Commentary & Perspective

Commentary & Perspective on
"Older Women with Fractures: Patients Falling Through the Cracks of Guideline-Recommended Osteoporosis Screening and Treatment"
by Adrianne C. Feldstein, MD, MS, et al.
and on
"Osteoporosis and Vitamin-D Deficiency Among Postmenopausal Women with Osteoarthritis Undergoing Total Hip Arthroplasty"
by Julie Glowacki, PhD, et al.

Commentary & Perspective by
Joseph M. Lane, MD*,
Department of Orthopedic Surgery, Hospital for Special Surgery, New York, NY

Osteoporosis is a disorder primarily affecting postmenopausal women and, to a smaller extent, elderly men. It is associated with increased fracture risk, most notably at the vertebral body, the hip, and the wrist. Two papers published in The Journal of Bone and Joint Surgery have studied the issues of under-recognition and undertreatment of osteoporosis in an orthopaedic population. The problem is that many patients who present with a fragility fracture have the fracture repaired, but the underlying bone disease is not addressed.

Feldstein and co-workers have examined a cohort of older women with fractures. Although this group of 3,812 patients with fragility fractures belonged to a closed HMO that had clearly elucidated guidelines for screening and treatment, 55% of the individuals were not treated according to the guidelines, and fewer than 5% of patients underwent a dual-energy x-ray absorptiometry (DEXA) examination within six months of the fracture. More than 40% of the patients sustained a fracture while taking a course of anti-osteoporosis medication (primarily hormone replacement therapy). Less than 10% of previously untreated patients were placed on anti-osteoporosis medicines after sustaining a fracture. More importantly, adherence to the guidelines did not improve between 1998 and 2001 despite the presence and promulgation of these guidelines within the institution. Patients with hip fractures were undertreated compared with patients with vertebral fractures. This paper, plus others by Gardner et al.¹, Kanis et al.², Broy et al.³, Cuddihy et al.⁴, and Freedman et al.⁵, confirms the ongoing problem in which orthopaedists tend to address the acute care fracture but do not investigate or treat the underlying cause of the fracture.

Glowacki et al. have shown that 25% of patients who presented with osteoarthritis of the hip and no history of hip fracture had unrecognized osteoporosis. Also, about 25% of the patients in both the osteoporotic and non-osteoporotic cohorts had evidence of Vitamin-D deficiency and the earlier stages of osteomalacia, most notably with a low 25-hydroxy Vitamin-D level. It has been presumed that a patient with osteoarthritis is very unlikely to have co-existing osteoporosis, but the current study by Glowacki et al. clearly shows this not to be valid. Thus, osteoporosis and osteomalacia may be relatively prevalent in the general orthopaedic population even in patients without fragility fractures. One might surmise that the increasing rate of periprosthetic fractures may thus reflect a subgroup of osteoporotic individuals with total hip arthroplasty who are at risk for sustaining subsequent low-energy fractures. In addition, the presence of osteomalacia could slow the porous ingrowth that is associated with total hip replacements.

On the basis of these two articles, my recommendations would include better surveillance and broader evaluation of the orthopaedic population for osteopenia. Second, patients in whom fragility fractures have occurred should undergo appropriate evaluation and treatment for osteoporosis. Third, there are now many postmenopausal women who have discontinued hormone replacement therapy and may not be taking any anti-osteoporosis medication. This is a population at risk for fracture. All patients with fragility fractures should be suspected of having osteoporosis or osteomalacia until proven otherwise. Currently available treatments could easily correct the underlying bone disorders.

*The author did not receive grants or outside funding in support of his 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.

References

1. Gardner MJ, Flik KR, Mooar P, Lane JM. Improvement in the undertreatment of osteoporosis following hip fracture. J Bone Joint Surg Am. 2002;84:1342-8.
2. Kanis JA, Delmas P, Burckhardt P, Cooper C, Torgerson D. Guidelines for diagnosis and management of osteoporosis. The European Foundation for Osteoporosis and Bone Disease. Osteoporosis Int. 1997(7):390-406.
3. Broy SB, Bohren A, Harrington T, Licata A, Shewman D. Are physicians treating osteoporosis after hip fracture? J Bone Miner Res. 2000;15(Suppl 1):S141.
4. Cuddihy MT, Gabriel SE, Crowson CS, Atkinson EJ, Tabini C, O'Fallon WM, Melton LJ 3rd. Osteoporosis intervention following distal forearm fractures: a missed opportunity? Arch Intern Med. 2002;162:421-6.
5. Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA. Treatment of osteoporosis: are physicians missing an opportunity? J Bone Joint Surg Am. 2000;82:1063-70.