OrthoBuzz occasionally receives posts from guest bloggers. This guest post comes from James Blair, MD, in response to a recent edition of the OrthoJOE podcast.
Geriatric hip fractures are among the fastest growing subset of injuries that orthopaedic surgeons treat. Often these injuries are the first objective signs of osteoporosis. While the surgical treatment of these fractures continues to improve, orthopaedic surgeons may be neglecting their role in triggering investigations into the underlying bone health of these patients.
A recent insurance database analysis by Sara Cromer, MD, presented at the Endocrine Society’s 2021 Annual Meeting, demonstrated a substantial drop in the use of bone-directed medications over the past decade, despite the rise in the number of osteoporotic-related fractures. It is unclear why this trend has occurred, but the main concern is that new diagnoses of osteoporosis are being overlooked.
This concern arose during a recent OrthoJOE podcast focused on distal radial fractures. OrthoEvidence Editor-in-Chief Dr. Mo Bhandari alluded to the confusion over who is responsible for bone-health intervention during treatment of a fragility fracture: the inpatient orthopaedic surgery team, the hospitalist, or the patient’s family physician or internist. “The thought is that someone is going to manage this,” Dr. Bhandari states. “Everyone is looking at everyone else, and it’s not happening.”
In fragility-fracture cases, JBJS Editor-in-Chief Dr. Marc Swiontkowski emphasized the importance of orthopaedic surgeons initiating investigations into their patients’ bone quality with evaluations of vitamin D, ionized calcium, and parathyroid and thyroid hormone levels. “We are failing miserably at this,” Dr. Swiontkowski laments, recalling seeing 3 elderly patients in a single day with a hip fracture that was preceded by a distal radial fracture a decade earlier–with no bone-health investigation ever performed at that time.
Initiatives like the American Orthopaedic Association’s (AOA’s) “Own The Bone” program try to raise awareness of our broader responsibility as orthopaedic surgeons when treating osteoporotic fractures such as those of the proximal femur, distal radius, and vertebrae. Drs. Bhandari and Swiontkowski strongly believe that the orthopaedic surgeon must claim ownership of their patients’ bone health, not necessarily by medically managing such cases, but by initiating a dialog with the patient’s primary care physician and/or rheumatologist/endocrinologist.
Click here to find out more about the AOA’s “Own The Bone” program.
James A. Blair, MD is the Director of Orthopaedic Trauma at the Medical College of Georgia at Augusta University and a member of the JBJS Social Media Advisory Board.
In response to the COVID-19 pandemic, an abundance of clinical orthopaedic information has been disseminated in a short period of time. Some of that has been compiled and commented upon here in OrthoBuzz.
On April 12, 2020, the editors of OrthoEvidence, led by Mohit Bhandari, MD, published a report of global recommendations that puts forth evidence-based principles to guide musculoskeletal care in the face of the coronavirus pandemic. The carefully referenced, 65-page report identifies pandemic-related best practices in outpatient care, elective procedures, urgent/emergent procedures, and peri-/postoperative care.
Nearly three-quarters of the 72 publications analyzed for the report were based on expert opinion and/or clinical experience; just over one-quarter were developed using evidence-based methods alone or a combination of evidence-based methods plus expert opinion. Using the GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) approach, the report’s authors assign strength ratings for all the recommendations compiled in the review.
The detailed information is best digested from the report itself, but here is a summary of the report’s overarching recommendations for orthopaedic management at this time:
- Ensure patient and staff safety.
- Stay up-to-date about evolving clinical guidelines and your institution’s capacity issues.
- Prevent unnecessary use of personal protective equipment and make contingency plans for supply shortages.
- Schedule only urgent or emergent surgical cases.
- Perform only operative interventions that can be expected to have superior outcomes relative to nonoperative management.
- Convene teams to make decisions about definitive management in semi-urgent or controversial cases.
- Prevent unnecessary follow-up visits.