.66 ± 1.74) compared to men (0.67 ± 1.59; p < 0.05), suggesting a more diffuse skeletal involvement in the female cohort (Table 2, Figure 1B). Among the 66 patients analyzed, 21 had osteopenia and 6 met WHO criteria for osteoporosis based on T-scores. These findings highlight a higher prevalence of osteopenic and osteoporotic values among women, potentially attributable to postmenopausal hormonal changes, as supported by prior literature [16,17]. From a biochemical perspective, serum vitamin D levels were below the optimal threshold of 20 ng/mL in both sexes (Table 1), with mean values of 19.8 ± 9.0 ng/mL in females and 18.9 ± 10.0 ng/mL in males (p = 0.75) (Table 2). Parathyroid hormone (PTH) levels were moderately elevated in both groups, with women showing higher mean values (95.2 ± 47.0 pg/mL) than men (78.3 ± 31.2 pg/mL; p = 0.11), possibly reflecting secondary hyperparathyroidism due to hypovitaminosis D. Notably, handgrip strength measurements demonstrated a statistically significant reduction in female patients (17.1 ± 8.2 kg) compared to male patients (27.3 ± 10.3 kg; p < 0.05) (Table 2, Figure 1C), suggesting greater musculoskeletal fragility and sarcopenia within the female subgroup [17]. Functional assessment through the Harris Hip Score (HHS) indicated lower scores in women (36.7 ± 19.4) compared to men (46.2 ± 17.0; p = 0.08) (Table 2, Figure 1D), reflecting poorer preoperative functional status.
Despite the high prevalence of vitamin D insufficiency identified across the cohort, only 9 patients were receiving vitamin D supplementation prior to surgery. Among these patients, 5 were taking 25,000 IU of cholecalciferol once monthly, 3 were taking 25,000 IU twice monthly, and 1 patient was on daily supplementation with 2000 IU. The mean duration of supplementation was 43.2 ± 7.4 months prior to surgery. Furthermore, none of the patients evaluated were undergoing any form of pharmacological anti-osteoporotic treatment at the time of the preoperative assessment.

4. Discussion

The relationship between osteoarthritis (OA) and osteoporosis (OP) is controversial. Some studies seem to demonstrate a prevalence of osteoporosis in patients awaiting hip arthroplasty [1,18], indicating a close correlation between the two pathologies; others instead indicate an inverse correlation between the two pathologies, assuming that the simultaneous presence in a patient is due only to the fact that both are common in advanced age [19]. The issue is less complex and controversial when osteoarthritis is correlated with vitamin D levels in the serum [20,21,22].
In a retrospective analysis of 66 patients undergoing hip arthroplasty, 21 were found to have osteopenia and 6 were diagnosed with osteoporosis based on T-score data.
Among the 66 patients, 59 (89.4%) had serum vitamin D levels below 30 ng/mL, and 42 patients (63.6%) had levels below 20 ng/mL, the threshold commonly used to define deficiency in the general population. Despite these findings, only 9 patients were receiving vitamin D supplementation prior to surgery. These findings indicated a very high prevalence of vitamin D insufficiency, which is associated with low femoral bone mass prior to hip arthroplasty.
All patients diagnosed with osteopenia or osteoporosis were enrolled in the Fragility Liaison Service (FLS) care pathway following total hip arthroplasty, with serial monitoring every 12 months for vitamin D, parathyroid hormone (PTH), creatinine, and lumbar and femoral DEXA scans, along with therapeutic adjustments for the prevention and treatment of osteoporosis.
Vitamin D is essential in the processes of bone mineralization, particularly by enhancing the intestinal absorption of calcium and phosphorus [23]. Several studies have highlighted that a deficiency in vitamin D can indirectly promote the development of osteomalacia and increase the risk of fractures in the event of accidental falls [24].
The results are consistent with previous studies that have explored the importance of vitamin D in bone health and postoperative recovery in orthopedic surgery. Vitamin D deficiency can impair prosthetic stability due to decreased bone mineralization and a reduced immune response [25,26]. However, no studies have been able to establish a correlation between low vitamin D levels and the success of prosthetic implants. The correlation between low vitamin D levels and post-operative complications can be explained in several ways. Vitamin D plays a crucial role in bone metabolism by regulating calcium absorption and maintaining bone density. In the presence of vitamin D deficiency [27], the periprosthetic bone may become less resistant, increasing the risk of complications such as fractures, prosthetic instability, or difficulty in osteointegrationIn the context of bone grafting, vitamin D has also been implicated as a key modulator of osteoinductive processes and graft incorporation. As reviewed by Markopoulos et al., vitamin D plays a multifaceted role in supporting new bone formation and remodeling, which is critical in revision arthroplasty or cases requiring structural grafting [24]. Taken together, these findings suggest that diminished periprosthetic bone resistance—whether due to systemic metabolic deficiency or local mechanical overload—can significantly jeopardize implant success and long-term prosthetic stability, underscoring the importance of optimizing bone health preoperatively.
Additionally, vitamin D has a modulatory effect on the immune system, and insufficient levels may compromise the body’s ability to respond to infections, increasing the likelihood of postoperative infectious complications [25]. Furthermore, vitamin D is involved in the control of inflammatory responses, and low levels could contribute to a delay in bone and soft tissue healing [28,29,30], thus increasing the risk of infections and prosthetic dislocations. In fact, it modulates the expression of antimicrobial peptides such as cathelicidins and defensins, enhances macrophage phagocytic activity, and suppresses excessive proinflammatory cytokine production, contributing to a balanced immune response [27].
The results demonstrated Hight PTH levels which may indicate secondary hyperparathyroidism, a common consequence of vitamin D deficiency, which can accelerate bone resorption and further decrease BMD.
These results evidenced a complex interaction where low vitamin D and elevated PTH contribute to increased bone fragility, as highlighted by DEXA measurements in both femoral and lumbar regions in this sample. Such metabolic imbalances may accelerate the progression of coxarthrosis. The analysis suggests that patients with a predisposition to hip OA, especially postmenopausal women, could benefit from regular monitoring of bone health, including vitamin D and PTH levels, to allow for early prevention and therapeutic measures aimed at maintaining bone density and reducing the risk of coxarthrosis progression. In postmenopausal women, estrogen deficiency has been shown to modify vitamin D receptor expression and activity in bone and muscle, impairing the activation of vitamin D and further exacerbating osteosarcopenia [31,32]. Moreover, in our cohort, female patients exhibited significantly lower handgrip strength compared to males, reflecting a higher prevalence of muscle weakness and potential sarcopenia, conditions often associated with low bone mineral density and vitamin D deficiency. These findings align with the concept of osteosarcopenia, a syndrome marked by the coexistence of osteoporosis and sarcopenia, which has been linked to increased frailty and poorer outcomes in orthopedic patients [33,34]. Osteosarcopenia reflects a pathophysiological interplay between deteriorating bone density and declining muscle mass and strength, both of which share common biological pathways, including chronic inflammation, hormonal dysregulation, and nutritional deficiencies [29]. The coexistence of these two conditions amplifies mechanical fragility and functional dependence, resulting in a higher risk of falls, fractures, and delayed postoperative recovery. Hirschfeld et al. highlighted that osteosarcopenia represents not merely the summation of two geriatric syndromes, but a distinct clinical entity where the impairment of bone and muscle tissues synergistically contributes to increased physical frailty and vulnerability to surgical stress [29]. From a clinical standpoint, patients with osteosarcopenia often demonstrate poorer performance on functional mobility assessments, lower baseline strength, and prolonged rehabilitation needs after orthopedic procedures.
As described by Kirk and colleagues, the syndrome also carries important prognostic implications: it has been associated with increased postoperative complications, longer hospital stays, and reduced quality of life in older adults undergoing joint replacement surgery [30]. The identification of osteosarcopenia in preoperative assessments may therefore aid in risk stratification and guide the implementation of targeted interventions, such as nutritional supplementation, resistance training, and pharmacological therapies, aimed at optimizing musculoskeletal health and improving surgical outcomes. Emerging evidence indicates that bone and muscle tissues engage in constant crosstalk through mechanical, biochemical, and endocrine signaling pathways, influencing each other’s development, maintenance, and regeneration under both physiological and pathological conditions [35,36]. Myokines such as irisin and interleukin-6, secreted by skeletal muscle during contraction, have been shown to stimulate osteoblast activity and bone formation, while osteokines including osteocalcin and sclerostin derived from bone modulate muscle metabolism and function [35]. This bidirectional communication is critical for maintaining musculoskeletal homeostasis and becomes particularly relevant in aging populations or in the presence of degenerative conditions such as osteosarcopenia. Under pathological conditions, such as vitamin D deficiency, chronic inflammation, or disuse, this bone–muscle axis becomes disrupted, contributing to simultaneous deterioration of bone density and muscle strength. Karsenty and Mera have elucidated several molecular pathways—such as Wnt/β-catenin, IGF-1, and FGF23—through which bone-derived signals influence myogenesis and muscle performance, suggesting potential targets for therapeutic intervention [36].
Despite the relatively small sample size, the results confirm the importance of vitamin D in the management of osteoporotic patients undergoing hip arthroplasty [3]. Patients with vitamin D deficiency, as shown in various studies, demonstrate significantly worse outcomes compared to those with adequate levels of this vitamin, both in terms of postoperative recovery and the reduction of complications [37,38]. Overall, our findings contribute new evidence to the orthopedic literature by linking vitamin D deficiency, low BMD, and impaired muscle strength in a single cohort of Italian patients. This is particularly relevant given the limited data available on Southern European populations.
This study had several limitations. First, the study was designed as a retrospective study. Therefore, we cannot exclude selection bias and insufficient data collection. Second, the present investigations did not evaluate other factors, which may be associated with vitamin D insufficiency. Third the number of patients included in the study is too small to have an adequate statistical significance. Additionally, the absence of assessment for fragility fractures, such as asymptomatic vertebral fractures, may have led to an underestimation of true osteoporosis prevalence, particularly among patients classified as osteopenic based on T-score alone. Lastly, as this was a single-center study, future large, multi-centered and prospective study are warranted.

5. Conclusions

This study offers important real-world insights into the metabolic bone status of THA candidates in a Southern European population. Significant sex-related differences were found in total femur BMD, lumbar spine BMD, and handgrip strength, suggesting a higher risk of osteosarcopenia in female patients. Despite these findings, vitamin D deficiency remained largely untreated, and no patients were receiving anti-osteoporotic therapies. These results underline the need for routine preoperative screening and targeted interventions to optimize outcomes and reduce complications in patients undergoing THA.

Author Contributions

Conceptualization, A.S.; methodology, A.S.; validation, U.T., E.G. and R.I.; formal analysis, U.T.; investigation, T.C.; data curation, T.C., C.R., A.C. and D.R.; writing—original draft preparation, A.S.; writing—review and editing, R.I.; supervision, U.T.; funding acquisition, U.T. All authors have read and agreed to the published version of the manuscript.

Funding

This research received no external funding.

Institutional Review Board Statement

The study was conducted in accordance with the Declaration of Helsinki, and approved by the Lazio Area 2 Territorial Ethics Committee (CET) (approval reference number #25/23).

Informed Consent Statement

Written informed consent has been obtained from the patients to publish this paper

Data Availability Statement

Data will be made available upon reasonable request.

Conflicts of Interest

The authors declare no conflict of interest.

References

  1. Xiao, P.L.; Hsu, C.J.; Ma, Y.G.; Liu, D.; Peng, R.; Xu, X.H.; Lu, H.D. Prevalence and treatment rate of osteoporosis in patients undergoing total knee and hip arthroplasty: A systematic review and meta-analysis. Arch. Osteoporos. 2022, 17, 16. [Google Scholar] [CrossRef]
  2. Krenzlin, H.; Schmidt, L.; Jankovic, D.; Schulze, C.; Brockmann, M.A.; Ringel, F.; Keric, N. Impact of Sarcopenia and Bone Mineral Density on Implant Failure after Dorsal Instrumentation in Patients with Osteoporotic Vertebral Fractures. Medicina 2022, 58, 748. [Google Scholar] [CrossRef] [PubMed]
  3. Aro, H.T.; Alm, J.J.; Moritz, N.; Mäkinen, T.J.; Lankinen, P. Low BMD affects initial stability and delays stem osseointegration in cementless total hip arthroplasty in women: A 2-year RSA study of 39 patients. Acta Orthop. 2012, 83, 107–114. [Google Scholar] [CrossRef] [PubMed]
  4. Yan, S.G.; Weber, P.; Steinbrück, A.; Hua, X.; Jansson, V.; Schmidutz, F. Periprosthetic bone remodelling of short-stem total hip arthroplasty: A systematic review. Int. Orthop. 2018, 42, 2077–2086. [Google Scholar] [CrossRef]
  5. Bernatz, J.T.; Brooks, A.E.; Squire, M.W.; Illgen, R.I., 2nd; Binkley, N.C.; Anderson, P.A. Osteoporosis Is Common and Undertreated Prior to Total Joint Arthroplasty. J. Arthroplast. 2019, 34, 1347–1353. [Google Scholar] [CrossRef]
  6. Delsmann, M.M.; Strahl, A.; Mühlenfeld, M.; Jandl, N.M.; Beil, F.T.; Ries, C.; Rolvien, T. High prevalence and undertreatment of osteoporosis in elderly patients undergoing total hip arthroplasty. Osteoporos. Int. 2021, 32, 1661–1668. [Google Scholar] [CrossRef]
  7. Yu, J.S.; Krishna, N.G.; Fox, M.G.; Blankenbaker, D.G.; Frick, M.A.; Jawetz, S.T.; Li, G.; Reitman, C.; Said, N.; Stensby, J.D.; et al. ACR Appropriateness Criteria® Osteoporosis and Bone Mineral Density: 2022 Update. J. Am. Coll. Radiol. 2022, 19, S417–S432. [Google Scholar] [CrossRef]
  8. Glowacki, J.; Hurwitz, S.; Thornhill, T.S.; Kelly, M.; LeBoff, M.S. Osteoporosis and vitamin-D deficiency among postmenopausal women with osteoarthritis undergoing total hip arthroplasty. J. Bone Jt. Surg. 2003, 85, 2371–2377. [Google Scholar] [CrossRef]
  9. Mäkinen, T.J.; Alm, J.J.; Laine, H.; Svedström, E.; Aro, H.T. The incidence of osteopenia and osteoporosis in women with hip osteoarthritis scheduled for cementless total joint replacement. Bone 2007, 40, 1041–1047. [Google Scholar] [CrossRef]
  10. Watanabe, N.; Miyatake, K.; Takada, R.; Ogawa, T.; Amano, Y.; Jinno, T.; Koga, H.; Yoshii, T.; Okawa, A. The prevalence and treatment of osteoporosis in patients undergoing total hip arthroplasty and the levels of biochemical markers of bone turnover. Bone Jt. Res. 2022, 11, 873–880. [Google Scholar] [CrossRef]
  11. Garnero, P. Biomarkers for osteoporosis management: Utility in diagnosis, fracture risk prediction and therapy monitoring. Mol. Diagn. Ther. 2008, 12, 157–170. [Google Scholar] [CrossRef] [PubMed]
  12. Tian, A.; Ma, J.; Feng, K.; Liu, Z.; Chen, L.; Jia, H.; Ma, X. Reference markers of bone turnover for prediction of fracture: A meta-analysis. J. Orthop. Surg. Res. 2019, 14, 68. [Google Scholar] [CrossRef] [PubMed]
  13. Wu, R.; Ma, Y.; Chen, D.; Li, M.; Li, Z.; Deng, Z.; Zheng, Q.; Fu, G. Bone turnover biomarkers predict one-year all-cause mortality and walking ability in geriatric hip fracture patients. Bone 2023, 177, 116922. [Google Scholar] [CrossRef]
  14. Okpara, C.; Negm, A.; Adachi, J.D.; Armstrong, D.; Atkinson, S.; Avram, V.; de Beer, J.; Hladysh, G.; Ioannidis, G.; Kennedy, C.; et al. Getting fit for hip and knee replacement: The Fit-Joints multimodal intervention for frail patients with osteoarthritis—A pilot randomized controlled trial. J. Frailty Aging 2025, 14, 100028. [Google Scholar] [CrossRef]
  15. World Medical Association. World Medical Association Declaration of Helsinki: Ethical principles for medical research involving human subjects. JAMA 2013, 310, 2191–2194. [Google Scholar] [CrossRef]
  16. World Health Organization. Assessment of Fracture Risk and Its Application to Screening for Postmenopausal Osteoporosis: Report of a WHO Study Group; World Health Organization Technical Report Series; WHO: Geneva, Switzerland, 1994; Volume 843, pp. 1–129. [Google Scholar]
  17. Cruz-Jentoft, A.J.; Bahat, G.; Bauer, J.; Boirie, Y.; Bruyère, O.; Cederholm, T.; Cooper, C.; Landi, F.; Rolland, Y.; Sayer, A.A.; et al. Sarcopenia: Revised European consensus on definition and diagnosis. Age Ageing 2019, 48, 16–31. [Google Scholar] [CrossRef]
  18. Lingard, E.A.; Mitchell, S.Y.; Francis, R.M.; Rawlings, D.; Peaston, R.; Birrell, F.N.; McCaskie, A.W. The prevalence of osteoporosis in patients with severe hip and knee osteoarthritis awaiting joint arthroplasty. Age Ageing 2010, 39, 234–239. [Google Scholar] [CrossRef]
  19. Dequeker, J.; Aerssens, J.; Luyten, F.P. Osteoarthritis and osteoporosis: Clinical and research evidence of inverse relationship. Aging Clin. Exp. Res. 2003, 15, 426–439. [Google Scholar] [CrossRef]
  20. Paranhos-Neto, F.P.; Vieira Neto, L.; Madeira, M.; Moraes, A.B.; Mendonça, L.M.C.; Lima, I.C.B.; Chagas, C.L.R.; Lira, D.A.; Spitz, J.F.; Guimarães, J.A.M.; et al. Vitamin D deficiency is associated with cortical bone loss and fractures in the elderly. Eur. J. Endocrinol. 2019, 181, 509–517. [Google Scholar] [CrossRef]
  21. Segheto, K.J.; Pereira, M.; Silva, D.C.G.D.; Carvalho, C.J.D.; Massardi, F.R.; Kakehasi, A.M.; Juvanhol, L.L.; Longo, G.Z. Vitamin D and bone health in adults: A systematic review and meta-analysis. Ciência Saúde Coletiva 2021, 26, 3221–3244. [Google Scholar] [CrossRef]
  22. Bruyère, O.; Cavalier, E.; Reginster, J.Y. Vitamin D and osteosarcopenia: An update from epidemiological studies. Curr. Opin. Clin. Nutr. Metab. Care 2017, 20, 498–503. [Google Scholar] [CrossRef] [PubMed]
  23. Minisola, S.; Cianferotti, L.; Biondi, P.; Cipriani, C.; Fossi, C.; Franceschelli, F.; Giusti, F.; Leoncini, G.; Pepe, J.; Bischoff-Ferrari, H.A.; et al. Correction of vitamin D status by calcidiol: Pharmacokinetic profile, safety, and biochemical effects on bone and mineral metabolism of daily and weekly dosage regimens. Osteoporos. Int. 2017, 28, 3239–3249. [Google Scholar] [CrossRef]
  24. Sitta, M.C.; Cassis, S.V.; Horie, N.C.; Moyses, R.M.; Jorgetti, V.; Garcez-Leme, L.E. Osteomalacia and vitamin D deficiency in the elderly. Clinics 2009, 64, 156–158. [Google Scholar] [CrossRef] [PubMed]
  25. Birinci, M.; Hakyemez, Ö.S.; Geçkalan, M.A.; Mutlu, M.; Yildiz, F.; Bilgen, Ö.F.; Azboy, İ. Effect of Vitamin D Deficiency on Periprosthetic Joint Infection and Complications After Primary Total Joint Arthroplasty. J. Arthroplast. 2024, 39, S151–S157. [Google Scholar] [CrossRef] [PubMed]
  26. Markopoulos, G.; Lepetsos, P.; Perrea, D.N.; Iliopoulos, D.C.; Nikolaou, V.S. Possible Roles of Vitamin D in Bone Grafting. Cureus 2021, 13, e14688. [Google Scholar] [CrossRef]
  27. Lips, P.; van Schoor, N.M. The effect of vitamin D on bone and osteoporosis. Best Pract. Res. Clin. Endocrinol. Metab. 2011, 25, 585–591. [Google Scholar] [CrossRef]
  28. Kelly, J.; Lin, A.; Wang, C.J.; Park, S.; Nishimura, I. Vitamin D and bone physiology: Demonstration of vitamin D deficiency in an implant osseointegration rat model. J. Prosthodont. 2009, 18, 473–478. [Google Scholar] [CrossRef]
  29. Aranow, C. Vitamin D and the immune system. J. Investig. Med. 2011, 59, 881–886. [Google Scholar] [CrossRef]
  30. Schwalfenberg, G.K. A review of the critical role of vitamin D in the functioning of the immune system and the clinical implications of vitamin D deficiency. Mol. Nutr. Food Res. 2011, 55, 96–108. [Google Scholar] [CrossRef]
  31. Mei, Z.; Hu, H.; Zou, Y.; Li, D. The role of vitamin D in menopausal women’s health. Front. Physiol. 2023, 14, 1211896. [Google Scholar] [CrossRef]
  32. Zhang, J.; Cheng, Y.; Chen, C.; Wang, Q.; Yang, C.; Qiu, J.; Li, J.; Liu, X.; Zhang, Y.; Liu, L.; et al. Interaction of estradiol and vitamin D with low skeletal muscle mass among middle-aged and elderly women. BMC Women’s Health 2023, 23, 491. [Google Scholar] [CrossRef]
  33. Hirschfeld, H.P.; Kinsella, R.; Duque, G. Osteosarcopenia: Where bone, muscle, and fat collide. Osteoporos. Int. 2017, 28, 2781–2790. [Google Scholar] [CrossRef] [PubMed]
  34. Kirk, B.; Zanker, J.; Duque, G. Osteosarcopenia: Epidemiology, diagnosis, and treatment-facts and numbers. J. Cachexia Sarcopenia Muscle 2020, 11, 609–618. [Google Scholar] [CrossRef] [PubMed]
  35. Dong, Y.; Yuan, H.; Ma, G.; Cao, H. Bone-muscle crosstalk under physiological and pathological conditions. Cell. Mol. Life Sci. 2024, 81, 310. [Google Scholar] [CrossRef]
  36. Karsenty, G.; Mera, P. Molecular bases of the crosstalk between bone and muscle. Bone 2018, 115, 43–49. [Google Scholar] [CrossRef]
  37. Lim, J.; Onozawa, M.; Saad, M.; Ong, T.A.; Malek, R.; Akaza, H.; A-CaP (Asian Prostate Cancer) Study; J-CaP (Japan Prostate Cancer Study Group); M-CaP (Malaysia Prostate Cancer Study Group). Recent trend of androgen deprivation therapy in newly diagnosed prostate cancer patients: Comparing between high- and middle-income Asian countries. Cancer Sci. 2021, 112, 2071–2080. [Google Scholar] [CrossRef]
  38. Fink, A.; Puchwein, P.; Fahrleitner-Pammer, A.; Eder-Halbedl, M.; Bernhardt, G.A. Increased Early Postoperative Complication Rate after Osteoporotic Hip Fracture in Patients with Low 25 (OH) Vitamin D Levels. Nutrients 2024, 16, 1917. [Google Scholar] [CrossRef]
Prosthesis 07 00073 g001
Figure 1. Boxplots (A–D) comparing total femur BMD, lumbar spine BMD, handgrip strength, and Harris Hip Score (HHS) between male and female patients. Statistically significant differences were observed in total femur BMD, lumbar spine BMD, and handgrip strength.
Figure 1. Boxplots (A–D) comparing total femur BMD, lumbar spine BMD, handgrip strength, and Harris Hip Score (HHS) between male and female patients. Statistically significant differences were observed in total femur BMD, lumbar spine BMD, and handgrip strength.
Prosthesis 07 00073 g001
Table 1. Summary of demographic, bone mineral density (BMD), vitamin D, parathyroid hormone (PTH), pre-op Harris Hip Score (HHS), and handgrip strength data for the study cohort. The values represent the mean, mode, median, and standard deviation for each parameter.
Table 1. Summary of demographic, bone mineral density (BMD), vitamin D, parathyroid hormone (PTH), pre-op Harris Hip Score (HHS), and handgrip strength data for the study cohort. The values represent the mean, mode, median, and standard deviation for each parameter.
VariablesMeanStandard Deviation
Age (years)67.559.07
Gender (M/F)35 M, 31 F-
Hip Femoral Neck BMD (T-score)−0.691.23
Total Femur BMD (T-score)−0.321.34
Lumbar Spine BMD (T-score)0.181.76
Vitamin D (ng/mL)19.339.76
Parathyroid Hormone (PTH, pg/mL)84.4239.38
Pre-op Harris Hip Score (HHS)43.1517.49
Handgrip Strength (kg)22.5910.94
Table 2. Comparison of demographic, bone density, biochemical, and functional parameters between male and female patients. Statistically significant differences (p < 0.05) are marked with an asterisk (*).
Table 2. Comparison of demographic, bone density, biochemical, and functional parameters between male and female patients. Statistically significant differences (p < 0.05) are marked with an asterisk (*).
VariablesFemale (Mean ± SD)Male (Mean ± SD)p-Value
Age (years)69.0 ± 9.2764.08 ± 9.150.07
Femoral Neck BMD (T-score)−0.99 ± 1.29−0.55 ± 1.280.26
Total Femur BMD (T-score)−0.98 ± 1.42−0.08 ± 1.04<0.05 *
Lumbar Spine BMD (T-score)−0.66 ± 1.740.67 ± 1.59<0.05 *
Vitamin D (ng/mL)19.81 ± 9.0318.91 ± 9.970.75
Parathyroid Hormone (PTH, pg/mL)95.22 ± 47.0378.26 ± 31.220.11
Harris Hip Score (HHS)36.65 ± 19.4146.16 ± 17.010.08
Handgrip Strength (kg)17.05 ± 8.1527.31 ± 10.34<0.05 *
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MDPI and ACS Style

Smakaj, A.; Iundusi, R.; Chiavoghilefu, A.; Cardelli, T.; Rossi, D.; Raso, C.; Tarantino, U.; Gasbarra, E. Prevalence of Osteoporosis and Vitamin D Levels in Patients Undergoing Total Hip Arthroplasty: Insights from a Single-Center Experience in Italy. Prosthesis 2025, 7, 73. https://doi.org/10.3390/prosthesis7040073

AMA Style

Smakaj A, Iundusi R, Chiavoghilefu A, Cardelli T, Rossi D, Raso C, Tarantino U, Gasbarra E. Prevalence of Osteoporosis and Vitamin D Levels in Patients Undergoing Total Hip Arthroplasty: Insights from a Single-Center Experience in Italy. Prosthesis. 2025; 7(4):73. https://doi.org/10.3390/prosthesis7040073

Chicago/Turabian Style

Smakaj, Amarildo, Riccardo Iundusi, Angela Chiavoghilefu, Tommaso Cardelli, Danilo Rossi, Claudio Raso, Umberto Tarantino, and Elena Gasbarra. 2025. "Prevalence of Osteoporosis and Vitamin D Levels in Patients Undergoing Total Hip Arthroplasty: Insights from a Single-Center Experience in Italy" Prosthesis 7, no. 4: 73. https://doi.org/10.3390/prosthesis7040073

APA Style

Smakaj, A., Iundusi, R., Chiavoghilefu, A., Cardelli, T., Rossi, D., Raso, C., Tarantino, U., & Gasbarra, E. (2025). Prevalence of Osteoporosis and Vitamin D Levels in Patients Undergoing Total Hip Arthroplasty: Insights from a Single-Center Experience in Italy. Prosthesis, 7(4), 73. https://doi.org/10.3390/prosthesis7040073

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