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.
Bone mineral density (BMD)—a measure of both cortical and trabecular bone—has been widely used as an index of bone fragility. The femoral neck and lumbar vertebrae are the areas most commonly measured with BMD, but hip osteoarthritis and lumbar spondylosis can mask systemic osteoporosis. In addition, the most common fragility fractures occur at the distal radius.
Investigators conducted a prospective study using high-resolution peripheral quantitative computed tomography (HR-pQCT) of the distal radius and tibia to determine whether baseline skeletal parameters could predict fragility fractures in women. A second goal was to establish whether women who have fragility fractures experience bone loss at a faster rate than those who do not have fractures.
Among 149 women older than 60 years who had baseline and 5-year follow-up HR-pQCT, 22 had a fragility fracture during the study period and 127 did not. HR-pQCT is able to record total bone mineral density (Tt.BMD), trabecular bone mineral density (Tb.BMD), trabecular number (Tb.N), and trabecular separation (Tb.Sp).
The analysis showed that women with fragility fractures had lower baseline Tt.BMD (19%), Tb.BMD (25%), and Tb.N (14%), along with higher Tb.Sp (19%) than women who did not experience a fracture. Analysis of the tibia measures yielded similar results, showing that women with incident fracture had lower Tt.BMD (15%), Tb.BMD (12%), cortical thickness (14%), and cortical area (12%). Also, women with fractures had lower failure load (10%) with higher total area and trabecular area than women without fractures.
For each standard deviation decrease of a measure at the distal radius, the odds ratio for fragility fracture was 2.1 for Tt.BMD. 2.0 for Tb.BMD, and 1.7 for Tb.N. ORs for those measures at the tibia were similar.
In contrast to these findings, the annualized percent rate of bone loss was not different between groups with and without fractures. These results suggest that future fragility-fracture risk prediction should rely at least as much on bone architecture and strength as on simple BMD measurements.
Burt LA, Manske SL, Hanley DA, Boyd SK. Lower Bone Density, Impaired Microarchitecture, and Strength Predict Future Fragility Fracture in Postmenopausal Women: 5-Year Follow-up of the Calgary CaMos Cohort. J Bone Miner Res. 2018 Jan 24. doi: 10.1002/jbmr.3347 PMID: 29363165
OrthoBuzz has published several posts about osteoporosis, fragility fractures, and secondary fracture prevention. In the May 17, 2017 edition of JBJS, Bogoch et al. add to evidence suggesting that a coordinator-based fracture liaison service (FLS) improves engagement with secondary-prevention practices among inpatients and outpatients with a fragility fracture.
The Division of Orthopaedic Surgery at the University of Toronto initiated a coordinator-based FLS in 2002 to educate patients with a fragility fracture and refer them for BMD testing and management, including pharmacotherapy if appropriate. Bogoch et al. analyzed key clinical outcomes from 2002 to 2013 among a cohort of 2,191 patients who were not undergoing pharmacotherapy when they initially presented with a fragility fracture.
- Eighty-four percent of inpatients and 85% of outpatients completed BMD tests as recommended.
- Eighty-five percent of inpatients and 79% of outpatients who were referred to follow-up bone health management were assessed by a specialist or primary care physician.
- Among those who attended the referral appointment, 73% of inpatients and 52% of outpatients received a prescription for anti-osteoporosis medication.
The authors conclude that “a coordinator-based fracture liaison service, with an engaged group of orthopaedic surgeons and consultants…achieved a relatively high rate of patient investigation and pharmacotherapy for patients with a fragility fracture.”
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.
In the past several years, the orthopaedic community has become highly engaged in improving the follow-up management of patients presenting with fragility fractures. We have realized that orthopaedic surgeons are central to the ongoing health and welfare of these patients and that the episode of care surrounding a fragility fracture represents a unique opportunity to get patients’ attention. Using programs such as the AOA’s “Own the Bone” registry, increasing numbers of orthopaedic practices and care centers are leading efforts to deliver evidenced-based care to fragility-fracture patients.
In the November 16, 2016 edition of The Journal, Aspenberg et al. carefully examine the impact of the anabolic agent teriparatide versus the bisphosphonate risedronate on the 26-week outcomes of more than 170 randomized patients (mean age 77 ±8 years) who were treated surgically for a low-trauma hip fracture. This investigation is timely and appropriate because our systems of care are evolving so that increasing numbers of patients are receiving pharmacologic intervention for low bone density both before and after a fragility fracture.
The secondary outcomes of the timed up and go (TUG) test and post-TUG test pain were better in the teriparatide group, but there were no differences in radiographic fracture healing or patient-reported health status.
Although this study was designed primarily to measure the effects of the two drugs on spinal bone mineral density at 78 weeks, these secondary-outcome findings confirm the value of initiating pharmacologic intervention early on after a fragility fracture, whether it’s a bisphosphonate or anabolic agent. The orthopaedic community needs to continue leading multipronged efforts to deal with the public health issues of osteoporosis and fragility fractures.
Click here for additional OrthoBuzz posts related to osteoporosis and fragility fractures.
Marc Swiontkowski, MD
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, June 23, 2016, the American Orthopaedic Association and the National Association of Orthopaedic Nurses will host a full-day symposium focused on how to establish and run a fracture liaison service.
- When: Thursday, June 23, 2016, 9:00 am to 5:30 pm
- Where: The Westin Seattle, Seattle, WA
Learn from national and local experts and network with other clinicians interested in secondary fracture prevention programs. JBJS Editor-in-Chief Marc Swiontkowski, MD will be one of the presenters.
Register before June 1 to receive reduced pricing.
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.
The statistics about osteoporosis and associated fragility fractures are sobering:
- One-quarter of adults living in the US currently have osteoporosis or low bone density.
- Twenty-four percent of people aged 50 and older who sustain a hip fracture will die within a year after the fracture.
- Patients who have had one fragility fracture have an 86% increased risk for a second fracture.
Amid these troubling data stands hope from an effective, team-based clinical response—the fracture liaison service (FLS). In the April 15, 2015 edition of JBJS, Miller et al . explain how an FLS works and the results it achieves.
The authors define the fracture liaison service as “a coordinated care model of multiple providers who help guide the patient through osteoporosis management after a fragility fracture to help prevent future fractures.” The three key players on the FLS team are a coordinator (usually an advanced-practice provider), a physician champion (whom the authors say should be an orthopaedic surgeon), and a “nurse navigator.” Miller et al. describe the roles these FLS core team members play (including patient care and education and communication with other clinical services and administrators), suggest ways to organizationally justify an FLS, and lay out a stepwise implementation roadmap.
The authors conclude that an FLS “is adaptable to any type of health-care system, improves patient outcomes, and decreases complications and readmissions related to secondary fractures.” And there’s an important fringe benefit: “The FLS can help improve performance on quality measures…and help health-care organizations during this transition from volume payment to quality payment,” they say.