Commentary
Osteoporosis: The Missed Opportunity of Orthopaedics
By Thomas A. Einhorn, MD

A recent investigation conducted by the Council on Research and Scientific Affairs of the American Academy of Orthopaedic Surgeons indicated that the most prevalent musculoskeletal conditions expected to affect the U.S. population over the next thirty years are osteoarthritis and osteoporosis. With respect to osteoarthritis, orthopaedists are well versed in the operative and non-operative management of this condition and are accustomed to prescribing a variety of anti-inflammatory drugs and physical therapy. We counsel patients with regard to their functional limitations and opportunities for improvement and advise them when these improvements are no longer possible, when deformities indicate end-stage joint disease, and when the benefits of joint arthroplasty outweigh the risks. However, sophisticated as we may be in the comprehensive care of osteoarthritis, we are equally unsophisticated in our management of osteoporosis.

In the article "Treatment of Osteoporosis: Are Physicians Missing an Opportunity?" (82A: 1063-1070, Aug. 2000), by Freedman et al., a search of a claims database including more than three million patients, identified 1,162 women, fifty-five years of age or older, who had sustained a distal radial fracture. Of these, 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. Only twenty women had both a bone-density scan and drug treatment. Moreover, there was a highly significant decrease in the rate of treatment of osteoporosis with increasing patient age at the time of fracture (p<0.0001).¹ I believe that the authors understated the situation when they concluded: "Current physician practice may be inadequate for the diagnosis and treatment of osteoporosis in postmenopausal women who have sustained a distal radial fracture."

Osteoporosis affects 45% of women who are fifty years of age or older, resulting in a lifetime risk of 40% for fractures of the hip, vertebra, or distal part of the forearm.² Patients who have sustained a distal radius fracture have nearly twice the relative risk of a future hip fracture^3,4,5 and several studies have shown that, in more than 90% of cases, a distal radial fracture alone is sufficient clinical evidence for a diagnosis of osteoporosis.^6,7,8,9 Because distal radial fractures, as a group, occur approximately fifteen years earlier than hip fractures, at least two epidemiological studies have strongly suggested that the occurrence of a distal radial fracture strongly forecasts a high risk for hip fracturein the future.^5,11 Thus I believe that an orthopaedic surgeon should not treat a distal radial fracture without evaluating the patient's risk for future fracture, whether by means of bone-density scanning, a metabolic bone-disease workup with the intent to treat the patient, or referral to another physician interested in managing osteoporosis.

Prior to 1995, options for improving skeletal health, preventing osteoporosis, or treating established osteoporosis were few. The only FDA-approved drugs were estrogen and injectable calcitonin. There was substantial public concern regarding the safety of hormone replacement therapy and a lack of consensus regarding the efficacy of calcitonin treatment in the prevention of future fractures. There were also non-approved, experimental treatments such as sodium fluoride, etidronate, and vitamin D, but orthopaedic surgeons were appropriately cautious regarding the use of these therapies. However, with the approvals by the Food and Drug Administration in 1995 of alendronate sodium (Fosamax) and nasal spray calcitonin (Miacalcin), and with the subsequent introduction of raloxifene hydrochloride (Evista) and another bisphosphonate, risedronate (Actonel), orthopaedic surgeons now have several treatment options at their disposal. All of these have been shown to be safe and effective in managing patients with osteoporosis. Treatment with anti-osteoporosis drugs has been shown to result in small increases in bone-mineral density and has also been shown to reduce the risk of hip fracture by 50% compared with the risk for untreated postmenopausal women.¹²

Bone densitometry and other screening methods for metabolic bone disease are not inexpensive. With increasing concern over health-care expenditures, all of us must "tighten our belts" and be responsible with respect to how we spend health-care dollars. The recommended guidelines of the National Osteoporosis Foundation state that physicians should perform an evaluation for osteoporosis using bone-density testing to confirm the diagnosis and to determine the disease severity for all postmenopausal women who present with a fracture.¹³ Certainly, as physicians, we are more comfortable instituting treatment when there are good methods for measuring the severity of disease and when these methods can be used to monitor treatment. On the other hand, the abundance of data supporting a relationship between the occurrence of a distal radial fracture and the diagnosis of osteoporosis should provide us with sufficient confidence to institute preventive therapy even if bone-density examination is not available or if there is some other reason not to incur the expenditure.^7,9,10,14,15

The finding by Freedman et al. that there was a significant decrease in the rate of treatment of osteoporosis with increasing patient age at the time of fracture is also disturbing. Data showing that the risk of a subsequent hip fracture following a distal radial fracture is greater among women who are seventy years of age or older at the time of wrist fracture than it is among those who are younger at the time suggests that this is precisely the group that requires our greatest attention.¹⁰ Moreover, as our population continues to age, a greater number of individuals will fall into this category, and patients who are seventy years of age or older will become a much larger portion of the population.

The Journal of Bone and Joint Surgery, the American Academy of Orthopaedic Surgeons, and the National Osteoporosis Foundation have instituted several efforts to enhance the role of the orthopaedic surgeon in the management of osteoporosis. These efforts have included the publication of review articles, continuing medical-education courses, textbooks, and other educational. Although it would appear that orthopaedic surgeons have ample opportunity to become knowledgeable in this area, evidence such as that provided in the article by Freedman et al. suggests that the impact has been minimal. In addition, the low attendance at the American Academy of Orthopaedic Surgeons-sponsored continuing medical-education courses on osteoporosis indicates a lack of interest. Simply put, we are missing an opportunity to help hundreds of thousands of patients with skeletal disease, and it is our mission to do so. The article by Freedman et al. should serve as a "wake-up call" to all of us and stimulate a deliberate response to provide the kind of musculoskeletal care that our patients deserve.

References

1. 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.

2. Melton LJ 3d, Chrischilles EA, Cooper C, Lane AW, Riggs BL. Perspective. How many women have osteoporosis? J Bone Miner Res. 1992;7:1005-10.

3. Johansson C., Mellstrom D. An earlier fracture as a risk factor for new fracture and its association with smoking and menopausal age in women. Maturitas. 1996;24:97-106.

4. Mallmin H, Ljunghall S. Distal radius fracture is an early sign of general osteoporosis: bone mass measurements in a population-based study. Osteoporos Int. 1994;4:357-61.

5. Mallmin H, Ljunghall S, Persson I, Naessen T, Kursemo UB, Bergstrom R. Fracture of the distal forearm as a forecaster of subsequent hip fracture: a population-based cohort study with 24 years of follow-up. Calcif. Tissue Int. 1993;52:269-72.

6. Black DM, Cummings SR, Karpf DB, Cauley JA, Thompson DE, Nevitt MC, Bauer DC, Genant HK, Haskell WL, Marcus R, Ott SM, Torner JC, Quandt SA, Reiss TF, Ensrud KE. Randomised trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet. 1996;348:1535-41.

7. Miller PD, Bonnick SL, Rosen CJ. Consensus of an international panel on the clinical utility of bone mass measurements in the detection of low bone mass in the adult population. Calcif. Tissue Int. 1996;58:207-14.

8. Morse ML, Leroy AA, Strom BL. COMPASS: A population-based postmarketing drug surveillance system. In: Inman W, editor. Monitoring for drug safety. 2nd ed. Philadelphia: JB Lippincott; 1986. p 237-45.

9. Clinical practice guidelines for the diagnosis and management of osteoporosis. Scientific Advisory Board, Osteoporosis Society of Canada. CMAJ. 1996;155:1113-33.

10. Owen RA, Melton LJ 3d, Johnson KA, Ilstrup DM, Riggs BL. Incidence of Colles' fracture in a North American community. Am J Public Health. 1982;72:605-7.

11. Bauer GCH. Epidemiology of fracture in aged persons. A preliminary investigation in fracture etiology. Clin. Orthop. 1960;17:219-25.

12. Riggs BL, Melton LJ 3d. The prevention and treatment of osteoporosis. N Engl J Med. 1992;327:620-7.

13. National Osteoporosis Foundation. Physician's guide to prevention and treatment of osteoporosis. Washington, D.C.: National Osteoporosis Foundation; 1999.

14. Sturtridge W, Lentle B, Hanley DA. Prevention and management of osteoporosis: consensus statements from the Scientific Advisory Board of the Osteoporosis Society of Canada. 2. The use of bone density measurement in the diagnosis and management of osteoporosis. CMAJ. 1996;155:924-9.

15. World Health Organization Study Group. Assessment of fracture risk and its application to screening for postmenopausal osteoporosis. Report no. 843. Geneva: World Health Organization; 1994. p 7-10.