Most research studies on osteoporosis and prevention of future fractures have been conducted on women, and what we know about managing fractures in women may not directly apply to men without modifications that consider sex differences.

AAOS Now

Published 3/1/2007
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Mary I. O’Connor, MD; Laura L. Tosi, MD

Putting a little sex in your orthopaedic practice

By Mary I. O’Connor, MD, and Laura L. Tosi, MD

Women have more hip fractures, so why are more men with fractured hips dying?

Great! Made you look! Now keep reading!

This column will provide important information for your practice about issues related to sex (determined by our chromosomes) and gender (how we present ourselves as male or female, which can be influenced by environment, families and peers, social institutions, etc.). It’s the first in a series of quarterly columns sponsored by the AAOS Women’s Health Issues Advisory Board and the Ruth Jackson Orthopaedic Society.

A sex and gender issue that should be of particular concern to our male colleagues is the worrisome evidence that although men suffer fewer hip fractures than women, their recuperation is significantly inferior. It’s also a concern to our female colleagues, which is one reason why we’ve chosen this topic for our first column.

All hip fractures are not the same
Are all hip fractures the same? Of course not. But have you ever stopped to seriously consider the nature of the differences? Hip fractures are a recognized public health problem in women; however, they are also a significant problem in men. Approximately one in four hip fractures in the United States occurs in men.

The incidence is lower in men than in women because men generally have higher peak bone density, lose less bone during aging, sustain fewer falls, do not go through menopause, and have shorter life spans. But the incidence data is changing. By 2025, the annual incidence of hip fracture in men could approximate the current incidence in women, and by 2050, there could be 2.5 million hip fractures worldwide annually in men aged 65 and older. And that’s a conservative projection.

Most people with hip fractures have osteoporosis, a condition of porous and fragile bones caused by low bone mass and decreased bone density. Unfortunately, almost all osteoporosis research and clinical treatment trials have been conducted on women. The few trials that have included men suggest that men and women may be clinically different, both at the time of fracture and during recovery.

What’s the difference?
So how do male and female patients with hip fractures differ? For starters, men have a higher number of risk factors for disease. They are more likely to have comorbidities such as chronic obstructive pulmonary disease and asthma, and they’re more likely to have risk factors such as smoking, high alcohol consumption, and low calcium intake.

Additionally, men and women sustain their fractures in different locations. Men tend to fracture their hips outdoors, while women tend to fall in the home. This difference is likely due to differing levels of activity; men with hip fractures are typically more active than women. But men who fracture a hip have a mortality rate that is twice as high as women with hip fractures.

This difference puzzles researchers. It cannot be fully explained by prefracture comorbidity, fracture type, procedure, or surgical complications. Rather, research suggests that the fracture may trigger a new or different postinjury process in men. Certainly this topic requires further research.

Worse yet, men are more likely than women to sustain a second hip fracture—particularly among individuals in their 60s and 70s. Overall, approximately 80 percent of those who survive a hip fracture regain functional independence. Yet 50 percent of male patients must be institutionalized as a direct result of their fracture. Although current data on the differences in postfracture functioning between men and women are limited, both men and women will experience declines in physical function over time. And, although women are less likely to recover function after disability occurs, men are more likely than women to experience severe disability.

We must do something
Most research studies on osteoporosis and prevention of future fractures have been conducted on women, and what we know about managing fractures in women may not directly apply to men without modifications that consider sex differences.

For example, the current National Osteoporosis Foundation (NOF) treatment guidelines for osteoporosis recommend pharmacologic intervention (including calcium and vitamin D, raloxifene, calcitonin, alendronate, and risedronate) for female patients who have a history of hip or vertebral fracture, regardless of bone mineral density. There are no nationally recognized guidelines for osteoporosis treatment in men and only two Food and Drug Administration–approved osteoporosis therapies (teriparatide and alendronate) for our male patients—neither of which has been proven successful in preventing hip fracture.

Despite recommendations by the NOF and other groups, most hip fracture patients are not evaluated for osteoporosis and do not receive definitive treatment to prevent secondary fractures. More men than women are underdiagnosed and undertreated: one study found that after a hip fracture, only 1 percent of men were discharged with treatment compared with 25 percent of women. This apparent sexism is causing serious problems for our country’s aging male population.

We may all be getting older, but we women don’t want to age alone. We want our men to be with us, and hip fractures are going to limit the fun we can have. We need to figure out how to prevent hip fractures and develop better diagnostic strategies and treatments. As orthopaedists, we need to recognize the differences between the patterns of functional recovery after hip fracture in men and women and to provide quality care for both men and women with hip fractures. After all, it takes two to tango!

We hope you appreciate the value of this information, and we welcome your questions and comments. This article references data from Orwig DL, Chan J, Magaziner J: Hip Fracture and its Consequences: Differences between Men and Women. Orthop Clin N Am. 2006; 37:611-622.

Mary I. O’Connor, MD, is chair of the AAOS Women’s Health Issues Advisory Board and past president of the Ruth Jackson Orthopaedic Society (RJOS); she can be reached at oconnor.mary@mayo.edu. Laura L. Tosi, MD, is also an RJOS past president; she can be reached at ltosi@cnmc.org