Theresa Kehoe, MD, FDA medical officer, addressed the issue of long-term use of bisphosphonates.

AAOS Now

Published 10/1/2012
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Laura L. Tosi, MD; Debra Sietsema, PhD, RN

AOA/NAON Collaborate on Hot Topics in Bone Health

Symposium presents cutting edge information

Laura L. Tosi, MD, and Debra Sietsema, PhD, RN

Hot Topics in Bone Health,” a collaboration between the American Orthopaedic Association (AOA) and the National Association of Orthopaedic Nurses (NAON), brought together more than 140 participants during the AOA’s 125th Annual Meeting in Washington, D.C., earlier this year to discuss a variety of pressing bone health issues. This was the first time that AOA/NAON coprovided a continuing education activity.

NAON’s engagement with the AOA Own the Bone® program through its Organizational Alliance led to this collaboration. Some interactive sessions and case studies were geared primarily toward nurses, who frequently coordinate and champion the Own the Bone program at their institutions.

Atypical femur fractures
Kyle J. Jeray, MD,
of the Greenville Hospital System University Medical Center, and Richard M. Dell, MD, of the Southern California Kaiser Permanente Medical Group, discussed the recognition and management of atypical femur fractures. Both agreed that the recognition and incidence of these fractures is increasing. Patients frequently have a history of thigh or groin pain and many have been taking bisphosphonates for an extended period, although these injuries can occur in individuals who have never received bisphosphonate therapy.

Patients are commonly younger than the typical hip fracture patient, female, and white or Asian. Radiographs may show a thickened or flared lateral cortex. Although these changes have most frequently been described in the subtrochanteric region, they can be seen anywhere along the femoral shaft.

Both Drs. Jeray and Dell agreed that rodding, not plating, is the preferred treatment. Dr. Jeray also supports prophylactic roding of femurs with signs and symptoms of an atypical fracture to reduce the risk of complications and repeat surgery and enable patients to return to their previous levels of activity quickly. Dr. Dell, however, noted that prophylactic rodding may not always be necessary because many patients will heal if they are taken off bisphosphonates, put on restricted weight bearing and exercise, and observed carefully.

Long-term use of bisphosphonates
According to Theresa Kehoe, MD, U.S. Food and Drug Administration (FDA) medical officer, the agency recently held hearings on the long-term use of bisphosphonates. She noted that few studies have followed patients taking these drugs beyond 5 years and the studies that have been conducted were not designed to demonstrate impact on fractures.

Although the literature confirms the efficacy of bisphosphonates in reducing the risk for fracture, Dr. Kehoe noted that atypical fractures appear to be associated with bisphosphonate use. The relationship between duration of use and atypical fractures is unclear, however, and causality is uncertain. Available data suggest that it may not be necessary to keep patients on bisphosphonates indefinitely and that therapy can be safely discontinued after 3 to 5 years in many cases. A subset of patients, however, might benefit from continued therapy.

Dr. Kehoe noted that additional data are needed to define the appropriate duration of drug cessation (a “drug holiday”) needed to protect patients from these fractures, as well as to define interim monitoring criteria.

Vitamin D and calcium
According to Chad T. Price, MD, of Orlando Regional Healthcare, an increasing amount of research has focused on the negative side effects of increasing calcium with calcium supplementation. Recent reports have shown an increase in the number of myocardial infarctions (MI) in patients taking calcium supplements; increasing dietary calcium, however, shows no such association.

The current hypothesis is that ingesting calcium supplements results in high levels of calcium that cannot be absorbed appropriately; dietary calcium is released and absorbed more slowly, which is safer. Dr. Price noted that calcium supplements should only be used when benefits outweigh the risks.

Osteoporosis
Laura L. Tosi, MD,
of the Children’s National Medical Center, addressed the changing epidemiology of osteoporosis. She noted that osteoporotic fractures do not only affect Caucasian women. In fact, similar to Caucasian women, the risk of a fragility fracture in minority women is more common than MI, stroke, and breast cancer combined.

Low bone mass is the most accurate predictor of increased fracture risk, according to Joseph M. Lane, MD, of the Hospital for Special Surgery. Dr. Lane proposed using several laboratory tests—including a complete blood count, erythrocyte sedimentation rate, calcium, albumin, phosphorous, comprehensive metabolic panel (SMA 12), intact parathyroid, 25 (OH) vitamin D, and 24-hour urinary calcium—to evaluate patients for secondary causes of osteoporosis. Other indicators would include thyroid (T3, T4, thyroid stimulating hormone), testosterone, estradiol, immunoelectrophoresis (myeloma), and sprue (celiac) panel.

Dr. Dell noted that The World Health Organization’s FRAX® tool integrates clinical risk factors and bone mineral density testing. The online tool focuses on quantitative assessment of fracture risk and can be used by anyone; it is also useful in determining cost-effective intervention thresholds.

Preventing recurring fractures
Stephen L. Kates, MD,
of the University of Rochester, discussed the key components of a geriatric fracture program and stressed the importance of having a program that encourages comanagement by appropriate specialties. Susan Randall MSN, FNP, senior director, science and education, at the National Osteoporosis Foundation, reviewed effective patient education strategies, such as tailoring teaching plans, using “teach back,” involving the whole team, and recognizing the importance of cultures, beliefs, and experiences. Case studies were used to illustrate the need to consider bone health in adults older than age 50 with a fracture; evaluating fracture risk using clinical risk factors, FRAX, and DXA scans; counseling and evaluating the patient for lifestyle risk factors; reducing fall risk; and prescribing osteoporosis medications.

Overall, the symposium provided a venue for education and discussion on some of today’s most challenging and intriguing bone health questions. The next Own the Bone symposium will be held in collaboration with the Orthopaedic Trauma Association on Friday, Oct. 5, 2012, in Minneapolis. For additional information, visit www.ota.org

Laura L. Tosi, MD, is a member of the AAOS Women’s Health Issues Advisory Board; Debra Sietsema, PhD, RN, is the clinical research director at Orthopaedic Associates of Michigan.