S4 OSTEOPOROSIS FROM THE ORTHOPAEDIC PERSPECTIVE

Abstract

Orthopedic surgeons treat numerous patients in whom osteoporosis (OP) is an important factor: inflammatory arthritides (rheumatoid arthritis); sports medicine (the anorexic, amenorrhoeic female athlete); in consultation to renal, transplant and cardiac units; patients on corticosteroids, as well as others. Orthopedic procedures in patients who have osteoporotic bone require special techniques and precautions. A common example is hip replacement, where, through endosteal resorption, the medullary canal is large, cortices are thin, and the risk of femoral fracture and a poor outcome is higher.

The commonest interface of orthopedic surgery with OP is in the management of fractures. In North America, most orthopedic surgeons manage fractures in hospital and in the fracture clinic, where typically 3%–8% of patient visits are for classic fragility fractures. Traumatic fractures also commonly occur in osteoporotic bone. The yield of screening for OP in orthopedic wards and clinics, targeting fragility fracture patients, is much higher than screening in a general population. Published guidelines based on Level I evidence indicate that fragility fracture patients are at highest risk of future hip fractures, which often occur within one year of index fragility fracture, and that preventive treatment is economical and safe.

Treatment prevents 30–50% of hip fractures in high risk groups. Unfortunately, less than 20% of fragility fracture patients generally receive appropriate OP care, in multiple studies in developed countries. There is a growing international focus on developing care delivery systems that will promote consistent OP investigation and treatment in the inpatient and outpatient orthopedic environment.

In Ontario, Canada, an Osteoporosis Exemplary Care Program was initiated in 2003 to identify, educate, evaluate, refer, and treat female (> 40 years) and male (> 50 years) fragility fracture patients for OP. In the first year of the program, over 95% of inpatients and outpatients were appropriately diagnosed, treated, or referred for OP care. Success resulted from the presence of a dedicated coordinator and cooperation by orthopedic surgeons and residents, technologists, allied health professionals and administrative staff.

Regional, national and international orthopedic associations have developed initiatives designed to improve processes of care for OP in the orthopedic environment.