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A dual-energy x-ray absorptiometric scan for a 61-year-old white woman. Sarwark JF (ed): Essentials of Musculoskeletal Care 4. Rosemont, IL, American Academy of Orthopaedic Surgeons, 2010, p. 153

AAOS Now

Published 4/1/2013

Face Off: Bone Health Management

POINT: Internists should be in charge of bone health.
Douglas W. Lundy, MD, FACS

In taking the “internist” side of this argument, I must admit to being somewhat conflicted. Although I firmly believe that orthopaedic surgeons should be more involved in the bone health of our patients, I can see that internal medicine physicians are more focused on a daily basis on the issues that often lead to poor bone health and the treatment of those conditions.

Clearly, chasing down metabolic labs and acting on the results of these values is more along the daily tasks of the internal medicine physician. The internist is the expert in understanding the interplay of disease processes, medicines, and lab values.

Few orthopaedic surgeons understand how to interpret bone densitometry reports. As orthopaedic surgeons, we have different workflows focused on issues other than the treatment of osteoporosis. Knowing the effects of the different osteoporosis medications, their interactions with other drugs that the patient is taking, and their impact on renal function is within the purview of the internist. They are the experts in the medical treatment of patients.

Few orthopaedic surgeons have the time or interest to engage and keep up-to-date on these activities and the overall care of patients with bone health issues. Most internists have a better knowledge base in these areas than we do. Our focus is more episodic: Fix the problem and get the patient well. Long-term treatment of chronic disease like osteoporosis doesn’t necessarily fit well in an orthopaedic practice.

Even if an individual orthopaedist is interested in bone health, obtaining “buy-in” and changing the attitudes of his or her partners are challenging. Concerns over medical liability for refilling unfamiliar prescription medications will be ever-present if all of the physicians in the practice aren’t on board. An orthopaedic surgeon’s partners may not be all that enthusiastic about seeing a hospital consult for bone health—especially during a long day on call while also taking care of surgical issues, paperwork, and rounds. As a result, all of the partners in the practice would have to be receptive to the concept of caring for the bone health of the clinic’s patients.

Duplication of cost is also an issue. If the internist is already actively managing the patient’s other chronic conditions, why should the patient make yet another appointment with an orthopaedic surgeon to have his or her bone health evaluated? Many of these patients have limited resources and physical difficulties getting to and from physician appointments.

Centralizing care is paramount to decreasing cost, reducing complications from conflicting treatments, enhancing communication, and improving overall outcomes. Fragmentation of care is never ideal, and the consolidation of care in one spot is what is best for the patient.

One last real concern for many orthopaedic surgeons is the perceived impact on referrals. Orthopaedic surgeons may wonder whether the internal physicians who refer patients to their offices will be offended by the surgeons’ decision to see patients for osteoporosis and stop sending patients their way. Although an awkward concept to consider, this is a real concern for many orthopaedic surgeons. Our livelihood is often associated with maintaining good relations with our referring physicians, and we do not relish the thought of damaging those relationships. The concept of “stealing patients” from those who send these same patients to us is unpalatable.

A fracture liaison person or service may alleviate this perceived risk or concern. Because the liaison is usually a nurse practitioner or physician’s assistant, the internist and the surgeon should have less anxiety if the liaison evaluates patients and communicates treatment.

Having now made the argument that bone health belongs in the hands of the internist, allow me to state my true view. Regardless of the points I have advocated, I firmly believe that orthopaedic surgeons are the best choices to manage the bone health of our patients, and no other physicians are better suited to achieve this goal.

Douglas W. Lundy, MD, FACS, is a member of the AAOS Now Editorial Board and a trauma specialist at Resurgens Orthopaedics.

Disclosure information: Dr. Lundy—Synthes; Livengood Engineering; Clinical Orthopaedics and Related Research (CORR); Journal of Orthopaedic Trauma; Orthopedics; AAOS; American Board of Orthopaedic Surgery, Inc.; American College of Surgeons; Georgia Orthopaedic Society; Orthopaedic Trauma Association.

COUNTERPOINT: Orthopaedists should be in charge of bone health.
Clifford B. Jones, MD, FACS

Osteoporosis is a healthcare crisis. The burden of cost to society is more than congestive heart failure, breast cancer, and asthma combined. With more than one in two women and one in four men affected, the prevalence is common. Furthermore, baby boomers are now getting older and will be afflicted with this not-so-silent disease.

A better term for osteoporosis treatment is bone health. Bone health encompasses prevention of bad bone health, enhancement fracture healing, and prevention of potentially preventable fractures.

As orthopaedic surgeons, we should be in charge of bone health for three main reasons. First, we should lead the way in preventing osteoporotic fractures. Second, we should enhance fracture healing in our patients. Third, we should relieve some of the burden of this chronic disease from our hard-working medical colleagues.

Preventing osteoporotic fractures is paramount. The aging population is growing. The number of osteoporotic hip fractures is growing even more rapidly. With one-fourth to one-third of all hip fractures resulting in death within 3 to 6 months of the event, the mental burden to the family is terrible, and the financial burden to society is enormous.

We need to do whatever is needed to prevent this tsunami of future fractures. When treating a fracture resulting from a low energy fall, the orthopaedist should initiate the bone health evaluation, diagnosis, and treatment process. Unless the orthopaedist sounds the alarm, the patient will be missed and forgotten until he or she has another low energy fall fracture.

Enhancing fracture healing starts with initiating bone health treatment. Metabolic problems have been reported in fracture patients, particularly those who have fracture-healing problems and nonunions. Removing or reducing bad bone health factors—such as poor diet, little or no exercise, and smoking—is more difficult than it sounds.

Is the patient taking any harmful bone-health medicines (anti-seizure medicines, antacids, long-term bisphosphonates, or steroids)? Should the patient be taking vitamin D, vitamin C, and calcium-containing compounds to supplement his or her diet? These are aspects of the intake history and physical components of importance to the orthopaedic surgeon.

Today’s internist is overworked and overburdened with other, more acute patient diseases. Many internists are not accepting new patients and are booking evaluations for known patients 6 months to 9 months in advance. Orthopaedists who manage bone health would not be stealing their patients.

We are trying to show that we care about things other than just operating and that we can “shoulder some of the burden” of bone health. As orthopaedic surgeons, we know more about bone health factors, mechanisms of injury, fracture patterns, bone quality, fracture fixation, and causes of delayed union or nonunion than anyone else.

A low energy fall-induced fracture may be the first time a patient is evaluated for bone health. This is the potential “canary in the coal mine.” A comminuted or extensive fracture pattern or marginal impaction resulting from a low energy fall should raise suspicion for inferior bone health.

We are the ones who operate on bone. We clamp, drill, and put screws into the bone during fracture fixation and implant insertion. We can assess bone quality during every operative case and this assessment can aid the interpretation of the bone density via a DEXA scan.

To enhance bone health treatment and prevent osteoporotic fractures, a change in paradigm is required. As orthopaedic surgeons, we need to take more of a lead role in bone health initiation and management because we are the bone health experts. Comments of being “too busy,” “too uncomfortable,” and “not my responsibility” for bone health issues from orthopaedic surgeons—who graduate at the top of medical school classes and should be involved with bone health—are inappropriate and irresponsible.

We should be the stewards of bone health and fracture prevention. We must find better methods to communicate, educate, and engage our internal medicine brethren for “shared” or “co-managed” care of our patients. We cannot ignore or shirk this duty. A fracture liaison position, as suggested by the American Orthopaedic Association, may be the answer for both arguments and specialties. The fracture liaison may also be the person who attends to the patient’s bone health, fracture prevention, and patient education once the fracture has healed and the patient is discharged from the surgeon’s care.

Clifford B. Jones, MD, FACS, specializes in trauma surgery at Orthopaedic Associates of Michigan.

Disclosure information: Dr. Jones—Journal of Bone and Joint Surgery–American; Trauma Newsletter; Journal of Orthopaedic Trauma; CORR.