Managing chronic osteoporosis is the key to preventing serious fragility fractures

Presence of a fracture is the best indicator of later fractures. Patients need more calcium, vitamin D.

Orthopedists are not doing enough to manage osteoporosis and prevent fragility fractures, according to a noted osteoporosis researcher. DEXA scans, calcium and vitamin D supplements, bisphosphonates and other medications are available to help prevent those fractures but are under-used.

Most patients with fragility fractures are not treated for osteoporosis, Susan B. Broy, MD, said at the 119th Annual Meeting of the American Orthopaedic Association. Broy is a rheumatologist who maintains a clinical and research practice at the Center for Arthritis & Osteoporosis at Illinois Bone & Joint Institute, Morton Grove, Ill.

Fragility fractures, commonly affecting the hip and spine, stem from minimal trauma, such as a fall from standing height, or from no detectable mishap, and they are closely linked to osteoporosis and are best predictor of later fractures, Broy said.

“If you look at patients who have high bone density, the relative risk of a future fracture is 1,” she said. “Low bone density increases the relative risk 7 times. However, look what happens if you just have one fracture and yet you have high bone density. The presence of one fracture is 10 times the risk of having a subsequent fracture. Fracture predicts fracture better than bone density.”

“Bone attack”

Broy, the principal investigator in 25 osteoporosis and 2 rheumatology studies, called osteoporosis a chronic illness that, like cardiac disease, is manageable.

“We manage myocardial infarctions and call them heart attacks, strokes, brain attacks,” she said. “We need to consider an osteoporotic fracture as a bone attack.”

She noted how cardiologists use beta blockers, aspirin and cholesterol-reducing medications to manage heart disease and reduce mortality associated with heart attacks. Similarly, orthopedists can use calcium, vitamin D and medications to prevent future fractures after fragility fractures.

Prompt intervention is key. Broy tried to set up a fracture protocol but encountered multiple barriers, including surgeons understandable reluctance to evaluate and manage the underlying medical condition.

“This is one of the biggest problems in managing these patients,” she said. “We need to make a connection between the surgeon who manages the actual fracture and the person who's going to manage the long-term disease. We have to make that connection.”

Broy also blamed studies that downplay the value of calcium. “Most trials with calcium are very poorly controlled,” she said. “These aren’t pharmaceutical trials that are very carefully controlled, where we know exactly what’s happened with the patient. It’s very difficult to determine how much calcium supplement he’s getting.”

Other studies clearly show lacking treatment. For example, in a study on osteoporosis treatment after hip fracture, Broy found, at two-year follow-up, only 12% of patients receiving DXA scans, 27% getting calcium and/or vitamin D and 26% taking prescription medications. Fewer than 8% of patients were using bisphosphonates, she said.

A trial of in-patients at Massachusetts General Hospital showed that 57% of the patients were vitamin D deficient. Vitamin D deficiency is an “epidemic” that may be eradicated, Broy said.

She cited a randomized, controlled trial for vitamin D that showed 700 to 800 units of the vitamin decreasing hip fractures by 26%.

The Recommended Daily Allowance for vitamin D will likely be increased, Broy said.

Editors note: This article is taken from the August 2006 issue of Orthopedics Today, page 58.

For more information:
Broy S. Treating osteoporosis and fragility fractures: the time is now. Presented at the 119th Annual Meeting of the American Orthopaedic Association. June 23-25, 2006. San Antonio.