“We believe that bone health screening should be considered in all orthopaedic surgical candidates who are ≥50 years of age.” So proclaim Kadri et al., based on results of their study of 124 patients who were referred by orthopaedic surgeons for preoperative bone health optimization. The study appeared in the April 1, 2020 issue of The Journal of Bone & Joint Surgery.
The importance of identifying poor bone health before reconstructive orthopaedic surgery is well known but poorly implemented. The bone health evaluation in this cohort consisted of a physical examination, structured history-taking focused on prior fracture, and collection of Fracture Risk Assessment Tool (FRAX) data. Most (122 patients) also underwent dual X-ray absorptiometry (DXA), and more than two-thirds were evaluated with a trabecular bone score. Incidental CT scans were available for and evaluated in 43 patients. Based on these data, Kadri et al. found the following:
- >90% of the cohort met National Osteoporosis Foundation criteria for osteoporosis treatment.
- A high FRAX risk (major osteoporotic fracture ≥20% or hip ≥3%) was present in 82% of the patients.
- Osteoporosis, as defined by T scores of ≤─2.5 points, was present in 45% of the women and 20% of the men.
- Trabecular bone scores identified 34% of patients as having degraded bone microarchitecture.
As a result of these findings, 75% of the cohort were prescribed treatment for osteoporosis; 45% were prescribed anabolic agents and 30% were prescribed antiresorptive therapy.
For patients with clinical risk factors for osteoporosis and high FRAX risk, Kadri et al. recommend bone health optimization strategies for a minimum of 3 months prior to any planned orthopaedic surgery. “It has been our experience that patients are generally satisfied and are grateful to undergo bone health optimization despite a delay in the surgical procedure,” they write.
Although postsurgical outcomes among these patients were not analyzed, the authors intuitively point out that bone health optimization probably reduces the likelihood of postoperative complications and revisions and therefore would lead to improved outcomes and lower costs. Preoperative bone health optimization could also help surgeons select the most effective surgical technique and/or implant, they say.
The orthopaedic community began to move away from individual fracture classifications in the mid-1980s. The basis for that shift was the need for wider recognition that fractures represent a “continuous variable,” with infinite varieties of orientations and combinations of fracture lines. Trying to fit fractures into a narrow classification system can lead to confusion and misinformation. Furthermore, surgeons often disagree when determining a fracture’s classification and, therefore, which treatment is best.
To move away from individual classification systems, orthopaedic journals have generally moved toward the compendium of fracture classifications approved by the OTA and AO. Still, there are times when a new fracture classification seems appropriate, and in the June 5, 2019 issue of The Journal, Pieroh et al. have provided us with an example that classifies fragility fractures of the pelvis (FFP). The 4-group FFP classification is based on fracture morphology with different degrees of instability and includes treatment recommendations.
The authors collected the CT scans of 60 patients from 6 different hospitals who were ≥60 years old and had sustained a pelvic fracture from low-energy trauma. These CT scans were shown to 6 experienced surgeons, 6 inexperienced surgeons, and 1 surgeon who had direct experience/training with the FFP system. Each surgeon was asked to classify the pelvic fractures according to the FFP classification. Inter- and intra-rater reliabilities for the fracture classifications were calculated from these readings, and the overall inter-rater Kappa coefficient was found to be 0.53, while the overall intra-rater Kappa coefficient was 0.46 (Kappa coefficients of 0.61 to 0.41 constitute “moderate” reliability). In terms of percent agreement, there was greater agreement between surgeons when it came to classifying FFP Group 1 fractures than for FFP Group 2 and 3 fractures. This is noteworthy because Group 3 fractures are thought to require surgical treatment, while primary treatment for Group 2 fractures is usually nonoperative.
Pelvic fractures that are associated with low bone density and low-energy trauma are becoming increasingly frequent as our population continues to skew older. Having a validated, relatively straightforward classification system like the FFP to assist us in managing these patients will be of great assistance. The sound methodology used to develop the FFP classification system and its decent reliability, face validity, and construct and criterion validity can assure all of us about the usefulness of the FFP classification as the basis for future clinical investigations and to advance the care of these patients.
Marc Swiontkowski, MD
Osteoporosis is a “silent” disease, often becoming apparent only after a patient older than 50 sustains a low-energy fracture of the wrist, proximal humerus, or hip. Monitoring serum vitamin D levels and DEXA testing represent ideal screening methods to prevent these sentinel fragility fractures. In addition, through programs such as the AOA’s “Own the Bone” initiative, the orthopaedic community has taken a leadership role in diagnosing and treating osteoporosis after the disease presents as a fragility fracture. Own the Bone is active in all 50 states and, through local physician leadership, is identifying individuals who present with a fragility fracture so they can receive follow-up care that helps mitigate bone loss and prevent secondary fractures.
We still have a long way to go, however. Recent analyses show that only 30% of candidate patients (albeit up from 20%) are receiving this type of evidence-based care. The best-case scenario would be to identify at-risk men and women (osteoporosis does not affect women exclusively) before a potentially serious injury.
In the December 5, 2018 issue of The Journal, Anderson et al. present strong evidence that computed tomography (CT) can provide accurate data for diagnosing osteoporosis. CT is increasingly used (perhaps overused in some settings) across a spectrum of diagnostic investigations. The osseous-related data from these scans can be used to glean accurate information regarding a patient’s bone quality by analyzing the Hounsfield unit (HU) values of bone captured opportunistically by CT. HU data are routinely ignored, but the values correlate strongly with bone mineral density, and they could help us recommend preventive care to our patients before a fragility fracture occurs. (For example, a threshold of <135 HU for the L1 vertebral body indicates a risk for osteoporosis.)
Orthopaedists should discuss the possibility of asking their radiologist colleagues who read CT scans of older patients to routinely share that data. When indicated, we could promptly refer patients back to their primary care provider for discussion of pharmacological treatment and lifestyle changes proven to help prevent primary fragility fractures. There is little doubt that our patients are getting older. Reviewing CT data could help us dramatically improve preventive care and decrease the risk of first-time fragility fractures.
Click here for additional OrthoBuzz posts about fragility fractures.
Marc Swiontkowski, MD
Fracture liaison services and similar coordinated, multidisciplinary fragility-fracture reduction programs for patients with osteoporosis work (see related OrthoBuzz posts), but until now, the data corroborating that have come from either academic medical centers or large integrated health care systems. The November 7, 2018 issue of The Journal of Bone and Joint Surgery presents solid evidence from a retrospective cohort study that a private orthopaedic practice-based osteoporosis management service (OP MS) also successfully reduces the risk of subsequent fragility fractures in older patients who have already sustained one.
Sietsema et al. collected fee-for-service Medicare data for Michigan residents who had any fracture from April 1, 2010 to September 30, 2014 (mean age of 75 years). From that data, they compared outcomes for patients who received nurse-practitioner-led OP MS care from a single-specialty private orthopaedic practice within 90 days of the first fracture to outcomes among a propensity-score-matched cohort of similar patients who did not receive OP MS care. There were >1,300 patients in each cohort, and both groups were followed for an average of 2 years. The private practice’s OP MS services incorporated the multidisciplinary protocols promulgated by the American Orthopaedic Association’s “Own the Bone” program.
The cohort exposed to OP MS had a longer median time to subsequent fracture (998 versus 743 days), a lower incidence rate of any subsequent fracture (300 versus 381 fractures per 1,000 person-years), and higher incidence rates of osteoporosis medication prescriptions filled (159 versus 90 per 1,000 person-years). Over the first 12 months of the follow-up period, total medical costs did not differ significantly between the 2 cohorts.
These findings are consistent with those reported from academic or integrated health-system settings. According to the authors, this preponderance of evidence “emphasize[s] the importance of coordinated care in reducing subsequent fractures, lengthening the time to their occurrence, and improving patient outcomes.” Sietsema et al. conclude further that “the U.S. Medicare population would benefit from widespread implementation of such models in collaboration with orthopaedic providers and payers.”
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.
On Thursday evening, June 28 and all day Friday, June 29 in Boston, The American Orthopaedic Association (AOA) and the National Association of Orthopaedic Nurses (NAON) will present two educational/networking events concentrating on secondary fragility fracture prevention.
The Thursday evening Workshop, available only to those attending the Friday Symposium, will convene clinicians with expertise in counseling and treating fragility fracture patients. “This new two-hour workshop provides an additional opportunity to learn more about identifying, assessing, counseling, and treating fragility fracture patients,” said program co-chair Debra Sietsema, PhD, RN. “The Workshop also includes special breakout stations on calcium, FRAX, and the AOA’s ‘Own the Bone’ initiative.”
The all-day Symposium on Friday focuses on how to establish a multidisciplinary secondary fragility fracture program. In addition, the Symposium will include relevant case studies demonstrating how to translate the principles into hospital, private-practice, or clinic settings. “This Symposium is a great opportunity for orthopaedic surgeons and allied health professionals to get the full picture in one day,” said Dr. Sietsema. “Attendees will gain both basic and expanded knowledge to put their programs in place.”
Register by May 15 to receive early-bird pricing for these important events. NAON members and clinicians from enrolled Own the Bone institutions save an additional $50.
How well do fracture liaison services (FLSs) work in terms of patients who’ve had a fragility fracture receiving a recommendation for anti-osteoporosis treatment? Very well, according to findings from an analysis of more than 32,000 patients by Dirschl and Rustom in the April 18, 2018 edition of The Journal of Bone & Joint Surgery.
A fracture liaison service is a coordinated, multidisciplinary model of care designed to reduce the risk of future fractures among patients who’ve sustained a primary fragility fracture. (Click here for another recent JBJS article about the FLS model.) The American Orthopaedic Association (AOA) has been a major proponent of the FLS model, and it is a cornerstone of the AOA’s “Own the Bone” national quality-improvement program.
Dirschl and Rustom found that between 2009 and 2016, at 147 sites participating in an FLS through Own the Bone, 72.8% of 32,671 patients initially evaluated for a fragility fracture received a recommendation for anti-osteoporosis treatment. That’s a vast improvement compared with previous reports that indicate only 20% of patients with a fragility fracture received either an osteoporosis evaluation or treatment. In this current study, a sedentary lifestyle and having a parent who had sustained a hip fracture were the patient factors associated with those most likely to receive a recommendation for treatment.
OrthoBuzz editors were surprised to read that anti-osteoporosis treatment was initiated in only 12.1% of the patients in this study. When we asked JBJS Editor-in-Chief Marc Swiontkowski, MD for a further explanation, he noted that the study captured data only from the initial post-fracture encounter between patients and FLS clinicians. The percentage of patients initiating treatment would have been much higher, he said, if the data had included those who followed up their initial FLS evaluation with a primary care physician. He also remarked that some people are dissuaded from taking an FDA-approved prescription anti-osteoporosis medication by the disproportionate focus on side effects that patients read in social media and the lay press. And there are some patients for whom prescription anti-osteoporosis drugs are truly contraindicated.
But with an estimated 2 million people in the US sustaining a fragility fracture each year, these results indicate substantial progress in practices that will prevent secondary fractures.
Click here for a listing of upcoming Own the Bone events.
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.