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Prevention of secondary osteoporotic fractures—why are we ignoring the evidence?
Injury, Int. J. Care Injured (2004) 35, 986—988
Prevention of secondary osteoporotic fractures–—why are we ignoring the evidence? Robin Seaggera,*, Jonathon Howellb, Huw Davidb, Simon Gregg-Smitha a
Department of Orthopaedics, Royal United Hospital, Bath BA1 3NG, UK Department of Orthopaedics, Derriford Hospital, Plymouth PL6 8DH, UK
b
Accepted 22 October 2003
KEYWORDS Osteoporotic fractures; Orthopaedic; Femur
Summary Osteoporosis is a major problem world-wide. In the UK, it costs the NHS about £1.7 billion per annum. Admission to orthopaedic units for treatment and rehabilitation with fractured necks of femur makes up a large proportion of the cost. The evidence suggests simple, cost-effective treatments can reduce fractures and re-fractures attributable to osteoporosis by up to 50%, and easy to follow guidelines exist. Our study, of a typical large district general hospital suggests that ideally placed orthopaedic surgeons are however not taking the opportunity to start these treatments or offer advice about this common condition. Commencing these treatments could prevent more than 7000 fractures per year in the UK. ß 2003 Elsevier Ltd. All rights reserved.
Introduction Fractures of the femoral neck are reaching epidemic proportions across the world. In 1990, there were 1.66 million fractures and it is estimated by 2050 there will be 2.26 million.6 These fractures are not only a cause of considerable morbidity and mortality but also cost the NHS up to £1 billion per annum.3,6 Many fractures are associated with osteoporosis and it has been demonstrated that effective medical treatments can reduce the risk of fracture by up to 50%.1,2,5 Even if patients present with osteoporotic fractures medical treatment can reduce the risk of further fractures by a similar figure.1
*Corresponding author.
Orthopaedic surgeons should be in good position to identify patients with osteoporotic fractures and to initiate further medical intervention. Guidelines have been developed that are simple to follow.4 Not only does it appear that treatment for osteoporosis is cost effective1,4, but it also should improve the life of orthopaedic surgeons by slowing the inexorable demand for trauma surgery. Despite this, orthopaedic surgeons do not appear to take the opportunity to commence treatment. Surveys have been carried out suggesting that between 10 and 61% of British and Irish surgeons say that they recommend treatment for osteoporosis after osteoporotic fractures.7,8 There is however no evidence to demonstrate that even this proportion of patients receives further treatment. Our study aimed to determine whether patients presenting with osteoporotic hip fractures were being offered advice and commenced on treatment, when appropriate, prior to discharge.
0020–1383/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.10.017
Prevention of secondary osteoporotic fractures–—why are we ignoring the evidence?
987
Table 1 Prior to admission
Three patients diagnosed with osteoporosis 14 previous fractures attributed to osteoporosis No documented advice regarding osteoporosis
Treatment
Two patients admitted on treatment Two patients given documented advice Two started on treatment for osteoporosis Three discharged on treatment-1 had treatment stopped
Outcome
Eight patients subsequently treated for osteoporotic fracture No further documented advice or treatment
Summary
23% (22 in 96) of patients suffered other fractures attributable to osteoporosis (14.6% prior to, and 8.4% after the index fracture) Only 3% discharged on treatment for osteoporosis
Methods and results We defined the ‘index fractures’ as the first 100 necks of femur fractures operated upon at Derriford Hospital, Plymouth, UK, from 1 January 1998. All notes, drug charts and discharge summaries of these patients were then reviewed after a period of 3 years. We recorded if these patients had suffered any fractures associated with osteoporosis, prior to, or since the ‘index fracture’. We determined what advice and treatment had been documented in the records. Four patients were excluded (one young, high energy fracture; one fracture through malignant metastases; two incomplete notes) so 96 met the criteria to be included in the study. From all fracture episodes, the following results were obtained (see Table 1).
Discussion Despite the evidence in the literature, our study showed that only 3% of our patients were discharged on treatment for osteoporosis after the index fractures and no further treatment was started despite re-fracture. Twenty-three percent of our patients suffered re-fractures attributable to osteoporosis. These patients had therefore suffered two fractures linked with osteoporosis and still were not given advice or simple, cheap and effective therapies. Our study suggests that orthopaedic surgeons are failing to initiate simple medical measures that not only potentially improve the quality of life of their patients, but would also, in the medium term, reduce the demands for their trauma services. We have no reason to suggest that this large district general hospital is different to any other unit.
The average admission rate at Derriford Hospital, for neck of femur fractures is approximately 500 per annum. If our figures are typical of this population, this correlates to a re-fracture rate of 115 per year, 42 of which would be readmissions after neck of femur fracture fixation. The literature suggests this may be reduced by up to 50%, i.e. 57.5 less fractures a year in a resident population of 450, 000. This suggests a possible reduction in the national refracture rate of up to 7028 per annum by starting simple medical treatments alone!
Conclusions The literature shows compelling evidence that osteoporotic fractures can be reduced or prevented by simple medical therapies. Admission to hospital with an osteoporotic fracture is an ideal opportunity to commence such treatments. It appears that orthopaedic surgeons are not taking this opportunity and therefore are failing to alleviate the increasing burden upon trauma resources.
References 1. Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, et al. The Fracture Intervention Trial Research Group. Randomised trial of effect of aledronate on risk of fracture in women with existing vertebral fractures. Lancet 1996;348(9041):1535—41. 2. Chapuy MC, Arlot M, Duboeuf F, Brun J, Crouzet B, Arnaud S, et al. Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med 1992;327(23):1637—42. 3. Dolan P, Togerson DJ. The cost of treating osteoporotic fractures in the United Kingdom female population. Osteoporos Int 1998;8:611—7. 4. Eastell R, Reid RM, Compston J, Cooper C, Fogelman I, Francis RM, et al. Secondary prevention of osteoporosis: when should a non-vertebral fracture be a trigger for action? Q J Med 2001;94:575—97.
988
5. Michaelson K, Baron JA, Farahmand BY, Johnell O, Magnusson C, Persson PG. The Swedish Hip fracture Study Group. Hormone replacement therapy and risk of hip fracture: population based case—control study. BMJ 1998;316(7148): 1858—63. 6. National Osteoporosis Society Website. http://www.nos. org.uk.
R. Seagger et al.
7. Pal B, Morris J, Muddu B. The management of osteoporosis related fractures: a survey of orthopaedic surgeons practice. Clin Exp Rheumatol 1998;16(1):61—2. 8. Sheehan J, Mohamed F, Reilly M, Perry IJ. Secondary prevention following fractured neck of femur: a survey of orthopaedic surgeons practice. Ir Med J 2000;93(4): 105—7.
Prevention of secondary osteoporotic fractures–—why are we ignoring the evidence? Robin Seaggera,*, Jonathon Howellb, Huw Davidb, Simon Gregg-Smitha a
Department of Orthopaedics, Royal United Hospital, Bath BA1 3NG, UK Department of Orthopaedics, Derriford Hospital, Plymouth PL6 8DH, UK
b
Accepted 22 October 2003
KEYWORDS Osteoporotic fractures; Orthopaedic; Femur
Summary Osteoporosis is a major problem world-wide. In the UK, it costs the NHS about £1.7 billion per annum. Admission to orthopaedic units for treatment and rehabilitation with fractured necks of femur makes up a large proportion of the cost. The evidence suggests simple, cost-effective treatments can reduce fractures and re-fractures attributable to osteoporosis by up to 50%, and easy to follow guidelines exist. Our study, of a typical large district general hospital suggests that ideally placed orthopaedic surgeons are however not taking the opportunity to start these treatments or offer advice about this common condition. Commencing these treatments could prevent more than 7000 fractures per year in the UK. ß 2003 Elsevier Ltd. All rights reserved.
Introduction Fractures of the femoral neck are reaching epidemic proportions across the world. In 1990, there were 1.66 million fractures and it is estimated by 2050 there will be 2.26 million.6 These fractures are not only a cause of considerable morbidity and mortality but also cost the NHS up to £1 billion per annum.3,6 Many fractures are associated with osteoporosis and it has been demonstrated that effective medical treatments can reduce the risk of fracture by up to 50%.1,2,5 Even if patients present with osteoporotic fractures medical treatment can reduce the risk of further fractures by a similar figure.1
*Corresponding author.
Orthopaedic surgeons should be in good position to identify patients with osteoporotic fractures and to initiate further medical intervention. Guidelines have been developed that are simple to follow.4 Not only does it appear that treatment for osteoporosis is cost effective1,4, but it also should improve the life of orthopaedic surgeons by slowing the inexorable demand for trauma surgery. Despite this, orthopaedic surgeons do not appear to take the opportunity to commence treatment. Surveys have been carried out suggesting that between 10 and 61% of British and Irish surgeons say that they recommend treatment for osteoporosis after osteoporotic fractures.7,8 There is however no evidence to demonstrate that even this proportion of patients receives further treatment. Our study aimed to determine whether patients presenting with osteoporotic hip fractures were being offered advice and commenced on treatment, when appropriate, prior to discharge.
0020–1383/$ — see front matter ß 2003 Elsevier Ltd. All rights reserved. doi:10.1016/j.injury.2003.10.017
Prevention of secondary osteoporotic fractures–—why are we ignoring the evidence?
987
Table 1 Prior to admission
Three patients diagnosed with osteoporosis 14 previous fractures attributed to osteoporosis No documented advice regarding osteoporosis
Treatment
Two patients admitted on treatment Two patients given documented advice Two started on treatment for osteoporosis Three discharged on treatment-1 had treatment stopped
Outcome
Eight patients subsequently treated for osteoporotic fracture No further documented advice or treatment
Summary
23% (22 in 96) of patients suffered other fractures attributable to osteoporosis (14.6% prior to, and 8.4% after the index fracture) Only 3% discharged on treatment for osteoporosis
Methods and results We defined the ‘index fractures’ as the first 100 necks of femur fractures operated upon at Derriford Hospital, Plymouth, UK, from 1 January 1998. All notes, drug charts and discharge summaries of these patients were then reviewed after a period of 3 years. We recorded if these patients had suffered any fractures associated with osteoporosis, prior to, or since the ‘index fracture’. We determined what advice and treatment had been documented in the records. Four patients were excluded (one young, high energy fracture; one fracture through malignant metastases; two incomplete notes) so 96 met the criteria to be included in the study. From all fracture episodes, the following results were obtained (see Table 1).
Discussion Despite the evidence in the literature, our study showed that only 3% of our patients were discharged on treatment for osteoporosis after the index fractures and no further treatment was started despite re-fracture. Twenty-three percent of our patients suffered re-fractures attributable to osteoporosis. These patients had therefore suffered two fractures linked with osteoporosis and still were not given advice or simple, cheap and effective therapies. Our study suggests that orthopaedic surgeons are failing to initiate simple medical measures that not only potentially improve the quality of life of their patients, but would also, in the medium term, reduce the demands for their trauma services. We have no reason to suggest that this large district general hospital is different to any other unit.
The average admission rate at Derriford Hospital, for neck of femur fractures is approximately 500 per annum. If our figures are typical of this population, this correlates to a re-fracture rate of 115 per year, 42 of which would be readmissions after neck of femur fracture fixation. The literature suggests this may be reduced by up to 50%, i.e. 57.5 less fractures a year in a resident population of 450, 000. This suggests a possible reduction in the national refracture rate of up to 7028 per annum by starting simple medical treatments alone!
Conclusions The literature shows compelling evidence that osteoporotic fractures can be reduced or prevented by simple medical therapies. Admission to hospital with an osteoporotic fracture is an ideal opportunity to commence such treatments. It appears that orthopaedic surgeons are not taking this opportunity and therefore are failing to alleviate the increasing burden upon trauma resources.
References 1. Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, et al. The Fracture Intervention Trial Research Group. Randomised trial of effect of aledronate on risk of fracture in women with existing vertebral fractures. Lancet 1996;348(9041):1535—41. 2. Chapuy MC, Arlot M, Duboeuf F, Brun J, Crouzet B, Arnaud S, et al. Vitamin D3 and calcium to prevent hip fractures in the elderly women. N Engl J Med 1992;327(23):1637—42. 3. Dolan P, Togerson DJ. The cost of treating osteoporotic fractures in the United Kingdom female population. Osteoporos Int 1998;8:611—7. 4. Eastell R, Reid RM, Compston J, Cooper C, Fogelman I, Francis RM, et al. Secondary prevention of osteoporosis: when should a non-vertebral fracture be a trigger for action? Q J Med 2001;94:575—97.
988
5. Michaelson K, Baron JA, Farahmand BY, Johnell O, Magnusson C, Persson PG. The Swedish Hip fracture Study Group. Hormone replacement therapy and risk of hip fracture: population based case—control study. BMJ 1998;316(7148): 1858—63. 6. National Osteoporosis Society Website. http://www.nos. org.uk.
R. Seagger et al.
7. Pal B, Morris J, Muddu B. The management of osteoporosis related fractures: a survey of orthopaedic surgeons practice. Clin Exp Rheumatol 1998;16(1):61—2. 8. Sheehan J, Mohamed F, Reilly M, Perry IJ. Secondary prevention following fractured neck of femur: a survey of orthopaedic surgeons practice. Ir Med J 2000;93(4): 105—7.