Trabecular bone score as a possible new surgical recommendation in patients with asymptomatic primary hyperparathyroidism

Purpose: TBS usefulness in primary hyperparathyroidism (PHPT) management is uncertain. The primary aim was to evaluate the significance of performing Trabecular Bone Score (TBS) in addition to classical PHPT surgical recommendations. The explorative objective was to characterize bone quality in a cohort of patients with asymptomatic PHPT. Methods: From 1/1/2021 to 5/31/2024, of 265 consecutively evaluated PHPT patients, 125 met inclusion and exclusion criteria. Patients underwent complete biochemical evaluation in the same laboratory, Dual Energy X-ray Absorptiometry (DXA) at three sites, TBS with the same densitometer, and renal ultrasound. We retrospectively applied to each patient all the criteria to recommend parathyroidectomy as per the Fifth International Workshop, adding also TBS ≤ 1.2. Results: Almost one-third of patients presented degraded TBS (≤ 1.2), 36.0% partially degraded TBS, and 31.2% preserved TBS (≥ 1.35). Mean TBS was partially degraded (1.286 ± 0.134). Osteoporotic patients had lower TBS than osteopenic patients (1.207 ± 0.101 vs. 1.27 9 ± 0.110; p <.001). Patients with degraded TBS had a greater number of fragility fractures than those with TBS > 1.2 (34.2% vs. 8.3%; p <.001). In the group of osteopenic patients (34.4%), 10/43 (23.3%) showed degraded TBS. 13 patients (10.4%) did not meet any surgical criteria, and of these, 3/13 (23.1%) had degraded TBS and were osteopenic. Conclusion: More than one-fifth of patients who did not meet the current surgical recommendations presented degraded TBS and osteopenia. The combination of degraded TBS and osteopenia as a possible new surgical recommendation could increase the number of patients who might benefit from curative parathyroidectomy, with potential reduction of fracture risk.