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Current Issues
The Orthopaedic Surgeon’s Initiative –
A Call to Arms to Improve Osteoporosis Care
a report by
Karsten Dreinhöfer,
1
Lars Lidgren
2
and Sara Martin
3
1. Department of Orthopaedics, University of Ulm, and RKU University and Rehabilitation Hospitals, Ulm;
2. Department of Orthopaedics, Clinical Sciences, Lund University; 3. The Bone and Joint Decade (BJD)
A Matter Requiring Urgent Attention patients who sustain a fracture of the hip will die as a result within the first
Concern from osteoporosis groups has been rising over the last decade year after the fracture. Thirty per cent will suffer permanent disability, 40%
about the growing menace of fragility fractures, which affect a staggering will no longer be able to walk independently, 80% will be unable to carry
one in three women and one in five men over 50 years of age. However, out at least one independent daily living activity and up to 25% will have to
despite the undeniable statistics of fracture risk and the associated mortality, go into long-term residential care.
4
morbidity and costs in our ageing populations, little seems to have changed
in the way fracture patients are treated: shamefully, even today few receive A Vicious Circle
any evaluation or treatment for osteoporosis – the underlying cause of most It is a fact that patients who have had a fracture at any site have more
of these fractures. The Orthopaedic Surgeon’s Initiative is aiming to change than twice the risk of sustaining a future fracture compared with
this. Important international groups, such as The Bone and Joint Decade individuals who have never experienced such an injury as an adult.
5
Up to
(BJD), the International Osteoporosis Foundation (IOF) and the International 50% of patients with a vertebral fracture will experience additional
Society for Fracture Repair (ISFR), have joined together and issued a call to vertebral fractures within three years, many within the first year.
arms to raise awareness about fragility fractures as a global public health
problem. Furthermore, the intention is to improve the understanding of Underdiagnosis
osteoporosis among orthopaedic surgeons, recognise it as a cause of Despite the above, fragility fractures are still underdiagnosed and
fragility fractures and motivate surgeons to take an active role in optimising undertreated. Despite the availability of therapies proved to reduce fracture
care of the fragility fracture patient, with the ultimate goal of preventing risk, diagnosis and treatment of osteoporosis among fragility fracture
future fractures. The Orthopaedic Surgeon’s Initiative believes that patients remains low – even in patients who have already suffered a
orthopaedic surgeons have a unique opportunity to transform the landscape fracture. In an example from Freedman et al., researchers looked at 1,162
of osteoporosis care: a fragility fracture is often the first indication that a women over the age of 50 years with low-energy distal radius fracture at
patient has osteoporosis, and orthopaedists are often the first and possibly six months post-fracture, and found that 266 (23%) had been prescribed
the only physician involved in the treatment. By the very nature of this osteoporosis medication, 33 (2.8%) had received a bone density scan and
position, the orthopaedic surgeon has a pivotal role in optimising care. only 20 (1.7%) had received a bone density scan plus osteoporosis
medication. So, a handful of women received correct care, but 883 (76%)
The Growing Magnitude of the Problem received neither a bone density test nor medical treatment for their obvious
There is no lack of data to show us that the prevalence and incidence of osteoporosis.
6
In 2000, Gehlbach et al. found that of 132 women over 60
osteoporotic fractures is vast, and increases exponentially with age. A years of age who sustained osteoporotic vertebral compression fractures,
simple search on the IOF’s website (http://www.iofbonehealth.org/facts- which were identified during radiological examinations, only 20% actually
and-statistics.html) will yield startling statistics: received any treatment for either the fracture or the osteoporosis.
7
• Every third woman and every fifth man over the age of 50 years will What Is Going On?
eventually suffer from an osteoporosis-related fracture. Mounting evidence such as the above, showing that orthopaedic surgeons
• The risk of a hip fracture is between 11 and 18% in women, which is are not familiar with osteoporosis, led the BJD, the IOF and the ISFR to survey
equal to the combined risk for breast, uterine and ovarian cancers. 3,422 orthopaedic surgeons about osteoporotic fracture management in
• Vertebral fractures are between two and three times more prevalent France, Germany, Italy, Spain, the UK and New Zealand. The majority of
than those in the hip, but only one-third are ever diagnosed. respondents in all countries believed that the orthopaedic surgeon should
identify and initiate the assessment of osteoporosis in patients with fragility
However, this is only the beginning. The number of people over 65 years of fractures, yet results showed that when push come to shove, identification
age is expected to almost double by the year 2040, and as the population and treatment of the osteoporosis patient is alarmingly insufficient across
ages the number of hip fractures is predicted to rise exponentially. Cooper the board: only 10% always initiated a bone density test after surgically
et al. project that by 2050 the total number of hip fractures worldwide will treating a patient for a fragility fracture, 20% said that they never referred
rise to 6.26 million.
1
Furthermore, the economic costs associated with a patient after a fragility fracture for a bone mineral density (BMD) test and
osteoporosis and fragility fractures are overwhelming. In Europe, the total 75% admitted that they were lacking the appropriate knowledge about
direct costs of osteoporotic fractures are over €31 billion and are expected osteoporosis, having received little or no training about the disease. Thus,
to increase to more than
2,3
€76 billion in 2050. It is not just about the majority of patients with fragility fractures are discharged without
economics, though. The negative impact on quality of life after a hip or adequate evaluation of osteoporosis. Despite the evidence in support of
vertebral fracture is a foremost concern. According to Cooper et al., 20% of appropriate management, it seems that up to 95% are discharged without
12 © TOUCH BRIEFINGS 2007
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