FRAGILITY FRACTURES (2005)

“Our hope is that Americans can live long and live well. Unfortunately, fractures—the most common and devastating consequence of bone disease—frequently make it difficult...” “Much of the burden of bone disease can potentially be avoided if at-risk individuals are identified and appropriate interventions... are... timely.... (H)ealth care providers frequently fail to identify and treat individuals at high risk for osteoporosis or other disorders of bone...” “... a number of `red flags'... signal potential problems with an individual's bone health at different ages. One of the most important flags is a previous fragility-related fracture.”1 In releasing the Surgeon General's report, Bone Health and Osteoporosis, Secretary Tommy Thompson of the Department of Health and Human Services declared: “Osteoporosis, fractures, and other chronic diseases no longer should be thought of as an inevitable part of growing old.” Seniors should “live long and live well.” To achieve that goal, Secretary Thompson contends, we must move beyond the traditional focus on providing health care and emphasize prevention. “By focusing on prevention and lifestyle changes, including physical activity and nutrition, as well as early diagnosis and appropriate treatment, Americans can avoid much of the damaging impact of bone disease and other chronic diseases.” He argues that a good fraction of the $12 to $18 billion a year that is currently spent on osteoporosis and fracture care can be avoided if our citizens develop healthier lifestyles. Secretary Thompson and Surgeon General Richard Carmona believe that we can improve the quality of life for millions of Americans if we actively identify fractures as a “red flag” signaling the need to begin proper osteoporosis evaluation and treatment. The American Academy of Orthopaedic Surgeons (AAOS) brought this matter to the attention of orthopaedists last year, with the publication of its position statement “Recommendations for Enhancing the Care of Patients with Fragility Fractures” (see Appendix). In this issue of The Journal, Gardner et al.2 expand the already extensive literature describing the challenges in developing effective approaches for the care of patients who have sustained a fracture. The authors focus on whether a perioperative intervention program that consists of patient education and provides patients with a list of questions to ask their primary care physician would increase the percentage of patients who received appropriate follow-up evaluation after a fracture. The authors conclude that such empowered patients are indeed much more likely to have appropriate follow-up. This is a simple step that many orthopaedists can implement easily. However, implicit in the study are two important caveats. The first is that the need for evaluation of secondary causes of osteoporosis must be considered. Although Gardner et al. considered a dual-energy x-ray absorptiometry scan alone as constituting good follow-up, a scan is only one element of the management plan. Virtually all clinical osteoporosis specialists believe that a fragility fracture after the age of fifty is strong evidence of poor bone quality and a high risk of repeat fractures and that intervention strategies including calcium and vitamin D, exercise, fall prevention, and usually medication are required. Second, 40% of eligible patients declined the offer to participate in the trial conducted by Gardner et al. because they thought that their fracture was not a result of osteoporosis. It is alarming and disappointing that, despite what seem like endless public education campaigns relating to bone health launched in recent years by the National Osteoporosis Foundation, the American Academy of Orthopaedic Surgeons, and other health-conscious organizations, the connection between fragility fractures and osteoporosis is not being made by patients. The valuable research and recommendations presented by Gardner et al. are only one step in what must be a system-wide solution. As the percentage of patients who declined to participate in their study indicates, even better national education is essential. The public must understand that a fragility fracture is a signal portending more fractures, and a fracture should prompt patients to ask their physicians for an osteoporosis work-up. Similarly, patients need to understand the critical role of physical activity, nutrition, and lifestyle in preventing bone disease. Such education could be part of the courses on healthy lifestyles that high schools across the country are teaching today. Systemic solutions are also needed to improve the education of both primary care physicians and specialists in the proper follow-up of a patient who presents with a fracture. Many of today's clinicians were trained at a time when osteoporosis was considered a natural part of aging. The model presented by Gardner et al. breaks through a professional “silo” mentality that limits communication among specialists. Algorithm-style guidelines could be applied to the treatment of all patients presenting with a fragility fracture. Such guidelines could be made part of standard operating procedures for the nation's emergency rooms as well as for discharge-planning teams. They could also be part of continuing education programs for primary care physicians and specialists. Physicians and other caregivers must recognize that fracture rates can be reduced with appropriate therapy and a comprehensive post-fracture follow-up regimen. Traditionally, orthopaedic surgeons have claimed to “own the bone.” Our profession must view the Surgeon General's report as a wake-up call that fracture care encompasses prevention as well as acute management. If we are truly to “own the bone,” we must lead in developing multidisciplinary teams that design and implement algorithms to enhance fracture care and prevention in clinics and hospitals. The AAOS position statement and the protocol described by Gardner et al. are excellent first steps, but there is a tremendous amount of work ahead. Let's begin! Appendix The AAOS position statement “Recommendations for Enhancing the Care of Patients with Fragility Fractures” is available with the electronic versions of this article, on our web site at jbjs.org (go to the article citation and click on “Supplementary Material”) and on our quarterly CD-ROM (call our subscription department, at 781-449-9780, to order the CD-ROM).