Mr. Cobb incorrectly looked at the data in terms of the decrease seen in the hip fracture rate in our study. The historic hip fracture rate for each age group is what we used to calculate expected hip fractures for the current study population. In each age group, we saw a decrease in the expected number of hip fractures with the largest reduction in patients 85 years of age or older. By multiplying the historic age adjusted hip fracture rate by the total number of patients in each age group then adding the expected hip fractures, we expected to see 2544 hip fractures. The actual number of hip fracture we saw 1574. This was the 38.1% reduction that we discussed in the paper.

To the Editor:

In amplification of my letter regarding Dr. Dell’s paper (1), I have had the opportunity to review the raw data from which the graphs that he drew were drawn.

The authors claimed a huge reduction in fractures over the predicted rate. The table below shows that there was no real change at all in the fracture rate over the three years reported for any age group (Table 1). The reduction they report is solely based on the increasing number of people being diagnosed as osteoporotic on the basis of DXA scans performed for screening purposes. By increasing the number of people tested for osteoporosis, they increased the number being diagnosed and treated for it.

Over 50,000 more DXA scans were performed, at an approximate cost of $100 per person or $5,000,000 in total. In addition, approximately 50,000 people were treated for a condition they did not know they had, at a cost of at least $500, or $25,000,000. Over this time, there was no significant change in the number of people sustaining hip fractures, despite the huge increase in diagnoses in asymptomatic people.

The only certain outputs of this program are that more than $30 million has been spent with no measurable effect, and that over 80,000 people face an unknown but increasing risk of atypical fractures which may only reveal themselves over the decades to come.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received 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, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

Reference

1. Dell RM, Greene D, Anderson D, Williams K. Osteoporosis disease management: what every orthopaedic surgeon should know. J Bone Joint Surg Am. 2009;91:79-86.

The treatment of osteoporosis with bisphosphonates comes with a risk-benefit ratio. The risks include very uncommon atypical femur stress fractures that we have identified in approximately 40 patients in the last 3 years so far in the more than 172,000 patients who we have had on an oral bisphosphonate since we started our Healthy Bones Program (unpublished data). In the last 3 years, we estimate we have prevented over 3,000 hip fractures based on our own age-sex adjusted hip fracture rate that has strong agreement with the age and sex adjusted hip fracture rate reported by Ettinger et al (1). The trade off then would be potentially causing 40 of these atypical femur stress fractures while helping to prevent roughly 3,000 hip fractures. How many of these 40 patients with atypical femur stress fractures would have had a hip fracture is unknown and exactly how many of the 3,000 less hip fractures were conclusively prevented by having the patients taking an oral bisphosphonate is unknown. Also unknown is to what degree oral bisphosphonates usage contributed to the reduction in the hip fracture rate in developed counties. I do not believe it is a coincidence that the reduction in the rate of hip fractures began around 1997, around the same time that the usage of oral bisphosphonates increased. There is a general consensus in the bone mineral research community that oral bisphosphonates are still considered the first line pharmacologic treatment of osteoporosis even with their low risk profile. These are potent medications that do have long half lives and should not be used without clear indications. But when indicated, oral bisphosphonates continue to play a leading role in osteoporosis treatment. The day when the orthopedic surgeon could say “I just fix the fracture” is over. Orthopedic surgeons have a responsibility not just to fix the fracture but to do everything we can to prevent the next fracture. If an orthopedic surgeon is uncomfortable about prescribing prescription anti-osteoporosis medications, they can refer the patient to a clinician for further evaluation and treatment.

Reference

1. Ettinger B, Black DM, Dawson-Hughes B, Pressman AR, Melton LJ 3rd. Updated fracture incidence rates for the US version of FRAX. Osteoporos Int. 2010;21:25-33.

To the Editor:

The authors of the article entitled, "Orthopaedic Disease Management: What Every Orthopaedic Surgeon Should Know" include some direct advice to initiate anti-osteoporosis treatment with bisphosphonates (1). This is a class of drug that prevents bone turn-over, with a half-life of years (2) and is associated with an entirely new type of fracture (3-6), whose prevalence may increase for many years, owing to their pharmacokinetics. The authors provide no real data to justify this stance, showing a remarkable reduction against a predicted rate of fracture, but no hard data on actual numbers of fractures occurring. The real rate of hip fracture in the developed world seems to be static or falling (7,8), or only increasing in the very old (9). This is unlikely to be due to the prescription of drugs of any class. Orthopaedic surgeons should know how to fix fractures, but should be wary about initiating drug treatments whose long term consequences are still unfolding.

The author did not receive any outside funding or grants in support of his research for or preparation of this work. Neither he nor a member of his immediate family received 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, division, center, clinical practice, or other charitable or nonprofit organization with which the author, or a member of his immediate family, is affiliated or associated.

References

1. Dell RM, Greene D, Anderson D, Williams K. Osteoporosis disease management: what every orthopaedic surgeon should know. J Bone Joint Surg Am. 2009;91:79-86.

2. Lin JH. Bisphosphonates: a review of their pharmacokinetic properties. Bone. 1996;18:75-85.

3. Edwards MH, McCrae FC, Young-Min SA. Alendronate-related femoral diaphysis fracture-what should be done to predict and prevent subsequent fracture of the contralateral side? Osteoporos Int. 2009 Jun 27 [Epub ahead of print].

4. Ali T, Jay RH. Spontaneous femoral shaft fracture after long-term alendronate. Age Ageing. 2009;38:625-6.

5. Schneider JP. Bisphosphonates and low-impact femoral fractures: current evidence on alendronate-fracture risk. Geriatrics. 2009;64:18-23.

6. Napoli N, Novack D, Armamento-Villareal R. Bisphosphonate-associated femoral fracture: implications for management in patients with malignancies. Osteoporos Int. 2009 Aug 11 [Epub ahead of print].

7. Fisher AA, O'Brien ED, Davis MW. Trends in hip fracture epidemiology in Australia: possible impact of bisphosphonates and hormone replacement therapy. Bone. 2009;45:246-253.

8. Melton LJ 3rd, Kearns AE, Atkinson EJ, Bolander MD, Achenbach SJ, Huddleston JM, Therneau TM, Leibson CL. Secular trends in hip fracture incidence and recurrence. Osteoporos Int. 2009;20:687-94.

9. Bergström U, Jonsson H, Gustafson Y, Pettersson U, Stenlund H, Svensson O. The hip fracture incidence curve is shifting to the right. Acta Orthop. 2009;80:520-4.