Does surgery for primary hyperparathyroidism (PHPT) improve bone quality?

From the Guidelines

Surgery for primary hyperparathyroidism (PHPT) is highly effective in improving bone quality by normalizing parathyroid hormone levels, which in turn reduces bone resorption and increases bone mineral density. The evidence from the most recent study 1 suggests that successful parathyroidectomy leads to significant improvements in bone health, particularly in patients with low pre-operative bone density and high parathyroid hormone levels.

Key Findings

• After successful parathyroidectomy, most patients experience increased bone mineral density (BMD), with gains of 6-8% in the lumbar spine and 3-5% in the hip within the first year post-surgery 1.
• The recovery process involves normalization of bone turnover markers within weeks to months after surgery, with decreased bone resorption occurring first, followed by reduced bone formation.
• Cortical bone (found in the hip and forearm) typically shows more dramatic improvement than trabecular bone (spine).

Recommendations for Optimal Bone Recovery

• Patients should ensure adequate calcium intake (1000-1200 mg daily) and vitamin D supplementation (800-1000 IU daily) post-surgery to support bone health.
• Removing the abnormal parathyroid gland eliminates the excess parathyroid hormone that was causing accelerated bone breakdown, allowing normal bone remodeling to resume and bone density to increase 1.

Clinical Implications

• The improvements in bone quality after surgery for PHPT can reduce the risk of fractures and other skeletal complications, ultimately improving the patient's quality of life.
• The study highlights the importance of timely surgical intervention in patients with PHPT to prevent long-term bone damage and related morbidity.

From the Research

Bone Quality Improvement After Surgery for Primary Hyperparathyroidism

• Surgery for primary hyperparathyroidism (PHPT) has been shown to improve bone quality in several studies 2, 3, 4, 5, 6.
• A study published in 2004 found that about 50% of patients had increased bone mass after PHPT surgery, although the increase in bone density was difficult to predict for individual patients 2.
• Another study from 2012 found that bone metabolism normalized after parathyroidectomy, and bone mineral density (BMD) of the lumbar spine increased significantly within one year after surgery 3.
• A 2018 review noted that parathyroidectomy has a long-term beneficial effect on the skeleton and is probably prudent to refer PHPT patients for surgery in all cases where increased bone fragility is suspected 4.
• A study from 2012 found that BMD improved in up to 75% of patients after curative parathyroidectomy for PHPT, with younger patients and those with severe PHPT deriving the most skeletal benefits from parathyroidectomy 5.
• Factors associated with improved bone quality after surgery include:
  • Younger age 5
  • Lesser preoperative BMD 5
  • Greater preoperative levels of parathyroid hormone (PTH) 5
  • Greater preoperative levels of serum calcium 5
  • Higher baseline 24-hour urinary calcium 6
• The use of calcium and vitamin D supplements after surgery may also be beneficial for bone health, particularly in patients with low oral calcium intake and vitamin D deficiency 2, 6.