What happens to the bone structure after normocalcemic primary hyperparathyroidism surgery?

Published:November 01, 2021DOI:



      Bone disease in primary hyperparathyroidism is a clear indication for surgical treatment. However, it is not known whether surgery benefits hypercalcemic primary hyperparathyroidism and normocalcemic primary hyperparathyroidism equally. The aim of our study was to evaluate the bone changes in patients undergoing parathyroidectomy based on the biochemical profile 1 and 2 years after surgery.


      This prospective study included 87 consecutive patients diagnosed with primary hyperparathyroidism who underwent surgery between 2016 and 2018. Bone densitometry (1/3 distal radius, lumbar, and femur) and bone remodeling markers (osteocalcin, type 1 procollagen [P1NP], β-cross-linked telopeptide of type I collagen [BCTX]) were performed preoperatively and postoperatively. Postoperative changes in bone mineral density and bone markers were compared and evaluated according to the clinical characteristics and the individual biochemical profile.


      One year after surgery, all patients showed an increase in bone mineral density at the lumbar site (mean, 0.029 g/cm2; range, 0.017–0.04; P < .001) and femur neck (mean, 0.025 g/cm2; range, 0.002–0.05; P < .001); however, there were no changes in the distal third of the radius (mean, -0.003 g/cm2; range, -0.008 to 0.002; P = NS). There were no significant differences when comparing normocalcemic primary hyperparathyroidism and hypercalcemic primary hyperparathyroidism. Serum osteocalcin (37 ± 17.41), P1NP (67.53 ± 31.81) and BCTX (0.64 ± 0.37) levels were elevated before surgery. One year after the surgery, we observed a significant decrease in P1NP (33.05 ± 13.16, P = .001), osteocalcin (15.80 ± 6.19, P = .001), and BCTX (0.26 ± 0.32, P < .001) levels.


      Our findings indicate that parathyroidectomy has similar benefits for normocalcemic primary hyperparathyroidism and hypercalcemic primary hyperparathyroidism in terms of bone improvement. Although the most substantial improvement occurred during the first postoperative year in both groups, we consider that studies with longer follow-up are warranted.
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        • Walker M.D.
        • Silverberg S.J.
        Primary hyperparathyroidism.
        Nat Rev Endocrinol. 2018; 14: 115-125
        • Silverberg S.J.
        • Bilezikian J.P.
        “Incipient” primary hyperparathyroidism a “forme fruste” of an old disease.
        J Clin Endocrinol Metab. 2003; 88: 5348-5352
        • Applewhite M.K.
        • White M.G.
        • Tseng J.
        • et al.
        Normohormonal primary hyperparathyroidism is a distinct form of primary hyperparathyroidism.
        Surgery. 2017; 161: 62-69
        • Gomez- Ramirez J.
        • Mihai R.
        Normocalcemic primary hyperparathyroidism: a diagnosis and therapeutic algorithm.
        Langenbeck’s Arch Surg. 2017; 402: 1103-1108
        • Dawood N.B.
        • Yan Kl
        • Shieh A.
        • Livhits M.J.
        • Yeh M.W.
        • Leung A.M.
        Normocalcaemic primary hyperparathyroidism: an update on diagnostic and management challenges.
        Clin Endocrinol (OXf). 2020; 93: 519-527
        • Zang Lu
        • Liu Xiaomei
        • Li Hongwei
        Long-term skeletal outcomes of primary hyperparathyroidism patients after treatment with parathyroidectoy: a systematic review and metaanalysis.
        Horm Metab Res. 2018; 50: 242-249
        • Gomez-Ramirez J.
        • Gómez- Valdazo A.
        • Luengo P.
        • Porrero B.
        • Osorio I.
        • Rivas S.
        Comparative prospective study on the presentation of normocalcemic primary hyperparathyroidism. It is more aggressive than the hypercalcemic form?.
        Am J Surg. 2020; 219: 150-153
        • Koumakis E.
        • Souberbielle J.C.
        • Sarfati E.
        • et al.
        Bone mineral density evolution after successful parathyroidectomy in patients with normocalcemic primary hyperparathyroidism.
        J Clin Endocrinol Metab. 2013; 98: 3213-3320
        • Lee D.
        • Walter M.D.
        • Chen H.Y.
        • Chabot J.A.
        • Lee J.A.
        • Kuo J.H.
        Bone mineral density changes after parathyroidectomy are dependent on biochemical profile.
        Surgery. 2019; 165: 107-113
        • Lundstam K.
        • Keck A.
        • Godang K.
        • et al.
        Effect of surgery versus observation: skeletal 5-year outcomes in a randomized trial of patients with primary HPT (the SIPH study).
        J Bone Miner Res. 2017; 32: 1907-1914
        • Rajeev P.
        • Movseysan A.
        • Baharani A.
        Changes in bone turnover markers in primary hyperparathyroidism and response to surgery.
        Ann R Coll Surg Engl. 2017; 99: 559-562
        • Sharma J.
        • Moss L.
        • Li C.
        • Weber C.
        Predictors of bone mineral density improvement in patients undergoing parathyroidectomy for primary hyperparathyroidism.
        World J Surg. 2014; 38: 1268-1273
        • Traini E.
        • Bellantone R.
        • Tempera S.E.
        • Russo S.
        • et al.
        Is parathyroidectomy safe and effective in patients with normocalcemic primary hyperparathyroidism?.
        Langenbecks Arch Surg. 2018; 403: 317-323
        • Miguel G.A.
        • Carranza F.H.
        • Rodríguez J.C.R.
        • et al.
        Trabecular bone score, bone mineral density and bone markers in patients with primary hyperparathyroidism 2 years after parathyroidectomy.
        Horm Metab Res. 2019; 51: 186-190
        • Shetty S.
        • Cherian K.E.
        • Shetty S.
        • et al.
        Does baseline pth influence recovery of bone mineral density, trabecular bone score and bone turnover markers? A prospective study following curative parathyroidectomy in primary hyperparathyroidism.
        Endocr Pract. 2020; 26: 1442-1450
        • Alonso S.
        • Ferrero E.
        • Donat M.
        • Martínez G.
        • Vargas C.
        • Hidalgo M.
        • Moreno E.
        The usefulness of high preoperative levels of serum type I collagen bone markers for the prediction of changes in bone mineral density after parathyroidectomy.
        J Endocrinol Invest. 2012; 35: 640-644
        • Costa A.G.
        • Bilezikian J.P.
        Bone turnover markers in primary hyperparathyroidism.
        J Clin Densitom. 2013; 16: 22-27