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Secondary prevention of osteoporosis after Colles fracture: Current practice
Available online at www.sciencedirect.com
Joint Bone Spine 75 (2008) 50e52 http://france.elsevier.com/direct/BONSOI/
Original article
Secondary prevention of osteoporosis after Colles fracture: Current practice Harish V. Kurup a,*, J. Glynne Andrew b b
a Royal Glamorgan Hospital, Llantrisant CF72 8XR, UK Ysbyty Gwynedd Hospital, Bangor, North Wales LL57 2PW, UK
Received 14 August 2006; accepted 15 January 2007 Available online 31 August 2007
Abstract Objectives: Colles fracture in the elderly is accepted as evidence of osteoporosis. NICE (National Institute of Clinical Excellence) recommends osteoporosis treatment in all fragility fractures over 75 without a DXA (Dual Energy X-ray Absorptiometry) scan and after DXA scan in younger patients. All clinicians involved in the patient’s care are said to be responsible for this. Methods: We reviewed current practice in United Kingdom to find out the role played by orthopaedic surgeons in organising this treatment. We sent a questionnaire to 150 BOTA (British Orthopaedic Trainees Association) members by e-mail. Results: The response rate excluding bounced mails was 63%. Only 5% of respondents prescribed osteoporosis treatment and 32% requested general practitioner to do this. Twenty-four percent referred the patients for either DXA or to an osteoporosis service. Although 86% were aware of NICE guidelines regarding osteoporosis, only 35% thought it could amount to negligence on the surgeon’s part for not dealing with this. Fourteen percent worked in hospitals having an osteoporosis service which co-ordinated further management of these patients. Eleven percent expressed concerns over the source of funding for the management of osteoporosis and said that this was the reason for not offering treatment themselves. Conclusion: This survey highlights the importance of concrete local protocols in management of osteoporosis especially secondary prevention after an osteoporotic fracture. At present, it appears to be safe practice to indicate this in correspondence to patient’s general practitioner and inform the patient as well. Ó 2007 Elsevier Masson SAS. All rights reserved. Keywords: Colles fracture; Osteoporosis; Secondary prophylaxis
1. Introduction Two hundred million people worldwide suffer from osteoporosis and the prevalence continues to escalate with the increasing elderly population [1]. Osteoporosis increases risk of fragility fractures leading to morbidity, mortality, and decreased quality of life. Osteoporosis poses considerable costs to healthcare and this is expected to double by 2050. The occurrence of an osteoporotic fracture is a very strong predictor
* Corresponding author. Tel.: þ44 1443 443 443; fax: þ44 1443 443 385. E-mail address: [email protected] (H.V. Kurup).
of further fractures with 20% of patients experiencing a second fracture within the first year. Out of the osteoporotic fractures the one that increases burden of healthcare most is hip fracture and secondary prophylaxis in osteoporosis is aimed at preventing this. By the age of 80 years, every fifth woman and by 90 years almost every second woman suffers a hip fracture [2]. A Colles’ fracture associated with minor trauma is indicative of an overall 50% increase in the risk of a subsequent hip fracture [3]. Even though NICE has published guidance on secondary prevention on osteoporotic fractures, most surgeons and general practitioners do not initiate investigations or treatment after a Colles fracture [4]. This study investigates current practice among
1297-319X/$ - see front matter Ó 2007 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jbspin.2007.01.043
H.V. Kurup, J.G. Andrew / Joint Bone Spine 75 (2008) 50e52
orthopaedic surgeons in training in United Kingdom in the management of an osteoporotic Colles fracture. 2. Methods We did a questionnaire survey of 150 members of BOTA (British Orthopaedic Trainees Association) working at Specialist Registrar grade in United Kingdom. The questionnaire (Table 1) was sent to their e-mail addresses as given in the BOTA yearbook 2005e06. The questionnaire explored the clinical workload from Colles fracture on fracture clinics, the management trends followed in various centres or by individual surgeons, the awareness among surgeons about the existing guidelines and safe practices. Additional comments were used to collect extra information especially on the availability of specialised osteoporosis units in respective hospitals. Answers received within a month were included in this study. 3. Results Twenty-three percent of the e-mailed questionnaires bounced from the respective address. Response rate after excluding bounced e-mails was 63% (73 out of 115). The responses received were tabulated into a Microsoft excel sheet for analysis. Results are given in Table 2. Only 5% of respondents prescribed osteoporosis treatment themselves and 32% requested general practitioner to do this. Twenty-four percent referred patients for either DXA scan or to an osteoporosis service. Eleven percent expressed concerns over the source of funding for management of osteoporosis and said that this was the reason for not offering treatment themselves. Although 86% of respondents were aware of NICE guidelines regarding osteoporosis, only 35% thought it could amount to negligence on the orthopaedic surgeon’s part for not dealing with this. Fourteen percent of respondents worked in hospitals having an osteoporosis service which co-ordinated further management of these patients. 4. Discussion History of a fragility fracture (defined as a fracture sustained by a fall from a standing height) is one of the Table 1 The questionnaire Osteoporosis treatment after Colles’ fracture 1 2 3 4 5 6 7 8
How many Colles’ fractures do you see in a typical fracture clinic? Do you prescribe any osteoporosis treatment for these patients? Do you instruct the patient’s GP to start this (on your letter)? Do you ask the patient to contact GP for osteoporosis treatment/ investigations? Are you aware of current NICE guidelines on secondary prevention in osteoporosis? Do you think it amounts to negligence not to act on a situation like this? If you are not already suggesting this to GP, do you think you should in future? Comments
51
Table 2 Responses to questionnaire Total number of respondents >3 Colles fractures seen per fracture clinic Will prescribe osteoporosis treatment Ask general practitioner to do so Inform patient about osteoporosis Aware of NICE guidelines Ignoring osteoporosis amounts to negligence Will consider one of these measures in future (46 responses) Refer to osteoporosis team/DXA Availability of specialist osteoporosis service Source of funding for osteoporosis influences management
73 60 4 23 42 63 25 17 17 10 8
(82%) (5%) (32%) (58%) (86%) (35%) (37%) (24%) (14%) (11%)
recognised risk factors of osteoporosis and subsequent fractures [5]. It has been shown that patients who had a Colles fracture have a significant risk of osteoporosis with increased risk of further fractures. Indeed, any post menopausal fracture is an independent risk factor for a future hip fracture. Elderly women with Colles fracture have been shown to have a low BMD (Bone Mineral Density) in up to 85% [6] with 75% being eligible for osteoporosis treatment [7]. Sensitive diagnostic modalities such as DXA scan are readily available nowadays in most places and treatment with bisphosphonates has been shown to reduce incidence of a second fracture by 50% [8]. But still there are deterrents to implementing osteoporosis management guidelines, one of them being the clinicians involved in patient care themselves. Colles fracture despite being a very common fracture and proven risk factor in the occurrence of a future hip fracture still appears to end as a missed opportunity in many patients. Wide scale implementation of secondary prevention policies are yet to be established in many orthopaedic units. NICE guidelines [9] in use in England and Wales advise that women over 75 years who sustain a fragility fracture can be treated without the need of a DXA scan and those under 75 after the scan. Most patients attending fracture clinics with a Colles fracture are over 75 and all they would appear to need is medical treatment of osteoporosis, the currently favoured being bisphosphonates [10]. There appear to be ongoing debate on who should bear the financial burden of providing this service and most orthopaedic surgeons prefer the patient’s general practitioner to organise management of osteoporosis [11]. Fracture liaison services which co-ordinate osteoporosis management have already been shown to improve diagnosis and management rates of osteoporosis after low energy fractures [12]. But still referral to such a service remains the responsibility of either the surgeon or general practitioner. Orthopaedic surgeons should at the very least highlight this subset of patients to the general practitioners or osteoporosis service [4]. Most osteoporosis services are run by Rheumatologists and their involvement is vital in successful implementation of local protocols for osteoporosis management [13] and this should reduce the extra burden on orthopaedic services as well. Time is an important factor in secondary prevention and women with osteoporotic vertebral fractures have been shown to be at high risk of a second fracture within the first year [14]. Orthopaedic surgeons being the first to get involved in care of
52
H.V. Kurup, J.G. Andrew / Joint Bone Spine 75 (2008) 50e52
these patients have the advantage of time to their hand. Our survey shows that orthopaedic surgeons are aware and willing to take this responsibility should an osteoporosis service be readily available. This improvement in awareness and referral pattern is substantial compared to that reported by Pal et al. [15] in 1998. It is reassuring to note that, with steady increase in BMD testing and osteoporosis treatment a declining hip fracture incidence has been predicted in future [16]. Fifty-eight percent of respondents in our survey informed patients that their fracture is indicative of osteoporosis. But only 35% of respondents thought it could be quoted as negligence not to investigate and treat osteoporosis in these patients. With available evidence and guidelines, it could amount to negligence for failing to act on the diagnosis of osteoporosis. This survey highlights the need for concrete local protocols in management of osteoporosis especially secondary prevention after a fragility fracture. Most surgeons are aware of the existing guidelines on secondary prophylaxis of osteoporosis, however, are hesitant to initiate treatment partly due to absence of a specialist osteoporosis service or due to issues with source of funding for further management. At present, it appears to be safe practice to indicate this in correspondence to patient’s general practitioner and inform the patient so that this is acted upon. Acknowledgements We wish to thank the BOTA members who participated in this survey. References [1] Reginster JY, Burlet N. Osteoporosis: a still increasing prevalence. Bone 2006;38:S4e9.
[2] Kannus P, Parkkari J, Sievanen H, et al. Epidemiology of hip fractures. Bone 1996;18:57Se63. [3] Owen RA, Melton III LJ, Ilstrup DM, et al. Colles’ fracture and subsequent hip fracture risk. Clin Orthop Relat Res 1982;171:37e43. [4] Chami G, Jeys L, Freudmann M, et al. Are osteoporotic fractures being adequately investigated? A questionnaire of GP & orthopaedic surgeons. BMC Fam Pract 2006;7:7. [5] Accidents, falls, fractures and osteoporosis: a strategy for primary care groups and local health groups. Produced by the National Osteoporosis Society. Radstock: National Osteoporosis Society; 2000. [6] Hegeman JH, Oskam J, van der Palen J, et al. The distal radial fracture in elderly women and the bone mineral density of the lumbar spine and hip. J Hand Surg [Br] 2004;29:473e6. [7] Jutberger H, Sinclair H, Malmqvist B, et al. Screening for postmenopausal osteoporosis. Women with distal radius fractures should be evaluated for bone density. Lakartidningen 2003;100:31e4. [8] Epstein S. Update of current therapeutic options for the treatment of postmenopausal osteoporosis. Clin Ther 2006;28:151e73. [9] NICE. The clinical effectiveness and cost effectiveness of technologies for the secondary prevention of osteoporotic fractures in postmenopausal women. TA087, http://www.nice.org.uk/TA087guidance; January 2005. [10] Russell RG. Bisphosphonates: from bench to bedside. Ann N Y Acad Sci 2006;1068:367e401. [11] Simonelli C, Killeen K, Mehle S, et al. Barriers to osteoporosis identification and treatment among primary care physicians and orthopedic surgeons. Mayo Clin Proc 2002;77:334e8. [12] McLellan AR, Gallacher SJ, Fraser M, et al. The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int 2003;14:1028e34. [13] Levasseur R, Sabatier JP, Guilcher C, et al. Medical management of patients over 80 years admitted to orthopedic surgery for low-energy fracture. Joint Bone Spine 2007;74:160e5. [14] Lindsay R, Silverman SL, Cooper C, et al. Risk of new vertebral fracture in the year following a fracture. JAMA 2001;17:320e3. [15] Pal B, Morris J, Muddu B. The management of osteoporosis-related fractures: a survey of orthopaedic surgeons’ practice. Clin Exp Rheumatol 1998;16:61e2. [16] Jaglal SB, Weller I, Mamdani M, et al. Population trends in BMD testing, treatment, and hip and wrist fracture rates: are the hip fracture projections wrong? J Bone Miner Res 2005;20:898e905.
Joint Bone Spine 75 (2008) 50e52 http://france.elsevier.com/direct/BONSOI/
Original article
Secondary prevention of osteoporosis after Colles fracture: Current practice Harish V. Kurup a,*, J. Glynne Andrew b b
a Royal Glamorgan Hospital, Llantrisant CF72 8XR, UK Ysbyty Gwynedd Hospital, Bangor, North Wales LL57 2PW, UK
Received 14 August 2006; accepted 15 January 2007 Available online 31 August 2007
Abstract Objectives: Colles fracture in the elderly is accepted as evidence of osteoporosis. NICE (National Institute of Clinical Excellence) recommends osteoporosis treatment in all fragility fractures over 75 without a DXA (Dual Energy X-ray Absorptiometry) scan and after DXA scan in younger patients. All clinicians involved in the patient’s care are said to be responsible for this. Methods: We reviewed current practice in United Kingdom to find out the role played by orthopaedic surgeons in organising this treatment. We sent a questionnaire to 150 BOTA (British Orthopaedic Trainees Association) members by e-mail. Results: The response rate excluding bounced mails was 63%. Only 5% of respondents prescribed osteoporosis treatment and 32% requested general practitioner to do this. Twenty-four percent referred the patients for either DXA or to an osteoporosis service. Although 86% were aware of NICE guidelines regarding osteoporosis, only 35% thought it could amount to negligence on the surgeon’s part for not dealing with this. Fourteen percent worked in hospitals having an osteoporosis service which co-ordinated further management of these patients. Eleven percent expressed concerns over the source of funding for the management of osteoporosis and said that this was the reason for not offering treatment themselves. Conclusion: This survey highlights the importance of concrete local protocols in management of osteoporosis especially secondary prevention after an osteoporotic fracture. At present, it appears to be safe practice to indicate this in correspondence to patient’s general practitioner and inform the patient as well. Ó 2007 Elsevier Masson SAS. All rights reserved. Keywords: Colles fracture; Osteoporosis; Secondary prophylaxis
1. Introduction Two hundred million people worldwide suffer from osteoporosis and the prevalence continues to escalate with the increasing elderly population [1]. Osteoporosis increases risk of fragility fractures leading to morbidity, mortality, and decreased quality of life. Osteoporosis poses considerable costs to healthcare and this is expected to double by 2050. The occurrence of an osteoporotic fracture is a very strong predictor
* Corresponding author. Tel.: þ44 1443 443 443; fax: þ44 1443 443 385. E-mail address: [email protected] (H.V. Kurup).
of further fractures with 20% of patients experiencing a second fracture within the first year. Out of the osteoporotic fractures the one that increases burden of healthcare most is hip fracture and secondary prophylaxis in osteoporosis is aimed at preventing this. By the age of 80 years, every fifth woman and by 90 years almost every second woman suffers a hip fracture [2]. A Colles’ fracture associated with minor trauma is indicative of an overall 50% increase in the risk of a subsequent hip fracture [3]. Even though NICE has published guidance on secondary prevention on osteoporotic fractures, most surgeons and general practitioners do not initiate investigations or treatment after a Colles fracture [4]. This study investigates current practice among
1297-319X/$ - see front matter Ó 2007 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.jbspin.2007.01.043
H.V. Kurup, J.G. Andrew / Joint Bone Spine 75 (2008) 50e52
orthopaedic surgeons in training in United Kingdom in the management of an osteoporotic Colles fracture. 2. Methods We did a questionnaire survey of 150 members of BOTA (British Orthopaedic Trainees Association) working at Specialist Registrar grade in United Kingdom. The questionnaire (Table 1) was sent to their e-mail addresses as given in the BOTA yearbook 2005e06. The questionnaire explored the clinical workload from Colles fracture on fracture clinics, the management trends followed in various centres or by individual surgeons, the awareness among surgeons about the existing guidelines and safe practices. Additional comments were used to collect extra information especially on the availability of specialised osteoporosis units in respective hospitals. Answers received within a month were included in this study. 3. Results Twenty-three percent of the e-mailed questionnaires bounced from the respective address. Response rate after excluding bounced e-mails was 63% (73 out of 115). The responses received were tabulated into a Microsoft excel sheet for analysis. Results are given in Table 2. Only 5% of respondents prescribed osteoporosis treatment themselves and 32% requested general practitioner to do this. Twenty-four percent referred patients for either DXA scan or to an osteoporosis service. Eleven percent expressed concerns over the source of funding for management of osteoporosis and said that this was the reason for not offering treatment themselves. Although 86% of respondents were aware of NICE guidelines regarding osteoporosis, only 35% thought it could amount to negligence on the orthopaedic surgeon’s part for not dealing with this. Fourteen percent of respondents worked in hospitals having an osteoporosis service which co-ordinated further management of these patients. 4. Discussion History of a fragility fracture (defined as a fracture sustained by a fall from a standing height) is one of the Table 1 The questionnaire Osteoporosis treatment after Colles’ fracture 1 2 3 4 5 6 7 8
How many Colles’ fractures do you see in a typical fracture clinic? Do you prescribe any osteoporosis treatment for these patients? Do you instruct the patient’s GP to start this (on your letter)? Do you ask the patient to contact GP for osteoporosis treatment/ investigations? Are you aware of current NICE guidelines on secondary prevention in osteoporosis? Do you think it amounts to negligence not to act on a situation like this? If you are not already suggesting this to GP, do you think you should in future? Comments
51
Table 2 Responses to questionnaire Total number of respondents >3 Colles fractures seen per fracture clinic Will prescribe osteoporosis treatment Ask general practitioner to do so Inform patient about osteoporosis Aware of NICE guidelines Ignoring osteoporosis amounts to negligence Will consider one of these measures in future (46 responses) Refer to osteoporosis team/DXA Availability of specialist osteoporosis service Source of funding for osteoporosis influences management
73 60 4 23 42 63 25 17 17 10 8
(82%) (5%) (32%) (58%) (86%) (35%) (37%) (24%) (14%) (11%)
recognised risk factors of osteoporosis and subsequent fractures [5]. It has been shown that patients who had a Colles fracture have a significant risk of osteoporosis with increased risk of further fractures. Indeed, any post menopausal fracture is an independent risk factor for a future hip fracture. Elderly women with Colles fracture have been shown to have a low BMD (Bone Mineral Density) in up to 85% [6] with 75% being eligible for osteoporosis treatment [7]. Sensitive diagnostic modalities such as DXA scan are readily available nowadays in most places and treatment with bisphosphonates has been shown to reduce incidence of a second fracture by 50% [8]. But still there are deterrents to implementing osteoporosis management guidelines, one of them being the clinicians involved in patient care themselves. Colles fracture despite being a very common fracture and proven risk factor in the occurrence of a future hip fracture still appears to end as a missed opportunity in many patients. Wide scale implementation of secondary prevention policies are yet to be established in many orthopaedic units. NICE guidelines [9] in use in England and Wales advise that women over 75 years who sustain a fragility fracture can be treated without the need of a DXA scan and those under 75 after the scan. Most patients attending fracture clinics with a Colles fracture are over 75 and all they would appear to need is medical treatment of osteoporosis, the currently favoured being bisphosphonates [10]. There appear to be ongoing debate on who should bear the financial burden of providing this service and most orthopaedic surgeons prefer the patient’s general practitioner to organise management of osteoporosis [11]. Fracture liaison services which co-ordinate osteoporosis management have already been shown to improve diagnosis and management rates of osteoporosis after low energy fractures [12]. But still referral to such a service remains the responsibility of either the surgeon or general practitioner. Orthopaedic surgeons should at the very least highlight this subset of patients to the general practitioners or osteoporosis service [4]. Most osteoporosis services are run by Rheumatologists and their involvement is vital in successful implementation of local protocols for osteoporosis management [13] and this should reduce the extra burden on orthopaedic services as well. Time is an important factor in secondary prevention and women with osteoporotic vertebral fractures have been shown to be at high risk of a second fracture within the first year [14]. Orthopaedic surgeons being the first to get involved in care of
52
H.V. Kurup, J.G. Andrew / Joint Bone Spine 75 (2008) 50e52
these patients have the advantage of time to their hand. Our survey shows that orthopaedic surgeons are aware and willing to take this responsibility should an osteoporosis service be readily available. This improvement in awareness and referral pattern is substantial compared to that reported by Pal et al. [15] in 1998. It is reassuring to note that, with steady increase in BMD testing and osteoporosis treatment a declining hip fracture incidence has been predicted in future [16]. Fifty-eight percent of respondents in our survey informed patients that their fracture is indicative of osteoporosis. But only 35% of respondents thought it could be quoted as negligence not to investigate and treat osteoporosis in these patients. With available evidence and guidelines, it could amount to negligence for failing to act on the diagnosis of osteoporosis. This survey highlights the need for concrete local protocols in management of osteoporosis especially secondary prevention after a fragility fracture. Most surgeons are aware of the existing guidelines on secondary prophylaxis of osteoporosis, however, are hesitant to initiate treatment partly due to absence of a specialist osteoporosis service or due to issues with source of funding for further management. At present, it appears to be safe practice to indicate this in correspondence to patient’s general practitioner and inform the patient so that this is acted upon. Acknowledgements We wish to thank the BOTA members who participated in this survey. References [1] Reginster JY, Burlet N. Osteoporosis: a still increasing prevalence. Bone 2006;38:S4e9.
[2] Kannus P, Parkkari J, Sievanen H, et al. Epidemiology of hip fractures. Bone 1996;18:57Se63. [3] Owen RA, Melton III LJ, Ilstrup DM, et al. Colles’ fracture and subsequent hip fracture risk. Clin Orthop Relat Res 1982;171:37e43. [4] Chami G, Jeys L, Freudmann M, et al. Are osteoporotic fractures being adequately investigated? A questionnaire of GP & orthopaedic surgeons. BMC Fam Pract 2006;7:7. [5] Accidents, falls, fractures and osteoporosis: a strategy for primary care groups and local health groups. Produced by the National Osteoporosis Society. Radstock: National Osteoporosis Society; 2000. [6] Hegeman JH, Oskam J, van der Palen J, et al. The distal radial fracture in elderly women and the bone mineral density of the lumbar spine and hip. J Hand Surg [Br] 2004;29:473e6. [7] Jutberger H, Sinclair H, Malmqvist B, et al. Screening for postmenopausal osteoporosis. Women with distal radius fractures should be evaluated for bone density. Lakartidningen 2003;100:31e4. [8] Epstein S. Update of current therapeutic options for the treatment of postmenopausal osteoporosis. Clin Ther 2006;28:151e73. [9] NICE. The clinical effectiveness and cost effectiveness of technologies for the secondary prevention of osteoporotic fractures in postmenopausal women. TA087, http://www.nice.org.uk/TA087guidance; January 2005. [10] Russell RG. Bisphosphonates: from bench to bedside. Ann N Y Acad Sci 2006;1068:367e401. [11] Simonelli C, Killeen K, Mehle S, et al. Barriers to osteoporosis identification and treatment among primary care physicians and orthopedic surgeons. Mayo Clin Proc 2002;77:334e8. [12] McLellan AR, Gallacher SJ, Fraser M, et al. The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int 2003;14:1028e34. [13] Levasseur R, Sabatier JP, Guilcher C, et al. Medical management of patients over 80 years admitted to orthopedic surgery for low-energy fracture. Joint Bone Spine 2007;74:160e5. [14] Lindsay R, Silverman SL, Cooper C, et al. Risk of new vertebral fracture in the year following a fracture. JAMA 2001;17:320e3. [15] Pal B, Morris J, Muddu B. The management of osteoporosis-related fractures: a survey of orthopaedic surgeons’ practice. Clin Exp Rheumatol 1998;16:61e2. [16] Jaglal SB, Weller I, Mamdani M, et al. Population trends in BMD testing, treatment, and hip and wrist fracture rates: are the hip fracture projections wrong? J Bone Miner Res 2005;20:898e905.