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.
I recently returned from the 13th meeting of the Combined Orthopaedic Associations, affectionately known as COMOC 2016. This meeting is unique in that it brings together seven different national orthopaedic organizations from six countries (America, Australia, Britain, Canada, New Zealand, and South Africa).
The concept for this combined meeting originated with R.I. Harris, a Canadian orthopaedic surgeon who had been the president of both the Canadian Orthopaedic Association and the American Orthopaedic Association (AOA). Dr. Harris felt that improved communication between American, British, and Canadian orthopaedic surgeons would be of benefit to all. He was also responsible for the institution of the American-British-Canadian (ABC) Traveling Fellowship.
The first combined meeting involved only US, Canadian, and British orthopaedic surgeons. At that time travel would have been by ship or train. The original idea was to hold this meeting every six years and to move the venue from country to country on a predetermined schedule. This year, COMOC was held in Cape Town, South Africa, and in six years the US will be the host country.
The structure of the meeting is unique in that countries are given a forum to present orthopaedic issues most relevant to their national organizations. On Monday, April 11, both the American Academy of Orthopaedic Surgeons and the AOA presented plenary sessions. On Tuesday Australia took its turn in the morning, and New Zealand presented in the afternoon. Wednesday saw a presentation from the United Kingdom, with Canada taking the podium on Thursday. The plenaries wrapped up on Friday with the host South African Orthopaedic Association.
This meeting is an enduring link with the past and the future, continuing the orthopaedic tradition of fellowship and friendship that is the hallmark of our specialty. The Cape Town meeting was exceptional in venue, content, and organization. The Local Organizing Committee and Programme Committee are to be congratulated for an exceptional job in developing a program that maintained significant audience interest despite the competing attractions of Cape Town and the South African countryside.
When COMOC comes to America in 2022, I hope North American orthopaedists—especially younger ones—will take the once-in-a-career opportunity to meet and talk with musculoskeletal colleagues from all over the world.
James P. Waddell, MD, FRCSC
JBJS Deputy Editor
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.