Fragility fractures: Taking control of management, follow-up and assessment

The National Osteoporosis Foundation estimates 54 million Americans have low bone density or osteoporosis, with 50% of women and 25% of men older than 50 years expected to have an osteoporosis-related fragility fracture.

“There are between 1.5 million and 2 million fragility fractures in the United States, about 300,000 hip fractures and about 750,000 vertebral fractures that occur every year,” Susan V. Bukata, MD, told Orthopedics Today.

However, according to Laura L. Tosi, MD, the rate of hip fractures has been declining since the mid-1990s, which may be due to people taking better care of themselves.

“Prior to the mid-1990s, hip fracture rates were going steadily upward. Since the mid-1990s, they have been going down and we do not understand why that is,” Tosi said. “We are seeing a phenomenal change in the physiologic well-being of our citizenry. They are exercising more and they have better nutrition. People, particularly in the United States, are smoking less, drinking less and wearing their seat belts.”

Image: Kerry Hoffmann, UCLA Orthopedics

However, the statistics are not as clear on osteoporotic vertebral fractures, which, according to Steven D. Glassman, MD, may be diagnosed if patients are having persistent pain.

“A high percentage of older osteoporotic patients, if you X-ray them, have compression fractures,” Glassman said. “The people who get to an orthopedist are the ones who have severe pain or persistent pain after their fracture.”

Overall, Bukata noted post-fracture management of fragility fractures is important to help patients avoid another fracture.

“If you get a fracture, it can dramatically change your independence and function,” Bukata said. “Once you have had a fracture, you are much more likely to fracture again. If you have ever had a fragility fracture, you need to be on treatment or there is a high risk you are going to fracture again.”

Post-fracture management

When it comes to post-fracture management, both the patient and the physician are responsible in keeping up with the variables that go into medical management.

“Part of the responsibility lies with patients to seek additional care or follow the recommendation of the provider after a fragility fracture,” Asif M. Ilyas, MD, told Orthopedics Today. “The other part is the physician’s end, we have to have some kind of infrastructure to manage not only the fracture acutely, but also the post-fracture management, including the osteoporosis evaluation.”

However, most patients do not receive follow-up osteoporosis diagnosis and care, according to Bukata who noted 20% of patients who experienced fragility fractures for the hip received follow-up care.

“In spine, it is probably much lower because three-quarters of spine fractures never present clinically,” Bukata said.

According to Roy W. Sanders, MD, since older patients may live alone and may not be able to drive, it is difficult for older patients to receive the follow-up care they need after a fragility fracture.

“[Hip fracture patients] cannot walk, so they get sent to the emergency room diagnosed as having hip fracture — either get it fixed or get it replaced — and then they have trouble getting back to the doctor, so they do not get managed well,” Sanders said.

Tosi also noted hip fracture patients tend to go to nursing homes or other rehabilitation facilities to receive the rest of their care instead of being followed up by their surgeon.

Patients who experience a vertebral compression fracture with no adverse effects to the alignment of the spine may heal without having to see an orthopedist or spine doctor, according to Glassman. If there is a significant amount of kyphosis and malalignment, patients will experience persistent pain and will be more likely to go for follow-up, he added.

“It is often a dilemma because they can be symptomatic and yet the treatments, once they have these deformities, are difficult,” Glassman said. “These patients have problems in terms of follow-up because they are older, are sicker and it is hard for them to get to the doctor sometimes and they have multiple other medical problems that take up their time. But the good piece is, most get better if you wait them out.”

Patients also may enter what Bukata calls the “sea of denial” in which patients begin to deny they have osteoporosis once their fracture begins to heal.

“Eventually, the patient is saying osteoporosis is an old person disease. The patient fell hard, and after one or two incidences like that, they will not engage. They will not go to their appointments necessarily for the follow-up. They do not consider it a concern for them, and they do not realize they have osteoporosis,” Bukata said.

Fall prevention programs

When it comes to fragility fractures, 95% occur because of a fall, Bukata said. Following a fall, patients may be offered fall prevention strategies during inpatient stay and rehabilitation to help prevent further fractures.

“[Fall prevention] involves therapy, both cognitive-behavioral and physical therapy, to improve an individual’s gait, function and strength to avoid falling and, if one were to fall, to avoid a fracture,” Ilyas said.

According to Bukata, fall prevention should start in the home with removal of objects patients could trip over, including throw rugs and cords. Grip bars in the shower, next to the toilet and other areas should be installed to help prevent falls, Bukata noted. Tosi also noted physicians should perform a medication review to ensure patients are not being overmedicated.

“Many [older] patients end up taking three different bottles of the same medicine, so they are making themselves profoundly hypotensive,” Tosi said.

She added this could be due to loss of vision, and patients should undergo regular eye examinations, which could also help in fall prevention.

“Many of our older [patients] have not been to the eye doctor in a while, and so, the reason why they fell down is purely and simply because they could not see where they were going,” Tosi said.

Bukata noted patients need to learn how to carefully stand from either sitting or lying positions, as well as learn to use assistive devices to remain mobile.

“Once you have had a couple of fractures, a lot of times patients will swing themselves forward up and out of a chair, and then momentum will carry them forward,” Bukata said. “It is teaching them about strategies for getting in and out of bed, making sure you are not dizzy before you try to stand.”

Fall prevention programs also can help with an individual’s core strength and reflexes. According to Sanders, older individuals in retirement communities tend to perform more athletic exercises, allowing them to maintain better proprioception, stabilization and mobility, compared with older individuals who are not active.

“Fall prevention is complex, but simple in that it involves a lot of different things. There are simple, little things to sort of retrain people,” Bukata said. “Think about it in terms of a kid who is learning how to walk, how we help them as they are struggling through some of those early points with either things that help to hold them up or we make sure we baby-proof the house. A lot of it is a similar thought process.”

However, Bukata added, while all patients are educated on fall prevention strategies, most patients never attend a fall prevention program after being released from the hospital.

“A sad reality is that so many of our patients are frail or have Alzheimer’s [disease] or have such severe medical problems that there is no opportunity to get them into a fall prevention program,” Tosi said. “I certainly believe in it for everybody, but it is hard to do.”

Surgery and technology

Ilyas noted that during the last 15 years intramedullary fixation has increased in utilization relative to plate and screw fixation for the treatment of patients with an intertrochanteric fractures, while total hip arthroplasty is being used more often for patients with femoral neck fractures. The positive outcomes that have come with total hip arthroplasty have helped usher this trend, according to Sanders.

“More [surgeons] are willing [to perform] total hip in [patients] with displaced femoral neck fractures than they have been in the past because femoral neck fractures that are treated with a standard technique of three, cannulated percutaneous screws often fail and those people then need a secondary operation,” Sanders said. “If you do a hemi-arthroplasty or a total hip as indicated for an unstable displaced fracture, [patients] tend to mobilize quicker, have less pain and are able to get out of bed sooner and out of the hospital sooner.”

Glassman noted since patients with vertebral fractures have poor bone, treatment with spine surgery may not be beneficial to the patient.

“Most often there is not great surgical treatment for kyphosis related to osteoporotic vertebral fractures because those patients have poor bone, which is why they broke in the first place; and because the operations to realign the spine are big operations and these tend to be old people who are not that healthy,” he said.

Patients who experience or who may be at risk for fragility fractures can have their bone mineral density checked through a DXA scanner. When the National Osteoporosis Foundation released The Clinician’s Guide to Prevention and Treatment of Osteoporosis in January 2010, it was noted use of a DXA scanner could establish or confirm a diagnosis of osteoporosis of the hip and spine, as well as predict future fracture risk and help monitor women aged 65 years and older and men aged 70 years and older by performing serial assessments.

“The challenge with the DXA is that because the cost it is not included in the [diagnosis-related group] DRG for fracture care, it cannot be done while the patient is in hospital,” Tosi said.

Sanders also noted a decline in reimbursement for using DXA scanners has been linked with decreased use of the technology.

“The reality is there was the Bone and Joint Decade 2000-2010 that the American Academy of Orthopaedic Surgeons promoted, and there was this big push for osteoporosis diagnosis and treatment, and so our patients got a DXA scans and treatment,” Sanders said. “Then the government, for some reason, decided it was not cost-effective, so they reduced the reimbursement for it, which made it difficult for independent orthopedists to do much other than prescribe tests, which the patient did not always obtain.”

Another technology that can help guide physicians to a pathway of care for patients with osteoporosis are electronic medical records, according to Bukata.

“Where we are using technology [is] with electronic medical records becoming much more prevalent. The record helps flag the profiles for the physicians to remind them [this] patient needs osteoporosis care based on the type of fracture they had,” Bukata said. “[Electronic medical records are] helping in a lot of places that now have these fracture liaison services with these geriatric fracture care algorithms. A red flag comes up when you log into the patient’s medical records, and it gives you a pathway to care.”

Pharmacologic management

From a pharmacologic perspective, there are several medications that can help reduce the risk of osteoporosis in older patients.

“The medications that are out there are terrific and are not perfect, that is for sure, but have the potential to, depending on where the fracture is, reduce the risk of future fracture by 35% to 50%,” Tosi said.

It is suggested that patients who are at high risk for or who experienced a fragility fracture take calcium and vitamin D, which can help slow the onset of osteoporosis and revitalize bone, according to Bukata.

“It is important for people to understand that calcium and vitamin D alone will not prevent fractures,” Bukata said. “You need sufficient calcium and vitamin D to maintain the skeleton you have. If you do not have enough calcium and vitamin D, you will lose bone or you will not have all the tool you need to maintain the bone you have.”

Vitamin D is also important for fall prevention, she added, with several recent studies showing patients older than 70 years with low vitamin D levels were more prone to falls. According to Ilyas, bisphosphonates are the most common pharmacologic agents for the medical management of osteoporosis and can be provided as a pill or intravenously (IV).

“[Bisphosphonates] are excellent at fracture prevention, at least 50% for the pills in terms of spine fracture prevention and about 25% for hip fracture prevention,” Bukata said. “For the IV, that number is about 75% for spine fracture reduction and 40% reduction in risk for the hip.”

However, Tosi noted there are adverse events to bisphosphonates.

“Bisphosphonates have been hard to take, and there have been all kinds of different modifications: taking them once a week or taking them once a month, but they are always going to be hard to take,” Tosi said. “Once you have taken them, usually the side effects are minimal.”

One adverse event is acute phase reaction, which can include an inflammatory risk and flu-like symptoms, such as muscle aches, hand aches and a low-grade fever, according to Bukata.

“The more concentrated the dose you give for someone who has never had these medicines before, the more likely you are to have the reaction and the more intense the reaction can be in the days after the first few doses,” Bukata said. “[Patients] can lessen the symptoms they get by taking acetaminophen on the day they start the medication.”

Although Ilyas noted osteonecrosis of the jaw and atypical femur fractures are two of the more severe complications that may occur while taking bisphosphonates, research has shown low risks for either complication.

“[The risk for] atypical femur fracture, if [the patient has] taken the bisphosphonates for a long time, is 0.16 per 1,000 and osteonecrosis of the jaw is 0.01 per 1,000,” Bukata said. “So the risk of dying from complications from a fracture is thousands of folds greater than your risk of getting these rare side effects.”

Besides the adverse events associated with bisphosphonates, Glassman noted medications for osteoporosis may not be covered by insurance.

“The issue is usually [medications for osteoporosis] are expensive and a lot of times patients already have the simple [medications]. When you suggest the more advanced medications, patients cannot afford them or they are not covered by their insurance,” Glassman said. – by Casey Tingle

• References:
• National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. Available at: http://nof.org/files/nof/public/content/file/344/upload/159.pdf. Accessed July 30, 2015.
• National Osteoporosis Foundation. Debunking the myths. Available at: http://nof.org/OPmyths. Accessed July 30, 2015.

• For more information:
• Susan V. Bukata, MD, can be reached at the University of California, Los Angeles, 1250 16th St., Suite 2100, Santa Monica, CA 90404; email: sbukata@mednet.ucla.edu.
• Steven D. Glassman, MD, can be reached at Norton Leatherman Spine Center, 210 E. Gray St., #900, Louisville, KY 40202; email: sdg12345@aol.com.
• Asif M. Ilyas, MD, can be reached at The Rothman Institute at Thomas Jefferson University, 925 Chestnut St., #5, Philadelphia, PA 191407; email: asif.ilyas@rothmaninstitute.com.
• Roy W. Sanders, MD, can be reached at the Florida Orthopaedic Institute, 13020 Telecom Parkway N., Temple Terrace, FL 33637; email: ots1@aol.com.
• Laura L. Tosi, MD, can be reached at Children’s National Health System, 111 Michigan Ave. NW, Washington, DC 20010; email: kgraves@childrensnational.org.

Disclosures: Bukata is a consultant for Amgen, Merck and Eli Lilly, and is on the speakers bureau for Eli Lilly. Glassman is the past president of the Scoliosis Research Society and received royalties from Medtronic. Sanders is a design surgeon and consultant for Smith & Nephew. Tosi serves on the Steering Committee and the Medical Advisory Board of the American Orthopaedic Association’s Own the Bone program.

Should orthopedic surgeons be involved in the evaluation and treatment of osteoporosis post fracture?

Patient referral

Orthopedic surgeons are in an ideal position to diagnose fragility fractures with low-energy mechanisms. Fragility fractures occurring in late middle age and older adults should prompt the concern for a diagnosis of osteoporosis. Secondary osteoporosis frequently results from vitamin D deficiency and is readily diagnosed with a serum calcium and 25 (OH) vitamin D level. It is also readily treated by the orthopedic surgeon with administration of an oral vitamin D replacement.

A suspicion of osteoporosis should prompt the surgeon to inform the patient of the likely diagnosis of osteoporosis. In such cases, a DXA scan should be ordered for documentation if it has not been recently performed. The DXA scan is generally simple to interpret and explain to the patient. The fracture risk assessment tool can also be used to show the patient their future risk of fracture.

At this point, the surgeon would have the option of initiating treatment for the osteoporosis or to refer the patient to a colleague who is knowledgeable in the treatment of osteoporosis. Although there are many perceived barriers to performing the steps mentioned above, it is essential that the orthopedic surgeon diagnose and initiate treatment or refer the patient for treatment around the time of the fragility fracture. The American Orthopaedic Association’s Own the Bone program, which has been designed for orthopedic surgeons, is available to help with this process. This program includes patient-friendly literature to explain the diagnosis and treatment of osteoporosis and lays out a program for osteoporosis follow-up. It is low-cost and high value to surgeons and patients.

Orthopedic surgeons are in an ideal position to recognize a fracture to be a fragility fracture, inform their patients of the correct diagnosis and to place the patient on a pathway to prevent future fractures.

Stephen L. Kates, MD, is the Hansjörg Wyss professor of Orthopaedic Surgery at the University of Rochester.
Disclosure: Kates reports he is a committee member of the AOA Own the Bone program, an editor of Geriatric Orthopaedic Surgery and Rehabilitation and a consultant for Surgical Excellence.

Opposing trend

The answer to the question is yes, but the trend appears to be the opposite. From 2000 to 2009, there were declining rates of osteoporosis management following fragility fracture. Skedros and colleagues noted the majority of orthopedic surgeons surveyed thought they should expand their role in the medical management of patients with osteoporosis.

The concept of orthopedic surgeons “owning the bone” and being holistic providers of musculoskeletal care rather than just surgeons makes sense. Like cardiologists or heart surgeons who would be remiss in not testing for high cholesterol while caring for patients with heart disease, orthopedic surgeons might be considered remiss if they did not check fracture patients older than 50 years for osteoporosis.

Mandating that all orthopedic surgeons be involved with osteoporosis is probably not practical. Providing treatment of a geriatric polytrauma patient flown in to a level 1 trauma center from an outlying hospital is dramatically different than seeing an established, long-standing senior patient with a Colles’ fracture in a private office setting. Whether the orthopedic surgeon is employed by the hospital or is a private practice physician in a multispecialty group also may change the financial and logistical calculus. Lastly, if an orthopedic surgeon is diagnosing and managing osteoporosis, then the opportunity cost of not being in the OR has to be considered.

In a recent conversation about osteoporosis, a colleague said he thought of the role of the orthopedic surgeon as more of an “interested advisor” than as a “manager.” A team of providers is often optimal when it comes to the treatment of patients with osteoporosis. For now, the answer to the question of whether orthopedic surgeons should be involved with the evaluation and treatment of osteoporosis remains, “Yes, but ... ”

• References:
• Balasubramanian A, et al. J Bone Joint Surg Am. 2014;doi:10.2106/JBJS.L.01781.
• Bunta AD. Osteoporos Int. 2011;doi:1007/s00198-011-1704-0.
• Skedros JG, et al. J Bone Joint Surg Am. 2006;doi:10.2106/JBJS.D.02949
• Tosi LL, et al. J Bone Joint Surg Am. 2008;doi:10.2106/JBJS.G.00682.

Craig S. Roberts, MD, MBA, is the K. Armand Fischer Professor and Chair at the University of Louisville School of Medicine.
Disclosure: Roberts reports no relevant financial disclosures.