A Systematic Approach to the Diagnosis and Treatment of Osteoporosis in Fragility Fracture Patients

Earl R. Bogoch M.D., FRCSC
Victoria Elliot-Gibson MSc
Toronto, ON

Fragility fractures are defined as fractures of the distal radius, proximal humerus, vertebrae and proximal femur that result from minimal trauma, such as a fall from a standing height. These fractures, which are most likely the result of osteoporosis, are common injuries presenting in outpatient fracture clinics and inpatient orthopaedic wards, and represent a major portion of the work of general orthopaedic units. Up to 95% of hospitalized fracture inpatients over 75 years of age, and 80% to 90% of fractures in patients between 60 and 74 years of age can be attributed to osteoporosis1. In this high risk population, fracture begets fracture. The risk of future fracture increases 1.5- to 9.5-fold following a fragility fracture2-3. Moreover, mortality after hip fracture ranges from 22 to 33% within one year of hip fracture4-5. Loss of independence results in the majority of patients who survive a hip fracture, with approximately one-quarter requiring permanent admission to a chronic care facility in the year following the fracture6-7. The large number of fragility fractures treated by Canadian orthopaedic surgeons represents a major public health opportunity to prevent future, clinically significant, fractures of the hip.

The incidence of hip fracture has been projected to increase nearly four-fold by 2041 in Canada8. Thus the orthopaedic and medical communities are facing a public health crisis that could, in part, be mitigated by the development of evidence-based interventions to promote osteoporosis identification, assessment and treatment of fragility fracture patients in the orthopaedic environment.

The 2002 clinical practice guidelines for the diagnosis and management osteoporosis in Canada9 report level-one evidence for the use of aminobisphosphonates in post-menopausal women with osteoporosis in preventing vertebral and non-vertebral fractures, and increasing bone mineral density at spine and hip. It is clear that treatment of osteoporosis with calcium, Vitamin D and a bisphosphonate can prevent hip fracture by approximately 50% in high-risk patients10-11 and such treatment may also result in lower mortality post-fracture5.

A systematic review of 37 articles on the diagnosis and treatment of osteoporosis following a fragility fracture12, demonstrated, unfortunately, that patients with fragility fractures assessed in fracture clinics and/or by orthopaedic surgeons did not receive appropriate investigation and treatment of osteoporosis. In Canadian studies, fewer than 20% of patients received appropriate care for underlying osteoporosis after fracture. This is the challenge for Canadian orthopaedic surgeons, who, by virtue of our centralized, high-volume system of care, treat nearly all fragility fractures in concentrated foci i.e. in fracture clinics. For example, in Ontario, where the population is over 10 million people, there are only 72 active fracture clinics where patients with fragility fractures can be easily found and treated for osteoporosis.

Once patients are identified, educated and referred by the orthopaedic surgeon for appropriate osteoporosis investigation and treatment, the patient usually receives adequate care by the family doctor, or specialists such as endocrinologists, gynecologists, rheumatologists or nephrologists. The key step, and the step that is often lacking, is for the fragility fracture to be recognized and documented as such, for the communication of this to the patient, and for the referral to be made. In medical systems throughout the developed world, it has proven surprisingly difficult to initiate programmes that result in consistent identification and referral of fragility fracture patients for osteoporosis care and treatment. Fortunately, Canadian orthopaedic surgeons, in a survey in October, 2003, identified themselves in a high proportion of cases to be willing to actively involve themselves in basic osteoporosis referral and care for fragility fracture patients under their care13.

Evidence to date indicates that the key step in initiating a reliable programme to consistently result in osteoporosis care for fragility fracture patients is the presence of a dedicated osteoporosis coordinator at the site of care, in the fracture clinic, and visiting the orthopaedic inpatient ward14. This coordinator, whose job is specifically coordinating the identification, education, investigation, referral and treatment of these patients, is the most valuable resource for the team who wish to improve osteoporosis care.

An example of such a programme that addresses the appropriate identification, education, assessment, referral and treatment of osteoporosis in fragility fracture patients has been developed at St. Michael's Hospital and is described in the Journal of Bone and Joint Surgery14. System modifications included coordination between the orthopaedic, metabolic bone disease clinic and nuclear medicine units to provide a continuum of care for these patients. Individual barriers were addressed through ongoing education of physicians, staff and patients to increase knowledge and awareness of osteoporosis. This programme has recently been adapted for use in the fracture clinic at the Peterborough Regional Health Centre to test its efficacy in a regional community setting.

For orthopaedic surgeons considering starting such a programme to address fragility fracture patients, the following are steps that should be considered.

1. Advocate for the hiring of a nurse, physical therapist or other health professional, either half-time or full-time, who will have the following duties:

a. Patient Screening and Identification: Daily screening of all orthopaedic inpatients and fracture clinic outpatients by reviewing patients electronic or hard copy charts for inclusion criteria, and review cases with orthopaedic surgeon/resident and patient if necessary.
b. Patient Education: Provide patient/family with educational materials and have detailed discussion re: risk factors and management of osteoporosis. For outpatients, this can be done during the patients wait for radiographs or to see the surgeon. Patient identification and education are not to interrupt patient flow through the outpatient clinic. Educational materials developed in collaboration with Osteoporosis Canada and the Ontario Orthopaedic Association are available by contacting us at 416-864-5350 or by e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it..
c. Patient Referral: Completion of bone mineral density requisition; completion of consultation requisition (if needed); and/or, completion of a form letter to be sent to the family doctor or specialist detailing patients identification and recommended treatment pathway. A sample form letter is available by contacting Victoria Elliot-Gibson at 416-864-6060 ext 2555 or e-mail at This email address is being protected from spambots. You need JavaScript enabled to view it..
d. Patient Treatment: Recommendation for the patient to take 800 IU of Vitamin D3 and 1000 mg of calcium daily, +/- initiation of a bisphosphonate (if not contraindicated) by the orthopaedic surgeon. Only Quebec permits unrestricted access to aminobisphosphonates on formulary, the other provinces have specific limited use criteria.

2. Review of resources available in the community and/or hospital.

a. Bone mineral density machine: Is there a densitometer (DEXA) available in the area, accessible for your patients? Establish a relationship with the administrators of the DEXA machine.
b. Specialists/Family Physicians: Are there specialists interested in osteoporosis who will accept referral of your patients? Establish relationships with these specialists and a convenient mechanism for referral. If specialists are not available, communicate with the family doctor about the patients need for osteoporosis investigation and treatment. This can be done within the dictated note regarding the fracture, or if there is no dictated note in your unit, a form letter, signed off by the orthopaedic surgeon, can be mailed by the clinic staff to the patients family physician.
c. Osteoporosis Canada: Is there a local chapter of Osteoporosis Canada in your area? The phone number of Osteoporosis Canada can be provided to patients (1-800-463-6842). Osteoporosis Canada has pamphlets/tear sheets available for physicians to give to patients that contain their 1-800 number and their web site (www.osteoporosis.ca).

3. Promotion of local physician awareness re: osteoporosis. For example, invite an osteoporosis specialist to speak at rounds. A successful programme requires broad support.

With current fiscal restrictions in the health care system, one might question the cost of such a programme. To evaluate the cost-effectiveness of employing a dedicated coordinator who coordinates care of fragility fracture patients, a one-year decision analysis model was developed in collaboration with health care economists, utilizing data from the osteoporosis programme at St. Michaels Hospital15. Results indicated that a coordinator was cost-saving: 1) over reasonable ranges of cost of care, 2) even if only half of patients initiated treatment and then only half of those complied, 3) even if treatment reduced fractures by only 20% (which is very conservative) and 4) even if only 194 patients were seen annually by the coordinator. Therefore, employing a coordinator to manage fragility fracture patients may reduce further hip fractures and appears to be cost-effective from a system perspective.

References

 

  1. Goeree R., OBrien B., Pettitt D., Cuddy L., Ferraz M., J.D. An assessment of the burden of illness due to osteoporosis in Canada. J Soc Obstet Gynaecol Can. 1996; 18: 15-24.
  2. Haentjens P., Autier P., Collins J., Velkeniers B., Vanderschueren D., Boonen S. Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women. A meta-analysis. J Bone Joint Surg . 2003; 85A: 1936-43.
  3. Klotzbuecher C.M., Ross P.D., Landsman P.B., Abbott III T.A., Berger M. Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res. 2000; 15: 721-39.
  4. Wiktorowicz M.E., Goeree R., Papaioannou A., Adachi J.D., Papadimitropoulos E. Economic implications of hip fracture: health service use, institutional care and cost in Canada. Osteoporos. Int. 2001; 12: 271-8.
  5. Cree M., Soskolne C.L., Belseck E., Hornig J., McElhaney J.E., Brant R., Suarez-Almazor M. Mortality and institutionalization following hip fracture. J Am Geriatr. Soc., 48, 283, 2000.
  6. Cummings R.G., Melton L.J. Epidemiology and outcomes of osteoporotic fractures. Lancet, 2002; 359: 1761-7.
  7. Cummings R.G., Klineberg R., Katelaris A. Cohort study of institutionalization after hip fracture. Aust N Z J Public Health. 1996; 20(6): 579-82.
  8. Papadimitropoulos E.A, Coyte P.C., Josse R.G., Greenwood C.E. Current and projected rates of hip fracture in Canada. Can Med Assoc J. 1997; 157: 1357-63.
  9. Brown J.P., Josse R.G.; Scientific Advisory Council of the Osteoporosis Society of Canada. 2002 clinical practice guidelines for the diagnosis and management of osteoporosis in Canada. CMAJ. 2002; 167 (10 Suppl): S1-34.
  10. Chrischilles E.A., Dasbach E.H., Rubenstein L.M., Cook J.R., Tabor H.K., Black D.M. The effect of alendronate on fracture-related healthcare utilization and costs: the Fracture Intervention Trial. Osteoporos Int. 2001; 12: 654-60.
  11. Harris S.T., Watts N.B., Genant H.K., et al. Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. Vertebral Efficacy With Risedronate Therapy (VERT) Study Group. JAMA. 1999; 282: 1344-52.
  12. Elliot-Gibson V., Bogoch E.R., Jamal, S.A., Beaton D.E. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporosis Int. 2004; 15: 767-778.
  13. Bogoch E.R. Current orthopaedic osteoporosis initiatives across Canada. Can Orthop Assoc Bull. 2004; 64: 23.
  14. Bogoch E., Elliot-Gibson V., Beaton D.E., Jamal S.A., Josse R.G., Murray T.M. Effective Initiation of Osteoporosis Diagnosis and Treatment in Fragility Fracture Patients in an Orthopaedic Environment. J Bone Joint Surg Am. 2006; 88: 25-34.
  15. Maetzel A., Sander B., Elliot-Gibson V., Beaton D.E., Bogoch E.R. Targeting fragility fractures in an orthopaedic treatment unit: Cost effectiveness of a dedicated coordinator. J Bone Miner Res. 2004;19 (Suppl 1):S319.

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