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The Effect of Parathyroidectomy on Bone Fracture Risk in Patients With Primary Hyperparathyroidism
Lindi H. VanderWalde, MD;
In-Lu Amy Liu, MS;
Theodore X. O’Connell, MD;
Philip I. Haigh, MD, MSc, FRCSC
Arch Surg. 2006;141:885-891.
Background Parathyroidectomy may increase bone density in primary hyperparathyroidism (PHPT), but it is unclear whether fracture risk is decreased.
Hypothesis Parathyroidectomy decreases fracture risk.
Design Retrospective cohort study with median follow-up of 6.5 years.
Setting Twelve regional hospitals in California.
Patients One thousand five hundred sixty-nine patients with PHPT.
Interventions Parathyroidectomy or observation.
Main Outcome Measure Fracture-free survival.
Results Mean initial calcium, parathyroid hormone, and creatinine levels were 11.2 mg/dL (2.8 mmol/L), 123.0 pg/mL, and 0.9 mg/dL (79.6 µmol/L), respectively. Parathyroidectomy was performed in 452 (28.8%) patients, and 1117 (71.2%) were observed. The 10-year fracture-free survival after PHPT diagnosis was 73% in patients treated with parathyroidectomy compared with 59% in those observed (hazard ratio [HR], 0.53; 95% confidence interval [CI], 0.38-0.73; P<.001). Parathyroidectomy decreased the 10-year hip fracture rate by 8% (P = .001) and the upper extremity fracture rate by 3% (P = .02). Parathyroidectomy was independently associated with a decreased fracture risk (HR, 0.68; 95% CI, 0.47-0.98), whereas female sex (HR, 1.82; 95% CI, 1.19-2.80) and increased creatinine level (HR per 1-mg/dL [88.4-µmol/L] increment, 2.05; 95% CI, 1.22-3.46) remained independently associated with an increased fracture risk. Age of 50 years or older (HR, 1.62; 95% CI, 0.99-2.66), initial parathyroid hormone level (HR, 1.00; 95% CI, 0.99-1.02), and calcium level (HR, 1.02; 95% CI, 0.75-1.37) were not independently associated with fracture risk after adjusting for all other variables.
Conclusions Parathyroidectomy is associated with a decreased risk of fracture in PHPT. The largest decrease was in hip fractures. Parathyroidectomy should be considered for all patients with PHPT to reduce fracture risk, regardless of age or calcium or parathyroid hormone levels.
Author Affiliations: Department of Surgery, Kaiser Permanente Los Angeles Medical Center, Los Angeles, Calif (Drs VanderWalde, O’Connell, and Haigh); and Center for Research and Evaluation, Kaiser Permanente Regional Offices, Pasadena, Calif (Ms Liu).
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