Advances in the performance and longevity of total joint arthroplasty (TJA) have been enabled by related progress in implant materials, device designs, and surgical techniques. Successful TJA also depends upon adequate bone quality to provide an enduring mechanical foundation. Bone quality can be defined as the ability to repetitively withstand physiologically-relevant loads without excess deformation or fracture. It is now recognized that bone quality encompasses more than just material quantity, i.e. densitometrically-measured bone mass. Bone quality is also determined by: material composition and arrangement, cortical and cancellous structure, and extent of microdamage. These properties, together with the appropriate mass, confer bone with the biomechanical competence needed to meet the repetitive load-bearing demands imposed by total joint implants.

The need for TJA continues to increase in the aging global baby-boomer population. Unfortunately, this group is also experiencing increases in related comorbidities including: osteoporosis, kidney dysfunction, and diabetes, among others. Collectively these three comorbidities afflict more than 74 million Americans, and each is increasing at 2–8% annually. More importantly, each of these comorbidities negatively affects bone quality through alterations in bone turnover independent of bone mass changes commonly associated with these diseases. Specifically, alterations in bone turnover result in abnormal mineral-to-matrix ratios as measured by Fourier transform infra-red (FTIR) spectroscopy (Fig. 1) and altered Young's moduli (shape-independent resistance to deformation) as measured by nanoindentation (Fig. 2). These parameters are related to bones' fracture toughness and load-bearing capabilities, respectively. Also, low bone turnover is associated with mechanically important structural changes, i.e., decreased trabecular thickness (Fig. 3), cortical thickness and cancellous volume. Furthermore, low bone turnover may result in reducing the repair rate of physiologically – induced bone microdamage. This may lead to increases in the number or length of bone cracks, crack coalescence, and ultimately reduced energy needed for fracture.

Therefore, patients needing TJA who also have comorbidities associated with abnormal bone quality are at risk for inferior arthroplasty results. Recognition and treatment of the TJA-relevant biomechanical implications of these comorbidities may help improve outcomes.