Underdiagnosis of primary hyperparathyroidism in patients with osteoarthritis undergoing arthroplasty

Hypercalcemia and Postoperative Joint Symptoms Following Joint Replacement for Osteoarthritis

INTRODUCTION

Calcium metabolism dysregulation in the setting of primary hyperparathyroidism (PHPT) mediated chondrocalcinosis is implicated in joint pain, a key element in the decision regarding arthroplasty for osteoarthritis. The relationship between hypercalcemia and joint pain, before and after arthroplasty, is unknown. This study investigates the association between preoperative hypercalcemia and postoperative outcomes following total knee (TKA) and total hip arthroplasty (THA).

METHODS

A retrospective chart review was conducted on patients who underwent initial elective THA or TKA. Patients with a preoperative serum calcium >10.2 mg/dL were matched (1:2-1:4) with nearest neighbor to patients with normal serum calcium. THA and TKA functional outcomes were measured at baseline and 1-y postoperatively using patient-reported Hip Disability and Osteoarthritis Outcome Scores and Knee Injury and Osteoarthritis Outcome Scores surveys. Postoperative complications, readmissions, length of stay, and functional outcome scores were compared.

RESULTS

Four hundred ninety-five patients (106 hypercalcemic cases, 389 matched controls) were included. Of these, 223 patients underwent THA (46 cases; 177 controls) and 272 patients underwent TKA (61 cases; 211 controls). There were no differences in Hip Disability and Osteoarthritis Outcome Scores and Knee Injury and Osteoarthritis Outcome Scores scores, postoperative complications, readmissions, or length of stay between cases and controls. Only 19/106 (18%) hypercalcemic patients had a parathyroid hormone (PTH); of these, 9 (47%) had possible PHPT (PTH > 40).

CONCLUSIONS

Patients with hypercalcemia undergoing arthroplasty have similar functional and postoperative outcomes as normocalcemic patients. As PTH was obtained in <20% of hypercalcemic cases and 50% had possible PHPT, we recommend that hypercalcemic patients undergo PHPT workup. Additional investigation is needed to determine the effect of PHPT on arthroplasty outcomes.

Lithium-associated primary hyperparathyroidism:: An evaluation of screening and referral patterns in a southeastern veteran population

BACKGROUND

Long-term lithium therapy has a well-established but under-recognized association with primary hyperparathyroidism. Rates of hypercalcemia, screening for primary hyperparathyroidism, and referral for parathyroidectomy were evaluated among United States veterans on long-term lithium therapy.

METHODS

Patients undergoing chronic long-term lithium therapy (>12 months) were identified from 1999 to 2022. Demographics, long-term lithium therapy duration, post-treatment calcium, parathyroid hormone, creatinine, and vitamin D levels were abstracted. Rates of screening for hypercalcemia (calcium ≥10.2 mg/dL), primary hyperparathyroidism (parathyroid hormone ≥30 pg/mL in the setting of hypercalcemia), referral for parathyroidectomy, and outcomes were evaluated.

RESULTS

A total of 1,356 patients underwent long-term lithium therapy, 514 of whom received chronic long-term lithium therapy. Baseline characteristics of patients with and without post-treatment hypercalcemia were compared. Of 148 patients with post-treatment hypercalcemia, 112 (74.7%) underwent no further evaluation for primary hyperparathyroidism, while 36 (25.3%) patients had a parathyroid hormone level recorded. Although 33 (91.7%) hypercalcemic patients screened positive for primary hyperparathyroidism, only 5 (13%) were referred for parathyroidectomy. Of the 4 patients who underwent parathyroidectomy, mean calcium was 11.2 mg/dL (range 11.1-11.4), and mean parathyroid hormone was 272 pg/mL (range 108-622). Three patients were localized on preoperative imaging, 2 of whom underwent unilateral exploration with cure, with 1 experiencing recurrence at 31 months. The remaining patient who localized preoperatively underwent bilateral exploration and had 2 ipsilateral glands resected and persistence. The patient who did not localize preoperatively underwent bilateral exploration with 3 gland resection and cure.

CONCLUSIONS

Screening for primary hyperparathyroidism and referral for parathyroidectomy are underutilized in United States veterans undergoing chronic long-term lithium therapy. Institutional protocols to standardize screening, surveillance, and referrals to endocrinology/endocrine surgery could benefit this population at increased risk for primary hyperparathyroidism.

Parathyroidectomy and the Risk of Major Cerebrovascular and Cardiovascular Events in the Elderly

OBJECTIVE

We aimed to determine the incidence of major cardiovascular and cerebrovascular events in elderly patients with primary hyperparathyroidism (pHPT) and the impact of parathyroidectomy.

SUMMARY BACKGROUND DATA

pHPT is underdiagnosed and undertreated in the United States. It is associated with increased cardiovascular disease risk, but its association with cerebrovascular disease risk is not well-established. It is also unknown if parathyroidectomy reduces these risks.

METHODS

The incidence of major cerebrovascular and cardiovascular events in 108,869 patients with pHPT diagnosed in the Medicare database between 2008 and 2018 and a matched comparison group of 1,088,690 Medicare subjects was prospectively evaluated. We estimated hazard ratios (HR) for the association of pHPT and parathyroidectomy for the risk of these outcomes from Cox proportional hazards models. Survival curves were calculated to obtain 5-year disease-free survival estimates.

RESULTS

For patients with pHPT, five-year disease-free survival was lower, and HRs were higher than the comparison group for any outcome (75.9% vs. 78.4; HR 1.11, 95% confidence interval [CI] 1.09-1.13), major cerebrovascular events (84.5% vs. 86.3%; HR 1.14, 95% CI 1.12-1.17), and major cardiovascular events (87.7% vs. 88.8%; HR 1.06, 95% CI 1.03-1.08). However, in patients who had parathyroidectomy, the risks of major cerebrovascular and cardiovascular events did not differ from the comparison cohort. The lower risk in patients who had parathyroidectomy was maintained in subgroup analyses.

CONCLUSIONS

Older patients with pHPT have an increased risk of major cerebrovascular and cardiovascular events compared with patients without the disease. Physicians treating older patients with primary hyperparathyroidism should consider parathyroidectomy.R.M.P. and N.N. contributed equally to the preparation of this manuscript.

Underdiagnosis of Hyperparathyroidism in Patients With Nephrolithiasis in a Community Setting

Objective Untreated primary hyperparathyroidism (PHPT) has wide-ranging multisystemic effects. Recent studies based in the US have shown a less than 25% screening rate for PHPT. Our study aims to detect whether similar deficiencies exist in our community healthcare system while quantifying the prevalence of PHPT underdiagnosis and inadequate surgical referrals. Study design This retrospective quantitative study enrolled patients aged ≥18 years with imaged-confirmed nephrolithiasis at our healthcare facilities from 2017 to the present (n=2021). Patients with documented calcium levels and kidney/ureter stones were included. Descriptive and univariate analyses were performed. Results A total of 2021 subjects met the criteria to be enrolled in the study. 26.6% (n=537) of patients with nephrolithiasis had elevated calcium levels on record. 13.6% (n=73) of hypercalcemic patients were screened for PHPT with an intact parathyroid hormone (PTH). A majority (63%, n=46) of patients with intact PTH had PHPT defined as PTH levels >55 pg/mL. Ultimately, only 19.6% (n=9) of patients with PHPT were referred for surgical intervention, and there was no significant difference in referral rate between patients with PHPT and those without (p=0.913). Conclusions PHPT is underdiagnosed in our community, leading to a significantly low rate of surgical referral and delay in management. Implementation of hospital protocols to aid in improving diagnosis and interventions could improve outcomes for PHPT patients.

A Case of TKA Failure in Patient with Primary Hyperparathyroidism

BACKGROUND

Primary hyperparathyroidism (PHPT) is an endocrine disorder with high serum calcium and parathyroid hormone (PTH) levels. Excessive secretion of PTH can cause bone loss and may have potential damage to implant fixation after total knee arthroplasty (TKA). However, there is currently no research or literature reporting prosthesis loosening after TKA associated with PHPT.

CASE PRESENTATION

This case report describes a TKA failure of tibial prothesis loosening associated with PHPT. The patient faced aggravated pain and difficulty in walking 6 months after the primary TKA. Further examinations showed high serum calcium and PTH levels indicating the presence of PHPT. After the surgery of parathyroidectomy, the patient received revision TKA with 3D-printed metaphyseal cone. Knee symptoms and function were finally improved.

CONCLUSION

PHPT is a risk factor for prosthesis loosening after TKA. Preoperative screening test of serum calcium and PTH levels is important to diagnose PHPT. For patients with PHPT undergoing TKA, preoperative endocrinotherapy and parathyroidectomy are recommended to improve the survival of prosthesis.

Older Patients With Asymptomatic Primary Hyperparathyroidism: Should Criteria for Surgery Be Expanded?

Context

Patients with primary hyperparathyroidism (PHPT) can present with variable signs, symptoms, and end-organ effects. Clinical practice guidelines influence referral for consideration of parathyroidectomy.

Objective

This study compared the demographic, biochemical, and symptom profile and examine indications for surgery in patients older than 50 years who underwent parathyroidectomy to determine how changes to current guidelines may affect recommendations for parathyroidectomy.

Methods

A retrospective review was conducted of patients age 50 years or older who underwent initial parathyroidectomy for sporadic PHPT from 2012 to 2020. Patients were classified by indications for surgery per guideline criteria (classic, asymptomatic, and no criteria met) and age group (AG): 50 to 59 years; 60 to 69 years; 70 years or older. Patients were treated at a high-volume tertiary medical center by endocrine surgeons.

Results

Of 1182 patients, 367 (31%) classic and 660 (56%) asymptomatic patients met the criteria for surgery. The most common indications for surgery were extent of hypercalcemia (51%), osteoporosis (28%), and nephrolithiasis (27%). Of the 155 (13%) patients who did not meet the criteria, neurocognitive symptoms (AG1: 88% vs AG2: 81% vs AG3: 70%; P = .14) and osteopenia (AG1: 53% vs AG2: 68% vs AG3: 68%; P = .43) were frequently observed regardless of patient age. If the age threshold of younger than 50 years was expanded to 60, 65, or 70 years, an additional 61 (5%), 99 (8%), and 124 (10%) patients in the entire cohort would have met the guideline criteria for surgery, respectively.

Conclusion

Expanding current guidelines for PHPT to include a broader age range, osteopenia, and neurocognitive symptoms may allow for earlier surgical referral and evaluation for definitive treatment.