Failure in diagnosis and under-treatment of osteoporosis in elderly patients with fragility fractures

  • Sofia Bougioukli
  • Panagoula Κollia
  • Theodora Koromila
  • Sokratis Varitimidis
  • Michael Hantes
  • Theofilos Karachalios
  • Κonstantinos Ν. Malizos
  • Zoe H. Dailiana
Original Article


We evaluated whether osteoporosis is adequately managed and treated in patients suffering from fragility fractures. Factors that influenced osteoporosis diagnosis and treatment rates were also assessed. To this end, patients with the principal diagnosis of low-energy hip, vertebral, or distal radius fractures were recruited for the study. Collected data included risk factors for osteoporosis, history of previous fractures, known history of osteoporosis, and osteoporosis treatment at the time of admission. The patients’ prefracture risk profile was also assessed to determine whether osteoporosis could have been identified prior to the index fracture. We identified 308 patients with fragility fractures, including 214 hip, 41 vertebral, and 53 distal radius fractures. Overall, 238 patients (77.3%) had at least one risk factor for osteoporosis. Eighty-eight patients (28.6%) had sustained ≥ 1 prior fragility fractures in the past. However, only 79 patients (25.6%) were aware that they had osteoporosis and even fewer (66 patients, 21.4%) had been receiving osteoporosis treatment preceding the current admission. Anti-osteoporotic agents were more commonly prescribed in patients 66–75 years old (p = 0.008), with a family history of osteoporosis (p = 0.009) or history of a prior fragility fracture (p = 0.012). The treatment rate was higher in women than men (p = 0.026) and in patients with vertebral or multiple prior fractures compared to patients with prior hip fractures. The current study provides evidence that individuals who experience fragility fractures are not adequately managed for osteoporosis. Only few of the historically known risk factors for osteoporosis were adequately recognized and associated with osteoporosis evaluation and treatment.


Fragility fracture Osteoporosis Osteoporosis risk assessment Anti-osteoporotic treatment 



The authors would like to thank Dr. Antonios Koutalos for his invaluable assistance with patient interviews.

Compliance with ethical standards

Conflict of interest

The authors declare no conflicts of interest.

Ethical approval

The study has been approved by the University’s institutional research board and has been performed in accordance with the ethical standards as laid down in the 1964 Declaration of Helsinki and its later amendments.

Supplementary material

774_2018_923_MOESM1_ESM.docx (472 kb)
Supplementary material 1 (DOCX 472 kb)
774_2018_923_MOESM2_ESM.docx (78 kb)
Supplementary material 2 (DOCX 78 kb)


  1. 1.
    Cooper C, Campion G, Melton LJ III (1992) Hip fractures in the elderly: a world-wide projection. Osteoporos Int 2:285–289CrossRefPubMedGoogle Scholar
  2. 2.
    Johnell O, Kanis J (2005) Epidemiology of osteoporotic fractures. Osteoporos Int 16:S3–S7CrossRefPubMedGoogle Scholar
  3. 3.
    Center JR, Bliuc D, Nguyen TV, Eisman JA (2007) Risk of subsequent fracture after low-trauma fracture in men and women. JAMA 297:387–394CrossRefPubMedGoogle Scholar
  4. 4.
    Klotzbuecher CM, Ross PD, Landsman PB, Abbott TA III, Berger M (2000) Patients with prior fractures have an increased risk of future fractures: a summary of the literature and statistical synthesis. J Bone Miner Res 15:721–739CrossRefPubMedGoogle Scholar
  5. 5.
    Kanis JA (2002) Diagnosis of osteoporosis and assessment of fracture risk. Lancet 359:1929–1936CrossRefPubMedGoogle Scholar
  6. 6.
    Hajcsar EE, Hawker G, Bogoch ER (2000) Investigation and treatment of osteoporosis in patients with fragility fractures. CMAJ 163:819–822PubMedPubMedCentralGoogle Scholar
  7. 7.
    Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE (2004) Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int 15:767–778CrossRefPubMedGoogle Scholar
  8. 8.
    McLellan AR, Gallacher SJ, Fraser M, McQuillian C (2003) The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int 14:1028–1034CrossRefPubMedGoogle Scholar
  9. 9.
    Bunta AD, Edwards BJ, Macaulay WB Jr, Jeray KJ, Tosi LL, Jones CB, Sietsema DL, Kaufman JD, Murphy SA, Song J, Goulet JA, Friedlaender GE, Swiontkowski MF, Dirschl DR (2016) Own the bone, a system-based intervention, improves osteoporosis care after fragility fractures. J Bone Jt Surg Am 98:e109CrossRefGoogle Scholar
  10. 10.
    World Health Organization (1998) Guidelines for preclinical evaluation and clinical trials in osteoporosis. Accessed 28 Feb 2018
  11. 11.
    Genant HK, Wu CY, van Kuijk C, Nevitt MC (1993) Vertebral fracture assessment using a semiquantitative technique. J Bone Miner Res 8:1137–1148CrossRefPubMedGoogle Scholar
  12. 12.
    Tuppurainen M, Kröger H, Saarikoski S, Honkanen R, Alhava E (1995) The effect of gynecological risk factors on lumbar and femoral bone mineral density in peri- and postmenopausal women. Maturitas 21:137–145CrossRefPubMedGoogle Scholar
  13. 13.
    Shuster LT, Rhodes DJ, Gostout BS, Grossardt BR, Rocca WA (2010) Premature menopause or early menopause: long-term health consequences. Maturitas 65:161–166CrossRefPubMedGoogle Scholar
  14. 14.
    Prentice A (2004) Diet, nutrition and the prevention of osteoporosis. Public Health Nutr 7:227–243CrossRefPubMedGoogle Scholar
  15. 15.
    Epstein S, Inzerillo AM, Caminis J, Zaidi M (2003) Disorders associated with acute rapid and severe bone loss. J Bone Miner Res 18:2083–2094CrossRefPubMedGoogle Scholar
  16. 16.
    Johnell O, Kanis JA, Odén A, Sernbo I, Redlund-Johnell I, Petterson C, De Laet C, Jönsson B (2004) Fracture risk following an osteoporotic fracture. Osteoporos Int 15:175–179CrossRefPubMedGoogle Scholar
  17. 17.
    Suhm N, Lamy O, Lippuner K, OsteoCare study group (2008) Management of fragility fractures in Switzerland: results of a nationwide survey. Swiss Med Wkly 138:674–683PubMedGoogle Scholar
  18. 18.
    Ruggiero C, Zampi E, Rinonapoli G, Baroni M, Serra R, Zengarini E, Baglioni G, Duranti G, Ercolani S, Conti F, Caraffa A, Mecocci P, Brandi ML (2015) Fracture prevention service to bridge the osteoporosis care gap. Clin Interv Aging 10:1035–1042PubMedPubMedCentralGoogle Scholar
  19. 19.
    USPSTF (2016) Final Recommendation Statement. Vitamin D and calcium to prevent fractures: preventive medication. Accessed 18 Oct 2016
  20. 20.
    Boonen S, Vanderschueren D, Haentjens P, Lips P (2006) Calcium and vitamin D in the prevention and treatment of osteoporosis—a clinical update. J Intern Med 259:539–552CrossRefPubMedGoogle Scholar
  21. 21.
    Neer RM, Arnaud CD, Zanchetta JR, Prince R, Gaich GA, Reginster JY, Hodsman AB, Eriksen EF, Ish-Shalom S, Genant HK, Wang O, Mitlak BH (2001) Effect of parathyroid hormone (1–34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 344:1434–1441CrossRefPubMedGoogle Scholar
  22. 22.
    Joffe HV (2013) Calcitonin salmon for the treatment of postmenopausal osteoporosis. Silver spring (MD): FDA; Accessed 21 Jan 2017
  23. 23.
    European Medicines Agency’s Committee for Medicinal Products for Human Use (2013) Recommendation to restrict the use of Protelos/Osseor (strontium ranelate). Accessed 5 Mar 2018
  24. 24.
    Hawker G, Ridout R, Ricupero M, Jaglal S, Bogoch E (2003) The impact of a simple fracture clinic intervention in improving the diagnosis and treatment of osteoporosis in fragility fracture patients. Osteoporos Int 14:171–178CrossRefPubMedGoogle Scholar
  25. 25.
    Panneman MJ, Lips P, Sen SS, Herings RM (2004) Undertreatment with anti-osteoporotic drugs after hospitalization for fracture. Osteoporos Int 15:120–124CrossRefPubMedGoogle Scholar
  26. 26.
    Balasubramanian A, Tosi LL, Lane JM, Dirschl DR, Ho PR, O’Malley CD (2014) Declining rates of osteoporosis management following fragility fractures in the U.S., 2000 through 2009. J Bone Jt Surg Am 96:e52CrossRefGoogle Scholar
  27. 27.
    Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA (1999) Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet 353:878–882CrossRefPubMedGoogle Scholar
  28. 28.
    Ensrud KE (2013) Epidemiology of fracture risk with advancing age. J Gerontol A Biol Sci Med Sci 68:1236–1242CrossRefPubMedGoogle Scholar
  29. 29.
    Ahmed LA, Center JR, Bjørnerem A, Bluic D, Joakimsen RM, Jørgensen L, Meyer HE, Nguyen ND, Nguyen TV, Omsland TK, Størmer J, Tell GS, van Geel TA, Eisman JA, Emaus N (2013) Progressively increasing fracture risk with advancing age after initial incident fragility fracture: the Tromsø study. J Bone Miner Res 28:2214–2221CrossRefPubMedGoogle Scholar
  30. 30.
    Maher RL, Hanlon J, Hajjar ER (2014) Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf 13:57–65CrossRefPubMedGoogle Scholar
  31. 31.
    Rabenda V, Vanoverloop J, Fabri V, Mertens R, Sumkay F, Vannecke C, Deswaef A, Verpooten GA, Reginster JY (2008) Low incidence of anti-osteoporosis treatment after hip fracture. J Bone Jt Surg Am 90:2142–2148CrossRefGoogle Scholar
  32. 32.
    Marsh D, Akesson K, Beaton DE, Bogoch ER, Boonen S, Brandi ML, McLellan AR, Mitchell PJ, Sale JE, Wahl DA, IOF CSA Fracture Working Group (2011) Coordinator-based systems for secondary prevention in fragility fracture patients. Osteoporos Int 22:2051–2065CrossRefPubMedGoogle Scholar
  33. 33.
    Walters S, Khan T, Ong T, Sahota O (2017) Fracture liaison services: improving outcomes for patients with osteoporosis. Clin Interv Aging 10:117–127CrossRefGoogle Scholar

Copyright information

© The Japanese Society for Bone and Mineral Research and Springer Japan KK, part of Springer Nature 2018

Authors and Affiliations

  • Sofia Bougioukli
    • 1
  • Panagoula Κollia
    • 2
  • Theodora Koromila
    • 2
  • Sokratis Varitimidis
    • 1
  • Michael Hantes
    • 1
  • Theofilos Karachalios
    • 1
  • Κonstantinos Ν. Malizos
    • 1
  • Zoe H. Dailiana
    • 1
  1. 1.Department of Orthopaedic Surgery, Faculty of MedicineUniversity of ThessalyLarissaGreece
  2. 2.Department of Genetics and Biotechnology, Faculty of BiologyNational and Kapodistrian University of AthensAthensGreece

Personalised recommendations