Secondary prevention of hip fractures among the hospitalized elderly: are we doing enough?

Are we treating osteoporotic fractures of the hip adequately? A Middle Eastern cohort study

Fragility hip fractures treated in a center in the Middle East were retrospectively studied for adequacy of osteoporosis management. Of the 318 patients treated, over 70% did not have a structured investigation and about 30% did not receive any therapeutic supplements. Our series showed a preventable 8.8% secondary fracture rate.

PURPOSE

To study the adequacy of evaluation and treatment of osteoporosis after fragility fractures of the hip. The study also attempts to estimate the prevalence of secondary fractures after the original injury.

METHODS

This is a retrospective evaluation of the electronic database to search all the admissions for fractures of the hip in patients over 50 years at a tertiary care Trauma and Orthopaedic center in the Sultanate of Oman. The study period was defined as October 2010 to December 2015. Their case records, BMD reports, and laboratory data were analyzed. Pharmacological interventions and the documented compliance with such therapy were also recorded.

RESULTS

Over the study period, 318 fragility fractures of the hip were treated. Of these, 233 (73.3%) did not receive a DEXA scan and 94% did not have their vitamin D₃ (vit D) tested. About 29.9% percent cases did not receive any nutritional supplement or therapeutic intervention though diagnosed as fragility fracture. Twenty-eight patients (8.8%) reported for secondary fractures of the hip. Of these, 86% was initiated on supplement after their index fracture though 78.6% had not had a BMD study.

CONCLUSIONS

Less than 27% patients receive BMD test following fragility fracture of the hip and only 6% a vit D3 assay. Secondary fractures of the hip tend to occur in approximately 9% of the cases in Oman; this seems to occur equally in patients who have had as well as not had any calcium and vit D supplements after the index injury.

Two-year adherence to treatment and associated factors in a fracture liaison service in Spain

A fracture liaison service in Spain is able to maintain 73 % of the patients on antiresorptive 2 years after the fracture.

INTRODUCTION

The purpose of this study was to evaluate the 2-year effectiveness of a program for the secondary prevention of fractures.

METHODS

Fragility fractures in patients over 50 attending the emergency room in our centre are captured by the recruitment system of a secondary prevention program. The unit is attended by a nurse, coordinated by two rheumatologists and with the collaboration of primary care consisted of a training program and annual meetings. The outcome of the program was analysed 2 years after implementation, including: (1) percentage of attendees/eligible; (2) percentage of attendees who start treatment with antiresorptive; (3) percentage of patients who retain treatment after 6, 12, 18 and 24 months; and (4) factors associated to adherence.

RESULTS

After 2 years of implementation, the program detected 1674 patients with fracture, of whom 759 finally entered the program (57 % of eligible). After 3 months, 82 % of patients prescribed an antiresorptive started treatment. After a year, 52 % of the patients in the program, 72 % of those of a prescribed treatment, were taking antiresorptives. Adherence at 24 months among those who had prescribed anti-fracture drugs was 73 %. Factors associated with adherence at 12 months were female sex (76 vs 45 %; p = 0.01) and previous treatment with antiresorptive (86 vs 68 %; p = 0.02).

CONCLUSIONS

In Spain, a program designed to prevent secondary fragility fractures based on the collaboration between primary care and rheumatology seems effective in terms of recruitment of patients and adherence to treatment in the mid/long-term.

Fracture mortality: associations with epidemiology and osteoporosis treatment

The rates of incident osteoporotic fractures seem to be stabilizing; however, fragility fractures are still associated with considerable disability, costs and an increased risk of mortality, which is particularly the case for fractures of the hip and vertebra. Mortality is usually highest during the first year after fracture; however, a notably increased mortality risk might persist for several years after the event. In addition to its efficacy in the prevention of new and recurrent osteoporotic fractures, medical treatment has been associated with improved survival after osteoporotic fractures. Observational studies and randomized controlled clinical trials have reported increased survival in patients with a fracture who are treated with bisphosphonates. Rates of medical treatment in patients with osteoporosis remain low, and although the rationale for the putative increase in survival is unclear, this emerging evidence might help further justify the use of medical treatment after fracture. However, further work is needed before medical therapy for mortality prevention in patients with osteoporotic fractures is accepted.

Prevention and clinical management of hip fractures in patients with dementia

Hip fractures and dementia increase exponentially with age, and patients who are afflicted by both conditions suffer significant morbidity and mortality. The aging of our population heightens the need to recognize the interaction of these conditions in order to improve our efforts to prevent hip fractures, provide acute care that improves outcomes, and provide secondary prevention and rehabilitation that returns patients to their previous level of functioning. Identification and treatment of vitamin D deficiency and osteoporosis and assessment and interventions to reduce falls in patients with dementia can significantly impact the incidence of first and subsequent hip fractures. Acute management of hip fractures that focuses on comanagement by orthopedic surgeons and geriatricians and uses protocol-driven geriatric-focused care has been shown to decrease mortality, length of hospitalization, readmission rates, and complications including delirium. Patients with mild-to-moderate dementia benefit from intensive geriatric rehabilitation to avoid nursing home placement. Recognizing the need to optimize primary and secondary prevention of hip fractures in patients with dementia and educating providers and families will lead to improved quality of life for patients affected by dementia and hip fractures.

Factors influencing diagnosis and treatment of osteoporosis after a fragility fracture among postmenopausal women in Asian countries: a retrospective study

Background

A vast amount of literature describes the incidence of fracture as a risk for recurrent osteoporotic fractures in western and Asian countries. Osteoporosis evaluation and treatment after a low-trauma fracture, however, has not been well characterized in postmenopausal women in Asia. The purpose of this study was to characterize patient and health system characteristics associated with the diagnosis and management of osteoporosis among postmenopausal women hospitalized with a fragility fracture in Asia.

Methods

Patient surveys and medical charts of postmenopausal women (N=1,122) discharged after a fragility hip fracture from treatment centers in mainland China, Hong Kong, Singapore, South Korea, Malaysia, Taiwan, and Thailand between July 1, 2006 and June 30, 2007 were reviewed for bone mineral density (BMD) measurement, osteoporosis diagnosis, and osteoporosis treatment.

Results

The mean (SD) age was 72.9 (11.5) years. A BMD measurement was reported by 28.2% of patients, 51.5% were informed that they had osteoporosis, and 33.0% received prescription medications for osteoporosis in the 6 months after discharge. Using multivariate logistic regression analyses, prior history of fracture decreased the odds of a BMD measurement (OR 0.63, 95% CI 0.45-0.88). Having a BMD measurement increased the odds of osteoporosis diagnosis (OR 10.1, 95% CI 6.36-16.0), as did having health insurance (OR 4.95, 95% CI 1.51-16.21 for private insurance with partial self-payment relative to 100% self-payment). A history of fracture was not independently associated with an osteoporosis diagnosis (OR 0.80, 95% CI 0.56-1.15). Younger age reduced the odds of receiving medication for osteoporosis (OR 0.59, 95% CI 0.36-0.96 relative to age ≥65), while having a BMD measurement increased the odds (OR 1.79, 95% CI 1.23-2.61).

Conclusions

Osteoporosis diagnosis and treatment in Asian countries were driven by BMD measurement but not by fracture history. Future efforts should emphasize education of general practitioners and patients about the importance of fracture.

Prevalence of thoracic vertebral fractures in Spanish patients hospitalized in Internal Medicine Departments. Assessment of the clinical inertia. (PREFRAMI study)

PURPOSE

To study the prevalence of vertebral fractures (VF), the associated risk factors and the degree of diagnosis and prescription upon discharge in a series of hospitalized medical patients ≥50 years of age.

METHODS

A cross-sectional, multicentre and observational study in which a prevalence cut-off was carried out concerning patients admitted to six Internal Medicine departments in Malaga (Spain). The main variables were the existence of a fracture in the spine lateral x-ray, the inclusion of the diagnosis of a fracture in the discharge report, and the establishment of anti-osteoporotic treatment at discharge.

RESULTS

254 patients were included (mean age 66.4±14.9 years). The prevalence of VF was of 14.2% (36 cases). Patients with VF presented with a higher mean age, compared to those without VF (70.14 vs. 65.7 years) (p=0.035). The means contrast for the FRAX index variable (major osteoporotic and hip fracture), grouping according to the presence of VF, did not show any statistical significance (p=0.369 and p=0.788, respectively). Only in 8.3% of the discharge reports of patients with VF had the diagnosis of VF and/or osteoporosis been recorded and the prescription of anti-osteoporotic drugs been included.

CONCLUSIONS

A high prevalence of asymptomatic VF is verified in medical inpatients ≥50 years of age. The FRAX index did not turn out to be predictive of the presence of VF in this population. There is an underdiagnosis of osteoporotic VF in the coding at hospital discharge. Action protocols are necessary to avoid clinical inactivity regarding this entity.

Appraising osteoporosis care gaps

To evaluate physician response to dual-energy X-ray absorptiometry (DXA) report within the Geisinger Medical Center's Mobile DXA Program and treatment adherence at 1 year. Between 10/01/2004 and 3/30/2005, 1381 DXA scans were performed in our Mobile DXA Program. Within this cohort, we identified 366 high-risk, drug-naive patients and report the percentage of patients placed on prescription drug therapy within 90 days of DXA result. Additionally, we identified 191 patients with Z-score of -1.0 or worse and report whether laboratory tests were ordered within 90 days of DXA results in this group. Finally, we determined treatment adherence at 1 year. 269 patients (74%) were offered prescription therapy within 3 months of DXA results. Of those, 210 (57%) were still adherent to drug therapy at 1 year. The main reason for discontinuation of treatment was an adverse drug side effect. Additionally, in 50% cases, physicians ordered 1 or more laboratory tests to evaluate low Z-score. Within our Mobile DXA Program, 74% of high-risk, drug-naïve patients were treated. Interestingly, in 50% cases, when a low Z-score was reported, our physicians ordered 1 or more laboratory tests. Treatment adherence was 57% at 1 year.

The Fracture Risk Assessment Tool (FRAX®): applications in clinical practice

Osteoporosis is a serious health concern affecting millions of Americans, with many patients going undiagnosed and untreated. Fractures due to osteoporosis and fracture-related complications are the most clinically relevant and costly consequences of this disorder. The Fracture Risk Assessment Tool (FRAX®), released by the World Health Organization (WHO) in February 2008, is a major achievement in helping determine which patients may be candidates for pharmacological therapy for osteoporosis. This Web-based algorithm, which has been incorporated into some dual x-ray absorptiometry (DXA) reporting software, calculates the 10-year probability of major osteoporotic fracture (clinical vertebral, hip, forearm, or humerus) and the 10-year probability of hip fracture in men and women based on easily obtained clinical risk factors and bone mineral density (BMD) of the femoral neck (optional). The National Osteoporosis Foundation updated its U.S. guidelines in February 2008 to incorporate FRAX and recommends that all postmenopausal women and men aged ≥50 years with a hip or vertebral fracture, a T-score ≤-2.5 at the femoral neck or spine (excluding secondary causes), or low bone mass (T-score between -1.0 and -2.5) and a 10-year probability of hip fracture ≥3% or of major osteoporosis-related fracture ≥20% (based on FRAX) should be considered candidates for drug therapy. Despite its demonstrated clinical utility, FRAX has limitations and should not be used in all situations. Acceptance and clinical use of FRAX may help identify men and women at increased risk for osteoporotic fracture, but implementing the tool into clinical practice may be a challenge for busy physicians.

An effective team approach to improve postoperative hip fracture care

OBJECTIVE

To develop an initiative using standardized discharge orders to improve the posthip fracture care of patients aged 50 years or older.

DESIGN

Prospective nonrandomized study.

SETTING

Hospital orthopaedic service.

PARTICIPANTS

Patients at our institution older than age 50 years sustaining a hip fracture who were followed for at least 6 months and qualified for osteoporosis medication.

INTERVENTION

The endocrinology and orthopaedic areas agreed to add calcium/vitamin D supplementation, a dual-energy x-ray absorptiometry scan request, and a consult with endocrinology to the hospital discharge orders.

OUTCOME MEASURES

The proportions of patients using calcium or bisphosphonate before and after the intervention were compared using the McNemar test. The designated level of significance was 0.05.

RESULTS

Originally, 37 of 137 patients were taking calcium/vitamin D supplements. Following this initiative, 92 of 137 were taking the supplement (P < 0.0001). Seventeen of 137 patients were taking bisphosphonate initially and 65 of 137 after the initiative (P < 0.0001). After the initiative, 100% of the discharged patients were offered calcium/vitamin D, a dual-energy x-ray absorptiometry scan, and an endocrinology appointment. All of the patients who reported for the endocrinology consult appointment were offered bisphosphonate therapy. Eighty-two patients kept the appointment for the dual-energy x-ray absorptiometry scan, and 54 saw the endocrinologist.

CONCLUSION

The addition of a calcium/vitamin D supplement and an endocrinology appointment to the hospital discharge orders was an effective method of improving treatment and enhancing compliance.

What is the best balance of benefits and risks among anti-resorptive therapies for postmenopausal osteoporosis?

Pharmacologic osteoporosis therapy, particularly anti-resorptives, is recommended in postmenopausal women with clinical risk factors for fracture. Treatment decisions should be made based on the relative benefit-risk profile in different patient populations. Emerging options [e.g., selective estrogen receptor modulators (SERMs) and denosumab] may hold promise for providing protection from bone loss and for fracture risk reduction.Osteoporosis, the most common clinical disorder of bone metabolism, is characterized by low bone mineral density, deterioration of microarchitecture, and a consequent increase in bone fragility and risk of fracture. Pharmacologic therapy is recommended in postmenopausal women with clinical risk factors for fracture and includes anti-resorptive agents such as bisphosphonates, hormone therapy, SERMs, and calcitonin. The anabolic agent teriparatide (parathyroid hormone) is usually reserved for high-risk patients or those with glucocorticoid-induced osteoporosis. Strontium ranelate, available outside the USA, has both anti-resorptive and anabolic properties. Supplementation with calcium and vitamin D is recommended for all women aged 50 years and older. Bisphosphonates are often considered first-line therapy for osteoporosis and have the largest base of clinical trial data showing efficacy for global fracture risk reduction. Low-dose hormone therapy is appropriate for younger women who are experiencing other menopausal symptoms. In women for whom bisphosphonates are not appropriate or not tolerated or in younger postmenopausal women who have a low risk for hip fracture, SERMs are a suitable treatment option. Calcitonin is designated for patients who are unable or unwilling to tolerate other osteoporosis agents. Emerging options, including newer SERMs (e.g., bazedoxifene and lasofoxifene) and the monoclonal antibody denosumab, may hold promise for providing protection from bone loss and for fracture risk reduction. Because no single agent is appropriate for all patients, treatment decisions should be made on an individual basis, taking into account the relative benefits and risks in different patient populations.

[Secondary prevention in osteoporotic fractures. The GIOS project]

BACKGROUND AND OBJECTIVE

The aim of this report is to describe and evaluate the results of a secondary prevention program in osteoporotic fractures in 70 Spanish hospitals. This project was started to improve the treatment of these fractures, with the inhospital implementation of software collecting epidemiological data on patients with osteoporotic fractures.

PATIENTS AND METHODS

A prospective case study was conducted between March 2003 and March 2006 involving a consecutive sample of 24,534 patients with established fragility fracture seen in 70 hospitals. The study exclusion criterion was secondary osteoporotic fracture. The project consists of implementing software in hospitals, designed to collect such epidemiological data among these patients. Based on this information and on the published scientific evidence, the software automatically generates drug therapy recommendations and non pharmacologic measures of prevention to be included in the discharge report.

RESULTS

The number of patients with osteoporotic fractures included in the program totalled 24,534 subjects. Of these patients, only 22.7% were receiving treatment for osteoporosis. Implementation of the program made it possible to discharge 19,033 patients (77.6%) with prescribed treatment, but in only 15,153 patients (61.8%) the treatment was correct.

CONCLUSIONS

The GIOS project has proved effective in increasing the identification of fragility fractures and improve the percentage of secondary prevention measures, both pharmacological and non pharmacological, for patients with these fractures.

Intravenous zoledronic acid for the treatment of osteoporosis: The evidence of its therapeutic effect

INTRODUCTION

Osteoporosis is a disease characterized by low bone mineral density and poor bone quality resulting in reduced bone strength and increased risk of fracture. Oral bisphosphonates, first-line therapy for most patients with osteoporosis, are associated with suboptimal adherence to therapy due to factors that include a complex dosing regimen and gastrointestinal intolerance in some patients. Intravenous bisphosphonates address these limitations through infrequent injectable dosing that assures 100% bioavailability. Intravenous zoledronic acid is the newest bisphosphonate to be approved for the treatment of osteoporosis.

AIMS

This review assesses the evidence for the therapeutic effects of intravenous zoledronic acid for the treatment of osteoporosis.

EVIDENCE REVIEW

Zoledronic acid 5 mg administered as an annual 15-min intravenous infusion has been shown to reduce the risk of vertebral fractures, hip fractures, and other fractures in a three-year randomized, double-blind, placebo-controlled trial in women with postmenopausal osteoporosis. In a randomized, double-blind, placebo-controlled trial in women and men with a recent surgical repair of low-trauma hip fracture, it reduced the risk of new clinical fractures and improved survival. In both studies, zoledronic acid was associated with a good safety profile and was generally well tolerated. Zoledronic acid has the potential to improve clinical outcomes by reducing the risk of fracture in patients with osteoporosis.

CLINICAL VALUE

Intravenous zoledronic acid 5 mg every 12 months reduces fracture risk in women with postmenopausal osteoporosis and in women and men with recent low-trauma hip fracture.

Excess mortality in men compared with women following a hip fracture. National analysis of comedications, comorbidity and survival

INTRODUCTION

osteoporosis is a common disease, and the incidence of osteoporotic fractures is expected to rise with the growing elderly population. Immediately following, and probably several years after a hip fracture, patients, both men and women, have a higher risk of dying compared to the general population regardless of age. The aim of this study was to assess excess mortality following hip fracture and, if possible, identify reasons for the difference between mortality for the two genders.

METHODS

this is a nationwide register-based cohort study presenting data from the National Hospital Discharge Register on mortality, comorbidity and medication for all Danish patients (more than 41,000 persons) experiencing a hip fracture between 1 January 1999 and 31 December 2002. Follow-up period was until 31 December 2005.

RESULTS

we found a substantially higher mortality among male hip fracture patients than female hip fracture patients despite men being 4 years younger at the time of fracture. Both male and female hip fracture patients were found to have an excess mortality rate compared to the general population. The cumulative mortality at 12 months among hip fracture patients compared to the general population was 37.1% (9.9%) in men and 26.4% (9.3%) in women. In the first year, the risk of death significantly increased for women with increasing age (hazard ratio, HR: 1.06, 95% confidence interval, CI: 1.06-1.07), the number of comedications (HR 1.04, 95% CI 1.03-1.05) and the presence of specific Charlson index components and medications described below. For men, age (HR 1.07, 95% CI 1.07-1.08), number of comedications (HR 1.06, 95% CI 1.04-1.07) and presence of different specific Charlson index components and medications increased the risk. Long-term survival analyses revealed that excess mortality for men compared with women remained strongly significant (HR 1.70, 95% CI 1.65-1.75, P < 0.001), even when controlled for age, fracture site, the number of medications, exposure to drug classes A, C, D, G, J, M, N, P, S and for chronic comorbidities.

CONCLUSION

excess mortality among male patients cannot be explained by controlling for known comorbidity and medications. Besides gender, we found higher age and multimorbidity to be related to an increased risk of dying within the first year after fracture; acute complications might be one of the explanations. This study emphasises the need for particular rigorous postoperative diagnostic evaluation and treatment of comorbid conditions in the male hip fracture patient.

Current and emerging pharmacologic therapies for the management of postmenopausal osteoporosis

Postmenopausal osteoporosis is an asymptomatic skeletal disease that is often underdiagnosed and undertreated. Osteoporotic fractures are associated with substantial morbidity and mortality and impaired quality of life-socially, emotionally, and financially. Considering the growing burden of osteoporotic fractures worldwide, there remains an ongoing need for progress in the diagnosis of osteoporosis, identification of individuals at high fracture risk, and treatment to prevent fractures. Adequate intake of calcium and vitamin D is recommended as baseline therapy for osteoporosis prevention and treatment. Available pharmacological agents for the management of postmenopausal osteoporosis may not be appropriate for all women. Oral bisphosphonates are generally considered first-line therapy for patients with osteoporosis, but their use may be limited by gastrointestinal side effects. Other agents include hormone therapy, the selective estrogen receptor modulator (SERM) raloxifene, salmon calcitonin, teriparatide (human recombinant parathyroid hormone), and strontium ranelate (in some countries). Factors that may contribute to poor compliance and persistence with current osteoporosis therapies include drug intolerance, complexity of dosing regimens, and poor understanding of the relative benefit and risk with treatment. Emerging therapies for postmenopausal osteoporosis include novel SERMs (bazedoxifene, lasofoxifene, ospemifene, arzoxifene) and denosumab. Because SERMs can display mixed functional estrogen receptor agonist or antagonist activity depending on the target tissue, they may confer beneficial effects on bone with limited stimulation of other tissues (e.g., breast, endometrium). Clinical investigation of these promising new agents is ongoing to evaluate efficacy and safety, with the goal of developing effective strategies to maximize long-term tolerance, compliance, and persistence with therapy.

Excess mortality following hip fracture: a systematic epidemiological review

This systematic literature review has shown that patients experiencing hip fracture after low-impact trauma are at considerable excess risk for death compared with nonhip fracture/community control populations. The increased mortality risk may persist for several years thereafter, highlighting the need for interventions to reduce this risk.Patients experiencing hip fracture after low-impact trauma are at considerable risk for subsequent osteoporotic fractures and premature death. We conducted a systematic review of the literature to identify all studies that reported unadjusted and excess mortality rates for hip fracture. Although a lack of consistent study design precluded any formal meta-analysis or pooled analysis of the data, we have shown that hip fracture is associated with excess mortality (over and above mortality rates in nonhip fracture/community control populations) during the first year after fracture ranging from 8.4% to 36%. In the identified studies, individuals experienced an increased relative risk for mortality following hip fracture that was at least double that for the age-matched control population, became less pronounced with advancing age, was higher among men than women regardless of age, was highest in the days and weeks following the index fracture, and remained elevated for months and perhaps even years following the index fracture. These observations show that patients are at increased risk for premature death for many years after a fragility-related hip fracture and highlight the need to identify those patients who are candidates for interventions to reduce their risk.

Identification and treatment of osteoporosis among elderly patients with hip fractures

OBJECTIVE

To evaluate the profile of osteoporosis treatment among patients hospitalized due to hip fractures at a tertiary-level university hospital. To compare the impact of hospitalization on approaches toward treating bone mass losses.

METHOD

The medical records of 123 hip fracture patients aged 60 years and over at the Institute of Orthopedics, Hospital das Clínicas, University of São Paulo School of Medicine, between 2004 and 2006 were reviewed and analyzed with respect to approaches towards investigating osteoporosis and treatments before and after fracture.

RESULTS

The patients' mean age was 78 +/- 8.3 years, and the majority were women (71.54%). The patients had a mean of 2.72 comorbidities and used 3.26 medications on average. Among these patients, 12.3% reported a previous diagnosis of osteoporosis, and 5.83% were on medication for this. The mean waiting time for surgery was 6.3 +/- 7.54 days, and seven patients (5.7%) died during the hospitalization. There were no investigations using bone densitometry, no changes in osteoporosis therapy between admission and discharge (p = 0.375), and no reports of referrals for the patient to have access to treatment.

CONCLUSIONS

Investigations and treatments of osteoporosis and strategies for preventing new fractures were not implemented during the hospitalization of these elderly patients with hip fractures, even though this is the most feared complication of osteoporosis. These data need to be disseminated so that professionals dealing with elderly patients are attentive to the need for primary and secondary prevention of osteoporosis because of the impact of fractures on these patients' quality of life, independence, morbidities, and mortality.

Undertreatment of osteoporosis following hip fracture in the elderly

The national Finnish guidelines for medical treatment of hip fracture patients are: osteoporosis medication and the daily concomitant use of vitamin D and calcium supplements. We investigated the post-fracture medical therapy for osteoporosis and the calcium and vitamin D therapy among hip fracture patients in two Finnish hospitals. The pre-fracture osteoporosis medication and use of calcium and vitamin D supplements of the patients were inquired on admission. The patient-specific use of osteoporosis medication and of prescribed calcium and vitamin D therapy during the follow-up time were checked from The Finnish Social Insurance Institution. At the end of the follow-up, those who were alive were inquired about the use of medication at the time. Eight percent of the 223 patients used osteoporosis medication and 8% used prescribed calcium and vitamin D supplements before the fracture. During the follow-up, the figures were 39% (52/133) and 53% (70/133), respectively, and at the end of the follow-up, correspondingly, 25% (29/114) and 44% (50/114). The follow-up time was 19.5-35 months. The post-fracture medical therapy for osteoporosis was insufficient. More effort should be focused on the secondary prevention following hip fracture in order to ensure the recommended treatment of osteoporosis.

Characteristics of males over 50 years who present with a fracture: epidemiology and underlying risk factors

Osteoporosis and fragility fractures in men constitute a considerable burden in healthcare. We have reviewed 2035 men aged over 50 years with 2142 fractures to clarify the epidemiology of these injuries and their underlying risk factors. The prevalence of osteoporosis ranged between 17.5% in fractures of the ankle and 57.8% in those of the hip. The main risk factors associated with osteoporosis were smoking (47.4%), alcohol excess (36.2%), body mass index < 21 (12.8%) and a family history of osteoporosis (8.4%). Immobility, smoking, self-reported alcohol excess, a low body mass index, age >/=72 and loss in height were significantly more common among men with fractures of the hip than in those with fractures elsewhere.

Advances in the medical management of osteoporosis

Osteoporosis is a skeletal disorder characterised by compromised bone strength predisposing to increased risk of fracture, which is rapidly reaching epidemic proportions as the population ages. Many patients presenting with a fracture caused by a fall from standing height or less are not on any kind of therapy and many patients who sustain these fragility fractures are not started on therapy by their orthopaedic surgeon. In 2004, the United States Surgeon General released a report on osteoporosis recommending that physicians adopt a pyramidal approach to therapy. The base of the pyramid includes calcium, vitamin D, physical therapy and fall prevention. The second level calls for management or elimination of secondary causes of osteoporosis. The third level consists of treatment with either anti-resorptive or anabolic medications. The orthopaedic surgeon is in an ideal position to diagnose fragility fractures and suggest treatment in the hope of preventing future fractures. Anti-resorptive and anabolic therapies currently available are discussed.

Implementation of a Mandatory Rheumatology Osteoporosis Consultation in Patients With Low-Impact Hip Fracture

BACKGROUND

Osteoporosis remains an underdiagnosed and undertreated major health problem. The current treatment rate for patients who have experienced at least 1 osteoporotic fracture is 20%-25%. Therefore, the Rheumatology and Internal Medicine Departments of Ochsner Clinic Foundation New Orleans implemented a mandatory rheumatology osteoporosis consult as part of preprinted admission orders for all patients after hip fracture surgery on the Internal Medicine service.

METHODS

We conducted a retrospective study of 78 patients admitted with a low-impact hip fracture between June 2004 and July 2005. These patients were seen by the rheumatology service in the hospital after hip fracture repair (exposed group). Osteoporosis evaluation was performed based on an interview questionnaire. Seventy-eight age-matched patients previously admitted for low-intensity or low-impact hip fracture in 2002-2003 but not exposed to the mandatory rheumatology consult served as our comparison group. Pearson chi2 test was used for statistical analysis.

RESULTS

Mean patient age was 80 years. Of the 78 unexposed patients, 17 (22%) were on treatment (calcium, vitamin D, hormones or antiresorptive agents) before the hip fracture, and 18 (23%) were on treatment after fracture repair. Of the 78 patients exposed to the compulsory rheumatology consultation, 34 (44%) patients were receiving osteoporosis treatment before hip fracture and 75 (96%) patients were receiving treatment after fracture repair. Of the patients not treated before hip fracture repair, there was a significant increase in the percent treated for those patients exposed to the rheumatology consult versus those not exposed (97.6% vs. 2.4%, respectively, P < 0.0001).

CONCLUSIONS

In our institution, we were successful in identifying and initiating appropriate therapy for osteoporosis patients through an automatic rheumatology osteoporosis consultation after hip fracture. The implementation of a mandatory osteoporosis consult resulted in a statistically significant increase in treatment of the exposed group compared with the unexposed group.

Medical management of patients over 50 years admitted to orthopedic surgery for low-energy fracture

OBJECTIVE

To develop a cost-effective strategy for improving osteoporosis management in patients admitted to an orthopedic surgery department for low-energy fractures.

METHODS

From November 2003 to July 2004, all patients over 50 years admitted to the orthopedics department of the Caen Teaching Hospital (France) for low-energy fractures were identified and evaluated by rheumatology department physicians in the same hospital.

RESULTS

During the study period, 313 patients were identified, 257 women (mean age, 79.5+/-10.2 years) and 56 men (mean age, 74.6+/-10.8 years), each with one fracture (proximal femur, 58.9%; wrist, 13%). Among them, 91 (29%) had a previous history of osteoporotic fractures. Mean bone mineral density (BMD) values were lower at the femoral neck than at the total hip or lumbar spine (e.g. in women, -2.3+/-0.9 versus -1.8+/-1.0 and -1.4+/-1.7, respectively). Osteoporosis treatment was given to 88 (28%) patients and consisted of calcium and vitamin D supplements, combined with alendronate in 32 patients. Complete loss of self-sufficiency occurred in 73 patients. Thus, 161 patients (88 with osteoporosis treatment and 73 with loss of self-sufficiency) received optimal treatment.

CONCLUSION

Cooperation between the orthopedics and rheumatology departments improved the management of osteoporosis in patients with low-energy fractures. However, appropriate investigation and treatment of osteoporosis proved difficult in the oldest old and in patients with cognitive impairments.