Parathyroidectomy associated with a reduction in fracture risk among adults with primary hyperparathyroidism
1. This large, population-based cohort study demonstrated that adults with primary hyperparathyroidism who underwent parathyroidectomy within one year of diagnosis had reduced risk of any site fracture and hip fracture compared to those who managed nonoperatively.
Evidence Rating Level: 2 (Good)
Study Rundown: Primary hyperparathyroidism (PHPT) is associated with a higher risk of fractures. A previous study demonstrated that parathyroidectomy in patients with PHPT reduces fracture risk compared to observation or medical treatment; however, due to some critical limitations from the study, the results could not be used on their own to guide management decisions. This population-based, longitudinal cohort study of Medicare beneficiaries diagnosed with PHPT (210 206 participants) from January 1, 2006, until December 31, 2017, investigated whether parathyroidectomy in older adults with PHPT is independently associated with decreased clinical fracture risk. Patients were defined as the parathyroidectomy treatment group if they received a parathyroidectomy within one year of diagnosis; the remainder of patients with PHPT were defined as the nonoperative cohort. The primary outcome was the incidence of clinical fracture at any site, and the secondary outcome was the incidence of hip fracture. Among all included participants in the study, 30% received parathyroidectomy within the first year of diagnosis. Among 63 136 parathyroidectomy patients, 6447 (10.2%) developed a fracture compared to 20 076/147 070 (13.7%) in the nonoperative cohort. There was a reduced adjusted risk of any clinical fracture (hazard ratio [HR]: 0.78 [95% CI: 0.76-0.80]) and hip fracture (HR: 0.76 [95% CI: 0.72-0.79]) in parathyroidectomy patients compared to nonoperative patients. The reduction in risk of fractures remained statistically significant after controlling for age, sex, osteoporosis, frailty, and even those who did not meet operative guidelines. Recurrent laryngeal nerve injury was rare among patients who received parathyroidectomy (0.99%). Overall, parathyroidectomy treatment for older adults diagnosed with PHPT was strongly associated with a lower risk of any clinical fracture; therefore, surgery in this population deserves more consideration to reduce disability. This study included a large, national cohort of adults with PHPT increasing the likelihood of generalizing it to other populations. One limitation of this study, however, is the lack of data in Medicare regarding the severity of PHPT and baseline bone mineral density data, which could have resulted in selection bias for those who received parathyroidectomies.
Click to read the study in JAMA Internal Medicine
Click to read an accompanying editorial in JAMA Internal Medicine
Relevant Reading: The relationship of parathyroidectomy and bisphosphonates with fracture risk in primary hyperparathyroidism: an observational study
Image: PD
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