Osteoporosis and osteopenia are systemic skeletal diseases characterized by low bone mass and microarchitectural deterioration of bone tissue. They manifest as increased cortical porosity and reduced trabecular bone volume, leading to decreased bone strength, and increased risk of fracture. The degree of bone loss and strength loss depends on multiple factors. However, Verhulp et al., reported that the resistance to normal hip-joint loading of an osteoporotic femur is 59% of that of a normal femur (1). According to the World Health Organization, osteoporosis is defined by a bone mineral density (BMD) T-score ≤−2.5, while osteopenia refers to a T-score between −1.0 and −2.5 (2). The global prevalence of osteoporosis and osteopenia has been estimated to be ∼20% and 40%, respectively (3). It is estimated that one in three women and one in five men over the age of 50 will experience an osteoporotic fracture during their lifetime (4). The risk of fracture rises exponentially with decreasing BMD, as each standard deviation reduction in BMD approximately doubles fracture risk (5).

Fragility fractures result from low-energy trauma, such as a fall from a standing height or less. These fractures represent the most severe consequences of osteoporosis. It is estimated that 30% of individuals aged 65 years or older will experience at least one fall per year (6), highlighting the high exposure of this population to the initiating event that, combined with reduced bone strength, can lead to fractures (6).

Common fragility fracture sites include the hip, distal radius, proximal humerus, spine and the pelvic ring, which together account for most osteoporotic fractures seen in clinical practice (7). Among fragility fractures, hip fractures are associated with the highest mortality and socioeconomic burden for patients, families and healthcare systems (8–10). The one-year mortality after a hip fracture ranges from 20% to 36%, largely due to postoperative complications, immobility and comorbidities in the elderly population (8, 11–14). Fractures also cause chronic pain and disability. Approximately 20%–50% of fracture patients require long-term nursing home care and suffer from decreased quality of life (4). Although hip fractures account for only 14% of all fragility fractures, they account for roughly 72% of total fracture-related costs (10). The global burden of hip fractures has increased substantially—from an estimated 1.3 million cases in 1990 to more than 14 million in 2019—and is projected to double again by 2050 (15, 16). This growing burden has been described as a “crisis” by multiple expert groups, underscoring the urgent need for novel strategies to reduce the risk of fragility fractures (13, 17–19).

Current treatment guidelines for osteoporosis are developed by multidisciplinary teams comprising geriatricians, endocrinologists, and orthopedic surgeons, and typically combine patient education, nutrition, exercise, and pharmacological therapy. Non-pharmacological interventions target modifiable risk factors such as diet modification, smoking cessation, excessive alcohol avoidance, and regular weight-and muscle-strengthening exercise (20–22). While regular weight-bearing activities (e.g., walking, stair climbing) and progressive resistance or balance training (e.g., Tai Chi, strength exercises) have been shown to improve bone density and reduce risk of falling, there is a lack of evidence showing that they reduce fracture risk (18). Pharmacologic treatments aim to decrease bone loss or stimulate bone formation, thereby increasing bone mass and bone strength (22). Anti-resorptive agents such as bisphosphonates or denosumab inhibit osteoclast-mediated bone loss, anabolic agents such as teriparatide stimulate osteoblast activity; romosozumab does both (23). While these systemic therapies are effective at reducing overall fracture incidence, their protective effect at the hip has been shown to be limited to approximately 50% risk reduction (24–34). Moreover, adherence rates fall below 50% after one year due to side effects, complex dosing regimens and the long time—often 12–18 months—required to achieve measurable therapeutic effect at the hip (24–36). Consequently, there remains a clear need for novel, targeted strategies to further reduce risk.

Preventative strategies to reduce hip fracture risk have long been explored. External hip protectors have been studied but suffer from poor comfort and compliance (37). Surgical strategies aimed at mechanically reinforcing the proximal femur using permanent materials, such as metal implants or non-resorbable cements, have also been investigated, but these approaches are limited by their creating a mismatch in biomechanical properties vs. native bone, increasing the risk for long-term complications (38, 39).

The local osteo-enhancement procedure (LOEP) was developed as a percutaneous, surgical approach to locally strengthen osteoporotic bone by addressing bone voids including those in the proximal femur caused by trauma and bone diseases such as osteoporosis (40). LOEP involves the injection of a bioresorbable, calcium-salt-based material that hardens in situ with an exothermic reaction that does not exceed normal body temperature, improving the mechanical stability of the proximal femur (40). Pre-clinical and clinical studies have demonstrated its safety, capacity to increase local bone strength and support new bone formation (41–45). This manuscript presents a detailed description of the surgical technique for this treatment.

In the early 1900s, Sir Reginald Watson-Jones, an academic orthopedic surgeon, was credited with saying that “you are born through the brim of the pelvis, and you leave through the hip”. Unfortunately, this statement remains as true today as it was then. Despite major advances in surgical technique, fixation devices, perioperative care, and pharmacologic treatments, fragility fractures—particularly those of the hip—remain a persistent global challenge (17). The annual incidence of hip fractures is estimated to have exceeded 14 million in 2019, with further increases projected worldwide (6, 15, 16). For healthcare systems, the economic burden is substantial, while for patients and their families, hip fractures result in loss of independence, diminished quality of life and excess mortality (6). One-year mortality rates, following surgical stabilization of hip fracture, have been reported as 37% in men and 28% in women (47). Furthermore, up to 10% of patients experience a contralateral hip fracture within one year of the index event, and these second fractures are associated with even poorer outcomes (48, 49).

There is broad consensus across national and international guidelines that osteoporosis pharmacotherapy after an index fracture is essential (50). Unfortunately, the treatment gap remains high. Even in patients with a hip fracture, treatment is initiated within a year only 20% of the time (51, 52). Initiating pharmacologic treatment for osteoporosis remains difficult for several reasons. Patients and physicians often fail to recognize osteoporosis as it is a silent disease until a fracture occurs. Contributing factors include diagnostic delays, limited post-fracture follow-up programs, patient reluctance and concerns about the side effects of medication. Even when treatment begins, real-world adherence is low (<50% after 12 months), substantially limiting effectiveness (53, 54). Pharmacotherapies such as bisphosphonates, denosumab, and anabolic agents can increase femoral-neck BMD by 2%–6% and some reduce hip fracture risk by up to approximately 50% in placebo-controlled trials, but their benefit becomes measurable at the hip only after 12–18 months of therapy (24, 27, 30, 55–58). Therefore, while pharmacotherapy remains essential, it cannot close the post-fracture treatment gap by itself. This may explain why LOEP appears in the European guidance for the diagnosis and management of osteoporosis in postmenopausal women as developed by the scientific advisory board of the European Society for Clinical and Economic Aspects of Osteoporosis (ESCEO) as well as the committee of scientific advisors and national societies of the International Osteoporosis Foundation (IOF) (50). Orthopedic surgeons, positioned at the interface of acute fracture care and prevention, may therefore play a crucial role in developing targeted, preventative surgical strategies to reduce the burden of future fractures.

LOEP offers a promising, biologically compatible approach to treating local bone loss, thereby helping to address hip fragility. The treatment addresses key limitations of prior augmentation techniques and may help to address persistent unmet needs in fracture prevention. While early clinical results are encouraging, data from a large, long-term, randomized study are necessary to confirm its impact on fracture incidence, safety, cost-effectiveness and feasibility for incorporation into standard-of-care treatment protocols.