Archives of Orthopaedic and Trauma Surgery

, Volume 133, Issue 8, pp 1101–1108 | Cite as

Surgeons save bones: an algorithm for orthopedic surgeons managing secondary fracture prevention

  • M. Gosch
  • C. Kammerlander
  • T. Roth
  • H. K. Doshi
  • R. W. Gasser
  • M. Blauth
Trauma Surgery

Abstract

Postmenopausal osteoporosis has a big impact on health care budget worldwide, which are expected to double by 2050. In spite of severe medical and socioeconomic consequences from fragility fractures, there are insufficient efforts in optimizing osteoporotic treatment and prevention. Undertreatment of osteoporosis is a well known phenomenon, particularly in elderly patients. Treatment rates remain low across virtually all patient, provider, and hospital-level characteristics, even after fragility fractures. In-hospital initiation is one of the options to increase treatment rates and improve osteoporosis management. However, multiple factors contribute to the failure of initiating appropriate treatment of osteoporosis in patients with fragility fractures. These include a lack of knowledge in osteoporosis and an absence of a comprehensive treatment guideline among family physicians and orthopedic surgeons. Furthermore, orthopedic surgeons are hardly willing to accept their responsibility for osteoporosis treatment due to the fact that they are usually not familiar with the initiation of specific drug treatments. The presented algorithm offers trauma surgeons and orthopedic surgeons a safe and simple guided pathway of treating osteoporosis in postmenopausal women appropriately after fragility fractures based on the current literature. From our point of view, this algorithm is useful for almost all cases and the user can expect treatment recommendations in more than 90 % of all cases. Nevertheless, some patients may require specialized review by an endocrinologist. The proposed algorithm may help to increase the rate of appropriate osteoporosis treatment hence reducing the rates of fragility fractures.

Keywords

Osteoporosis Secondary fracture prevention Fragility fracture Osteoporosis treatment Treatment algorithm 

References

  1. 1.
    WHO (1998) Guidelines for preclinical evaluation and clinical trials in osteoporosis. WHO, Geneva, p 59Google Scholar
  2. 2.
    US Department of Health and Humane Services (DHHS) (2003) Report of the surgeon general’s workshop on osteoporosis and bone health. Available at http://www.surgeongeneral.gov/library/bonehealth/index.html Accessed 26 Jan 2013, pp 1–100
  3. 3.
    Reginster JY, Burlet N (2006) Osteoporosis: a still increasing prevalence. Bone 38(2 Suppl 1):S4–S9PubMedCrossRefGoogle Scholar
  4. 4.
    Oden A, Dawson A, Dere W, Johnell O, Jonsson B, Kanis JA (1998) Lifetime risk of hip fractures is underestimated. Osteoporos Int 8(6):599–603PubMedCrossRefGoogle Scholar
  5. 5.
    Häussler B, Gothe H, Göl D, Glaeske G, Pientka L, Felsenberg D (2007) Epidemiology, treatment and costs of osteoporosis in Germany—the Bone EVA Study. Osteoporos Int 18(1):77–84PubMedCrossRefGoogle Scholar
  6. 6.
    Johnell K, Fastbom J (2009) Undertreatment of osteoporosis in the oldest old? A nationwide study of over 700,000 older people. Arch Osteoporos 4((1–2)):17–23 Epub 2009 Mar 19PubMedCrossRefGoogle Scholar
  7. 7.
    Kammerlander C, Gosch M, Kammerlander-Knauer U, Luger TJ, Blauth M, Roth T (2011) Long-term functional outcome in geriatric hip fracture patients. Arch Orthop Trauma Surg 131(10):1435–1444PubMedCrossRefGoogle Scholar
  8. 8.
    Jennings LA, Auerbach AD, Maselli J, Pekow PS, Lindenauer PK, Lee SJ (2010) Missed opportunities for osteoporosis treatment in patients hospitalized for hip fracture. J Am Geriatr Soc 58:650–657PubMedCrossRefGoogle Scholar
  9. 9.
    Fonarow GC, Gheorghiade M, Abraham WT (2004) Importance of in-hospital initiation of evidence based medical therapies for heart failure-a review. Am J Cardiol 94(9):1155–1160PubMedCrossRefGoogle Scholar
  10. 10.
    Muhlestein JB, Horne BD, Bair TL, Li Q, Madsen TE, Pearson RR, Anderson JL (2001) Usefulness of in-hospital prescription of statin agents after angiographic diagnosis of coronary artery disease in improving continued compliance and reduced mortality. Am J Cardiol 87(3):257–261PubMedCrossRefGoogle Scholar
  11. 11.
    Center JR, Bliuc D, Nguyen TV, Eisman JA (2007) Risk of subsequent fracture after low-trauma fracture in men and women. JAMA 297(4):387–394PubMedCrossRefGoogle Scholar
  12. 12.
    Queally JM, Kiernan C, Shaikh M, Rowan F, Bennett D (2012) Initiation of osteoporosis assessment in the fracture clinic results in improved osteoporosis management: a randomised controlled trial. Osteoporos Int. (Epub ahead of print) PubMed PMID: 23242431Google Scholar
  13. 13.
    Eisman JA, Bogoch ER, Dell R, Harrington JT, McKinney RE Jr, McLellan A, Mitchell PJ, Silverman S, Singleton R, Siris E (2012) Making the first fracture the last fracture: ASBMR task force report on secondary fracture prevention. J Bone Miner Res 27(10):2039–2046PubMedCrossRefGoogle Scholar
  14. 14.
    Kammerlander C, Gosch M, Blauth M, Lechleitner M, Luger TJ, Roth T (2011) The tyrolean geriatric fracture center: an orthogeriatric co-management model. Z Gerontol Geriatr 44(6):363–367PubMedCrossRefGoogle Scholar
  15. 15.
    Gosch M, Roth T, Kammerlander C, Joosten-Gstrein B, Benvenuti-Falger U, Blauth M, Lechleitner M (2011) Treatment of osteoporosis in postmenopausal hip fracture patients after geriatric rehabilitation: changes over the last decade. Z Gerontol Geriatr 44(6):381–386PubMedCrossRefGoogle Scholar
  16. 16.
    Premaor MO, Pilbrow L, Tonkin C, Adams M, Parker RA, Compston J (2010) Low rates of treatment in postmenopausal women with a history of low trauma fractures: results of audit in a fracture liaison service. QJM 103(1):33–40PubMedCrossRefGoogle Scholar
  17. 17.
    Kates SL, Mendelson DA, Friedman SM (2010) Co-managed care for fragility hip fractures (rochester model). Osteoporos Int 21(Suppl 4):S621–S625PubMedCrossRefGoogle Scholar
  18. 18.
    Chakravarthy J, Ali A, Iyengar S, Porter K (2008) Secondary prevention of fragility fractures by orthopaedic teams in the UK: a national survey. Int J Clin Pract 62(3):382–387PubMedCrossRefGoogle Scholar
  19. 19.
    Ringe JD, Doherty JG (2010) Absolute risk reduction in osteoporosis: assessing treatment efficacy by number needed to treat. Rheumatol Int 30(7):863–869PubMedCrossRefGoogle Scholar
  20. 20.
    Kanis JA, McCloskey EV, Johansson H, Cooper C, Rizzoli R, Reginster JY (2013) On behalf of the scientific advisory board of the European society for clinical and economic aspects of osteoporosis and osteoarthritis (ESCEO) and the committee of scientific advisors of the international osteoporosis foundation (IOF). European guidance for the diagnosis and management of osteoporosis in postmenopausal women. Osteoporos Int 24(1):23–57PubMedCrossRefGoogle Scholar
  21. 21.
    Gates BJ, Sonnett TE, Duvall CA, Dobbins EK (2009) Review of osteoporosis pharmacotherapy for geriatric patients. Am J Geriatr Pharmacother 7(6):293–323PubMedCrossRefGoogle Scholar
  22. 22.
    Rabar S, Lau R, O’Flynn N, Li L, Barry P (2012) Guideline development group. Risk assessment of fragility fractures: summary of NICE guidance. BMJ 345:e3698. doi:10.1136/bmj.e3698 PubMedCrossRefGoogle Scholar
  23. 23.
    Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM (2006) Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J Bone Joint Surg Am 88(1):25–34PubMedCrossRefGoogle Scholar
  24. 24.
    http://www.shef.ac.uk/FRAX. Accessed 11 May 2013
  25. 25.
    Brown EM, Hebert SC (1997) Calcium-receptor-regulated parathyroid and renal function. Bone 20(4):303–309PubMedCrossRefGoogle Scholar
  26. 26.
    Khairallah W, Fawaz A, Brown EM, El-Hajj Fuleihan G (2007) Hypercalcemia and diabetes insipidus in a patient previously treated with lithium. Nat Clin Pract Nephrol 3(7):397–404PubMedCrossRefGoogle Scholar
  27. 27.
    http://www.ema.europe.eu. Accessed 26 Jan 2013
  28. 28.
    Chauvelier S, Péquignot R, Amzal A, Hanon O, Belmin J (2012) Comparison between the three most popular formulae to estimate renal function, in subjects 75 years of age or older. Drugs Aging 29(11):885–890PubMedCrossRefGoogle Scholar
  29. 29.
    Verbrugge FH, Gielen E, Milisen K, Boonen S (2012) Who should receive calcium and vitamin D supplementation? Age Ageing 41(5):576–580PubMedCrossRefGoogle Scholar
  30. 30.
    Holick MF, Binkley NC, Bischoff-Ferrari HA, Gordon CM, Hanley DA, Heaney RP, Murad MH, Weaver CM (2011) Endocrine society. Evaluation, treatment, and prevention of vitamin D deficiency: an endocrine society clinical practice guideline. J Clin Endocrinol Metab 96(7):1911–1930PubMedCrossRefGoogle Scholar
  31. 31.
    Sinha A, Cheetham TD, Pearce SH (2012) Prevention and treatment of vitamin D deficiency. Calcif Tissue Int. (Epub ahead of print) PubMed PMID: 23124916Google Scholar
  32. 32.
    Boonen S, Lips P, Bouillon R, Bischoff-Ferrari HA, Vanderschueren D, Haentjens P (2007) Need for additional calcium to reduce the risk of hip fracture with vitamin D supplementation: evidence from a comparative metaanalysis of randomized controlled trials. J Clin Endocrinol Metab 92(4):1415–1423PubMedCrossRefGoogle Scholar
  33. 33.
    Bischoff-Ferrari HA, Dawson-Hughes B, Staehelin HB, Orav JE, Stuck AE, Theiler R, Wong JB, Egli A, Kiel DP, Henschkowski J (2009) Fall prevention with supplemental and active forms of vitamin D: a meta-analysis of randomised controlled trials. BMJ 339:b3692. doi:10.1136/bmj.b3692 PubMedCrossRefGoogle Scholar
  34. 34.
    Curtis JR, Arora T, Matthews RS, Taylor A, Becker DJ, Colon-Emeric C, Kilgore ML, Morrisey MA, Saag KG, Safford MM, Warriner A, Delzell E (2010) Is withholding osteoporosis medication after fracture sometimes rational? A comparison of the risk for second fracture versus death. J Am Med Dir Assoc 11(8):584–591PubMedCrossRefGoogle Scholar
  35. 35.
    Charlson M, Szatrowski TP, Peterson J, Gold J (1994) Validation of a combined comorbidity index. J Clin Epidemiol 47(11):1245–1251PubMedCrossRefGoogle Scholar
  36. 36.
    Mahoney FI, Barthel DW (1965) Functional evaluation: the barthel index. Md State Med J 14:61–65PubMedGoogle Scholar
  37. 37.
    Parker MJ, Palmer CR (1993) A new mobility score for predicting mortality after hip fracture. J Bone Jt Surg Br Vol 75(5):797–798Google Scholar
  38. 38.
    Nakazawa A, Nakamura K, Kitamura K, Yoshizawa Y (2012) Association between activities of daily living and mortality among institutionalized elderly adults in Japan. J Epidemiol 22(6):501–507PubMedCrossRefGoogle Scholar
  39. 39.
    Kammerlander C, Gosch M, Kammelrander-Knauer U, Luger TJ, Blauth M, Roth T (2011) Long-term functional outcome in geriatric hip fracture patients. Arch Orthop Trauma Surg 131(10):1435–1444PubMedCrossRefGoogle Scholar
  40. 40.
    Lyles KW, Colón-Emeric CS, Magaziner JS, Adachi JD, Pieper CF, Mautalen C, Hyldstrup L, Recknor C, Nordsletten L, Moore KA, Lavecchia C, Zhang J, Mesenbrink P, Hodgson PK, Abrams K, Orloff JJ, Horowitz Z, Eriksen EF, Boonen S, for the HORIZON Recurrent fracture trial (2007) Zoledronic acid in reducing clinical fracture and mortality after hip fracture. N Engl J Med 357:nihpa40967PubMedCrossRefGoogle Scholar
  41. 41.
    Boonen S, Black DM, Colón-Emeric CS, Eastell R, Magaziner JS, Eriksen EF, Mesenbrink P, Haentjens P, Lyles KW (2010) Efficacy and safety of a once-yearly intravenous zoledronic acid 5 mg for fracture prevention in elderly postmenopausal women with osteoporosis aged 75 and older. J Am Geriatr Soc 58(2):292–299PubMedCrossRefGoogle Scholar
  42. 42.
    Reid IR, Black DM, Eastell R, Bucci-Rechtweg C, Su G, Hue TF, Mesenbrink P, Lyles KW, Boonen S (2013) For the HORIZON pivotal fracture trial HORIZON recurrent fracture trial steering committees. Reduction in the risk of clinical fractures after a single dose of zoledronic acid 5 milligrams. J Clin Endocrinol Metab (Epub ahead of print) PubMed PMID: 23293335Google Scholar
  43. 43.
    Akehurst R, Brereton N, Ariely R, Lusa T, Groot M, Foss P, Boonen S (2011) The cost effectiveness of zoledronic acid 5 mg for the management of postmenopausal osteoporosis in women with prior fractures: evidence from Finland, Norway and the Netherlands. J Med Econ 14(1):53–64PubMedCrossRefGoogle Scholar
  44. 44.
    Goldhahn J, Féron JM, Kanis J, Papapoulos S, Reginster JY, Rizzoli R, Dere W, Mitlak B, Tsouderos Y, Boonen S (2012) Implications for fracture healing of current and new osteoporosis treatments: an ESCEO consensus paper. Calcif Tissue Int 90(5):343–353PubMedCrossRefGoogle Scholar
  45. 45.
    Eriksen EF, Lyles KW, Colón-Emeric CS, Pieper CF, Magaziner JS, Adachi JD, Hyldstrup L, Recknor C, Nordsletten L, Lavecchia C, Hu H, Boonen S, Mesenbrink P (2009) Antifracture efficacy and reduction of mortality in relation to timing of the first dose of zoledronic acid after hip fracture. J Bone Miner Res 24(7):1308–1313PubMedCrossRefGoogle Scholar
  46. 46.
    Amanat N, McDonald M, Godfrey C, Bilston L, Little D (2007) Optimal timing of a single dose of zoledronic acid to increase strenght in rat fracture repair. J Bone Miner Res 22:867–876PubMedCrossRefGoogle Scholar
  47. 47.
  48. 48.
    Falck-Ytter Y, Francis CW, Johanson NA, Curley C, Dahl OE, Schulman S, Ortel TL, Pauker SG, Colwell CW Jr (2012) American college of chest physicians. Prevention of VTE in orthopedic surgery patients: antithrombotic therapy and prevention of thrombosis, American college of chest physicians evidence-based clinical practice guidelines. Chest 141(2 Suppl) 9th edn: e278S–e325SGoogle Scholar
  49. 49.
    Diez-Perez A, Adachi JD, Agnusdei D, Bilezikian JP, Compston JE, Cummings SR, Eastell R, Eriksen EF, Gonzalez-Macias J, Liberman UA, Wahl DA, Seeman E, Kanis JA, Cooper C (2012) IOF CSA inadequate responders working group treatment failure in osteoporosis. Osteoporos Int 23(12):2769–2774PubMedCrossRefGoogle Scholar

Copyright information

© Springer-Verlag Berlin Heidelberg 2013

Authors and Affiliations

  • M. Gosch
    • 1
  • C. Kammerlander
    • 2
  • T. Roth
    • 2
  • H. K. Doshi
    • 3
  • R. W. Gasser
    • 4
  • M. Blauth
    • 2
  1. 1.Department of Geriatrics and Internal MedicineHospital HochzirlZirlAustria
  2. 2.Department of TraumatologyMedical University of InnsbruckInnsbruckAustria
  3. 3.Department of OrthopaedicsTan Tock Seng HospitalSingaporeSingapore
  4. 4.Department of Internal MedicineMedical University of InnsbruckInnsbruckAustria

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