Orthopaedic care teams can play an active role in evaluating and optimizing their patients’ bone health to help prevent primary and secondary fragility fractures and to improve postsurgical outcomes. In just about any orthopaedic scenario, helping patients optimize their bone health is an imperative for the delivery of quality care.
On Tuesday, September 11, 2018 at 8 pm EDT, the American Orthopaedic Association (AOA) and The Journal of Bone & Joint Surgery (JBJS) will host a complimentary one-hour webinar that will cover the basics of a bone-health assessment by orthopaedists.
- Christopher Shuhart, MD will discuss the fundamentals of bone-related laboratory workups and bone densitometry studies.
- Joe Lane, MD, FAOA will identify bone-health “red flags” in orthopaedic patients, including common nutritional deficiencies.
- Paul Anderson, MD, FAOA will cover recent advances in bone-density measurements.
Moderated by Douglas Lundy, MD, MBA, FAOA, orthopaedic trauma surgeon at Resurgens Orthopaedics, this webinar will include a 15-minute live Q&A session during which attendees can ask questions of the panelists.
Seats are limited so REGISTER NOW.
This basic science tip comes from Fred Nelson, MD, an orthopaedic surgeon in the Department of Orthopedics at Henry Ford Hospital and a clinical associate professor at Wayne State Medical School. Some of Dr. Nelson’s tips go out weekly to more than 3,000 members of the Orthopaedic Research Society (ORS), and all are distributed to more than 30 orthopaedic residency programs. Those not sent to the ORS are periodically reposted in OrthoBuzz with the permission of Dr. Nelson.
Over the decades, the meaning of the term “phenotype” has changed. In the past it was solely applied to inherited disorders and was based on physical appearance or clinical presentation. Similarly, the term “penetrance” was applied to the variations in phenotype severity relative to normal. Over time, it has been found that penetrance is usually a reflection of different mutations for the same gene at different parts of the allele, or a mutation in one of several specific genes that could contribute to a similar phenotype.
Now, both terms have been applied to a variety of genetic and environmental circumstances that may affect physical appearance and function. In osteoarthritis research, the term “phenotype” has increasingly been used to define physical, genetic, environmental, and other variables, both past and present.
The authors of a recent abstract use a modern application for the term phenotype to systematically review the literature for studies using knee characteristics relevant for phenotyping osteoarthritis (OA).1 A comprehensive search was performed limited to observational studies of individuals with symptomatic knee OA that identified phenotypes based on OA characteristics, and then the authors assessed phenotypic association with clinically important outcomes.
Based on their abstract, 34 of 2777 citations were included in a descriptive synthesis of the data. Clinical phenotypes were investigated most frequently, followed by laboratory, imaging, and etiologic phenotypes. Eight studies defined subgroups based on outcome trajectories (pain, function, and radiographic progression). Most studies used a single patient or disease characteristic to identify subgroups, while five included characteristics from multiple domains.
Evidence from multiple studies suggested that pain sensitization, psychological distress, radiographic severity, BMI, muscle strength, inflammation, and comorbidities are associated with clinically distinct phenotypes. Gender, obesity and other metabolic abnormalities, the pattern of cartilage damage, and inflammation may delineate distinct structural phenotypes. However, only a few of the 34 studies reviewed investigated the external validity of the chosen phenotypes or their prospective validity using longitudinal outcomes.
While the authors remarked on the heterogeneity of the data included in studies investigating knee OA phenotypes, they say that the phenotypic characteristics identified in their review could form a classification framework for future studies investigating OA phenotypes.
It should be noted that the FRAX score used to calculate fragility fracture risk could be considered a phenotypically based system, the validation of which is continuing.
- Deveza LA, Melo L, Yamato TP, Mills K, Ravi V, Hunter DJ. Knee osteoarthritis phenotypes and their relevance for outcomes: a systematic review. Osteoarthritis 2017 Aug 25. pii: S1063-4584(17)31156-1. doi: 10.1016/j.joca.2017.08.009. [Epub ahead of print].
Spring and Summer 2017 are busy seasons for Own the Bone, the American Orthopaedic Association’s national post-fracture, systems-based, multidisciplinary fragility fracture prevention initiative:
On Thursday, May 4, at 5:00pm CDT (6:00pm EDT) Paul A. Anderson, MD, FAOA, from the University of Wisconsin, and Karen Cummings, PA-C, from the University of Michigan, will discuss the components of a successful secondary fracture prevention program.
Join the National Association of Orthopaedic Nurses (NAON) and The American Orthopaedic Association for this full-day event on Friday, June 23. Attendees will receive a Fragility Fracture Symposium Certificate of Completion and continuing education credit.
Join Physician Assistants in Orthopaedic Surgery (PAOS) and Own the Bone for a full-day fragility fracture and bone health workshop on the first day of the PAOS Annual Conference, Monday, August 21, in Baltimore.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Brett A. Freedman, MD.
In the December 21, 2016 edition of the Journal of Bone & Joint Surgery, Bunta, et al. published an analysis of data from the Own the Bone quality improvement program collected between January 1, 2010 and March 31, 2015. Over this period of time, 125 sites prospectively collected detailed osteoporosis and bone health-related data points on men and women over the age of 50 who presented with a fragility fracture.
The Own the Bone initiative is more than a data registry; it’s a quality improvement program intended to provide a paradigm for increasing the diagnostic and therapeutic recognition (i.e. “response rate”) of the osteoporosis underlying fragility fractures among orthopaedic practices that treat these injuries. With more than 23,000 individual patients enrolled, and almost 10,000 follow-up records, this is the most robust dataset in existence on the topic.
This initiative has more than doubled the response rate among orthopaedic practices treating fragility fractures. The number of institutions implementing Own the Bone grew from 14 sites in 2005-6 to 177 in 2015. According to Bunta et al., 53% of patients enrolled in the Own the Bone quality Improvement program received bone mineral density testing and/or osteoporosis therapy following their fracture.
Own the Bone was a natural progression of rudimentary efforts that came about during the Bone and Joint Decade, and it marks a strategic effort on the part of the American Orthopedic Association to identify and treat the osteoporosis underlying fragility fractures. Multiple studies have demonstrated that only 1 out of every 4 to 5 patients who present with a fragility fracture will receive a clinical diagnosis of osteoporosis and/or active treatment to prevent secondary fractures related to osteoporosis. Ample Level-1 evidence demonstrates that the initiation of first-line agents like bisphosphonates, or second-line agents when indicated, can reduce the chance of a subsequent fragility fracture by at least 50%. We know these medicines work.
We also know that osteoporosis is a progressive phenomenon. Therefore, failing to respond to the osteoporosis underlying fragility fractures means we as a medical system fail to treat the root cause in these patients. The fracture is a symptom of an underlying disease that needs to be addressed or it will continue to produce recurrent fractures and progressive decline in overall health.
The members of the Own the Bone initiative must be commended for their admirable work. We as an orthopedic community need to attempt to incorporate lessons learned through the Own the Bone experience into our practice to ensure that we provide complete care to those with a fragility fracture. The report from Bunta et al. represents a large—but single—step forward on the journey toward universal recognition and treatment of the diminished bone quality underlying fragility fractures. I look forward to additional reports from this group detailing their continued success in raising the bar of understanding and intervention.
Brett A. Freedman, MD is an orthopaedic surgeon specializing in spine trauma and degenerative spinal diseases at the Mayo Clinic in Rochester, MN.
OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from Brett A. Freedman, MD, in response to a study published in JAMA about a new agent to prevent fractures in postmenopausal women with osteoporosis.
The August 16, 2016 issue of JAMA published the results of the ACTIVE (Abaloparatide Comparator Trial In Vertebral Endpoints) trial. This 28-site randomized trial allocated postmenopausal women with low bone mineral density (BMD) and/or a prior fragility fracture into one of three arms: abaloparatide (80 µg subcutaneously, daily ) vs. daily placebo injection vs. teriparatide (20 µg subcutaneously, daily). The primary end point was new vertebral fracture over the 18-month trial.
As expected, both anabolic agents significantly outperformed placebo, with incident vertebral fractures occurring in only 4 subjects in the abaloparatide arm (0.6%) and 6 in the teriparatide arm (0.8%), while there were 30 in the placebo arm (4.2%). Although the study was not powered to evaluate differences between the two anabolic agents, the results suggest that abaloparatide and teriparatide performed essentially the same over the 18-month period.
In an accompanying commentary,1 Cappola and Shoback note that institutional review boards (IRBs) approved a prospective clinical trial protocol in which patients with known osteoporosis and/or a prior fragility fracture were allowed to be randomized to a non-treatment arm for 18 months. Subjects whose BMD dropped more than 7% from baseline and those who experienced an incident fracture during the trial “were offered an option to discontinue and receive alternative treatment,” but in some sense IRB approval of this protocol implicitly acknowledged that osteoporosis is undertreated.
Turning back to the study itself, I noted with interest that subjects who had regularly used bisphosphonates in the last 5 years or denosumab in the last year were excluded. So, none of the 2463 subjects who were randomized had received any active treatment for osteoporosis in the 1 to 5 years prior to enrollment, despite the fact that the average T-score in the lumbar spine (-2.9 for all 3 arms) was in the osteoporotic range and that almost one-third of subjects had had at least one prior fragility fracture.
This is a sad commentary on “our” (meaning all providers involved in bone health) continued inability to diagnose and treat osteoporosis effectively. Despite the “National Bone and Joint Health Decade” (2002-2011) and our continued attempts to “Own the Bone,” we have made little progress in recognizing and treating the osteoporosis underlying the fragility fractures that we so frequently treat. Colleagues of mine and I published that only 38% of patients in 2002 with clinically diagnosed vertebral compression fragility fractures were receiving active treatment for osteoporosis.2 Over the ensuing decade, Solomon et al. showed that that figure actually decreased to 20%.3
This JAMA study provides empiric Level-I support for the efficacy of another anabolic agent to treat osteoporosis. Cost, subcutaneous delivery, and osteosarcoma concerns have limited the only FDA-approved anabolic osteoporosis medication, teriparatide, to second-line status, behind bisphosphonates. If and when approved, abaloparatide will probably bump up against the same limitations. Still, the parathyroid hormone receptor agonists are particularly pertinent to orthopaedic surgeons, because they are the most effective secondary fracture prevention agents—and the only ones that show meaningful improvement in bone mineral density. This bone-building property has also led to progressive acceptance of teriparatide as an important perioperative adjunct for instrumented spinal fusion surgery in patients with known osteoporosis.
However, as has been repeatedly shown, parathyroid receptor agonists only work when they are prescribed, and they are only prescribed when osteoporosis is diagnosed.2,3 Patients with incident clinical fragility fractures need to be effectively educated about osteoporosis, its treatment, and the impact of failing to treat it. Orthopaedic surgeons need to continue to set the signal flares and advocate for our patients to receive effective treatment for all their chronic musculoskeletal illnesses, not the least of which is osteoporosis.
- Cappola AR, Shoback DM. Osteoporosis Therapy in Postmenopausal Women With High Risk of Fracture. JAMA. 2016 Aug 16;316(7):715-6.
- Freedman BA, Potter BK, Nesti LJ, Giuliani JR, Hampton C, Kuklo TR. Osteoporosis and vertebral compression fractures-continued missed opportunities.Spine J. 2008 Sep-Oct;8(5):756-62.
- Solomon DH, Johnston SS, Boytsov NN, McMorrow D, Lane JM, Krohn KD. Osteoporosis medication use after hip fracture in U.S. patients between 2002 and 2011. J Bone Miner Res. 2014 Sep;29(9):1929-37.
In the July 20, 2016 issue of The Journal, Louer et al. detail the association between distal radial fractures and poor balance. We have long understood that inherently poor balance was a major contributor to fall risk, and now we have more hard evidence thanks to this research team.
In this case-control evaluation comparing 23 patients ≥65 years of age who had sustained a low-energy distal radial fracture with 23 age- and sex-matched control patients, the authors found that those in the fracture cohort:
- Demonstrated poorer balance based on dynamic motion analysis (DMA) scores
- Were able to perform the balance test for significantly less time
- Rated themselves as having worse mobility
Among both cohorts, only 3 patients had completed an evaluation of or treatment for balance deficiencies.
The orthopaedic community has begun to pay attention to fragility fracture risk reduction through programs such as the AOA’s “Own the Bone” initiative, which focuses on identifying patients with fragility fracture and applying evidence-based treatment and prevention guidelines. Fragility fracture programs led by nurse practitioners or physician assistants have gained traction in many centers and have been proven effective in identifying at-risk patients and providing appropriate follow-up care.
Any intervention for patients presenting with the first fragility fracture must include assessing fall risk. Home evaluations addressing hazards such as loose carpets, poor lighting, and poorly designed stairway transitions are critical. We also know that activities such as tai chi, low-impact aerobics, and yoga, when regularly practiced, can help preserve balance. Now, developing programs that actually improve postural balance must be part of our collective research agenda as we attempt to address the major public health issue of fall-related fragility fractures.
Marc Swiontkowski, MD
On Thursday, May 26, 2016, at 6:00 pm EST, the Own the Bone initiative will offer a webinar titled “Assessing Risk factors to Determine Osteoporosis Treatment.”
John Schousboe, MD, PhD, director of the Osteoporosis Center at Park Nicollet Clinic in Minnesota, will discuss how to identify the factors that make patients more susceptible to fragility fractures. Learn about the tools available to help you evaluate patient fracture risk, including the most well known, FRAX, and two additional validated tools.
The American Orthopaedic Association (AOA) developed Own the Bone as a quality improvement program to address the osteoporosis treatment gap and prevent subsequent fragility fractures.
On Thursday, December 10, 2015, from 6:00 to 6:30pm EDT, the Own the Bone initiative will offer a free webinar titled “Vitamin D in Chaos: A Common Sense Approach for Orthopaedics.”
Neil C. Binkley, MD, from the University of Wisconsin will review the physiology of vitamin D, current approaches to 25(OH)D testing, and recommendations for treatment of those whose levels are low. Defining “low” vitamin D status remains extremely controversial, but many fracture patients have vitamin D inadequacy that may contribute to low bone mass and fragility fracture risk.
The American Orthopaedic Association (AOA) developed Own the Bone as a quality improvement program to address the osteoporosis treatment gap and prevent subsequent fragility fractures.
In last month’s Editor’s Choice, JBJS Editor in Chief Vern Tolo. MD, called for more concerted efforts among orthopaedists to link care of fragility fractures to evaluation and treatment of osteoporosis. Now, JBJS Reviews Editor in Chief Thomas Einhorn, MD, echoes Dr. Tolo’s message in reference to the May 2 JBJS Reviews article on managing patients with osteoporotic distal radial fractures:
According to Dr. Einhorn, “This must-read article provides a concise summary of how to advance the diagnosis and treatment of osteoporosis and fragility fractures. The authors explain the latest evidence about the ‘three main pillars’ of treatment of distal radial fractures in people with osteoporosis: primary prevention, acute management, and reduction of risk of future fractures. The strides made among US orthopaedists to recognize and manage osteoporosis with programs such as the American Orthopaedic Association’s ‘Own the Bone’ initiative have been commendable. However, on a global scale, our specialty is woefully behind in taking an aggressive approach toward prevention and treatment of osteoporosis.”
The article “Declining Rates of Osteoporosis Management Following Fragility Fractures in the U.S., 2000 through 2009” by Balasubramanian, et al. in the April 2, 2014 JBJS is a bit discouraging, but it will hopefully serve as a wake-up call for orthopaedic surgeons to re-engage with our patients to diagnose and treat previously undetected osteoporosis.
Fragility fractures–which primarily affect the vertebrae, hip, distal radius, or proximal humerus–are often the initial indication of osteoporosis in older individuals. For more than a decade, orthopaedic surgeons treating these fractures have been strongly encouraged to evaluate patients in this age group for the osteoporosis generally associated with these fractures. The American Orthopaedic Association (AOA) in 2005 began developing the Own the Bone program, specifically addressing the need to evaluate and treat osteoporosis, as well as the fracture, in these patients. The AOA has formed liaisons with several other national organizations to advance this program, and by late 2013, 44 states had hospitals implementing Own the Bone at their local institutions.
This article is sobering. Despite concerted efforts to link care of fragility fractures to evaluation and treatment of co-existing osteoporosis, these authors report an actual decrease in the rate of osteoporosis management for these patients. Only one-third of the women and one-sixth of the men in this retrospective cohort study were evaluated and treated according to current clinical guidelines.
This is an important public health issue. Despite the fact osteoporosis management involves non-operative treatment, it is essential that orthopaedic surgeons become more cognizant of the association between fragility fractures and osteoporosis treatment, and put in place a protocol to ensure that these patients are evaluated and treated for osteoporosis, as well as for the fracture. Osteoporosis may not be under the direct guidance of the orthopaedic surgeon, but the recognition of this potential problem is squarely within the practice scope of orthopaedists, who are well positioned to initiate secondary prevention measures for these older individuals.