Commentary

Preventative Care in Orthopedics: Treating Injuries Before They Happen

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By 2025, it is estimated that the annual cost of treating osteoporosis-related fractures in the United States will be 25 billion dollars, which is 10 billion dollars more than was spent in 2010. 1 As healthcare costs in the United States continue to skyrocket, it is imperative that orthopedic surgeons take an active role in avoiding preventable injury and disease. For orthopedic surgeons, preventative medicine will include promoting bone health and educating patients on injury prevention. By incorporating these principles into residency and fellowship education, and by leveraging the electronic medical record to support preventive care through systematic reminders, orthopedic surgeons have a critical opportunity to take a leading role in promoting prevention to our patients.

In 2009, the American Orthopaedic Association (AOA) launched a “Own the Bone” campaign, a national quality improvement program designed to optimize the treatment of osteoporosis. 2 This program came about following the Surgeon General’s call, in 2004, for orthopedic surgeons to take a more active role in treating osteoporosis. The program primarily aims to improve treatment of osteoporosis after a fragility fracture in an inpatient setting. Early results from a 2010 follow-up study showed that the new emphasis on prevention inspired by this program is effective. As compared with patients who had osteoporosis work-up and treatment initiated during their hospital admission, the group of patients who were referred for osteoporosis treatment after discharge were found to have a significantly lower rate of diagnosis and treatment. 3 The loss of aftercare for patients who do not obtain immediate diagnosis and treatment for osteoporosis can and should be avoided. Many hospitals now have hip fracture services with multidisciplinary input. The successful outcomes of these programs include shorter times to the operating room, shorter hospital stays, decreased readmission, and decreased 30-day mortality. 4-6 These services provide an excellent opportunity to ensure that each patient has initiated management of osteoporosis before discharge. Ideally, patients would be scheduled for bone mineral density testing prior to leaving the hospital, when applicable, and would begin calcium and vitamin D supplementation or bisphosphonate treatment in the hospital, when appropriate. As part of these hip fracture services, a goal of clearly initiating or managing treatment for osteoporosis should be routinely addressed.

While patients presenting with hip fractures are an easily identifiable high-risk population, other patients present in an outpatient setting following fragility fractures, such as distal radius or vertebral compression fractures. These patients should be considered for osteoporosis work-up and counseled accordingly. A recent study compared the efficacy of the orthopedic surgeon initiating bone mineral density testing after a distal radius fracture, compared with referring the patient back to their primary care physician for testing. The study found a significantly higher rate of patients going on to bone mineral density testing when the surgeon initiated this process. 7 In the era of improved digital communication, the outpatient setting offers an opportunity for clinicians to communicate with patients’ primary care physicians and initiate a multidisciplinary approach to bone health and prevention. In the outpatient setting, the orthopedist can address nutritional issues and screening on a repeated basis. Studies have demonstrated that physician counseling can be very effective in changing behavior and helping patients to stop using tobacco. 8 In this vein, efforts by the physician to encourage calcium and vitamin D intake and weight-bearing exercise have the potential to be very effective.

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