Faculty and attendees of the AAOS/ORS Bone Quality and Fracture Prevention Research Symposium. The symposium provided state-of-the art information about bone quality, including the contribution of bone quality to skeletal integrity, noninvasive assessment of bone quality, and pharmacologic and surgical management of patients with impaired bone quality. Larger image (PDF)
Published 9/1/2013
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Terry Stanton
Osteoporosis and other bone fragility conditions pose an ever-expanding health problem, yet overall these conditions continue to go undermonitored and undertreated. At a recent Bone Quality and Fracture Prevention Research Symposium organized by the AAOS and the Orthopaedic Research Society (ORS), clinicians and researchers gathered to share the current state of knowledge in regard to bone quality and fracture prevention. They also discussed strategies to increase awareness and diagnostic vigilance and to achieve better treatment outcomes, both by exploring proven modalities and researching new ones.
The extent of the problem
Susan V. Bukata, MD, of the University of California Los Angeles, provided an overview of the extent of the problem, as follows:
- Osteoporotic fractures occur in 50 percent of women and 30 percent of men aged 50 and older.
- In the United States, 1.5 million to 2 million fragility fractures occur annually, including 300,000 hip fractures and 750,000 vertebral fractures.
- Over the next 50 years, “the numbers will only go up as the ‘silver tsunami’ comes through,” she said, and the problem will be even more acute in Asia.
- Osteoporotic fractures are a major risk factor for subsequent fractures (Fig. 1). Ten percent of persons with fragility fractures will have another fragility fracture within 1 year, 17 percent to 21 percent will have a second fracture within 2 years, and 9 percent of patients who have a hip fracture will break the other hip within 2 years.
Dr. Bukata noted that the 1-year mortality following fragility fractures is 25 percent for women and 30 percent for men. Even in a seemingly lower-risk population, she added, “11 percent of healthy, community-dwelling individuals who sustain a hip fracture will be dead 1 year after that fracture.”
Despite the risk for a second fracture incurred after the first, treatment is often insufficient. “We haven’t done a really great job of identifying people at risk,” Dr. Bukata said. “Whether with orthopaedic surgeons, primary care doctors, or endocrinologists who see these patients, patients are dropping through the cracks. Even after 10 years of public health campaigns, they’re not receiving proper osteoporosis treatment. Only about 20 percent of patients get treatment after having a fragility fracture.”
In light of the focus on reducing healthcare costs, said Dr. Bukata, “We need to do better. We have evidence that if we do better, we not only reduce fractures, we save money.”
Healthy Bones program
One place that achieved those goals was Kaiser Permanente Southern California. Under its Healthy Bones program, patients with fragility fractures were contacted and counseled by a nurse liaison to arrange osteoporosis care and treatment.
In a milestone study that tracked more than 625,000 male and female participating patients older than age 50 for 5 years, the program reduced the number of hip fractures by 38.1 percent, better than the 25 percent target rate. This represented a savings of $30 million a year.
Participating physicians implemented several initiatives including increasing the use of bone density tests (DXA scans) and anti-osteoporosis medications, adding osteoporosis education and home health programs, and standardizing the practice guidelines for osteoporosis management.
“It’s a misconception that nothing can be done to prevent or treat osteoporosis,” said Richard M. Dell, MD, of Kaiser Permanente. “It is possible to reduce the U.S. hip fracture rate by at least 25 percent if orthopaedic surgeons take a more active role in osteoporosis disease management.”
Challenges and compliance
Dr. Bukata identified several challenges in delivering therapy, as follows:
- identifying the patient correctly
- performing the correct intervention
- selecting the correct time to intervene
- achieving patient acceptance and then compliance
“Getting patients to recognize that there’s a problem can be difficult,” she noted. “You’ll hear 85-year-old patients say, ‘Oh, osteoporosis is an old person’s disease.’ They fall, but don’t think it will happen again. Because osteoporosis can be asymptomatic for most patients, it’s hard to prevent the first fracture. People think it’s a natural part of aging.”
Compliance is another challenge, she said. At 3 months, less than 50 percent of patients continue to fill their prescriptions, regardless of what the therapy is; 30 percent are compliant at 1 year, and just 16 percent are compliant at 3 years.
“That’s abysmal,” Dr. Bukata said. “Imagine if that was for hypertension medications.” Although weekly bisphosphonate dosing has a 45 percent compliance rate, Dr. Bukata noted that efficacy decreases dramatically with many medications. “If you take bisphosphonates 50 percent of the time, you get zero fracture protection.”
When patients are compliant, therapy works. Among women older than 65 years, the fragility fracture rate declines from 5.18 percent to 3.75 percent over 2.4 years. That extrapolates to 144,670 fewer fractures during the period. In compliant patients, the risk of spine fracture decreases by 50 percent to 77 percent, and the risk of hip fracture drops by 20 percent to 40 percent. Bisphosphonate therapy after hip fracture decreases mortality by 28 percent.
Many patients fail to comply because they are afraid of side effects or for other reasons. “They’ve checked the Internet and seen a laundry list of side effects,” Dr. Bukata said. “Unfortunately, they don’t also look at the YouTube ‘break your hip and die’ video. They are not feeling a tremendous benefit from the medication. And it might be expensive.”
Dr. Bukata said that measurement of bone turnover markers, such as serum C-telopeptide, urine N-telopeptide, and osteocalcin may be useful in predicting fracture risk and in determining dose interval and management of therapies for patients.
“We need to know patient characteristics to better match therapies with the patient. We have to move beyond bone mass density (BMD),” she said. “We know that bone turnover itself is an increased risk for fracture. Patients with low BMD and high turnover are even more likely to experience a fracture.”
Basic counseling about falls and fall prevention can be helpful, she said. “Falls beget fractures. We can teach patients how they can fall better. These are low-energy associated fractures, from standing height or less. It is a myth that you break first and then you fall; 95 percent of hip fractures are associated with a fall.”
She advised physicians to take a fall prevention history of their patients, she said. “See if they are using the chair arms to stand. Can they stand on a single leg for more than 5 or 10 seconds? Medications can make them dizzy and more likely to fall.”
Basics of home safety should be explained, including better lighting, clearing objects from the floor, installing safety devices in the bathroom, and using assistive devices.
Disclosure information: Dr. Bukata—Eli Lilly, Amgen, Merck, Bone and Joint Initiative, ASBMR Practice Committee, AAOS PAC; Dr. Dell: No conflicts reported.
Terry Stanton is senior science writer for AAOS Now. He can be reached at tstanton@aaos.org
Bottom Line
- Half of women and 30 percent of men older than age 50 will incur an osteoporosis-related fracture.
- One-year mortality following a fragility fracture is 25 percent for women and 30 percent for men.
- Osteoporosis continues to be underdiagnosed and insufficiently treated.
- Patient noncompliance with therapy is a contributing factor to fragility fractures.
Additional Information