Importance of underlying bone disease

Issue: September 2015

In regard to your article “An 82-year-old man with right hip trauma” featured in Orthopedics Today, June 2015, by Michael R. Conti Mica, MD; and Mitchell Bernstein, MD, FRCSC, it is unfortunate the authors failed to mention this patient did not actually have “hip trauma,” but sustained this injury from a standing-level fall. By definition, this was a fragility fracture and makes the patient’s accurate diagnosis severe established osteoporosis with pathologic fracture.

The authors did a great job fixing the fracture, but should have at least mentioned his underlying bone disease. This hip fracture puts the patient at high risk of further fragility fractures, with associated increased morbidity and mortality. This patient’s osteoporosis warrants appropriate pharmacologic treatment, in addition to simply fixing the fracture. Improved understanding of the underlying bone disease by treating surgeons should trigger accurate diagnosis, appropriate medical treatment and hopefully improved outcomes via a team approach to prevention.

Margaret Baker, MD, FACS, FAAOS
The Center for Bone & Joint Surgery
Port Angeles, Wash.

Disclosure: Baker reports she has done clinical research and is on the speakers bureau for Amgen, is on the speakers bureau for Eli Lily
and is the on the American Academy of Orthopaedic Surgeons (AAOS) Women’s Health Issues Advisory Board.

The authors respond

Dr. Baker brings up a valid point about the patient’s underlying diagnosis and the reason for such a pattern in an otherwise low-energy trauma. There is no dispute this fracture is a direct result of the pathological changes associated with osteoporosis. While our focus in the initial article was directed toward the technical challenges associated with approaching this pattern type, the treating orthopedist must consider this aspect of the patient’s case.

Of the nearly 2 million osteoporosis-related fractures seen annually in the United States, approximately 14% affect the hip. A critical risk factor for osteoporosis-related fracture is a history of previous osteoporosis-related fracture, yet fewer than 15% of patients with osteoporosis are treated. There is a substantial economic toll associated with hip fractures; they accounted for nearly 72% ($12 billion) of all fracture costs in 2005.

At our institution, we routinely screen for osteopenia and osteoporosis. Every patient, upon orthopedic admission, is screened automatically by our electronic medical record for the following criteria: women older than 65 years, men older than 70 years, history of or current low-energy fracture, history of or current fragility fractures, history of hypogonadism, and history of or current steroid use. All operative fractures are screened for low serum vitamin D. If the patient has any of the above risk factors, they undergo further testing, which includes complete blood cell count, renal function, hepatic function, serum calcium and 25 (OH) vitamin D levels. These patients are treated with an aggressive regimen of calcium citrate and vitamin D during a 3-month period. They are re-evaluated by their primary care provider following treatment.

With the increase in the U.S. aging population, osteoporosis and related fractures will become more prevalent, and so it is imperative the medical community takes a proactive role in the treatment of osteoporosis and the prevention of fragility fractures.

Michael R. Conti Mica, MD; and Mitchell Bernstein, MD, FRCSC
Loyola University Medical Center
Maywood, Ill.

Disclosures: Conti Mica and Bernstein report no relevant financial disclosures.

References:
Burge R, et al. J Bone Miner Res. 2007;doi:10.1359/jbmr.061113.
Edwards BJ, et al. J Bone Joint Surg Am. 2011;doi:10.2106/JBJS.I.00540.

Editor’s note

The guidelines from the AAOS with regards to hip fractures can be found at: www.aaos.org/research/guidelines/guidelinehipfracture.asp. These incorporate osteoporosis screening and treatment with calcium and vitamin D. In addition, many rheumatologists and internists also will treat with bisphosphates, denosumab or teriparatide in patients with osteoporosis and a fragility fracture. The risk factors included are important, but I would also include family history, smoking, rheumatoid arthritis, alcohol consumption and BMI, which are included in the FRAX risk factor calculator for future hip fracture.

Anthony A. Romeo, MD
Chief Medical Editor