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Orthopedic surgeons should embrace the treatment of osteoporosis
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Osteoporosis is the progressive loss of bone mass and density. The World Health Organization defines osteoporosis as a bone mineral density of 2.5 standard deviations or more below the mean peak bone mass for average of young, healthy adults as measured by dual-energy X-ray absorptiometry. Primary type 1 osteoporosis, the most common type, occurs in women after menopause.
The term “established osteoporosis” includes the history of a fragility fracture. A fragility fracture is defined as a fracture that occurs as result of low-energy trauma, such as falling from a standing position. These fractures most commonly occur in the vertebral body, proximal femur or distal radius. More than 2 million fragility fractures occur each year in the United States, and 50% of women and 25% of men will have a fragility fracture during their lifetime. When we consider the aging population, it is estimated that the number of fragility fractures will exceed 3 million fractures per year by 2020. The risk of fragility fractures can be reduced by making changes to lifestyle, including diet and exercise, and increasing efforts to reduce the risk of falling, as well as adding medications, most commonly bisphosphonates. All orthopedic surgeons are affected by these events, either personally or professionally.
Anthony A. Romeo
Fractures of the hip are particularly concerning. The risk of death within 1 year of a hip fracture has been reported to be as high as 25% in women and 30% in men. This risk has not changed despite advances in the management of hip fractures, including more rapid surgical treatment with sophisticated internal fixation devices. Patient health during hospitalization is typically best upon admission and may deteriorate quickly due to immobilization and nonsurgical treatment. A strong effort is being made to treat hip fractures within the first day of injury, followed by early mobilization and return to normal daily behavior.
Rapid, effective treatment
Most orthopedic surgeons fail to recognize the importance of their roles in patient education before fragility fractures occur in patients with osteoporosis. Not only do we need to lead the effort in rapid and effective treatment because it directly impacts clinical practice, but we also need to be proactively involved in the efforts to prevent fragility fractures. Patient education is key to prevent a patient’s downward spiral after a fragility fracture, which can lead to immobilization, metabolism changes, development or exacerbation of underlying medical conditions, life-threatening illnesses and death. The failure to become involved in the osteoporosis care after we assume the role of treating physician for the fracture is concerning, especially when these patients have twice the risk of another fracture compared to patients without fragility fractures.
Some orthopedic surgeons perceive their role as just fracture management. Little to no effort is made to discuss the management of osteoporosis either before a fragility fracture or after fracture treatment is completed. This contributes to the fact that only one of five patients with osteoporosis receives proper treatment. If we are going to “own the bone,” then we, as a professional society, need to better recognize patients who are at risk for osteoporosis and fragility fractures.
This call to action has been heard from many leaders in orthopedics without successful adoption in most clinical practices due to barriers that resist change. Numerous randomized controlled studies have shown that education of the surgeon results in a higher level of osteoporosis detection and treatment. However, the temporal relationships of these studies during the past decade suggests that local intervention has been successful, but the success has not translated to wide acceptance of responsibility. Published studies have shown that typically no more than one of five orthopedic surgeons is involved in osteoporosis care. This is disappointing when we are called on to treat patients with fragility fractures — the front line of the sentinel event of osteoporosis.
Role of the orthopedic surgeon
Understanding the role of the orthopedic surgeon in the management of osteoporosis begins in residency. In many residency programs, the focus has been on the basic science of osteoporosis and treatment of fractures, but not on the implementation of a comprehensive program of osteoporosis management, including fragility fractures. As numerous studies have demonstrated, if an education program is instituted for orthopedic surgeons, then the percentage of patients appropriated to treat osteoporosis more than doubles. If the treatment plans are included as part of orthopedic training programs with strong leadership and mentorship used in the implementation, then it is likely this practice would continue an orthopedic surgeons’ careers.
Own the Bone is a program organized by the American Orthopaedic Association. This web-based program provides tools to help institutions establish a fracture liaison service that promotes fragility fracture prevention measures and the evaluation and treatment of patients for osteoporosis. The program is typically implemented with a care coordinator, but needs participation and involvement from orthopedic surgeons who are responsible for fracture care. Own the Bone and other local efforts are helpful to establish our role as the point-of-service contact for all bone-related issues, including osteoporosis. Furthermore, these types of programs demonstrate our leadership role in the management and prevention of critical public health issues that require a multidisciplinary approach to be most effective.
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Disclosures: Romeo receives royalties, is on the speakers bureau and a consultant for Arthrex Inc.; does contracted research for Arthrex Inc. and DJO Surgical; receives institutional grants from AANA and MLB; and receives institutional research support from Arthrex Inc., Ossur, Smith & Nephew, ConMed Linvatec, Athletico and Miomed.