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Editorial: Secondary Fracture Prevention—What’s Your System?

Leopold, Seth S. MD

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Clinical Orthopaedics and Related Research: August 2020 - Volume 478 - Issue 8 - p 1703-1705
doi: 10.1097/CORR.0000000000001276
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Treating patients with fragility fractures of the hip and lumbar spine is perhaps the most-serious task that call-taking orthopaedic surgeons perform. Doing a good job on the operation, when surgery is indicated, can save a patient’s mobility; doing a good job with the consult can save a patient’s life. I’m drawing an important distinction here, because the consult doesn’t end with the last suture, staple, or dab of glue. Rather, that’s when the really important part begins. Good care for these patients depends on systems-based approaches [8, 23, 24]. If robust, multidisciplinary systems don’t exist for the care of patients with fragility fractures where you practice, take the opportunity to try to help create them.

Some 20% of patients with hip fractures will die within a year; the chance that a 50-year-old white woman will die from a hip fracture is 2.8%, which is about the same as her risk of death from breast cancer, and four times greater than her risk of dying from uterine cancer [5]. (I mention the race of the hypothetical patient here because it’s important; the prevalence of osteoporosis varies widely by self-reported race [21]).

The picture may be similarly bleak for patients with osteoporotic vertebral fractures [17]. Fractures related to osteoporosis cause more hospitalizations among women than do stroke, myocardial infarction, and breast cancer [19]. But this isn’t a “women’s health issue”; it’s a health issue. Although many more women break their hips than do men, the risk of death after hip fracture is higher for men than women [9]. Osteoporosis and fractures resulting from it are bad news for people of both sexes.

And while surgeons have seen statistics like these before [6, 16], the phenomenon of transfer bias [11] works against us really understanding them on a deep, personal level. Stated another way: We often don’t hear how these sad stories end. Our patients’ families might not let us know that their loved one passed away 9 months after a hip or vertebral fracture. Those families may not even connect the two events. While it’s natural for a surgeon assume that everything is fine when we don’t hear from a patient, in this case, it may not be true.

For these reasons, among others, the life-saving part of the consult happens after the surgical dressing is applied. And for as long as I’ve been a surgeon, we’ve been falling short on that part. Literally dozens of guidelines have sought to inform our practices vis-à-vis bone health, osteoporosis screening, and fracture risk [1, 7, 18, 21, 22], including a relatively recent one from our own Academy [2].

Regarding those that pertain to the aftercare of patients with fragility fractures, most of those guidelines boil down to something like this: We should do whatever we can do to prevent a second fracture in a patient who has experienced a hip or vertebral fracture.

The most-important thing we can do is to ensure that patients get screened for osteoporosis, though in the absence of other metabolic bone diseases, thoughtful observers have suggested that a hip or vertebral fracture alone in patients older than the age of 65 is diagnostic for the condition regardless of bone mineral density, because the fracture itself is so closely associated with the risk of a second such injury [4]. That being so, we also need to make sure these patients get treated.

This process of screening and treatment after a fracture is called secondary fracture prevention, and there have been evidence-based recommendations encouraging us to engage in this process for a long time now. Sadly, only a minority of patients with fragility fractures of the hip and spine receive secondary fracture prevention, and that has been the case for as long as I’ve been doing surgery.

This was the case in 1998 [20].

This was the case 10 years after that [14].

This was the case last year [3].

This fact, it seems we’re getting worse not better [15], despite clear evidence of the desperately severe risk—now called “imminent fracture risk”—of a second fracture occurring soon after a sentinel event like a hip or spine fracture [13], and despite evidence that secondary fracture prevention saves lives [8].

Which brings us to the present moment: Another important guideline has been published, this one from an international, multistakeholder group that tackled this complex problem with great thought and care [4]. Many of the recommendations it contains apply more to family physicians, endocrinologists, and internists than to orthopaedic surgeons, but my read of this guideline found several suggestions that apply directly to us. We should:

  • Communicate to patients who’ve had fractures that their risk of another fracture is enormous, that these fractures can rob them of mobility (and potentially of life itself), and that they can take specific steps to reduce their future risk.
  • Promptly inform the patient’s regular primary-care provider that the fracture occurred.
  • Encourage that provider to initiate treatment for osteoporosis without delay; that is, do not wait for bone mineral density testing, since the fracture alone is an indication to initiate treatment.
  • Avoid the use of medications that could make falls more likely, and take steps to reduce the risk of falling while the patients are in our care.
  • Guide patients to healthier choices about smoking, alcohol, and exercise, all of which influence fracture risk.

Those of you who’ve been following this topic for years or decades may notice that these are reminiscent of many earlier guidelines, which suggests to me that this is not a knowledge-deficit problem [10] but an evidence-into-practice problem, a theme we’ve explored here many times before [4, 10, 12].

I’ve spent years at a university, but I’ll confess to being skeptical of education; education alone just not “sticky” enough to remedy a problem as resistant as this one. We hear something important, but soon thereafter, we may forget. The frequency with which so many patients with fragility fractures do not get adequate follow-up after surgery despite robust evidence numerous well-considered clinical practice guidelines shows us that. While you might read this and make sure your next patient gets screened, we should worry together about the one after that, and after that, and after that. Fixing this calls for thoughtfully constructed systems.

Which brings me to the last recommendation in the latest set of guidelines [4] that applies to us: The importance of managing patients with hip fractures within a multidisciplinary context of case management. The common term for this comanagement model is a “fracture liaison service” [23, 24].

While not every practice or hospital system has the resources to create a fracture liaison service, it’s my belief that most can, since they’ve been shown to be cost effective across a variety of settings [24]. But this not the only way; it’s possible to do more with less. In fact, when less is what we have, it’s our obligation to do so. We need to get with our partners, and set up a means to track and ensure that every patient whom we treat for a fragility fracture gets the benefit of secondary fracture prevention.

With that in mind: What’s your system?

If the answer is “none”, or “I don’t know”, take this opportunity to change that. What you do next may save—or cost—lives.

Acknowledgment

I would like to thank Clare M. Rimnac PhD, for her suggestions, which improved this essay, and Matthew B. Dobbs MD, who suggested that I write it.

References

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