Treat the disease, not just the fracture

Orthopaedic surgeons frequently miss the opportunity to evaluate and treat osteoporosis.

Issue: Issue 4 2003

EFORT 2003 Helsinki [logo] HELSINKI — Whether it is a fracture of the hip, vertebrae, wrist, ankle or shoulder, all can be related to osteoporosis, according to a multinational group of orthopaedic surgeons at a symposium at the 5th Congress of the European Federation of National Associations of Orthopaedics and Traumatology, here.

“Since orthopaedic surgeons are often the first and only physicians to see fracture patients, we are in a unique position to identify untreated cases of osteoporosis,” said Prof. Olof Johnell of the International Osteoporosis Foundation.

In an international survey, however, conducted by the Bone and Joint Decade and the International Osteoporosis Foundation, a majority of orthopaedists reported that they are poorly trained to evaluate and treat osteoporosis. Most fracture patients treated by orthopaedic surgeons are not referred for a bone density test or given treatment.

“We believe that we have neglected our duty,” said W. Angus Wallace, FRCS, of Nottingham, England.

Expect a second fracture

Current data indicate that 50% of women and 30% of men will have an osteoporotic fracture in their lifetime. These fractures are associated with increased morbidity and mortality, with 50% of hip fractures causing long-term disabilities. A prior fracture is one of the strongest risk factors for a future fracture and will commonly occur with a year of the first vertebral fracture.

A majority of fracture patients are discharged without adequate evaluation for osteoporosis. Multinational data show that that up to 95% of fracture patients have not been evaluated. With the population aging worldwide, the number of hip fractures is expected to increase dramatically over the next few years.

Johnell, of Malmo, Sweden, cautioned that it is “important to act at the time of fracture. It is the responsibility of orthopaedic surgeons to investigate whether osteoporosis is the underlying cause of a fracture.

“Any patient who presents with a fragility fracture and osteoporosis should be treated,” he said.

National data

The survey of orthopedists in France, Germany, Italy, Spain, the United Kingdom and New Zealand yielded an overall response rate of about 25%. The majority of responders said they had received insufficient training or no training in osteoporosis. Most said they do not prescribe treatment for osteoporosis; if the condition is suspected, they refer the patient to a specialist or to a general practitioner.

In France, 77% said they would refer a patient with osteoporosis to a general practitioner or rheumatologist, according to Jean-Marc Feron, MD, PhD, of Paris. More than 60% of orthopaedists in that country said they lack sufficient training to treat the disease.

“It is our responsibility after a fracture repair to check that prevention measures and treatment have been initiated,” Feron said.

Robert Huber, MD, of Wittenberg, Germany, said that orthopaedists in his country reported that they may have insufficient training but the majority evaluate and treat patients with osteoporosis. This difference in Germany reflects the high number of orthopaedists in private practice and the split between orthopaedics and traumatology. Huber said that orthopaedists in his country should “cooperate with traumatologists to recombine fracture care and orthopaedic care.”

That level of confidence about treating osteoporosis was also reflected by Italian surgeons, who said they prescribe alendronate/risedronate to patients. In Spain, a majority reported insufficient training. Antonio Herrara, MD, of Madrid, said the Italian orthopaedic organization is recommending a prevention program for adults that include a balanced diet, physical activity and treatment of the disease.

In the United Kingdom, 55% said they would initiate diagnosis and treatment of osteoporosis. Goals for that country include development of new surgical and biological techniques for treating fractures, an emphasis on secondary prevention, and the creation of a fracture registry for monitoring the size of the problem.

“Insufficient priority is given to osteoporosis and the fractures it causes,” said Hamish Simpson, MD, of Edinburgh.

For your information:

Wallace A, Johnell O, Feron J-M, et al. Bone and Joint Decade symposium: Orthopaedic surgeons are missing the fracture opportunity — can we change this? Presented at the 6th Congress of the European Federation of National Associations of Orthopaedics and Traumatology. June 4-10, 2003. Helsinki.