Commentary & Perspective on
"Improvement in the Undertreatment of Osteoporosis
Following Hip Fracture"
by Michael J. Gardner, MD, et al.

Commentary & Perspective by
Thomas A. Einhorn, MD*,
Department of Orthopaedic Surgery,
Boston University School of Medicine, Boston, MA

(Revised August 26, 2002)

"An ounce of prevention is worth a pound of cure." This truism is especially meaningful now as we witness rapid advances in medical science. With more learned every day about the risks of disease in individuals and in populations and with data emerging from the Human Genome Project on an individual's genetic predisposition for disease, novel opportunities for prevention now present themselves.

Osteoporosis, a condition characterized by decreased bone mass and deterioration in the microarchitecture of bone, is estimated to affect forty-four million people who are fifty years of age or older in the United States¹. By the year 2010, it is estimated that over fifty-two million women and men in that age category will be affected, and, if current trends continue, this figure will rise to exceed sixty-one million by 2020². In light of these numbers, and in the absence of any preventive treatment for this condition, it has been estimated that one in every two women over the age of fifty years and one in every three men over the age of seventy-five years, will sustain an osteoporosis-related fracture at some time during their lives³. Several pharmaceutical agents have demonstrated efficacy in the prevention and treatment of osteoporosis. Therefore, it is now incumbent on physicians to recognize and treat this condition.

In this month's issue of The Journal, Gardner et al. demonstrate that elderly patients and postmenopausal women who are admitted to hospitals and diagnosed with a low-energy femoral neck fracture have been undertreated for osteoporosis. Although the authors provide the encouraging news that, over the last four years, there has been a significant increase in the rate of treatment, the fact remains that current treatment is woefully insufficient. The investigators derived these data from a retrospective cohort study performed with use of ICD-9 codes for femoral neck fractures in patient databases from two university medical centers and one university-affiliated community hospital. One hundred patient charts were randomly selected from each of the three medical centers and twenty-five patients from each year between 1997 and 2000 were included in the analysis. The results showed that, of the seventy-five patients from all centers for each year from 1997 to 2000, only 11%, 13%, 24% and 29%, respectively, were discharged with a prescription for either supplemental calcium or an antiosteoporotic medication. These data are reminiscent of those in an article by Freedman et al., published only two years ago⁴. In that study, of 1162 women who were fifty-five years of age or older and had sustained a distal radial fracture, only thirty-three (2.8%) underwent a bone-density scan and 266 (22.9%) were treated with at least one medication approved for the treatment of established osteoporosis. However, while the article by Freedman et al. demonstrated a serious deficiency in physicians' recognition of patients requiring treatment for osteoporosis and the associated risk of fracture, the article by Gardner et al. reveals an increasing awareness of this problem. Nevertheless, more needs to be done.

Prior to 1995, with the exception of hormone replacement therapy, treatment with injectable calcitonin, and recommendations regarding daily intake of calcium, there were few interventions to prevent or treat bone-loss syndromes. However, with the introduction of alendronate and other bisphosphonates such as risedronate, selective estrogen receptor modulators such as raloxifene, nasal-spray calcitonin, and now, the pending FDA approval of teriparatide (recombinant human parathyroid hormone 1-34), a true anabolic agent for bone formation, several good pharmaceutical agents exist for the management of osteoporosis. Reports on the use of these agents in randomized, controlled, prospective clinical trials in postmenopausal osteoporotic women who have sustained fractures have demonstrated results of moderate to substantial increases in bone-mineral density and very significant reductions in the incidence of new fractures. Therefore, with the advent of these treatments and preventive therapies, the need to identify the patients most likely to benefit from such interventions is increasingly important.

Orthopaedic surgeons must now have an increased awareness of osteoporosis and recognize that patients with certain types of fractures are at risk for "fragility fractures" in the future. Because orthopaedic surgeons are usually the first to treat patients who present with a fragility fracture, it is incumbent upon us to recognize the condition and ensure that these patients begin an appropriate treatment regimen to prevent future fractures.

*The author did not receive grants or outside funding in support of the research or preparation of this manuscript. He did not receive payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the author is affiliated or associated.

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