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Fig. 1 Preoperative AP pelvic radiograph showing a displaced right acetabular fracture in a 76-year-old woman with osteoporosis. Note that the patient has already received a left total hip arthroplasty. Reproduced from Schmidt AH, Braman JP, Duwelius PJ, McKee MD: Geriatric Trauma: The Role of Immediate Arthroplasty. Inst Course Lect 2014;63:49­–59.

AAOS Now

Published 10/1/2015
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Andrew D. Bunta, MD

Bone Health and the Challenge to Orthopaedic Surgeons

The time has come for orthopaedic surgeons to play a greater role in the bone health of our patients. The recent progress in both the evaluation and treatment of osteoporosis—coupled with an aging population, changing dietary habits among youth, and a general decrease in physical activity at all ages—means that we can no longer avoid our involvement in this significant public health issue.

Just what degree of involvement is necessary depends on each clinical practice situation. Nevertheless, myriad options exist, and it is incumbent upon each of us to decide what role to play in meeting the skeletal health needs of our patients.

Orthopaedic surgery presents itself as the leading specialty in the management of musculoskeletal diseases. Under the mantle of that leadership, we must treat or coordinate the treatment of the major injuries and disease states related to the musculoskeletal system. That scenario also implies working closely in an interdisciplinary fashion with other related specialties. In no other area is this more critical than in the realm of our patients’ bone health.

Orthopaedic surgery has markedly improved the health of the American public over the last few decades. Joint arthroplasty, spinal reconstruction, and fracture management are just a few of the ways that orthopaedics has led to major improvements in quality-adjusted life years for patients. More sophisticated surgical interventions with improved outcomes, modern rheumatologic drug therapy, including biologics, and advances in prosthetic and orthotic designs have all markedly improved the human condition.

At the same time, other medical specialties—such as cardiology and endocrinology—have made great gains in population health. Notable examples are the interventional techniques and the use of medical management for cardiovascular conditions and improved therapies for diabetes mellitus. The result is that more people are living longer and thus are being exposed to an increasing incidence of osteoporosis and the distress of the fragility fractures that often accompany that condition.

With the annual occurrence of two million or more low-trauma fractures in the United States, the bone health of our population has become a considerable public health concern. The Surgeon General clearly pointed out this problem more than a decade ago in the 2004 report, “Bone Health and Osteoporosis.” But despite that national call to action, the medical and orthopaedic communities have not adequately raised public awareness of the need for osteoporosis evaluation and treatment.

Making an attempt
In 2006, the AAOS began promoting the “Fit-to-a-T” program, developed by the U.S. Bone and Joint Initiative (USBJI). The program attempts to educate the public—especially older adults—about the need for DXA scanning and other bone health maintenance guidelines. The National Osteoporosis Foundation has an ongoing campaign directed at seniors and others who have bone health disorders, making them aware of osteoporosis and the need for better bone health to prevent fractures and disability.

As part of the USBJI campaign for increased public awareness of all musculoskeletal issues, including population bone health, Oct. 12–20 each year is designated “Bone and Joint Health Action Week,” and Oct. 20 is World Osteoporosis Day. (See “Get Ready for Bone and Joint Action Week.”)

In the United Kingdom, other European countries, Australia, New Zealand, and Canada, hip fracture patients are routinely offered coordinated evaluation of their underlying bone health. Increasingly, U.S. physicians and other population health experts now understand the value of a fracture liaison service. This model simply designates a midlevel provider as the coordinator of bone health treatment for fragility fracture patients.

The American Orthopaedic Association initiated its “Own the Bone” program in 2009 to bring this significant health issue to the attention of the orthopaedic community, while attempting to engage other medical specialties and primary care physicians in this vital public health challenge. The ultimate goal was to adopt the methodology of the cardiology community and their “Get with the Guidelines” program (the use of beta-blockers to prevent recurrent myocardial infarction), while also employing a web-based registry to document treatment and deliver benchmarking capabilities.

Although these efforts have met with some success, we still fail to evaluate and treat the vast majority of patients with fragility fractures for osteoporosis (Fig. 1). Only one in five patients (slightly more than 20 percent) is adequately counseled and treated, if necessary, for osteoporosis following a fragility hip fracture. If we considered the number and prevalence of vertebral fractures—many of which are not clinically evident, that percentage would be far lower. We also need to ask ourselves: How many older adults with distal radial fractures are advised to obtain a bone health evaluation?

A living system, an interdisciplinary approach
The general public does not understand that the skeleton is a “living organ system” that needs appropriate nutrition and maintenance as well as injury prevention. In addition, most primary care physicians and many medical specialists do not realize the crucial role that bone health maintenance should play in their patients’ aging process—not only to prevent fractures and their associated morbidity and disability but also to address the increased mortality associated with some fragility fractures.

As orthopaedic surgeons and geriatricians recognize the need for a more structured, interdisciplinary approach to the care of hospitalized fracture patients, geriatric fracture programs are being established. These programs can mitigate many of the severe, early complications—and some of the long-term disabilities—associated with fragility fractures. They use efficient preoperative evaluations, rapid surgical interventions, early postoperative mobilization, and bone health education in addition to structured order sets and appropriate medication for older adults. There can be no doubt that such programs are of great benefit to our patients.

Even the AAOS Clinical Practice Guideline for the “Management of Hip Fractures in the Elderly” includes osteoporosis evaluation and treatment, noting that a hip fracture is a sign and symptom of osteoporosis. In other words, this “sentinel event” must not be ignored. With multiple effective pharmacologic treatments for osteoporosis, including an anabolic agent as well as bisphosphonates, we can clearly make the case for therapeutic intervention in many fragility fracture patients.

The entire pediatric community, including our orthopaedic colleagues, must also emphasize the importance of maximizing younger patients’ bone health in the first three decades of life. The current increase in the number of spine surgeries, many with instrumentation, underscores the need for preoperative assessment of the bone health of those patients. Many orthopaedic spine surgeons do realize the importance of preoperative osteoporosis treatment for their patients so that bone density before surgery is optimized to enhance fixation and improve outcomes. Preoperative bone optimization may also have application in the joint arthroplasty community.

Certainly, the process of improving an older adult’s skeletal health can begin with simple things. These steps include obtaining a preoperative vitamin D level (25-OH vitamin D), ensuring adequate calcium intake and vitamin D supplementation, obtaining a DXA scan prior to elective surgery and following a fracture, and providing information on fall prevention and exercise programs.

This is the least we, as orthopaedic surgeons, should do for our patients. Multiple models of care are now available for osteoporosis treatment, depending on the structure of each practice and the degree of involvement the orthopaedist desires. Some may involve hospital programs and others may be outpatient or clinic-based. The expanding use of advanced practice providers (including nurse practitioners and physician assistants) in many practice settings offers an obvious and important opportunity to facilitate patients’ bone health care, or at least ensure some degree of coordination.

And yet, the challenge of maintaining bone health continues for older fracture patients in particular and for the population in general. It seems only fitting that the orthopaedic surgery community should now assume a far more proactive role in recognizing osteoporosis and responding with appropriate prevention and treatment. Many orthopaedists may think that this issue does not reside within our specialty, but if we expect to be true leaders in the musculoskeletal health of our patients and our population, we must step forward as a concerned medical and surgical specialty and take the lead in this public health challenge.

It’s been 11 years since the Surgeon General’s report and its national call to action. Let’s accept—and act on—that challenge now.

Andrew D. Bunta, MD, is an associate professor in the department of orthopaedic surgery at the Northwestern University Feinberg School of Medicine.

Editor’s Note: This is the first in a series of articles on osteoporosis and bone health. Future articles will cover the clinical assessment of osteoporosis, including lab and imaging studies, and an overview of current treatment modalities.

As author Andrew D. Bunta, MD, notes, bone health issues are not limited to older patients. Virtually every orthopaedic surgeon—whether a pediatric, sports, trauma, arthroplasty, or spine specialist—needs to understand the current concepts in bone quality assessment and therapeutics. AAOS Now invites readers to share their experiences, pearls, and frustrations in the management of bone quality issues; email them to aaoscomm@aaos.org