Home in on Bone Health in Patients with Fragility Fractures
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.
Owning the Bone in Spine Surgery
This post 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.
Approximately 20% of patients who undergo spine surgery have osteoporosis, which has a significant impact on spine-surgery complications such as failure of fixation devices and collapse fractures following fusion procedures. In a recent critical analysis review, authors focus on improving outcomes by identifying and optimizing patients with osteoporosis prior to spine surgery. The multidisciplinary team involved in that process should include primary care providers, endocrinologists, physical therapists, and orthopaedic surgeons.
The predominant tool for assessing bone mineral density (BMD) is dual x-ray absorptiometry. The diagnosis is based on a T score, which represents the number of standard deviations between the patient’s BMD and that of a healthy 30-year-old woman. Standard deviations ≤─2.5 define osteoporosis. The Z score is similar to the T score but compares the patient to an age- and sex-matched individual.
A history of low-energy fracture, such as a wrist fracture following a fall from a standing height, is considered a sentinel event for suspicion of fragility fractures. The combination of a fragility fracture and low BMD is considered to be severe osteoporosis. The most common form of osteoporosis is associated with a postmenopausal decrease in mineralization, but there are other causes. These include advanced kidney disease, hypogonadism, Cushing disease, vitamin D deficiency, anorexia and/or bulimia, rheumatoid arthritis, hyperthyroidism, primary hyperparathyroidism, and some medications (e.g., anticonvulsants, corticosteroids, heparin, and proton pump inhibitors).
Forty-seven percent of patients undergoing spine deformity surgery and 64% of cervical spine surgery patients have low vitamin D levels. Postoperative bone health can be enhanced in women ≥51 years old with daily intake of 800 to 1,000 units of vitamin D and 1,200 mg of daily calcium. There is no solid evidence that pre- or postoperative bisphosphonates have a positive impact on bone healing. Conversely, some series have shown that teriparatide, an anabolic parathyroid hormone, may improve time-to-fusion and help reduce screw pull-out after lumbar fusion in postmenopausal women.
Calcitonin has been shown to reduce the incidence of vertebral compression fracture, but there is no concrete evidence that it supports spine-fusion healing. Similarly, there is no strong evidence for the use of estrogen or selective estrogen receptor modulators in this surgical scenario. There is evidence that when the human monoclonal antibody denosumab is combined with teriparatide, spine-fusion healing may be improved relative to the use of teriparatide alone. Finally, the review article identifies screw size, screw position, and other surgical considerations that can improve fixation strength.
Using the “Own the Bone” practices promulgated by the American Orthopaedic Association and the technical considerations described in this review, we should be able to mitigate osteoporosis-related postoperative complications in spine-surgery patients.
Using CT Data to Diagnose Osteoporosis
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
JBJS Editor-in-Chief
More Evidence: Coordinated Care Reduces Risk of Second Fragility Fracture
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.”
Fragility Fracture Workshop & Symposium—June 28 & 29, 2018
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.
Upcoming Own the Bone Events
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:
Webinar: Components of a Secondary Fracture Prevention Program – May 4
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.
Fragility Fracture Workshop at PAOS Annual Conference – August 21, Baltimore, MD
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.
Own the Bone Webinar: Atypical Fractures and Osteo Medications
On Thursday, February 23, 2017, at 6:00 pm EST, the Own the Bone initiative will offer a webinar titled “Atypical Fractures and Osteoporosis Medication Considerations”
James Goulet, MD, from the University of Michigan, will discuss atypical fractures and other rare outcomes of the use of osteoporosis medication, including what to look for and how to treat these occurrences. He will also address drug holidays, and how and when to continue treatment on these complex cases.
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.
0.75 hour of CME credit is available.
Guest Post: Own the Bone Improves Osteoporosis Care
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.
Vitamin D Controversy Is Focus of Free Webinar
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.
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