5 Osteoporosis Fractures Lecture Summary

1Osteoporosis and fracturesAn orthopaedic perspective

Orthopaedic Surgeons InitiativeInternational Osteoporosis Foundation

International Society for Fracture RepairThe Bone and Joint Decade

21. Eastell et al. QJM 2001; 94:575-592. Bouxsein et al. J Am Acad Ortho Surg. 2004; 12:385-95

Why is the Orthopaedic Surgeons Initiative needed?

Fragility fractures are a large and growing health issue 1 in 2 women and 1 in 4 men over 50 yrs of age will suffer a fracture in

their remaining lifetime

A prior fracture increases the risk of a new fracture 2- to 5-fold

Yet few fracture patients receive evaluation and treatment of osteoporosis, the underlying cause of most fragility fractures Calls for action to improve the evaluation and treatment of fracture

patients have been published around the World1,2

31. Eastell et al. QJM 2001; 94:575-592. Bouxsein et al. J Am Acad Ortho Surg. 2004; 12:385-95

Orthopaedic surgeons have a unique opportunity

Fragility fracture is often the first indication a patient has osteoporosis

Orthopaedic surgeons are often the first and may be the only physician seen by fracture patients

The orthopaedist can serve a pivotal role in optimizing treatment, not only of the fracture, but also of the underlying disease

4Multinational Survey of Osteoporotic Fracture Management

Survey of 3422 orthopaedic surgeons from 6 countries

90% do not routinely measure bone density following the first fracture

75% are lacking appropriate knowledge about osteoporosis

Dreinhfer et al. Osteoporos Int 2005; 16:S44-S54

5Goals of the Orthopaedic Surgeons Initiative Improve awareness of the scope and magnitude of fragility

fractures as a global public health concern

Improve understanding of osteoporosis and recognition that it is the underlying cause of most fragility fractures

Motivate orthopaedic surgeons to take an active role in optimizing care of the fragility fracture patient with the ultimate goal of preventing future fractures

6Outline

Fragility fractures and osteoporosis: an expanding epidemic with devastating consequences

Osteoporosis and fragility fractures: definition and etiology

Optimal care of fragility fracture patient

7Outline

Fragility fractures and osteoporosis: an expanding epidemic with devastating consequences

8Osteoporosis and fragility fractures:

An expanding epidemic

9Fragility fractures are common

1 in 2 women and 1 in 5 men over age 50 will suffer a fracture in their remaining life time1

55% of persons over age 50 are at increased risk of fracture due to low bone mass

At age 50, a womans lifetime risk of fracture exceeds combined risk of breast, ovarian & uterine cancer

At age 50, a mans lifetime risk of fracture exceeds risk of prostate cancer

1. Johnell et al. Osteoporos Int. 2005; 16: S3-7

10

Fractures will be more common

Fracture incidence projected to increase 2- to 4-fold in the next decades due to ageing of the population

In Europe 12% to 17% of population >65 in 2002

20% to 25% of population >65 in 2025

Aged 70+

Men Women

19902030

Men Women

11

Projected to reach 3.25 million in Asia by 2050

Cooper et al. Osteoporos Int 1992; 2:285-289

Estimated number of hip fractures (1000s)

1950 2050

6

0

0

3

2

5

0

1950 2050

6

6

8

4

0

0

1950 2050

7

4

2

3

7

8

1950 2050

1

0

0

6

2

9

Number of hip fractures projected to increase 3 to 4-fold worldwide

Total number ofhip fractures

worldwide projected to increase 3- to 4-

fold in next 50 years

1950: 1.66 million

2050: 6.26 million

12

Osteoporotic fractures:Comparison with other diseases

1996 new cases,all ages184 300

750 000 vertebral

250 000 other sites

250 000forearm

250 000hip

0

500

1000

1500

2000

Osteoporotic fractures

Heartattack

Stroke Breastcancer

A

n

n

u

a

l

i

n

c

i

d

e

n

c

e

x

1

0

0

0

1 500 000

annual incidenceall ages

513 000

annual estimatewomen 29+

228 000

annual estimatewomen 30+

American Heart Association, 1996American Cancer Society, 1996Riggs & Melton, Bone, 1995; 17(5 suppl):505S-511S

13

Osteoporosis and fragility fractures:

Morbidity, mortality and costs

14

Consequences of hip fracture

Cooper. Am J Med 1997; 103(2A):12s-19s.

40%

Unable to walk

independently

30%

Permanentdisability

20%

Death within one year

80%

Patients (%)

Unable to carry out at least one independent activity of daily living

One year after hip fracture

15

Consequences of vertebral fractures Acute and chronic pain

Narcotic use, decrease mobility

Loss of height & deformity Reduced pulmonary function

Kyphosis, protuberant abdomen

Diminished quality of life: Loss of self-esteem, distorted body image, sleep disorders,

depression, loss of independence

Increased fracture risk

Increased mortality

16

O'Neill et al. Osteoporos Int. 2001; 12:555-558

Consequences of distal radius fractures

The most common fracture in women at middle age Incidence increases just after menopause

The most common fracture in men below 70 years

Only 50% report good functional outcome at 6 months

Up to 30% of individuals suffer long-term complications

17

Mortality due to hip fracture vs. stroke(deaths per 100,000 in older women)

Hip fracture data: age 80; Kanis. J Bone Miner Res. 2002; 17:1237Stroke data: ages 65-74; Sans et al. Eur Heart J 1997; 18:1231

Hip fracture Stroke

Sweden 177 154

Denmark 154 180

Germany 131 190

18

Cumulative survival probability

Center et al. Lancet 1999, 353:878-882

Age

MEN

S

u

r

v

i

v

a

l

p

r

o

b

a

b

i

l

i

t

y

0.2

0.4

0.6

0.8

0

1.0

60 65 70 75 80 85

Dubbo PopulationVertebral/Major FracturesProximal Femur Fractures

Age

WOMEN

S

u

r

v

i

v

a

l

p

r

o

b

a

b

i

l

i

t

y

1.0

0

0.2

0.4

0.6

0.8

60 65 70 75 80 85

19

Mortality after major types of osteoporotic fracture in men and women

Age-standardized mortality ratio

Fracture Women Men

Proximal femur 2.2 3.2

Vertebral 1.7 2.4

Other major 1.9 2.2

5-year prospective cohort study

Center et al. Lancet 1999; 353:878-882

20

1.91.81.92.0Minor fracture2.43.31.71.9Forearm1.81.44.42.3Spine1.91.42.52.3Hip

Minor fractureForearmSpineHip Site of prior fracture

Risk of subsequent fracture

Prior fracture increases the risk of subsequent fracture

Klotzbuecher et al. J Bone Miner Res 2000; 15:721-727

A prior fracture increases the risk of new fracture 2- to 5-fold

21Economic cost of osteoporosis and fragility fractures in Europe

In Europe the total direct costs of osteoporotic fractures are over 31 billion and are expected to increase to more that 76 billion in 20501

In France osteoporotic hip fractures are estimated to cost about 1 billion every year2

In Spain the total direct hospital cost of osteoporotic fractures in 1995 was ~ 222 million2

In England & Wales the total direct hospital cost of osteoporotic fractures in 1999 was ~ 847 million2

1. Kanis and Johnell, Osteoporos Int.2005; 16 Suppl 2:S3-72. Osteoporosis in the European Community: A Call to Action. IOF Nov, 2001

22

Economic impact of osteoporosis

Annual direct costDisease Prevalence including hospitalization

(millions) (US$ billion)

Cardiovascular 4.6 20.3disease

Asthma 15 7.5

Osteoporosis 10 13.8

Information supplied by National Heart, Lung & Blood Institute,National Osteoporosis Foundation, American Heart Association

Annual economic cost of treating fractures in the USA is similar to that of treating cardiovascular disease and

asthma

23

Fragility fractures are common and have severe consequences

Fragility fractures lead to major morbidity, decreased quality of life and increased mortality

10-25% excess mortality

50% unable to walk independently after hip fracture

50% show substantial decline from prior level of function (many lose ability to live independently)

Increased depression, chronic pain, disability

Increased risk of subsequent fracture

24

Outline Fragility fractures and osteoporosis: an expanding

epidemic with devastating consequences


25

a systemic skeletal disease characterized by low bone mass and micro-architectural deterioration of bone tissue, leading to enhanced bone fragility and a consequent increase in fracture risk.

Definition of osteoporosis

World Health Organization (WHO), 1994

26

Major risk factors for fractures

Prior fragility fracture

Increased age

Low bone mineral density

Low body weight

Family history of osteoporotic fracture

Glucocorticoid use

Smoking

27

Cooper et al. Trends Endocrinol Metab 1992; 3:224

755535

Men

Forearm

Vertebrae

Hip

Age

4,000

3,000

2,000

1,000

Women

Forearm

I

n

c

i

d

e

n

c

e

p

e

r

1

0

0

,

0

0

0

p

e

r

s

o

n

-

y

e

a

r

s

Vertebrae

Hip

55 7535

Osteoporotic fracture incidence

28

Type of fracture Men Women

Forearm 4.6 20.8

Hip 10.7 22.9

Spine 8.3 15.1

Proximal humerus 4.1 12.9

Other 22.4 46.4

Remaining lifetime fracture risk (%) in Caucasian population at the age of 50

Johnell et al. Osteoporos Int. 2005; 16 Suppl 2:S3-7

29

Femoral BMD T-score (SD)-3 -2 -1 0 1

0

10

20

10 year Hip Fracture

Probability (%)

50

60

70

80

Age (years) Women

Fracture risk depends on age and BMD

30

Assessing bone density

X-ray observation Osteopaenic on x-ray implies significant

bone loss already decreased opacity, thin cortices, wide canals, current fracture, healing fractures

A late finding in the course of the disease, but may be the first finding for a patient

31

Assessment of bone mineral density by DXACurrent gold standard for diagnosis of osteoporosis

BMD (g/cm2) = Bone mineral content (g) / area (cm2)

Diagnosis based on comparing patients BMD to that of young, healthy individuals of same sex

32

Fracture risk increase per 1 SD decrease in BMD

1.52.31.61.5Lumbar spine BMD

1.61.82.61.4Hip BMD

1.41.71.81.7Distal radius BMD

AllVertebralHipForearmFracture Site

Meta-analysis by Marshall et al, Br Med J. 1996

33

WHO criteria for diagnosis of osteoporosis

Kanis et al. J Bone Miner Res 1994; 9:1137-41

T-score: Difference expressed as standard deviation compared to young (20s) reference population

T-scoreNormal - 1.0 and aboveOsteopaenia - 1.0 to - 2.5Osteoporosis - 2.5 and belowSevere (established) osteoporosis

- 2.5 and below, plus one or more osteoporotic

fracture(s)

34

Osteoporotic fracture and BMD

Fractures per 1,000 person-years Number of fractures

1.0 0.5 0.0 -0.5 -1.0 -1.5 -2.0 -2.5 -3.0 -3.5

Fracture rate

Women with fractures

0

10

20

30

40

50

0

100

200

300

400

Siris et al. Arch Intern Med. 2004; 164:1108-1112

35

Bone strength is more than BMD

Images from L. Mosekilde, Technology and Health Care. 1998

young

elderlyImage courtesy of David Dempster

36

Determinants of whole bone strength

Geometry Gross morphology (size & shape)

Microarchitecture

Properties of bone material / bone matrix Mineralization

Collagen characteristics

Microdamage

37Bone remodelling balance influences bone strength

SIZE & SHAPE macroarchitecturemicroarchitecture

MATERIAL tissue compositionmatrix properties

BONE REMODELLINGformation / resorption

AGEING, DISEASE and THERAPIES

Bouxsein. Best Practice in Clin Rheum. 2005; 19:897-911

Bone strength

38

High Bone TurnoverResorption > Formation

Decreased Bone Strength

Disrupts Trabecular Architecture

Decreases Bone Mass

Increases Cortical PorosityDecreases Cortical Thickness

Alters Bone Matrix Composition

L. MosekildeTech and Health Care, 1998

Bouxsein. Best Practice in Clin Rheum. 2005; 19:897-911Seeman & Delmas, New England J Med, 2006; 354:2250-61

39

Bone size (mass)Bone shapeArchitectureMatrix properties

Fall incidence

Fall impact

Bonestrength

Fracture risk

Fall characteristicsEnergy absorptionExternal protection

Neuromuscular functionEnvironmental risksAge

But bone quality is not the only factor

40

Outline Fragility fractures and osteoporosis: an expanding

epidemic with devastating consequences


Optimal care of fragility fracture patient

Critical opportunity for orthopaedists

41

But is that enough?

Millions of fragility fractures a year with current orthopaedic management, most fractures will heal

42

Alarming facts

Awareness and knowledge about osteoporosis is low among fracture patients

43

385 patients with fragility fractures

Have you ever heard of osteoporosis?

NO: 20 % YES: 80 %

Do you think that the fracture you have experienced could be due to fragility of your bones?

NO: 73 % YES: 27 %

An Osteoporosis Clinical Pathway for the Medical Management of Patients with Low Trauma Fracture

Awareness and knowledge about osteoporosis in fracture patients is low

Chevalley et al. Osteoporos Int. 2002; 13:450-455

44

Alarming facts

Awareness and knowledge about osteoporosis is low among fracture patients

Despite availability of therapies proven to reduce fracture risk, even in patients who have already suffered a fracture, diagnosis and treatment of osteoporosis among fragility fracture patients remains low

45

Treatment of osteoporosis:Are physicians missing an opportunity?

Among 1162 women with distal radius fracture, at 6 mo 266 (23%) prescribed osteoporosis med 33 (2.8%) had bone density test 20 (1.7%) had bone density + OP therapy

883 (76%) received neither bone density test nor medical treatment of osteoporosis

Among 1654 patients (age > 50 yrs) admitted to hospital for a fracture resulting from a fall: ~ 50% hip fracture, at 1 yr 247 (15%) prescribed osteoporosis med Women: 3 times more likely to receive treatment than men (19% vs 5%)

Freedman et al. J Bone Joint Surg 2000; 82-A:1063-70Panneman et al. Osteoporos Int. 2004; 15:120-4

46

Fracture More to the story

47

Optimal care of the fragility fracture patient Diagnosis of fragility fracture

Identify fragility fracture & underlying disease, incorporate into existing workup

Influences treatment plan from the onset

General fracture management Stabilize patient, pain relief, fracture care

Rehabilitation Minimize dependence, maximize mobility

Secondary prevention Treat and monitor underlying disease, prevent future fractures

48

Optimal care of the fragility fracture patient

Diagnosis of fragility fracture Identify fragility fracture & underlying disease, incorporate into

existing workup


49

Diagnose fragility fracture

Accident pattern

Definition of fragility fracture:

Fracture during activity that would not normally injure young healthy bone (i.e., fall from standing height or less)

50

Fragility fracture?

Accident pattern Risk assessment

Risk factors for primary and secondary OP

Risk factors for fracture

Risk factors for fall

Mechanism of injury:

Low trauma?

Fall from standing height or less ?

Fragility fracture?

51

Major risk factors for fractures

Prior fragility fracture

Increased age

Low bone mineral density

Low body weight

Family history of osteoporotic fracture

Glucocorticoid use

Smoking

52

High risk for secondary osteoporosis

Severe chronic liver or kidney diseases

Steroid medication (>7.5mg for more than 6 months)

Malabsorption (eg. Crohns disease)

Rheumatoid arthritis

Systemic inflammatory disorders

Hyperthyroidism

Primary hyperparathyroidism

Antiepileptic medication

53

Fragility fracture patient assessment * In addition to routine pre-op or fracture evaluation

Family history of OP Menarche / Menopause Nutrition Medications

(past and present) Level of activity Fracture history Fall history & risk factors for falls Smoking, alcohol intake Risk factors for secondary OP Prior level of function

Historyshould include:

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Height Weight Limb exam

ROM, strength, deformity, pain, neurovascular status

Spine exam pain, deformity, mobility

Functional status

Physical examshould include:

Fragility fracture patient assessment In addition to routine pre-op or fracture evaluation

55

SR / CRP Blood count Calcium Phosphate Alkaline Phosphatase (AP) GGT Renal function studies Basal TSH Intact PTH Protein-immunoelectrophoresis Vit D (25 and 1.25)

Laboratory tests*

NOTES:

- * These are in addition to routine pre-op labs such as coagulation studies

- These are screening labs, more may be indicated based on these results

56

Bone mineral density and spine radiograph for vertebral fracture assessment

Bone mineral density assessment by DXA Establish severity of osteoporosis

Baseline for monitoring treatment efficacy

Consider spine radiographs (thoracic and lumbar, AP and ML views) for patients with: Back pain

Loss of height > 4 cm

Progressive kyphosis

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58

Complexity of elderly patients Mean age hip fracture

= 80 yrs Comorbidities

(median ASA 3) Murmurs

Renal - dialysis

COPD - home O2

Diabetes

Delirium / dementia

Pseudo-obstruction

Alcohol abuse

Impaired metabolic response to injury Hyponatraemia

Management problems Consent

Theatre scheduling

Discharge planning

Polypharmacy Warfarin

Plavix

Neurotropics

59

These factors can lead to a higher risk of failure at the implant-bone interface before healing achieved

Technical challenges of fracture fixation in osteoporotic bone

Impaired ability of osteoporotic bone to hold screws or support implants

Crushing of cancellous bone with subsequent voids after fracture reduction

60

Special considerations in fixationof fragility fractures

Arthroplasty / Hemiarthroplasty Also allows early mobilization, may be less painful

Implants designed for osteoporotic bone

Fixed angle locking plates

Hydroxyapatite-coated screws

Use of IM nail instead of onlay devices (plates and screws) for diaphyseal fractures

Void filling with cement or bone graft

61

Possible indications for arthroplasty

Hip Shoulder Knee Elbow

Images courtesy of John Keating

62

Hip hemiarthroplastyEstablished and widely preferred to ORIF in displaced subcapitalfractures

But current controversy

Total arthroplastyuse is increasing

Keating et al. J Bone Joint Surg. 2006; 88(A):249-60

Shoulder arthroplasty

Useful particularly for 3-part and 4-part fractures and fracture dislocations

Early treatment best Good pain relief, but poor

movement and function Soft tissues influence outcome

63

Female 82 yrs

1 YEAR1 MONTH

Screw head threaded engages with hole in plate

Single mechanical unit internal fixator

No compressive force on periosteum

POST OP

Plecko and Kraus, Oper Orthop Traumatol.2005; 17:25-50

Example of fixed angle locking plates

64

Fixation augmentation with hydroxyapatite-coated screws

OsteoTite HA-coated external fixation pin

HA-coated AO/ASIF lag screw

HA-coated AO/ASIF cortical bone screw

HA-coated AO/ASIF cancellous bone screw

Magyar G et al, J Bone Joint Surg Br. 1997 May;79(3):487-9Moroni A et al, Clin. Orthop. 1998 Jan;(346):171-77Moroni A et al, Clin Orthop. 2001 Jul(388):209-17Moroni A et al, J. Bone Joint Surg. Am. 2001 May;83-A(5):717-21Sandn B al, J. Bone Joint Surg. Br. 2002 Apr;84(3):387-91Caja VL et al, J. Bone Joint Surg. Am. 2003 Aug;85-A(8):1527-31Moroni A et al, Clin. Orthop. 2004 Aug;(425):87-92 Moroni A et al, J. Bone Joint Surg. Am. 2005 May;83-A(5):717-21

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Moroni et al. J Bone Joint Surg Am 2005; 87:753-9

HA-coated dynamic hip screw improved outcomes in osteoporotic patients with hip fracture

DHS fixed with standard vs HA-coated AO/ASIF screws in osteoporotic patients with

trochanteric fractures

Standard HA-coated1. HA-coated screws maintained better neck shaft angle at 6 mo

2. Patients with HA-coated device had better Harris hip scores and far less cut out of lag screw

66






67

Rehabilitation in the fragility fracture patient

Goal is to improve strength, balance, position sense, reactions to: Improve level of function /

independence

Decrease risk of falls

Decrease risk of fractures

Balance (position sense, reaction)

Mechanical vibration plate

Limb and core strength

Mobility in activities of daily living

Safety in gait and transfers

Sensory and visual limitations

Home safety evaluation and adaptation

68

Rehabilitation of fragility fracture patientFall prevention

A multidisciplinary, multifactorial intervention programreduces postoperative falls and injuries after femoral neck fractureM. Stenvall et al, Osteoporosis International (2007) 18: 167-75

Guideline for the prevention of falls in older personsAmerican Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons Panel on Falls Prevention. J Am Geriatr Soc (2001) 49: 664-672

Interventions for preventing falls in elderly people (Review)LD Gillespie et al, Cochrane Database Syst Rev (2003)

69

Optimal care of the fragility fracture patient

Diagnosis of fragility fracture Identify fragility fracture & underlying disease, incorporate into

existing workup




Secondary prevention Treat and monitor underlying disease, prevent future fractures

Ideally begins during acute and sub-acute fracture care

70

Secondary prevention basics Further evaluation of underlying disease

Bone mineral density

Rule out secondary causes of osteoporosis

Initiate osteoporosis therapy, as indicated

Fall prevention

Inform patient and primary MD doctor of probable fragility fracture and osteoporosis

Ensure patient has follow-up care with PT and physician treating osteoporosis (if not orthopaedist)

71

Interventions to reduce future fracture risk

Basics Nutrition, exercise, fall prevention strategies

Modify risk factors as able (smoking, excess alcohol)

Treat co-morbidities (i.e., endocrine disorder?)

Pharmacological agents

72

Interventions: General recommendations

Regular physical activity Maintaining safe ambulatory status, indep ADLs

Daily limb and core home exercise routine

Sufficient intake of calcium and vitamin D daily 1000-1500 mg calcium, 400-800 IU vitamin D

by foods or foods and supplements combined

Adequate nutrition

Avoid cigarettes, excess alcohol

73

Pharmacological agents for treatment of osteoporosis

Effective therapies are widely available andcan reduce vertebral, hip and other fractures

by 30% to 65%,

even in patients who have already suffered a fracture

74

Bisphosphonates Alendronate (FOSAMAX) Risedronate (ACTONEL) Ibandronate (BONVIVA) Zolendronate (ACLASTA)

Pharmacological agents shown to reduce fracture risk

SERMs Raloxifene (EVISTA)

Stimulators of bone formation rh-PTH (FORTEO)

Mixed mode of action Strontium ranelate (PROTELOS)

Hormone therapy Estrogen / progestin

75

Effect on vertebral fracture risk Effect on non-vertebral fracture risk

Osteoporosis With prior fractures

Osteoporosis With prior fractures

Alendronate + + NA + (incl. hip)Risedronate + + NA + (incl. hip)Ibandronate NA + NA +HRT + + + +Raloxifene + + NA NATeriparatide and PTH

NA + NA +

Strontium ranelate

+ + + (incl. hip) + (incl. hip)

NA, No evidence available; + , effective drug ; awomen with a prior vertebral fracture

Adapted from Boonen S. et al. 2005; Osteoporos Int; 16:239-54

76

Orthopaedists role in improving fragility fracture care

Opportunity or obligation?Either way, it is:

important not Difficult rewarding becoming standard of care

77

The orthopaedists responsibilities in fragility fracture care

Identify the orthopaedic patient with a possible fragility fracture

Inform the patient about the need for an osteoporosis evaluation

Investigate whether osteoporosis is an underlying cause of the fracture

Ensure that appropriate intervention is initiated

Educate the patient and the family

Coordinate care with other treating physicians

Bouxsein et al. J Am Acad Orthop Surg, 2004; 12:385-95

78

Summary and conclusions Fractures are common. Fractures will be more common

Osteoporotic fractures are associated with increased morbidity & mortality

A fracture is among the strongest risk factors for future fracture. Refracture rate is high

Majority of patients with fragility fractures are not evaluated or treated for osteoporosis

Effective treatments are available

Orthopaedic surgeons are usually the treating physician and can take an active role in optimizing care of the fragility fracture patient

79

Acknowledgements

Slide Development

Kristina kesson, MD

Mary L. Bouxsein, PhD

Nansa Burlet, MD

Karsten Dreinhfer, MD

Ghassan Maalouf, MD

David Marsh, MD

Aenor J. Sawyer, MD

International Osteoporosis Foundation

International Society for Fracture Repair

The Bone and Joint Decade

We kindly thank Novartis for their generous support for

development of the CD-ROM

80

Acknowledgements

In Memoriam

Olof Johnell, MD (1943 - 2006)

Who started this project, and continues to inspire us.

Francis R. Bouxsein (1920 - 2006)

Who died 5 months after suffering a hip fracture, reminding us why we need to improve care of fragility fracture patients.

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Online resources

www.iofbonehealth.org www.fractures.com www.boneandjointdecade.org www.aaos.org/osteoporosis/ www.niams.nih.gov/bone www.nof.org

Osteoporosis and fracturesAn orthopaedic perspectiveWhy is the Orthopaedic Surgeons Initiative needed?Orthopaedic surgeons have a unique opportunityMultinational Survey of Osteoporotic Fracture ManagementGoals of the Orthopaedic Surgeons InitiativeOutlineOutlineOsteoporosis and fragility fractures:Fragility fractures are commonFractures will be more commonNumber of hip fractures projected to increase 3 to 4-fold worldwideOsteoporotic fractures:Comparison with other diseasesOsteoporosis and fragility fractures:Consequences of hip fractureConsequences of vertebral fracturesConsequences of distal radius fractures Mortality due to hip fracture vs. stroke(deaths per 100,000 in older women)Cumulative survival probabilityMortality after major types of osteoporotic fracture in men and womenPrior fracture increases the risk of subsequent fractureEconomic cost of osteoporosis and fragility fractures in EuropeEconomic impact of osteoporosisFragility fractures are common and have severe consequencesOutlineDefinition of osteoporosisMajor risk factors for fracturesOsteoporotic fracture incidenceRemaining lifetime fracture risk (%) in Caucasian population at the age of 50Fracture risk depends on age and BMDAssessing bone densityAssessment of bone mineral density by DXAFracture risk increase per 1 SD decrease in BMDWHO criteria for diagnosis of osteoporosisOsteoporotic fracture and BMDBone strength is more than BMDDeterminants of whole bone strengthBone remodelling balance influences bone strengthBut bone quality is not the only factorOutlineMillions of fragility fractures a year with current orthopaedic management, most fractures will healAlarming factsAwareness and knowledge about osteoporosis in fracture patients is lowAlarming factsTreatment of osteoporosis:Are physicians missing an opportunity?Optimal care of the fragility fracture patient Optimal care of the fragility fracture patient Major risk factors for fracturesHigh risk for secondary osteoporosisFragility fracture patient assessment * In addition to routine pre-op or fracture evaluationBone mineral density and spine radiograph for vertebral fracture assessmentOptimal care of the fragility fracture patient Complexity of elderly patientsTechnical challenges of fracture fixation in osteoporotic boneSpecial considerations in fixationof fragility fracturesPossible indications for arthroplasty Hip hemiarthroplastyExample of fixed angle locking platesFixation augmentation with hydroxyapatite-coated screwsHA-coated dynamic hip screw improved outcomes in osteoporotic patients with hip fractureOptimal care of the fragility fracture patient Rehabilitation in the fragility fracture patientRehabilitation of fragility fracture patientFall preventionOptimal care of the fragility fracture patient Secondary prevention basicsInterventions to reduce future fracture riskInterventions: General recommendationsPharmacological agents for treatment of osteoporosisPharmacological agents shown to reduce fracture riskOrthopaedists role in improving fragility fracture careThe orthopaedists responsibilities in fragility fracture careSummary and conclusionsAcknowledgementsAcknowledgementsOnline resources

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