Why is the secondary prevention of fragility fracture important?

Many osteoporosis patients leave hospital with their fracture treated but their osteoporosis undiagnosed, uninvestigated and untreated. Refracture rates can be reduced by targeting assessment and treatment at patients who have previously sustained fractures.

Osteoporosis is a common, yet under-diagnosed and undertreated, musculoskeletal disease^1-3 characterised by low impact bone fractures. Approximately half of women and one third of men aged over 60 will sustain a fracture in their lifetime.¹ Importantly, Inderjeeth et al⁴ recently identified a significant lack of awareness, diagnosis and treatment of patients with documented fracture up to six months following discharge from a tertiary hospital institution in Australia, even in the high-risk, osteoporotic fracture group.⁵ It has been shown that fragility fracture is associated with significant rates of morbidity and mortality, particularly in the case of hip fractures,⁶ and places the individual at a considerably increased risk of further fractures.^7,8

Osteoporosis costs Australian taxpayers an estimated $7.4 billion per annum, claiming over 25,000 lives in 2000–01 in Australia.⁹ As the number of Australians aged over 65 years is expected to double to over 25% of the population by 2045,¹⁰ the economic cost and burden placed on the health care system by fragility fractures are also predicted to rise markedly.

X-ray of (a) vertebal bodies with no fracture; and (b) vertebral crush fracture.
Images kindly provided by Prof N Fazzalari, Head, Bone and Joint Research Laboratory, Institute of Medical and Veterinary Science and Hanson Institute, Discipline of Pathology, University of Adelaide.

As demonstrated by a whole body of evidence, the risk of subsequent fracture once a first osteoporosis fracture has occurred is estimated to increase fourfold.⁵ Regardless of the evidence that further fractures may be prevented through increased patient awareness and pharmacological treatment,¹¹ the prevalence of patient initiated assessment for osteoporosis is low,¹² and many patients who sustain a fracture do not receive any diagnosis, treatment or information regarding osteoporosis.¹³ This results in many patients leaving hospital with their fracture treated but their osteoporosis undiagnosed, uninvestigated and untreated.^13-15 Therefore, refracture rates can be reduced by targeting assessment and treatment of patients who have previously sustained fractures. This would subsequently ease the personal, social and economic costs of osteoporosis.

In Australia in 2007, hospitalisation for osteoporotic fracture averaged 262 per day, or one person every 5–6 minutes.⁵ In light of this, it is clear that to prevent healthcare systems being overwhelmed by cases of elderly trauma, determined efforts are required to curb the rising prevalence of fragility fracture, particularly at the hip.

Osteoporosis is a chronic disease that many patients endure for several decades, during which time they will suffer several acute fracture events. Unfortunately, osteoporosis often remains undetected and/or untreated until a fracture occurs. Furthermore, in the absence of a systematic approach to the delivery of secondary fracture prevention, the majority of patients presenting with fragility fractures fail to receive treatment to reduce future fracture risk.^16,17 The effective delivery of secondary preventative intervention when patients first present with fragility fracture, at any skeletal site, provides an opportunity to intervene to minimise the number of future hip fracture cases. Pharmacological intervention at this "signature" fracture stage has the potential to halve future fracture incidence, including hip fractures, during at least three years of treatment, contingent upon compliance with treatment.¹⁸ Thus, in a relatively short time frame, up to one quarter of hip fractures could be averted, in addition to substantial numbers of fractures at other skeletal sites. Economic assessments of health care have demonstrated such intervention to be highly cost-effective.^5,19

Mortality and morbidity from fractures

Osteoporotic fractures, commonly of the hip, spine, humerus, forearm and wrist, are typically sustained with little or no preceding trauma. Morbidity from fractures includes pain; deformity; being bed-ridden; reduction in independence and activities of daily living;²⁰ fear of falling; anxiety; social isolation; and emotional disturbances such as depression.²¹ Osteoporotic fractures are also associated with excess rates of nursing home admissions²² and reduced quality of life.²³ Hip fractures can be particularly disabling, with complications that, as with other fractures, can result in death.^24,25

All major osteoporotic fractures are associated with the doubling of the age-adjusted mortality rate in women and a threefold increase in men.²⁶ The probability of death in the first year after a hip fracture is estimated at 10–20%,²² while approximately half of the survivors are disabled and need help with activities of daily living or require long-term nursing care.²⁷ The relative risk of mortality is estimated to be 60% higher in women with vertebral fracture than in women without vertebral fracture.²⁸

Treatment

Important principles of osteoporosis management are the maximisation of bone mass and the prevention (in women) of post menopausal bone loss.²⁹ In this respect, the purpose of the pharmacological treatment of osteoporosis is to reduce morbidity and mortality associated with the first and all subsequent fractures.³⁰

This type of treatment for osteoporosis is warranted because:

• Fractures are associated with significant morbidity and mortality;
• Bone loss and fracture risk increase with advancing age; and
• Treatments are available to prevent accelerated bone loss, slow the deterioration of the bone’s microarchitecture, and reduce the subsequent risk of fractures.

To minimise the morbidity and mortality associated with fragility fractures, patients suffering minimal trauma fractures require follow-up investigation for osteoporosis after treatment of their fracture.

Article kindly written by:

Professor Nick Fazzalari PhD
Head, Bone and Joint Research Laboratory, Institute of Medical and Veterinary Science and Hanson Institute
Discipline of Pathology, University of Adelaide;
Editorial Advisory Board Member of the Virtual Bone Centre

References

1. Jones G, Nguyen T, Sambrook PN, Kelly PJ, Gilbert C, Eisman JA. Symptomatic fracture incidence in elderly men and women: the Dubbo Osteoporosis Epidemiology Study (DOES). Osteoporos Int. 1994; 4(5): 277-82.
2. Henry MJ, Pasco JA, Nicholson GC, Seeman E, Kotowicz MA. Prevalence of osteoporosis in Australian women: Geelong Osteoporosis Study. J Clin Densitom. 2000; 3(3): 261-8.
3. Nguyen TV, Center JR, Eisman JA. Osteoporosis: underrated, underdiagnosed and undertreated. Med J Aust. 2004; 180(5 Suppl): S18-22.
4. Inderjeeth CA, Glennon D, Petta A. Study of osteoporosis awareness, investigation and treatment of patients discharged from a tertiary public teaching hospital. Intern Med J. 2006; 36(9): 547-51.
5. Breaking Point – The economic cost of not adhering to bisphosphonate treatment for osteoporosis. Access Economics Pty Ltd, 2006.
6. March LM, Cameron ID, Cumming RG, Chamberlain AC, Schwarz JM, Brnabic AJ, et al. Mortality and morbidity after hip fracture: can evidence based clinical pathways make a difference? J Rheumatol. 2000; 27(9): 2227-31.
7. Lindsay R, Silverman SL, Cooper C, Hanley DA, Barton I, Broy SB, et al. Risk of new vertebral fracture in the year following a fracture. JAMA. 2001; 285(3): 320-3.
8. Haentjens P, Autier P, Collins J, Velkeniers B, Vanderschueren D, Boonen S. Colles fracture, spine fracture, and subsequent risk of hip fracture in men and women. A meta-analysis. J Bone Joint Surg Am. 2003; 85-A(10):1936-43.
9. The Burden of Brittle Bones: Costing osteoporosis in Australia. Canberra, ACT: Access Economics Pty Ltd, 2001.
10. Economic Implications of an Ageing Australia. Canberra, ACT: Productivity Commission, Australian Government, 2005.
11. Cranney A, Guyatt G, Griffith L, Wells G, Tugwell P, Rosen C. Meta-analyses of therapies for postmenopausal osteoporosis. IX: Summary of meta-analyses of therapies for postmenopausal osteoporosis. Endocr Rev. 2002; 23(4): 570-8.
12. Phillipov G, Phillips PJ, Leach G, Taylor AW. Public perceptions and self-reported prevalence of osteoporosis in South Australia. Osteoporos Int. 1998; 8(6): 552-6.
13. Smith MD, Ross W, Ahern MJ. Missing a therapeutic window of opportunity: an audit of patients attending a tertiary teaching hospital with potentially osteoporotic hip and wrist fractures. J Rheumatol. 2001; 28(11): 2504-8.
14. Seagger R, Howell J, David H, Gregg-Smith S. Prevention of secondary osteoporotic fractures – why are we ignoring the evidence? Injury. 2004; 35(10): 986-8.
15. Kamel HK, Hussain MS, Tariq S, Perry HM, Morley JE. Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med. 2000; 109(4): 326-8.
16. Giangregorio L, Papaioannou A, Cranney A, Zytaruk N, Adachi JD. Fragility fractures and the osteoporosis care gap: an international phenomenon. Semin Arthritis Rheum. 2006; 35(5): 293-305.
17. Elliot-Gibson V, Bogoch ER, Jamal SA, Beaton DE. Practice patterns in the diagnosis and treatment of osteoporosis after a fragility fracture: a systematic review. Osteoporos Int. 2004;15(10): 767-78.
18. Seeman E, Compston J, Adachi J, Brandi ML, Cooper C, Dawson-Hughes B, et al. Non-compliance: the Achilles’ heel of anti-fracture efficacy. Osteoporos Int. 2007; 18(6): 711-9.
19. King AB, Saag KG, Burge RT, Pisu M, Goel N. Fracture Reduction Affects Medicare Economics (FRAME): impact of increased osteoporosis diagnosis and treatment. Osteoporos Int. 2005; 16(12): 1545-57.
20. Nevitt MC, Ettinger B, Black DM, Stone K, Jamal SA, Ensrud K, et al. The association of radiographically detected vertebral fractures with back pain and function: a prospective study. Ann Intern Med. 1998; 128(10): 793-800.
21. Salkeld G, Cameron ID, Cumming RG, Easter S, Seymour J, Kurrle SE, et al. Quality of life related to fear of falling and hip fracture in older women: a time trade off study. BMJ. 2000; 320(7231): 341-6.
22. Cumming RG, Nevitt MC, Cummings SR. Epidemiology of hip fractures. Epidemiol Rev. 1997; 19(2): 244-57.
23. Johnell O, Oden A, Caulin F, Kanis JA. Acute and long-term increase in fracture risk after hospitalization for vertebral fracture. Osteoporos Int. 2001; 12(3): 207-14.
24. Center JR, Nguyen TV, Schneider D, Sambrook PN, Eisman JA. Mortality after all major types of osteoporotic fracture in men and women: an observational study. Lancet. 1999; 353(9156): 878-82.
25. Cauley JA, Thompson DE, Ensrud KC, Scott JC, Black D. Risk of mortality following clinical fractures. Osteoporos Int. 2000; 11(7): 556-61.
26. Randell AG, Nguyen TV, Bhalerao N, Silverman SL, Sambrook PN, Eisman JA. Deterioration in quality of life following hip fracture: a prospective study. Osteoporos Int. 2000; 11(5): 460-6.
27. Sernbo I, Johnell O. Consequences of a hip fracture: a prospective study over 1 year. Osteoporos Int. 1993; 3(3): 148-53.
28. Ismail AA, O’Neil TW, Cooper C, Finn JD, Bhalla AK, Cannata JB, et al. Mortality associated with vertebral deformity in men and women: results from the European Prospective Osteoporosis Study (EPOS). Osteoporos Int. 1998; 8(3): 291-7.
29. O’Neill S, MacLennan A, Bass S, Diamond T, Ebeling P, Findlay D, et al. Guidelines for the management of postmenopausal osteoporosis for GPs. Aust Fam Physician. 2004; 33(11): 910-9.
30. Sambrook PN, Seeman E, Phillips SR, Ebeling PR. Preventing osteoporosis: outcomes of the Australian Fracture Prevention Summit. Med J Aust. 2002; 176(Suppl): S1-16.