Defined by the National Institutes of Health as “a skeletal disorder characterized by compromised bone strength,” osteoporosis has been shown to predispose individuals to an increased risk of fracture.1 It is estimated in the United States that over 30% of women older than 65 years of age have osteoporosis.2 Fragility fractures, defined as fractures that occur from a standing height or less, are a consequence of low bone quality and density. Fragility fractures have been identified to be the only clinically relevant marker of bone quality.3 Today, they represent approximately 80% of all fractures in menopausal women older than 50 years of age.4 In addition to the global economic burden secondary to fragility fractures, there is the human pain and suffering, which causes a loss of independence and quality of life.5 Approximately 50% of women after a hip fracture cannot ambulate at their accustomed level,6 and mortality is increased to 20% during the first 6 months after fracture.7-9
With the risk of a subsequent fragility fracture being increased 1.5 to 9.5 times after a fragility fracture, other nonsurgical strategies are necessary.10-12 Bisphosphonates such as alendronate and zolendronate have been shown to reduce the number of new vertebral and hip fractures by 40% to 60% in the year after the index fracture.13 The world population is slowly aging, and the number of hip fractures will increase to 6.3 million per year by 2050.14,15 The fragility fracture epidemic requires a thoughtful and coordinated program of strategies to address this reality.
What Happens Today?
Clinical guidelines for the treatment of osteoporosis were published by the National Osteoporosis Foundation in 1999 in the United States and in Canada in 2002. The current focus is on the prevention of fragility fractures to lessen the health burden on the patient and society.5,16 Low-energy fragility fractures are indicative of bone quality, and such patients provide a unique opportunity to identify at-risk individuals.
Identifying patients at risk and getting the proper evaluation and treatment is still uncertain in many countries. Usually a recommendation is made to the patient to see their physician for follow-up care regarding osteoporosis.17 Orthopaedic surgeons being the first responders for the emergent fracture care can steer and influence the patient to initiate screening and follow-up care. The rigor of referral has been wholly inadequate with only 1% to 32% of patients with fragility fractures receiving a bone density scan with the preponderance under 15%. Additional workup confirming the diagnosis was made less than half the time.18 In a Canadian review, only 5.2% to 37.5% of patients with fragility fractures were being treated for osteoporosis at final fracture follow-up.19
What Are the Barriers to Adequate Osteoporosis Management?
There has been a disconnect between the realization that fragility fractures are the stigmata of osteoporosis and the engagement of the patient and physician team toward more universal diagnosis and treatment. Orthopaedic surgeons feel undertrained to treat osteoporosis and feel the primary care physician should lead this effort.20-22 In contrast, many primary care physicians believe that this responsibility should be a shared one.20,22 Additional barriers include: 1) There is controversy regarding the initiation of treatment in the context of an acute fracture and its effect on healing23; 2) interdisciplinary physician communication is lacking17; 3) recent orthopaedic residency and curricula training may not provide sufficient knowledge to allow osteoporosis management, especially the pharmacology. A survey conducted at the 2003 Annual Meeting of the Canadian Orthopaedic Association in Winnipeg reported older orthopaedic surgeons in Canada were more comfortable initiating osteoporosis therapies21; 4) the magnitude and severity of the osteoporosis disease burden is not appreciated by many physicians who place osteoporosis lower on the disease hierarchy22; 5) there persists the unproven belief that osteoporotic medications are bad for fracture healing and bone remodeling and should not be initiated at the time of fracture.24 One case-control study suggested that this might be true.25 It was refuted in a large, randomized controlled trial of zolendronate versus placebo in patients with hip fractures with no difference in healing time.26 This suggests that biphosphonate administration may be continued and or started in the perifracture period; 6) patients tend to be focused on the fracture event and not the underlying disease. They often confuse fracture management with control or cure for osteoporosis. This blissful ignorance is a major impediment to their own advocacy for treatment17; 7) finally, there have been economic and access barriers to timely diagnosis and treatment of osteoporosis.27
How Should the Problem of Lack of Adequate Osteoporotic Care Be Addressed?
Strategies to improve care for patients at risk for fragility fracture or postfracture have been instituted in Canadian fracture clinics with a coordinator-based model, in which a designated healthcare provider is focused on initiating and facilitating the screening and treatment of osteoporosis. Patients soon recognize the importance given to this effort and so are more likely to follow through with the recommendation. Better communication with the treating physician is another advantage of this type of system.28
Patients often see the orthopaedic surgeon as the captain of the team after they sustain a fragility fracture. Thus, when the surgeon recommends and helps initiate the osteoporosis screening, the patient is more likely to follow through.17 The American Orthopaedic Association has formally suggested that referring by letter patients to their primary care physicians for the purpose of initiating osteoporosis treatment generates higher compliance.29 In addition, educational tools in the form of brochures, web sites, and newsletters are excellent to engage and empower patients at risk as well as to dispel myths and inaccuracies about the risks and benefits of modern osteoporosis treatment.30
Our aging populations require government led efforts to standardize care and make it affordable and universal. Improving access to healthcare providers with the knowledge of validated treatment protocols will go a long way to ensuring that patients do not fall through the cracks of the system after the index fragility fracture.27
Clinical research will continue to help define and quantify the costs and benefits of this type of comprehensive effort to modify and lessen the morbidity of fragility fractures in patients worldwide.
1. Hellekson KL. NIH releases statement on osteoporosis prevention, diagnosis, and therapy. Am Fam Physician
2. Hooven F, Gehlbach S, Pekow P, et al. Follow-up treatment for osteoporosis after fracture. Osteoporosis Int
3. Papaioannou A, Watts NB, Kendler DL, et al. Diagnosis and management of vertebral fractures in elderly adults. Am J Med
4. Bessette, L, Ste-Marie LG, Jean S, et al. The care gap in diagnosis and treatment of women with a fragility fracture. Osteoporosis Int
5. Papaioannou A, Morin S, Cheung AM, et al. 2010 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada: summary. CMAJ
6. Riggs BL, Melton LJ 3rd. Involutional osteoporosis. N Engl J Med
7. Cummings SR, Kelsey JL, Nevitt MC, et al. Epidemiology of osteoporosis and osteoporotic fractures. Epidemiol Rev
8. Cooper c, Atkinson EJ, Jacobsen SJ, et al. Population-based study of survival after osteoporotic fractures. Am J Epidemiol
9. Magaziner J, Simonsick EM, Kashner TM, et al. Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol
10. Haentjens P, Autier P, Collins J, et al. Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women: a meta-analysis. J Bone Joint Surg Am
11. Klotzbuecher CM, Ross PD, Landsman PB, et al. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res
12. Schroder HM, Petersen KK, Erlandsen M. Occurrence and incidence of the second hip fracture. Clin Orthop Relat Res
13. Brown JP, Josse RG. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ
14. Cooper C, Campion G, Melton LJ 3rd. Hip fractures in the elderly: a world-wide projection. Osteoporosis Int
15. Cumming RG, Nevitt MC, Cummings SR. Epidemiology of hip fractures. Epidemiol Rev
16. National Osteoporosis Foundation.Clinician's Guide to Prevention and Treatment of Osteoporosis. Washington, DC: National Osteoporosis Foundation; 2008. Available at: www.nof.org/professionals/Clinicians_Guide.htm
. Accessed February 1, 2011.
17. Kaufman J, Bolander M, Bunta A, et al. Barriers and solutions to osteoporosis care in patients with a hip fracture. J Bone Joint Surg Am
18. Giangregorio L, Papaioannou A, Cranney A, et al. Fragility fractures
and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum
19. Papaioannou A, Giangregorio L, Kvern B, et al. The osteoporosis care gap in Canada. BMC Musculoskelet Disord
20. Ashe MC, Khan KM, Guy P, et al. Fragility fracture and osteoporosis investigation. BCMJ
21. Bogoch E. Canadian orthopedic surgeons and postfracture osteoporosis care: moving from persuasion toward facilitation. J Can Chir
22. Follin S, Black J, McDermott M. Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture. Pharmacotherapy
23. Andrade S, Majumdar S, Chan A, et al. Low frequency of treatment of osteoporosis among postmenopausal women following a fracture. Arch Intern Med
24. Jennings LA, Auerbach AD, Maselli J, et al. Missed opportunities for osteoporosis treatment in patients hospitalized for hip fracture. J Am Geriatr Soc
25. Solomon DH, Hochberg MC, Mogun H, et al. The relation between bisphosphonate use and non-union of fractures of the humerus in older adults. Osteoporosis Int
26. Lyles K, Colon-Emeric C, Magaziner J, et al. Zoledronic acid and clinical fractures and mortality after hip fracture. N Engl J Med
27. Harrington J, Broy S. Derosa A, et al.Broy S. Derosa A, et al. Hip fracture patients are not treated for osteoporosis: a call to action. Am Coll Rheumatol
28. Sander B, Elliot-Gibson V, Beaton D, et al. Targeting fragility fractures
in an orthopaedic treatment unit: cost-effectiveness of a dedicated coordinator. J Bone Miner Res
29. Tosi LL, Gliklich R, Kannan K et al. The American Orthopaedic Association's 'Own the Bone' initiative to prevent secondary fractures. J Bone Joint Surg Am
30. Skedros J. The orthopaedic surgeon's role in diagnosing and treating patients with osteoporotic fractures: standing discharge orders may be the solution for timely medical care. Osteoporosis Int