Assessing osteoporosis screening compliance in total joint surgery: a retrospective chart review
-
,
Abstract
Context
Osteoporosis is a prevalent concern, particularly among aging populations, leading to increased risk of fractures, including those related to hip and knee arthroplasty procedures. Screening for osteoporosis, especially with dual X-ray absorptiometry (DXA) scans, is crucial for early detection and management.
Objectives
This study aimed to assess adherence to osteoporosis screening guidelines among patients aged 65 and older undergoing elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) within a single health network. Factors influencing screening adherence were also explored.
Methods
A retrospective chart review of 2,160 patients undergoing elective THA or TKA between January 2019 and January 2023 was conducted. Demographic data, osteoporosis screening status, and occurrence of periprosthetic fractures were analyzed. Statistical analysis included descriptive statistics and chi-square tests.
Results
Only 24.1 % of eligible patients underwent a DXA scan prior to surgery. Females were more likely to undergo screening than males, and race was also associated with screening status. A total of 45 periprosthetic fractures were identified, with no significant correlation between osteoporosis status, DXA screening, and fracture occurrence.
Conclusions
Adherence to osteoporosis screening guidelines among geriatric patients undergoing elective total joint arthroplasty remains low within the studied health network. Despite the lack of correlation between screening and fracture occurrence in this study, the importance of screening and potential optimization in high-risk patients is emphasized. Further research is needed to assess outcomes associated with different care pathways in bone health screening and management for elective geriatric total joint patients.
Osteoporosis, a condition characterized by diminished bone mineral density (BMD) and altered bone microstructure, presents a significant challenge in modern healthcare [1], [2], [3]. Over 50 % of postmenopausal women and 20 % of men over the age of 50 are at risk of experiencing osteoporotic-related fractures, underscoring the urgency of addressing this pressing public health concern [3, 4]. With a global prevalence surpassing 200 million people and a notable upsurge in incidence as age progresses, osteoporosis garners increasing attention within the context of an aging population in which over 70 % of those aged 80 and above are affected [1], [2], [3].
Osteoporosis-related fractures, particularly hip fractures, are alarmingly common and have a mortality rate exceeding 20 %; therefore, early detection through bone density assessment becomes paramount in enhancing patient outcomes [5]. The central dual X-ray absorptiometry (DXA) scan stands out for its ability to assess BMD with minimal radiation exposure in a brief 5-minute procedure. There are peripheral DXA scans available that have been shown to be equal in their sensitivity to predicting fractures compared to central DXA scans, yet they are unable to quantify BMD [5, 6]. Currently, most treatment guidelines for osteoporosis are based on BMD from a central DXA [7]. The United States Preventive Services Task Force (USPSTF) currently does not recommend one specific screening test. The USPSTF, however, does recommend screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older [8]. The National Osteoporosis Foundation (NOF) also has a guideline for the prevention and treatment of osteoporosis. Unlike the USPSTF, the NOF recommends that men 70 and older be assessed for osteoporosis along with women 65 or older. Despite the availability of noninvasive screening procedures and recommendations, screening rates have notably been poor in both the general population as well as patients who have undergone arthroplasty. A study involving more than 400,000 women aged 65–79 found that only 26.5 % had undergone a DXA scan [9]. Several studies investigating patients’ osteoporotic status before undergoing arthroplasty have shown even worse deficiencies in screening. A 2019 study by Bernatz et al. [10] found that only 17.6 % of eligible patients had undergone screening, compared to a 2022 study by Wang et al. [11], which showed that only 12 % of patients had undergone bone density screening per the recommendations [11].
The volume of primary hip and knee arthroplasty in the United States has seen a significant rise, especially in the geriatric or Medicare population [12, 13]. Reports showed a 60 % increase in primary hip arthroplasty and more than a 40 % increase in primary knee arthroplasty from 2006 to 2015, with Medicare patients representing the majority of the patients [12, 13]. The potential for catastrophic outcomes becomes a paramount concern because of the aging population, the escalating count of geriatric patients undergoing elective total joint procedures, and the heightened vulnerability of elderly patients to the ensuing complications of periprosthetic fractures. This is particularly pronounced given their elevated risk for subsequent sequelae resulting from such fractures. Currently, no guidelines exist for preoperative bone health assessment and optimization before elective hip and knee arthroplasty procedures. Unlike various other medical comorbidities, bone health assessment and optimization are not routinely prioritized.
The primary objective of this study is to assess the number of patients within a single health network who have undergone either elective total hip arthroplasty (THA) or total knee arthroplasty (TKA) or both and who have undergone appropriate osteoporosis screening with a DXA scan according to the osteoporosis screening recommendations set forth by the USPSTF and NOF. We hypothesize that a significant portion of patients in our sample will have undergone appropriate screening for osteoporosis based on age recommendations as outlined by both the USPTF recommendations and the NOF screening guidelines. Possible factors leading to a gap in screening adherence may be a lack of awareness or patient-related barriers to complying with screening recommendations.
Methods
Patient selection
This study received prior approval from the Institutional Review Board of Kettering Health Network (IRB # KHN-2023-180). A retrospective chart review was conducted for all surgeons from a single private practice who performed surgeries at two network hospitals. All patients managed between January 2019 and January 2023 were screened for eligibility. Patients were identified utilizing the hospital’s diagnostic and operative code system within the network’s electronic health record (EHR). Patients were eligible if they were aged 65 and older and underwent elective THA or elective TKA at our institution between January 2019 and January 2023. The age criteria was applied based on the NOF guideline for screening as well as the USPTF recommendation for osteoporosis screening (Table 1). Charts were reviewed for the following variables: (1) age at the time of surgery; (2) sex; (3) race; (4) osteoporosis status; (5) DXA scan prior to surgery; (6) number of primary hip/knee replacements; and (7) occurrence of a periprosthetic femur fracture (PPFx) with a minimum timeframe of at least 6 months after surgery and a maximum of 4 years. Both a patient’s sex and race were recorded just as the patients themselves reported within their medical records. For our results, we adhered to the updated guidance on reporting patient characteristics in the medical literature [14]. The use of “other” within our data was only utilized when patients preferred not to answer their sex or their race.
Osteoporosis screening guideline criteria from NOF and USPTF recommendations.
| Women | Men | |
|---|---|---|
| NOF criteria | All age ≥65 younger postmenopausal and women in the menopausal transition with clinical risk factors for fracture | All age ≥70 age 50–69 years with clinical risk factors for fracture |
| Age 50 years who have had an adult age fracture. Adults with a condition (e.g., rheumatoid arthritis) or taking a medication (e.g., glucocorticoids in a daily dose of 5 mg prednisone or equivalent for 3 months) associated with low bone mass or bone loss | ||
| USPTF recommendations | The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in women 65 years and older. The USPSTF recommends screening for osteoporosis with bone measurement testing to prevent osteoporotic fractures in postmenopausal women younger than 65 years who are at increased risk of osteoporosis, as determined by a formal clinical risk assessment tool. |
The USPSTF concludes that the current evidence is insufficient to assess the balance of benefits and harms of screening for osteoporosis to prevent osteoporotic fractures in men. |
-
NOF, National Osteoporosis Foundation; USPTF, United States Preventive Services Task Force.
Statistical analysis
Data entry and analysis were performed utilizing SAS/STAT software [SAS 9.4, 2023] (Cary, NC). Descriptive statistics, such as means and frequencies, were calculated, and chi-square analysis was employed to compare the distribution of variables with the outcomes. All statistics were verified by a third-party statistician affiliated with Ohio University in Athens, Ohio.
Results
Demographics
A total of 2,160 adults were included in the study, with females making up 1,325 (of 2,160, 61.3 %) and 835 (of 2,160, 38.7 %) males. The average age was 74 years (range, 65–106 years). Eighty-eight percent of the patients were White. Our sample included 1711 TKAs and 819 THAs for a combined number of 2,530 elective total joint surgeries (Table 2).
Patient characteristics.
| DXA Scan(n=521, 24 %) | No DXA scan (n=1,639, 76 %) | Total (n=2,160) | |
|---|---|---|---|
| Average age, years (range) | 74 (66–93) | 74 (65–106) | |
| Male | 28 | 807 | 835 |
| White male | 28 | 722 | 750 |
| Black male | 0 | 41 | 41 |
| Other male | 0 | 39 | 39 |
| Islander male | 0 | 3 | 3 |
| Asian male | 0 | 2 | 2 |
| Female | 493 | 832 | 1,325 |
| White female | 439 | 713 | 1,152 |
| Black female | 37 | 62 | 99 |
| Other female | 14 | 55 | 69 |
| Islander female | 3 | 2 | 5 |
| Asian female | 0 | 0 | 0 |
| Joints | 623 | 1,907 | 2,530 |
| Total knees | 433 | 1,278 | 1,711 |
| Total hips | 190 | 629 | 819 |
| Periprosthetic fractures | 11 | 34 | 45 |
Osteoporosis screening
Overall, the number of adults over 65 who underwent a DXA scan prior to a total joint surgery was 521 (of 2,160, 24.1 %). A total of 1,639 (of 2,160, 75.9 %) adults who met the age criteria for screening were found to have not been screened, including 807 men. The majority of adults found to have been screened were female (493/521, 94.6 %). A chi-square test yielded a highly significant result (χ²[1]=320.7494, p<0.0001), indicating a strong association between the presence of a DXA scan and gender. Of those adults who underwent a DXA scan, the majority self-identified as White (467/521, 89.6 %), followed by 37 (of 521, 7.1 %) black patients. A significant association between race and DXA scan was identified (χ²[4]=9.4, p<0.0001). The total number of patients identified with osteoporosis was 148 (of 2,160, 9.03 %). Among these, 67 (of 148, 45.3 %) patients were found to have a diagnosis of osteoporosis in their chart related to an insufficiency fracture (i.e., vertebral, pelvis, hip, distal radius fracture), while 81 (of 148, 54.7 %) were diagnosed by DXA.
Periprosthetic fractures
After reviewing all 2,160 patient charts, we identified 45 periprosthetic fractures occurring at least 6 months after the index operation between January 2019 and January 2023. Thirty-four (of 45, 75.6 %) had no prior osteoporosis workup before their total joint surgery. Statistically, no strong association was found between osteoporotic status or pre-operative DXA scan and periprosthetic fractures (χ²[1]=1.3, p>0.253).
Discussion
Between January 2019 and January 2023, more than two-thirds of the 2,160 patients in our sample underwent either primary TKA or THA without proper osteoporosis screening, as set forth by USPTF and NOF guidelines. The overall percentage of periprosthetic fractures within our sample was found to be 2.1 %, which was well within the national reported expected value for within 5 years of a total joint surgery [15]. Although we could not statistically show a strong correlation between screening status and the presence or prevention of a periprosthetic fracture, our findings highlight the continued lack of attention that osteoporosis screening receives in the geriatric population. However, it should be outlined that there is currently no guideline in place regarding the best practice for an osteoporotic geriatric patient with debilitating osteoarthritis. The complications related to restricted or loss of mobility in geriatric patients are well documented in increasing the risk for falls, injuries, and hospitalization, all while drastically reducing one’s quality of life [16]. However, failure to properly optimize patients at high risk of a periprosthetic fracture carries its own risks as well. Given the absence of osteoporosis screening and potential optimization in our cohort within a single health network, we suspect that these findings are likely applicable to a broader spectrum of orthopedic practices across the United States.
Modern primary elective THA and TKA are considered highly successful surgeries [17, 18]. The projected annual surgical volumes for THA and TKA by 2040 are expected to increase by 176–300 % and 139–400 %, respectively [19, 20]. The average age for patients undergoing primary THA or TKA is between 65 and 67; therefore, the presence of osteoporosis within this age group should be highly suspected [21, 22]. This is supported by a 2020 publication that analyzed nearly 2,000 patients (aged 50–89) scheduled for primary TKA. The study involved preoperative DXA scans the day before their surgery, revealing that 50 % of the patients were diagnosed with osteoporosis [23]. A 2023 retrospective claims-based study of more than 250,000 patients found that more than one-third of all patients had a claim related to osteoporosis, yet less than 20 % of patients were tested and/or treated in the 12 months before their THA or TKA [24]. Standard preoperative clearance and optimization procedures are conducted before elective arthroplasty, addressing blood pressure, glucose levels, and tobacco use. However, the same cannot be said for bone health prior to elective arthroplasty. Furthermore, osteoporosis has been linked to numerous complications in arthroplasty, such as altered component positioning [25], aseptic loosening [26], and periprosthetic fractures [26], [27], [28], [29]. Reeves et al. [29] examined the costs and risk factors linked to periprosthetic knee fractures. According to their findings, patients undergoing open reduction internal fixation following TKA for a periprosthetic fracture had elevated rates of readmission and incurred greater overall costs compared to those undergoing a revision TKA for any other indication. Furthermore, the study revealed that females were more prone to periprosthetic fractures, which were associated with a 23-fold increase in 90-day mortality compared to primary TKA [29]. Therefore, assessing bone health in at-risk patients should be prioritized before elective arthroplasty.
The lack of osteoporosis management and screening offers an opportunity to improve patient care, especially for the geriatric population. Multiple factors are potentially at play for poor adherence to screening at-risk patients. One commonly cited reason is that osteoporosis is a silent disease that is not recognized without screening until a patient has a fracture. Additionally, increasing time constraints in the clinic and a lack of knowledge and misconceptions regarding the diagnosis and treatment of osteoporosis are a few factors associated with poor adherence [30]. Therefore, in an effort to reduce morbidity and mortality in patients undergoing elective total joint surgeries, we echo the recommendations previously made by Bernatz et al. [10], who stated: “If patients have not had DXA testing in the past 2 years, we recommend applying the NOF criteria to determine if such evaluation is indicated. Subsequently, for those with osteopenia or osteoporosis, we recommend referral to a bone health/fracture liaison service, primary care provider, or further evaluation by the orthopedic clinic. [For] patients with a confirmed diagnosis of osteoporosis, preoperative medical therapy should be considered for 3–6 months if elective surgery can be delayed.” [10].
We recognize that our study has limitations. Because our study is entirely retrospective, we acknowledge that our study is not designed or powered to demonstrate any causality between osteoporosis screening and periprosthetic fractures. Instead, we report a low prevalence of adherence to screening guidelines for osteoporosis in the largest at-risk cohort undergoing total joint arthroplasty. Multiple studies have presented the associated risks of untreated osteoporosis in patients with total joint arthroplasty. Another limitation is the potential for missing data within the EHR. With the advent of expanded network records, we believe that the potential for missing data within the EHR is less of a factor, but we must acknowledge that some out-of-state and private physician offices do not share EHR data with our health network. Lastly, our sample, even though it is over 2,000 patients, was primarily White (88 %); thus, these findings may not be generalizable to other populations.
Conclusions
Our study finds that screening adherence based on nationally accepted recommendations and guidelines for osteoporosis screening is poor within our single health network. Our sample of patients did not experience adverse events at higher rates than the national average despite our reduced adherence to screening recommendations. Bone health screening and compliance within our at-risk elective total joint patients should be further prioritized to reduce potential adverse events. Further longitudinal research is needed to assess outcomes associated with different care pathways in bone health screening and management in the elective geriatric total joint population.
Acknowledgments
The authors would like to thank the Ohio University Statistics Department for their assistance.
-
Research ethics: This study received prior approval from the Institutional Review Board of Kettering Health Network (IRB # KHN-2023-180).
-
Informed consent: Not applicable.
-
Author contributions: All authors provided substantial contributions to conception and design, acquisition of data, or analysis and interpretation of data; DH, SS, and AB drafted the article or revised it critically for important intellectual content; all authors gave final approval of the version of the article to be published; and all authors agree to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
-
Competing interests: None declared.
-
Research funding: None declared.
-
Data availability: Contact the corresponding author for all data inquiries.
References
1. Varacallo, MA, Fox, EJ. Osteoporosis and its complications. Med Clin North Am 2014;98:817–31. https://doi.org/10.1016/j.mcna.2014.03.007.Search in Google Scholar PubMed
2. Varacallo, MA, Fox, EJ, Paul, EM, Hassenbein, SE, Warlow, PM. Patients’ response toward an automated orthopedic osteoporosis intervention program. Geriatr Orthop Surg Rehabil 2013;4:89–98. https://doi.org/10.1177/2151458513502039.Search in Google Scholar PubMed PubMed Central
3. Varacallo, M, Seaman, TJ, Jandu, JS, Pizzutillo, P. Osteopenia. In: StatPearls. StatPearls Publishing; 2023. https://www.ncbi.nlm.nih.gov/pubmed/29763053.Search in Google Scholar
4. Coughlan, T, Dockery, F. Osteoporosis and fracture risk in older people. Clin Med 2014;14:187–91. https://doi.org/10.7861/clinmedicine.14-2-187.Search in Google Scholar PubMed PubMed Central
5. Prince, RL, Lewis, JR, Lim, WH. Adding lateral spine imaging for vertebral fractures to densitometric screening: improving ascertainment of patients at high risk of incident osteoporotic fractures. J Bone Miner Res 2019;34:282–9. https://doi.org/10.1002/jbmr.3595.Search in Google Scholar PubMed
6. Kanis, JA, Johansson, H, Harvey, NC, McCloskey, EV. A brief history of FRAX. Arch Osteoporosis 2018;13:118. https://doi.org/10.1007/s11657-018-0510-0.Search in Google Scholar PubMed PubMed Central
7. Rachner, TD, Hofbauer, LC, Göbel, A, Tsourdi, E. Novel therapies in osteoporosis: PTH-related peptide analogs and inhibitors of sclerostin. J Mol Endocrinol 2019;62:R145–54. https://doi.org/10.1530/JME-18-0173.Search in Google Scholar PubMed
8. U.S. Preventive Task Force (USPTF). Osteoporosis to prevent fractures: screening; 2018. Published June 26. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/osteoporosis-screening [Accessed 20 August 2023].Search in Google Scholar
9. Gillespie, CW, Morin, PE. Trends and disparities in osteoporosis screening among women in the United States, 2008-2014. Am J Med 2017;130:306–16. https://doi.org/10.1016/j.amjmed.2016.10.018.Search in Google Scholar PubMed
10. Bernatz, JT, Brooks, AE, Squire, MW, Illgen, RI2nd, Binkley, NC, Anderson, PA. Osteoporosis is common and undertreated prior to total joint arthroplasty. J Arthroplasty 2019;34:1347–53. https://doi.org/10.1016/j.arth.2019.03.044.Search in Google Scholar PubMed
11. Wang, Z, Levin, JE, Amen, TB, Arzani, A, Manzi, JE, Lane, JM. Total joint arthroplasty and osteoporosis: looking beyond the joint to bone health. J Arthroplasty 2022;37:1719–25.e1. https://doi.org/10.1016/j.arth.2022.04.010.Search in Google Scholar PubMed
12. Nham, FH, Patel, I, Zalikha, AK, El-Othmani, MM. Epidemiology of primary and revision total knee arthroplasty: analysis of demographics, comorbidities and outcomes from the national inpatient sample. Arthroplasty 2023;5:18. https://doi.org/10.1186/s42836-023-00175-6.Search in Google Scholar PubMed PubMed Central
13. Patel, I, Nham, F, Zalikha, AK, El-Othmani, MM. Epidemiology of total hip arthroplasty: demographics, comorbidities and outcomes. Arthroplasty 2023;5:2. https://doi.org/10.1186/s42836-022-00156-1.Search in Google Scholar PubMed PubMed Central
14. Flanagin, A, Frey, T, Christiansen, SL, AMA Manual of Style Committee. Updated guidance on the reporting of race and ethnicity in medical and science journals. JAMA 2021;326:621–7. https://doi.org/10.1001/jama.2021.13304.Search in Google Scholar PubMed
15. Meek, RMD, Norwood, T, Smith, R, Brenkel, IJ, Howie, CR. The risk of peri-prosthetic fracture after primary and revision total hip and knee replacement. J Bone Joint Surg Br 2011;93:96–101. https://doi.org/10.1302/0301-620X.93B1.25087.Search in Google Scholar PubMed
16. Maresova, P, Krejcar, O, Maskuriy, R. Challenges and opportunity in mobility among older adults – key determinant identification. BMC Geriatr 2023;23:447. https://doi.org/10.1186/s12877-023-04106-7.Search in Google Scholar PubMed PubMed Central
17. Lange, JK, Lee, YY, Spiro, SK, Haas, SB. Satisfaction rates and quality of life changes following total knee arthroplasty in age-differentiated cohorts. J Arthroplasty 2018;33:1373–8. https://doi.org/10.1016/j.arth.2017.12.031.Search in Google Scholar PubMed
18. Fujita, T, Hamai, S, Shiomoto, K. Analysis of factors influencing patient satisfaction after total hip arthroplasty in a Japanese cohort: the significant effect of postoperative physical activity. J Phys Ther Sci 2022;34:76–84. https://doi.org/10.1589/jpts.34.76.Search in Google Scholar PubMed PubMed Central
19. Shichman, I, Roof, M, Askew, N. Projections and epidemiology of primary hip and knee arthroplasty in Medicare patients to 2040-2060. JB JS Open Access 2023;8:e22.00112. https://doi.org/10.2106/JBJS.OA.22.00112.Search in Google Scholar PubMed PubMed Central
20. Singh, JA, Yu, S, Chen, L, Cleveland, JD. Rates of total joint replacement in the United States: future projections to 2020–2040 using the national inpatient sample. J Rheumatol 2019;46:1134–40. https://doi.org/10.3899/jrheum.170990.Search in Google Scholar PubMed
21. Passias, PG, Bono, OJ, Bono, JV. Total knee arthroplasty in patients of advanced age: a look at outcomes and complications. J Knee Surg 2020;33:1–7. https://doi.org/10.1055/s-0038-1676067.Search in Google Scholar PubMed
22. Bang, H, Chiu, YL, Memtsoudis, SG. Total hip and total knee arthroplasties: trends and disparities revisited. Am J Orthoped tpdel2010;39:E95–102. https://www.ncbi.nlm.nih.gov/pubmed/21290031.Search in Google Scholar
23. Ha, CW, Park, YB. Underestimation and undertreatment of osteoporosis in patients awaiting primary total knee arthroplasty. Arch Orthop Trauma Surg 2020;140:1109–14. https://doi.org/10.1007/s00402-020-03462-y.Search in Google Scholar PubMed
24. Jeray, KJ, Williams, SA, Wang, Y. Bone health management in elective orthopaedic surgery: a claims-based observational study. Geriatr Orthop Surg Rehabil 2023;14:21514593231216553. https://doi.org/10.1177/21514593231216553.Search in Google Scholar PubMed PubMed Central
25. Lee, DH, Padhy, D, Lee, SH, Nha, KW, Park, JH, Han, SB. Osteoporosis affects component positioning in computer navigation-assisted total knee arthroplasty. Knee 2012;19:203–7. https://doi.org/10.1016/j.knee.2011.02.010.Search in Google Scholar PubMed
26. Dubin, JA, Bains, SS, Paulson, AE. The current epidemiology of revision total knee arthroplasty in the United States from 2016 to 2022. J Arthroplasty 2024;39:760–5. https://doi.org/10.1016/j.arth.2023.09.013.Search in Google Scholar PubMed
27. Li, MG, Nilsson, KG. The effect of the preoperative bone quality on the fixation of the tibial component in total knee arthroplasty. J Arthroplasty 2000;15:744–53. https://doi.org/10.1054/arth.2000.6617.Search in Google Scholar PubMed
28. Marsland, D, Mears, SC. A review of periprosthetic femoral fractures associated with total hip arthroplasty. Geriatr Orthop Surg Rehabil 2012;3:107–20. https://doi.org/10.1177/2151458512462870.Search in Google Scholar PubMed PubMed Central
29. Reeves, RA, Schairer, WW, Jevsevar, DS. Costs and risk factors for hospital readmission after periprosthetic knee fractures in the United States. J Arthroplasty 2018;33:324–30.e1. https://doi.org/10.1016/j.arth.2017.09.024.Search in Google Scholar PubMed
30. Singer, AJ, Sharma, A, Deignan, C, Borgermans, L. Closing the gap in osteoporosis management: the critical role of primary care in bone health. Curr Med Res Opin 2023;39:387–98. https://doi.org/10.1080/03007995.2022.2141483.Search in Google Scholar PubMed
© 2024 the author(s), published by De Gruyter, Berlin/Boston
This work is licensed under the Creative Commons Attribution 4.0 International License.
Articles in the same Issue
- Frontmatter
- General
- Original Article
- Predictors of a positive attitude towards rural practice in female osteopathic medical students
- Medical Education
- Original Article
- Preference signaling in orthopaedic surgery: applicant perspectives and opinions
- Musculoskeletal Medicine and Pain
- Original Article
- Assessing osteoporosis screening compliance in total joint surgery: a retrospective chart review
- Neuromusculoskeletal Medicine (OMT)
- Review Article
- Neuropsychiatric considerations in treating anorexia nervosa patients with osteopathic manipulative medicine: a narrative review
- Neuromusculoskeletal Medicine (OMT)
- Case Report
- Treatment of migraine with aura with osteopathic manipulative treatment: a case report with renewed perspectives
- Public Health and Primary Care
- Commentary
- The rise of advanced practice provider independence bills: a misguided attempt to address the physician shortage
- Letters to the Editor
- A call to include intersectionality on board examinations
- Methodological limitations of the sternal brace test study
- Abstracts
- 2024 AOA Research Abstracts and Student Poster Competition
Articles in the same Issue
- Frontmatter
- General
- Original Article
- Predictors of a positive attitude towards rural practice in female osteopathic medical students
- Medical Education
- Original Article
- Preference signaling in orthopaedic surgery: applicant perspectives and opinions
- Musculoskeletal Medicine and Pain
- Original Article
- Assessing osteoporosis screening compliance in total joint surgery: a retrospective chart review
- Neuromusculoskeletal Medicine (OMT)
- Review Article
- Neuropsychiatric considerations in treating anorexia nervosa patients with osteopathic manipulative medicine: a narrative review
- Neuromusculoskeletal Medicine (OMT)
- Case Report
- Treatment of migraine with aura with osteopathic manipulative treatment: a case report with renewed perspectives
- Public Health and Primary Care
- Commentary
- The rise of advanced practice provider independence bills: a misguided attempt to address the physician shortage
- Letters to the Editor
- A call to include intersectionality on board examinations
- Methodological limitations of the sternal brace test study
- Abstracts
- 2024 AOA Research Abstracts and Student Poster Competition
