Secondary Prevention of Low-Trauma Fractures: In Search of an Effective Solution
The stimulation of bone turnover that occurs with anabolic agents is generally thought to accelerate bone healing. In animal studies, teriparatide has been found to enhance callus formation and mechanical strength [62–64], but there is no definitive data in humans to prove this effect [65].
In summary, there is strong evidence demonstrating the effectiveness of bisphosphonates and anabolic agents at decreasing the risk of fracture recurrence in patients with preexisting vertebral fractures. Zoledronic acid has also been shown to decrease the risk of fracture recurrence after a hip fracture. Anti-osteoporosis therapy after a fracture has no clinically significant effect on fracture healing.
The Gap Between Science and Practice
Practice Guidelines Versus Actual Practice
Based on the data presented above, multiple professional societies and expert groups have developed guidelines emphasizing the importance of evaluation and treatment for osteoporosis following a low-trauma fracture, especially those of the hip and spine [8,9,66–69]. In a 2009 multidisciplinary workshop of the International Society of Fracture Repair, an in-depth review of existing data showed no evidence for a negative effect of anti-osteoporosis drugs on fracture healing. As a result, it was recommended not to withhold osteoporosis therapy until fracture healing has occurred, and to initiate treatment before patient discharge from the fracture ward in order to improve follow-up [70].
However, despite these expert guidelines and the availability of several effective agents to decrease the risk of fracture and fracture recurrence, evaluation and treatment of patients for osteoporosis after a low-trauma fracture are very low. Several large-scale studies involving older patients with fractures in North America, Europe, Asia, and Australia have shown that the rates of BMD measurement or drug therapy for osteoporosis after a fragility fracture do not exceed 25% to 30% [71–80]. While treatment trends over time may have shown some improvement, they remain overall disappointing. For example, in a study of over 150,000 patients who sustained a fracture between 1997 and 2004, Roerholt et al found that around 20% of women were started on therapy after a vertebral fracture in 1997, while 40% received therapy in 2004. Among women with hip fracture, 3% received treatment in 1997 and 9% in 2004 [71]. Furthermore, when osteoporosis treatment rates are examined more closely, most of the patients who receive treatment after a fracture are those who were being treated prior to the fracture, so treatment is simply continued in them. New osteoporosis therapy is initiated in only 5% to 15% of patients who are not already on osteoporosis therapy at the time of fracture [72,73,77,81,82].
Analyses of prescription patterns suggest that patients with vertebral fractures are more likely to receive treatment compared to those with hip fractures [71,82], and that women are much more likely to receive therapy than men [71,74,77,83–88]. Other factors that decrease the chance of receiving therapy include black race [84], low income [74], older age, presence of multiple comorbidities, and polypharmacy [83].
Barriers to Care: Where Are We Failing?
The large discrepancy between science and practice when it comes to secondary prevention of fractures is quite puzzling and has been the subject of several investigations. A major barrier to proper care seems to be the lack of ownership of the problem by the orthopedic surgeons and medical providers, and the less than ideal collaboration between the 2 services in coordinating and providing secondary prevention [89–94]. The orthopedic surgeons are one of the first points of contact with health care for a patient with a low-trauma hip fracture. They are mainly charged with providing acute fracture care and often cannot provide long-term osteoporosis care, which would be more suitable for a medical specialist. However, while the acute care surgical team is not best suited to treat osteoporosis, it is still very important that they initiate patient referral to a provider who can provide long-term osteoporosis care. This transition of care–of lack of it–seems to be one of the major missing links, leading to patient loss [88] and suboptimal secondary prevention.
However, patient referral may not be a sufficient solution and interestingly, a medical consultation during an acute admission for hip fracture does not seem to increase the frequency of osteoporosis diagnosis [95]. This points to a deficiency in knowledge, and as a matter of fact, studies do suggest a problem with under-recognition of the connection between low-trauma fractures and underlying osteoporosis among medical and surgical providers alike [92,93,96]. In a survey of orthopedic surgeons and consultant physicians involved in the care of patients with low-trauma hip fractures, only 24% of respondents felt that osteoporosis therapy was indicated. The majority of providers thought that treatment with a bisphosphonate was indicated only if low BMD was present, rather than in all patients with low-trauma hip fractures [92]. This is further illustrated by the fact that only a minority of patients with a low-trauma fracture are formally given the diagnosis of osteoporosis [75,80,97] or are told that they have osteoporosis [79].
