Fragility fractures represent a major global health problem. Orthopaedic surgeons have a unique opportunity to improve outcomes for fracture patients by addressing the underlying osteoporosis. Currently, few fracture patients receive evaluation and treatment for osteoporosis despite the condition increasing their risk of future fractures 2-5 times. There is a need for orthopaedic surgeons to play a more active role in optimizing care through evaluating bone mineral density, educating patients on osteoporosis risks, and facilitating referrals to ensure fracture patients receive treatment to prevent future fractures.

1. 1
Osteoporosis and fractures
An orthopaedic perspective
By
A.Arputha Selvaraj APMP –IIM Calcutta

2. 2
Why is the Orthopaedic Surgeons Initiative needed?
• Fragility fractures are a large and growing health issue
– 1 in 2 women and 1 in 4 men over 50 yrs of age will suffer a fracture in
their remaining lifetime
• A prior fracture increases the risk of a new fracture 2- to 5-fold
• Yet few fracture patients receive evaluation and treatment of
osteoporosis, the underlying cause of most fragility fractures
– Calls for action to improve the evaluation and treatment of fracture
patients have been published around the World1,2
1.
2.
Eastell et al. QJM 2001; 94:575-59
Bouxsein et al. J Am Acad Ortho Surg. 2004; 12:385-95

3. Orthopaedic surgeons have a unique
opportunity
• Fragility fracture is often the first indication a patient has
osteoporosis
• Orthopaedic surgeons are often the first and may be the
only physician seen by fracture patients
• The orthopaedist can serve a pivotal role in optimizing
treatment, not only of the fracture, but also of the
underlying disease
1.
2.
Eastell et al. QJM 2001; 94:575-59
Bouxsein et al. J Am Acad Ortho Surg. 2004; 12:385-95
3

4. 4
Multinational Survey of
Osteoporotic Fracture Management
Survey of 3422 orthopaedic surgeons from 6 countries
•
90% do not routinely measure bone density following the first fracture
•
75% are lacking appropriate knowledge about osteoporosis
Dreinhöfer et al. Osteoporos Int 2005; 16:S44-S54

5. 5
Goals of the Orthopaedic Surgeons Initiative
• Improve awareness of the scope and magnitude of fragility
fractures as a global public health concern
• Improve understanding of osteoporosis and recognition that
it is the underlying cause of most fragility fractures
• Motivate orthopaedic surgeons to take an active role in
optimizing care of the fragility fracture patient with the
ultimate goal of preventing future fractures

6. 6
Outline
• Fragility fractures and osteoporosis: an expanding
epidemic with devastating consequences
• Osteoporosis and fragility fractures: definition and
etiology
• Optimal care of fragility fracture patient

7. 7
Outline
• Fragility fractures and osteoporosis: an expanding
epidemic with devastating consequences

8. 8
Osteoporosis and fragility
fractures:
An expanding epidemic

9. 9
Fragility fractures are common
• 1 in 2 women and 1 in 5 men over age 50 will suffer a
fracture in their remaining life time1
• 55% of persons over age 50 are at increased risk of
fracture due to low bone mass
• At age 50, a woman’s lifetime risk of fracture exceeds
combined risk of breast, ovarian & uterine cancer
• At age 50, a man’s lifetime risk of fracture exceeds risk of
prostate cancer
1.
Johnell et al. Osteoporos Int. 2005; 16: S3-7

10. 10
Fractures will be more common
• Fracture incidence projected to increase 2- to 4-fold in the
next decades due to ageing of the population
• In Europe
– 12% to 17% of population >65 in 2002
– 20% to 25% of population >65 in 2025
Aged 70+
1990
Men
Women
2030
Men
Women

11. 1950 2050
05 23
006
004
873
926
247
Total number of
hip fractures
worldwide projected
to increase 3- to 4fold in next 50 years
Projected to
reach 3.25
million in
Asia by 2050
866
Number of hip fractures projected
to increase 3 to 4-fold worldwide
11
1950 2050
1950: 1.66 million
001
1950 2050
2050: 6.26 million
1950 2050
Estimated number of hip fractures (1000s)
Cooper et al. Osteoporos Int 1992; 2:285-289

12. 12
Annual incidence x 1000
Osteoporotic fractures:
Comparison with other diseases
2000 annual incidence
all ages
1500
1000
1 500 000
250 000
hip
250 000
forearm
250 000
other sites
500
0
annual estimate
women 29+
513 000 annual estimate
women 30+
750 000
vertebral
Osteoporotic
fractures
228 000
Heart
attack
American Heart Association, 1996
American Cancer Society, 1996
Riggs & Melton, Bone, 1995; 17(5 suppl):505S-511S
Stroke
1996 new cases,
184 300 all ages
Breast
cancer

13. 13
Osteoporosis and fragility
fractures:
Morbidity, mortality and costs

14. 14
Consequences of hip fracture
One year after hip fracture
Unable to carry out at
least one independent
activity of daily living
80%
Unable to
walk
independently
Patients
(%)
Death within
one year
Permanent
disability
20%
Cooper. Am J Med 1997; 103(2A):12s-19s.
30%
40%

15. 15
Consequences of vertebral fractures
• Acute and chronic pain
– Narcotic use, decrease mobility
• Loss of height & deformity
– Reduced pulmonary function
– Kyphosis, protuberant abdomen
• Diminished quality of life:
– Loss of self-esteem, distorted body image, sleep disorders,
depression, loss of independence
• Increased fracture risk
• Increased mortality

16. 16
Consequences of distal radius fractures
• The most common fracture in women at
middle age
– Incidence increases just after menopause
• The most common fracture in men below
70 years
• Only 50% report good functional outcome
at 6 months
• Up to 30% of individuals suffer long-term
complications
O'Neill et al. Osteoporos Int. 2001; 12:555-558

17. 17
Mortality due to hip fracture vs. stroke
(deaths per 100,000 in older women)
Hip fracture
Stroke
Sweden
177
154
Denmark
154
180
Germany
131
190
Hip fracture data: age 80; Kanis. J Bone Miner Res. 2002; 17:1237
Stroke data: ages 65-74; Sans et al. Eur Heart J 1997; 18:1231

18. 18
Cumulative survival probability
WOMEN
1.0
Survival probability
Survival probability
1.0
0.8
0.6
0.4
0.2
0
60
65
70
75
MEN
80
85
0.8
0.6
0.4
0.2
0
60
65
Age
75
Age
Dubbo Population
Vertebral/Major Fractures
Proximal Femur Fractures
Center et al. Lancet 1999, 353:878-882
70
80
85

19. 19
Mortality after major types of
osteoporotic fracture in men and women
5-year prospective cohort study
Age-standardized mortality ratio
Fracture
Women
Men
Proximal femur
2.2
3.2
Vertebral
1.7
2.4
Other major
1.9
2.2
Center et al. Lancet 1999; 353:878-882

20. 20
Prior fracture increases the risk
of subsequent fracture
Risk of subsequent fracture
Site of prior
fracture
Hip
Spine
Forearm
Minor fracture
Hip
2.3
2.3
1.9
2.0
2.5
4.4
1.7
1.9
1.4
1.4
3.3
1.8
1.9
1.8
2.4
1.9
Spine
Forearm
Minor fracture
A prior fracture increases the risk of new fracture 2- to 5-fold
Klotzbuecher et al. J Bone Miner Res 2000; 15:721-727

21. Economic cost of osteoporosis and
fragility fractures in Europe
• In Europe the total direct costs of osteoporotic fractures are
over €31 billion and are expected to increase to more that
€76 billion in 20501
• In France osteoporotic hip fractures are estimated to cost
about €1 billion every year2
• In Spain the total direct hospital cost of osteoporotic
fractures in 1995 was ~ €222 million2
• In England & Wales the total direct hospital cost of
osteoporotic fractures in 1999 was ~ €847 million2
1. Kanis and Johnell, Osteoporos Int.2005; 16 Suppl 2:S3-7
2. Osteoporosis in the European Community: A Call to Action. IOF Nov, 2001
21

22. 22
Economic impact of osteoporosis
Annual economic cost of treating fractures in the USA is
similar to that of treating cardiovascular disease and
asthma
Prevalence
Annual direct cost
including hospitalization
(millions)
(US$ billion)
Cardiovascular
disease
4.6
20.3
Osteoporosis
10
13.8
Asthma
15
7.5
Disease
Information supplied by National Heart, Lung & Blood Institute,
National Osteoporosis Foundation, American Heart Association

23. 23
Fragility fractures are common and have
severe consequences
Fragility fractures lead to major morbidity, decreased quality of life
and increased mortality
– 10-25% excess mortality
– 50% unable to walk independently after hip fracture
– 50% show substantial decline from prior level of function (many lose
ability to live independently)
– Increased depression, chronic pain, disability
– Increased risk of subsequent fracture

24. 24
Outline
• Fragility fractures and osteoporosis: an expanding
epidemic with devastating consequences
• Osteoporosis and fragility fractures: definition and
etiology

25. 25
Definition of osteoporosis
“…a systemic skeletal disease
characterized by low bone mass and
micro-architectural deterioration of
bone tissue, leading to enhanced
bone fragility and a consequent
increase in fracture risk.”
World Health Organization (WHO), 1994

26. 26
Major risk factors for fractures
• Prior fragility fracture
• Increased age
• Low bone mineral density
• Low body weight
• Family history of osteoporotic fracture
• Glucocorticoid use
• Smoking

27. 27
Incidence per 100,000 person-years
Osteoporotic fracture incidence
Men
Women
4,000
3,000
Hip
Hip
2,000
Vertebrae
Vertebrae
1,000
Forearm
Forearm
35
55
35
75
Age
Cooper et al. Trends Endocrinol Metab 1992; 3:224
55
75

28. 28
Remaining lifetime fracture risk (%) in Caucasian
population at the age of 50
Type of fracture
Men
Women
4.6
20.8
10.7
22.9
Spine
8.3
15.1
Proximal humerus
4.1
12.9
22.4
46.4
Forearm
Hip
Other
Johnell et al. Osteoporos Int. 2005; 16 Suppl 2:S3-7

29. 29
Fracture risk depends on age and BMD
20
10 year Hip Fracture
80
Age
(years)
Women
70
Probability (%)
10
60
50
0
-3
-2
-1
0
Femoral BMD T-score (SD)
1

30. 30
Assessing bone density
• X-ray observation
– “Osteopaenic on x-ray” implies significant
bone loss already – decreased opacity,
thin cortices, wide canals, current fracture,
healing fractures
– A “late finding” in the course of the
disease, but may be the “first finding” for a
patient

31. 31
Assessment of bone mineral density by DXA
Current gold standard for diagnosis of osteoporosis
BMD (g/cm2) = Bone mineral content (g) / area (cm2)
Diagnosis based on comparing patient’s
BMD to that of young, healthy individuals of
same sex

32. 32
Fracture risk increase per 1 SD decrease in BMD
Fracture Site
Forearm
Hip
Vertebral
All
Distal radius
BMD
1.7
1.8
1.7
1.4
Hip BMD
1.4
2.6
1.8
1.6
Lumbar spine
BMD
1.5
1.6
2.3
1.5
Meta-analysis by Marshall et al, Br Med J. 1996

33. 33
WHO criteria for diagnosis of
osteoporosis
T-score: Difference expressed as standard deviation compared
to young (20’s) reference population
T-score
Normal
Osteopaenia
Osteoporosis
Severe (established)
osteoporosis
Kanis et al. J Bone Miner Res 1994; 9:1137-41
- 1.0 and above
- 1.0 to - 2.5
- 2.5 and below
- 2.5 and below, plus one
or more osteoporotic
fracture(s)

34. 34
Osteoporotic fracture and BMD
Fractures per 1,000 person-years
50
40
Number of fractures
Fracture rate
400
Women with fractures
300
30
200
20
100
10
0
1.0
0.5
0.0
-0.5
Siris et al. Arch Intern Med. 2004; 164:1108-1112
-1.0
-1.5
-2.0
-2.5
-3.0
-3.5
0

35. 35
Bone strength is more than BMD
young
elderly
Images from L. Mosekilde, Technology and
Health Care. 1998
Image courtesy of David Dempster

36. 36
Determinants of whole bone strength
• Geometry
– Gross morphology (size & shape)
– Microarchitecture
• Properties of bone material / bone matrix
– Mineralization
– Collagen characteristics
– Microdamage

37. Bone remodelling balance influences bone
strength
Bone strength
SIZE & SHAPE
macroarchitecture
microarchitecture
MATERIAL
tissue composition
matrix properties
BONE REMODELLING
formation / resorption
AGEING, DISEASE and THERAPIES
Bouxsein. Best Practice in Clin Rheum. 2005; 19:897-911
37

38. 38
High Bone Turnover
Resorption > Formation
Decreases Bone Mass
Disrupts Trabecular Architecture
Increases Cortical Porosity
Decreases Cortical Thickness
L. Mosekilde
Tech and Health Care, 1998
Alters Bone Matrix Composition
Decreased Bone
Strength
Bouxsein. Best Practice in Clin Rheum. 2005; 19:897-911
Seeman & Delmas, New England J Med, 2006; 354:2250-61

39. 39
But bone quality is not the only factor…
Neuromuscular function
Environmental risks
Age
Fall
incidence
Fall characteristics
Energy absorption
External protection
Fall
impact
Fracture risk
Bone size (mass)
Bone shape
Architecture
Matrix properties
Bone
strength

40. 40
Outline
• Fragility fractures and osteoporosis: an expanding
epidemic with devastating consequences
• Osteoporosis and fragility fractures: definition and
etiology
• Optimal care of fragility fracture patient
– Critical opportunity for orthopaedists

41. 41
Millions of fragility fractures a year –
with current orthopaedic management,
most fractures will heal…
But is that enough?

42. 42
Alarming facts
• Awareness and knowledge about osteoporosis is low
among fracture patients

43. Awareness and knowledge about osteoporosis
in fracture patients is low
385 patients with fragility fractures
“Have you ever heard of osteoporosis?”
NO: 20 %
YES: 80 %
“Do you think that the fracture you have experienced could be due
to fragility of your bones?“
NO: 73 %
An Osteoporosis Clinical Pathway for the Medical Management
of Patients with Low Trauma Fracture
Chevalley et al. Osteoporos Int. 2002; 13:450-455
YES: 27 %
43

44. 44
Alarming facts
• Awareness and knowledge about osteoporosis is low
among fracture patients
• Despite availability of therapies proven to reduce fracture
risk, even in patients who have already suffered a fracture,
diagnosis and treatment of osteoporosis among fragility
fracture patients remains low

45. 45
Treatment of osteoporosis:
Are physicians missing an opportunity?
• Among 1162 women with distal radius fracture, at 6 mo
– 266 (23%) prescribed osteoporosis med
– 33 (2.8%) had bone density test
– 20 (1.7%) had bone density + OP therapy
883 (76%) received neither bone density test nor medical treatment of
osteoporosis
• Among 1654 patients (age > 50 yrs) admitted to hospital for a
fracture resulting from a fall: ~ 50% hip fracture, at 1 yr
– 247 (15%) prescribed osteoporosis med
– Women: 3 times more likely to receive treatment than men (19% vs 5%)
Freedman et al. J Bone Joint Surg 2000; 82-A:1063-70
Panneman et al. Osteoporos Int. 2004; 15:120-4

46. 46
Fracture
More to the story…

47. 47
Optimal care of the fragility fracture patient
• Diagnosis of “fragility” fracture
– Identify “fragility” fracture & underlying disease, incorporate into
existing workup
– Influences treatment plan from the onset
• General fracture management
– Stabilize patient, pain relief, fracture care
• Rehabilitation
– Minimize dependence, maximize mobility
• Secondary prevention
– Treat and monitor underlying disease, prevent future fractures

48. 48
Optimal care of the fragility fracture patient
• Diagnosis of “fragility” fracture
– Identify “fragility” fracture & underlying disease, incorporate into
existing workup
– Influences treatment plan from the onset

49. 49
Diagnose fragility fracture
Accident pattern
Definition of fragility fracture:
Fracture during activity that would not normally injure young
healthy bone (i.e., fall from standing height or less)

50. 50
Fragility fracture?
Accident pattern
Mechanism of injury:
Low trauma?
Fall from standing height or
less ?
“Fragility” fracture?
Risk assessment
Risk factors for primary and
secondary OP
Risk factors for fracture
Risk factors for fall

51. 51
Major risk factors for fractures
• Prior fragility fracture
• Increased age
• Low bone mineral density
• Low body weight
• Family history of osteoporotic fracture
• Glucocorticoid use
• Smoking

52. 52
High risk for secondary osteoporosis
• Severe chronic liver or kidney diseases
• Steroid medication (>7.5mg for more than 6 months)
• Malabsorption (eg. Crohn´s disease)
• Rheumatoid arthritis
• Systemic inflammatory disorders
• Hyperthyroidism
• Primary hyperparathyroidism
• Antiepileptic medication

53. 53
Fragility fracture patient assessment
* In addition to routine pre-op or fracture evaluation
•
•
Menarche / Menopause
•
History
should include:
Family history of OP
Nutrition
•
Medications
– (past and present)
•
Level of activity
•
Fracture history
•
Fall history & risk factors for falls
•
Smoking, alcohol intake
•
Risk factors for secondary OP
•
Prior level of function

54. 54
Fragility fracture patient assessment
In addition to routine pre-op or fracture evaluation
Physical exam
should include:
• Height
• Weight
• Limb exam
– ROM, strength, deformity, pain,
neurovascular status
• Spine exam
– pain, deformity, mobility
• Functional status

55. 55
Laboratory tests*
•
•
•
•
•
•
•
•
•
•
•
NOTES:
SR / CRP
Blood count
- * These are in addition to
routine pre-op labs such as
Calcium
coagulation studies
Phosphate
- These are screening labs,
Alkaline Phosphatase (AP) more may be indicated based
on these results
GGT
Renal function studies
Basal TSH
Intact PTH
Protein-immunoelectrophoresis
Vit D (25 and 1.25)

56. 56
Bone mineral density and spine radiograph for
vertebral fracture assessment
• Bone mineral density assessment by DXA
– Establish severity of osteoporosis
– Baseline for monitoring treatment efficacy
• Consider spine radiographs (thoracic and lumbar, AP and
ML views) for patients with:
– Back pain
– Loss of height > 4 cm
– Progressive kyphosis

57. 57
Optimal care of the fragility fracture patient
• Diagnosis of “fragility” fracture
– Identify “fragility” fracture & underlying disease, incorporate into
existing workup
– Influences treatment plan from the onset
• General fracture management
– Stabilize patient, pain relief, fracture care

58. 58
Complexity of elderly patients
• Mean age hip fracture
= 80 yrs
• Comorbidities
(median ASA 3)
• Impaired metabolic
response to injury
– Hyponatraemia
• Management problems
– Murmurs
– Consent
– Renal - dialysis
– Theatre scheduling
– COPD - home O2
– Discharge planning
– Diabetes
– Delirium / dementia
– Pseudo-obstruction
– Alcohol abuse
• Polypharmacy
– Warfarin
– Plavix
– Neurotropics

59. 59
Technical challenges of fracture fixation in
osteoporotic bone
• Impaired ability of osteoporotic bone to hold screws or
support implants
• Crushing of cancellous bone with subsequent voids after
fracture reduction
These factors can lead to a higher risk of failure at the
implant-bone interface before healing achieved

60. 60
Special considerations in fixation
of fragility fractures
• Arthroplasty / Hemiarthroplasty
– Also allows early mobilization, may be less painful
• Implants designed for osteoporotic bone
– Fixed angle locking plates
– Hydroxyapatite-coated screws
• Use of IM nail instead of onlay devices
(plates and screws) for diaphyseal fractures
• Void filling with cement or bone graft

61. 61
Possible indications for arthroplasty
Hip
Images courtesy of John Keating
Shoulder
Knee
Elbow

62. 62
Shoulder arthroplasty
Hip hemiarthroplasty
Established
and widely
preferred to
ORIF in
displaced
subcapital
fractures
But current
controversy
Total
arthroplasty
use is
increasing
•
•
•
•
Keating et al. J Bone Joint Surg. 2006; 88(A):249-60
Useful particularly for 3-part and 4part fractures and fracture
dislocations
Early treatment best
Good pain relief, but poor
movement and function
Soft tissues influence outcome

63. 63
Example of fixed angle locking plates
POST OP
1 MONTH
1 YEAR
• Screw head threaded –
engages with hole in plate
• Single mechanical unit –
internal fixator
• No compressive force on
periosteum
Female 82 yrs
Plecko and Kraus, Oper Orthop Traumatol.2005; 17:25-50

64. 64
Fixation augmentation with hydroxyapatitecoated screws
OsteoTite HA-coated external fixation pin
HA-coated AO/ASIF lag screw
HA-coated AO/ASIF cortical bone screw
HA-coated AO/ASIF cancellous bone screw
Magyar G et al, J Bone Joint Surg Br. 1997 May;79(3):487-9
Moroni A et al, Clin. Orthop. 1998 Jan;(346):171-77
Moroni A et al, Clin Orthop. 2001 Jul(388):209-17
Moroni A et al, J. Bone Joint Surg. Am. 2001 May;83-A(5):717-21
Sandèn B al, J. Bone Joint Surg. Br. 2002 Apr;84(3):387-91
Caja VL et al, J. Bone Joint Surg. Am. 2003 Aug;85-A(8):1527-31
Moroni A et al, Clin. Orthop. 2004 Aug;(425):87-92
Moroni A et al, J. Bone Joint Surg. Am. 2005 May;83-A(5):717-21

65. 65
HA-coated dynamic hip screw improved outcomes in
osteoporotic patients with hip fracture
DHS fixed with standard vs HAcoated AO/ASIF screws in
osteoporotic patients with
trochanteric fractures
Standard
HA-coated
1. HA-coated screws maintained better neck shaft angle at 6 mo
2. Patients with HA-coated device had better Harris hip scores and far less
cut out of lag screw
Moroni et al. J Bone Joint Surg Am 2005; 87:753-9

66. 66
Optimal care of the fragility fracture patient
• Diagnosis of “fragility” fracture
– Identify “fragility” fracture & underlying disease, incorporate into
existing workup
– Influences treatment plan from the onset
• General fracture management
– Stabilize patient, pain relief, fracture care
• Rehabilitation
– Minimize dependence, maximize mobility

67. 67
Rehabilitation in the fragility fracture patient
Goal is to improve strength,
balance, position sense,
reactions to:
– Improve level of function /
independence
Balance (position sense, reaction)
Mechanical vibration plate
Limb and core strength
Mobility in activities of daily living
– Decrease risk of falls
Safety in gait and transfers
– Decrease risk of fractures
Sensory and visual limitations
Home safety evaluation and adaptation

68. 68
Rehabilitation of fragility fracture patient
Fall prevention
Guideline for the prevention of falls in older persons
American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic
Surgeons Panel on Falls Prevention. J Am Geriatr Soc (2001) 49: 664-672
Interventions for preventing falls in elderly people (Review)
LD Gillespie et al, Cochrane Database Syst Rev (2003)
A multidisciplinary, multifactorial intervention program
reduces postoperative falls and injuries after femoral neck fracture
M. Stenvall et al, Osteoporosis International (2007) 18: 167-75

69. 69
Optimal care of the fragility fracture patient
• Diagnosis of “fragility” fracture
– Identify “fragility” fracture & underlying disease, incorporate into
existing workup
– Influences treatment plan from the onset
• General fracture management
– Stabilize patient, pain relief, fracture care
• Rehabilitation
– Minimize dependence, maximize mobility
• Secondary prevention
– Treat and monitor underlying disease, prevent future fractures
– Ideally begins during acute and sub-acute fracture care

70. 70
Secondary prevention basics
• Further evaluation of underlying disease
– Bone mineral density
– Rule out secondary causes of osteoporosis
– Initiate osteoporosis therapy, as indicated
– Fall prevention
• Inform patient and primary MD doctor of probable fragility
fracture and osteoporosis
• Ensure patient has follow-up care with PT and physician
treating osteoporosis (if not orthopaedist)

71. 71
Interventions to reduce future fracture risk
• Basics
– Nutrition, exercise, fall prevention strategies
– Modify risk factors as able (smoking, excess alcohol)
– Treat co-morbidities (i.e., endocrine disorder?)
• Pharmacological agents

72. 72
Interventions: General recommendations
• Regular physical activity
– Maintaining safe ambulatory status, indep ADLs
– Daily limb and core home exercise routine
• Sufficient intake of calcium and vitamin D
– daily 1000-1500 mg calcium, 400-800 IU vitamin D
– by foods or foods and supplements combined
• Adequate nutrition
• Avoid cigarettes, excess alcohol

73. 73
Pharmacological agents for treatment of
osteoporosis
Effective therapies are widely available and
can reduce vertebral, hip and other fractures
by 30% to 65%,
even in patients who have already suffered a
fracture

74. 74
Pharmacological agents shown to reduce
fracture risk
Bisphosphonates
SERMs
•
Alendronate (FOSAMAX®)
•
Risedronate (ACTONEL®)
•
Ibandronate (BONVIVA®)
Stimulators of bone formation
•
Zolendronate (ACLASTA®)
•
Hormone therapy
•
Estrogen / progestin
•
Raloxifene (EVISTA®)
rh-PTH (FORTEO®)
Mixed mode of action
•
Strontium ranelate (PROTELOS®)

75. 75
Effect on vertebral fracture risk
Effect on non-vertebral fracture
risk
Osteoporosis
With prior
fractures
Osteoporosis
With prior fractures
Alendronate
+
+
NA
+
(incl. hip)
Risedronate
+
+
NA
+
(incl. hip)
Ibandronate
NA
+
NA
+
HRT
+
+
+
+
Raloxifene
+
+
NA
NA
Teriparatide and
PTH
NA
+
NA
+
Strontium
ranelate
+
+
+
(incl. hip)
+
(incl. hip)
NA, No evidence available; + , effective drug ; awomen with a prior vertebral fracture
Adapted from Boonen S. et al. 2005; Osteoporos Int; 16:239-54

76. 76
Orthopaedist’s role in improving fragility
fracture care
Opportunity or obligation?
Either way, it is:
• important
• not Difficult
• rewarding
• becoming standard of care

77. 77
The orthopaedist’s responsibilities in
fragility fracture care
• Identify the orthopaedic patient with a possible fragility
fracture
• Inform the patient about the need for an osteoporosis
evaluation
• Investigate whether osteoporosis is an underlying cause of
the fracture
• Ensure that appropriate intervention is initiated
• Educate the patient and the family
• Coordinate care with other treating physicians
Bouxsein et al. J Am Acad Orthop Surg, 2004; 12:385-95

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Summary and conclusions
• Fractures are common. Fractures will be more common
• Osteoporotic fractures are associated with increased
morbidity & mortality
• A fracture is among the strongest risk factors for future
fracture. Refracture rate is high
• Majority of patients with fragility fractures are not evaluated
or treated for osteoporosis
• Effective treatments are available
• Orthopaedic surgeons are usually the treating physician and
can take an active role in optimizing care of the fragility
fracture patient

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Online resources
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•
•
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•
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www.iofbonehealth.org
www.fractures.com
www.boneandjointdecade.org
www.aaos.org/osteoporosis/
www.niams.nih.gov/bone
www.nof.org

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Thank you
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