Prevention of Secondary Osteoporotic Fractures -- Why Are We Ignoring the Evidence?

All orthopaedic surgeons are aware of the tremendous impact that osteoporosis has on our patients, and the public health implications of this are staggering. It has been suggested that the cost of treating the upcoming epidemic of femoral neck fractures alone may overwhelm the healthcare system.

Orthopaedic surgeons are in a position to identify many of these patients when they first present with a "fragility" fracture. For all of these patients, medical intervention is indicated. Many orthopaedic organizations, including the American Academy of Orthopaedic Surgeons, have made the identification of osteoporosis and the appropriate referral of patients for treatment a major initiative.

In this study, the authors (from Derriford Hospital, Plymouth, United Kingdom) looked at the first 100 femoral neck fractures operated upon beginning January 1, 1998. All patient notes, drug charts, and discharge summaries were reviewed 3 years later. The authors noted whether these patients suffered any further fractures associated with osteoporosis, prior to or since their hip fracture, and determined what advice and treatment had been documented in the records (if any).

The authors found that for almost all of the patients, the diagnosis of osteoporosis was essentially ignored, despite the well-known fact that such patients often present with further fractures. Only 3% of the patients were discharged on treatment for osteoporosis after their hip fracture. Twenty-three percent of the patients suffered later fragility fractures, and no further treatment was started in these patients despite refracture. Thus, a number of patients suffered 2 fractures associated with osteoporosis and still were not provided advice, referral, or simple, inexpensive therapies.

The authors concluded that orthopaedic surgeons are failing to initiate simple medical measures that not only improve the quality of life of their patients, but also would lessen the demands upon them to provide fracture care. The situation is likely very similar at many North American hospitals, and each of us should do everything that we can to ensure that these patients do not fall through the cracks of our disjointed healthcare system.