Grandmother is 78, independent, active and was out watering her garden when she stumbled and fell. She sustained this fracture of her hip (see x-ray, figure 1). She is brought to the emergency room, admitted to the hospital, and then has major surgery to repair the broken hip. Interestingly, Grandma has suffered 2 prior fractures of the humerus (shoulder) and spine from standing level falls within the last 10 years. She has an established Primary Care Physician, with whom she’s been a loyal and compliant patient of for 20+ years. He has never done a screening DXA (bone density scan, recommended for all women by age 65 by Medicare) to check for osteoporosis. He is also unaware that Grandma’s 1st fragility fracture gives her a diagnosis of osteoporosis (by WHO criteria), and is an imperative to treat the underlying bone disease. After 3 days in the hospital, Grandma is transferred to a nursing home. Other than her new hip hardware, she receives no treatment for her underlying bone disease, and still no diagnosis of osteoporosis. She lingers in the nursing home, disabled, in pain, depressed about having lost her independence. Grandmother ultimately dwindles and dies from pneumonia and infected bed sores within a month.
Figure 1: Typical hip fragility fracture
The Fragility Fracture Epidemic: This sad scenario is unfortunately, all too common across the U.S. and other 1st world countries. Despite well-established national and international guidelines for screening, diagnosis and treatment, bone disease is commonly not attended to by many of us in the medical community, even after fragility fracture. Our lack of attention to bone health, especially in the elderly, has led to osteoporotic fractures being a national epidemic. Annually, 1.5 million fractures are caused by osteoporosis, including 350,000 hip fractures in the U.S. (figure 2.). Ten million Americans have osteoporosis, and 18 million more are at risk of developing the disease. Most patients suffering from osteoporosis and its devastating consequences are female (80%), however men sustaining hip fracture have worse outcomes compared to women, including higher risk of death. The mortality rates for patients sustaining hip or spine fragility fractures are increased, especially in the first year post-fracture
Figure 2: From The US Surgeon General’s report, 2012
F(20-33% increased mortality after hip fracture in females and males respectively). For those lucky enough to survive, many suffer lasting disability, pain, loss of independence, and poor quality of life. Major common risk factors for bone loss include include post-menopausal women, males over 70 years of age, chronic glucocorticoid (prednisone) use, tobacco use, alcohol abuse, and any ethnicity other than African-American or African. Osteoporosis is a disorder of major societal impact for 1st world countries, and fragility fractures are associated with significant disease burden, billions of dollars in healthcare costs annually, plus significant morbidity and mortality.
What is Osteoporosis? Osteoporosis is a widespread metabolic bone disease characterized by loss of bone mineral, decreased bone mass, poor bone quality and decreased strength. The mineral responsible for the majority of bone strength is Calcium. With aging and loss of our sex hormones (estrogen and testosterone), Calcium can gradually dissolve from our bones and is lost through the kidneys then out the urine. Our skeletons quite literally go down the toilet. Bone loss occurs over years and decades, with plenty of time for us in the medical community to intervene before the breaking point. Loss of bone mass and mineral reduces structural bone strength and increases the risk of low energy (fragility) fractures. Normal bone can withstand physiologic load and even some degree of trauma without failing. However osteoporotic bone is weak, full of holes and can fracture without any trauma. Think of your home with wood beams, joists and framing. If the wood is infested with termites and full of holes, it’s weakened and can collapse spontaneously. This is similar to the insidious process of bone mineral loss in our skeleton (see figure 3).
A fragility fracture is defined as having occurred from a standing level fall or less. Any bone may fracture as a
Figure 3: Normal (top) versus osteoporotic (bottom) vertebral bone cross section
result of osteoporosis, but common sites are the wrist, spine, and hip. A fragility fracture alone makes the diagnosis of osteoporosis, though this fact (and thus the diagnosis) is frequently missed by both primary care and specialty physicians. Another way we diagnosis is with DXA, a non-invasive, low radiation x-ray which measures bone density. By DXA, when a patient’s bone score is 2.5 standard deviations below the mean compared to healthy bone, we can make the diagnosis of osteoporosis even before fragility
fractures occur. Unfortunately, DXA is widely available across the U.S. but very underutilized. DXA screening indications and score results are also frequently misunderstood by both primary care and specialty physicians. Numerous national guidelines for osteoporosis screening and treatment are widely available, but unfortunately for patients, seldom adhered to by us in the medical community.
Osteoporosis, though very common, is an orphan disease. I’ve heard primary care physicians tell me “Specialists should treat it”, specialists say “Primary care should treat it”, and I’ve heard orthopedic surgeons tell me treating osteoporosis “Isn’t in the business plan.” It’s a shame when medical professionals ignore bone health, then their patients and their families pay the price. When no one takes responsibility, bone disease usually goes undiagnosed and untreated, even after patients are admitted and discharged from hospitals with hip fragility fractures. These patients are at the highest risk for further injuries.
Treatment Options: There have been recent major advances in our understanding of bone biology, including the exact physiologic mechanisms of bone loss. We have a wide selection of FDA-approved pharmacologic agents to stop bone loss, build bone, and effectively prevent fractures. These drugs act on bone cells directly or with cell-to-cell signaling. Efficacy for bone drugs ranges between 50-70% risk reduction for fractures. By national and international guidelines, patients with osteoporosis (diagnosed by DXA or after fragility fracture) should be on drug therapy to reduce the risk of fracture. Calcium and Vitamin D are not enough to effectively reduce risk, but should be used with a pharmacologic agent to reduce fracture risk. The oldest bone drugs are the bisphosphonates (alendronate, ibandronate, risedronate, zoledronate), many of which are now generic. Newer agents include denosumab, teriparatide and raloxifene. Each patient with osteoporosis deserves an individualized approach for a prescription which is best suited for their needs taking into account any other medical conditions that exist. Ignoring the underlying bone disease and simply treating the fracture is not prudent nor in the patient’s best interest, because a fragility fracture immediately increases that patient’s risk for further fractures. Fractures beget more fractures. A fragility fracture is a sentinel event, indicative of underlying bone disease. Think of a patient coming to a cardiologist with a heart attack. The cardiologist places a few stents to open the coronary arteries. If the cardiologist didn’t make an effort to also address the patient’s uncontrolled cholesterol, diabetes, hypertension and obesity which caused the heart attack, we would think the cardiologist imprudent. Perhaps even negligent? Yet even with so many good treatment options in 21st Century U.S. “state of the art” medicine, patients with osteoporotic fractures still rarely get diagnosed or treated for their underlying bone disease.
Figure 4: Atypical femur fracture
Safety Concerns with Bone Drugs: As with any pharmacologic agents, bone drugs can have adverse effects. Anti-resorptive agents (bisphosphonates, denosumab, raloxifene) potential safety concerns including osteonecrosis of the jaw and atypical femoral fractures (figure 4). Other potential serious adverse events with bone drugs include blood clot, kidney failure, infection, and potentially malignant bone tumor. The risks versus benefits of all treatment options should be discussed with patients before initiating treatment. In my practice, I review each patient’s entire medical history, do a physical exam, check basic labs, and then discuss options with the patient and family to get them started on a treatment plan that’s right for them. Simply ignoring the bone disease is not a valid option, in my opinion, when their risk is high for further potentially devastating or lethal injuries.
Summary: Substantial progress has been made in the past 2 decades in the science and management of osteoporosis and the patients it affects. Advances in bone biology have held major therapeutic advances in osteoporosis treatment in recent years. Several novel bone medications using different mechanisms of action are also in development. Diagnosis and screening is simple, but unfortunately often neglected. This “orphan” disease exists as an epidemic in the U.S. within a treatment gap, where too few physicians follow national standards. Lack of proper diagnosis and treatment often leads to 2nd, 3rd, and 4th fractures with poor outcomes or even death. Improved screening, education, diagnosis and treatment are indicated to bridge the treatment gap and keep our seniors stay healthy and independent.
Key Points
- Osteoporosis is a serious epidemic in the U.S. and 1st world countries
- Patients with osteoporosis are frequently not diagnosed or treated in the U.S., even after suffering a fragility fracture
- DXA (bone density scanning) is a simple, non-invasive and widely available screening tool to evaluate bone health and fracture risk before fractures occur, making prevention the very best medicine
- Major scientific advances have allowed multiple FDA-approved safe and effective treatment options for fracture prevention
- An osteoporotic fragility fracture is a sentinel event, similar to a heart attack in that it indicates underlying bone disease which puts patients at high risk for further devastating or deadly injury
For Further Information:
The Surgeon General’s Report on Osteoporosis, 2012, http://niams.nih.gov/health_info/bone/sgr/surgeon_generals_report.asp
CAPTURE THE FRACTURE: A GLOBAL CAMPAIGN TO BREAK THE FRAGILITY RACTURE CYCLE, www.iofbonehealth.org
Recommendations for Care of the Osteoporotic Fracture Patient to reduce the Risk of Future Fracture. Developed by the World Orthoped Osteoporosis Organization. Johnell O, Kaufman J, Cummings S, Lane J, Bouxein M. July 2, 2012, www.boneandjointdecade.de/downloads.
National Osteoporosis Foundation Releases New Data Detailing the Prevalence of osteoporosis.
September 23, 2013, www.nof.org .
Brauer CA, Coca-Perraillon M, Cutler DM, Rosen AB. Incidence and Mortality of Hip Fractures in the United States. JAMA. 2009;302(14):1573-9. doi: 10.1001/jama.2009.1462.
Clinician’s Guide to Prevention and Treatment of Osteoporosis. National Osteoporosis Foundation. Washington, DC; 2014, www.nof.org.
The relative efficacy of nine osteoporosis medications for reducing the rate of fractures in post-menopausal women Hopkins et al. BMC Musculoskeletal Disorders, 2011, 12:209
http://www.biomedcentral.com/1471-2474/12/209[:de]
Written by Orthopedic Surgeon Hip Knee Foot Ankle Sports Medicine Expert Witness
