Purpose: We report the prevalence of vitamin D deficiency and other causes of secondary osteoporosis in a group of typical and atypical fragility fracture patients.

Method: A chart audit of 399 patients (117 males, mean age 64.6, SD 12.8; 282 females, mean age 63.5, SD 14.6) referred from an inner city orthopaedic unit to the Metabolic Bone Disease Clinic (MBDC) over a three-year period was conducted. Fracture locations and etiology: 90 hip (76 fragility), 161 wrist (135 fragility), 8 vertebral (6 fragility), 77 shoulder (62 fragility), 62 other sites (45 fragility), 1 both hip and shoulder (fragility).

Results: Thirty percent of patients (42 males, 78 females) had a total of 149 secondary causes of OP recorded. Secondary causes included medication use (oral steroids, anti-convulsants); rheumatic, gastrointestinal and endocrine conditions (RA, IBD, Graves disease, Type I DM, hyperparathyroidism); hypogonadal states (premature ovarian failure, hypogonadism); genetic conditions (hypophosphatasia); hematological conditions (thalassemia); miscellaneous causes (smoking, renal impairment). A total of 308 patients completed blood work, including 269 patients who had a 25-OH vitamin D measurement: 7 patients were deficient at ≤ 25 nmol/l, 137 were insufficient at 26 to 74 nmol/l, and 125 were sufficient at ≥ 75nmol/l. There were no differences between males and females (p = 0.457), or among fracture locations (p 0.246). Over 75% of blood/urine analyses were within the normal range for: 1,25 vitamin D, ALP, ALT, AST, bilirubin, creatinine, T3, T4, homocysteine, magnesium, phosphorus, platelets, serum calcium, protein, albumin, globulin, TSH, tissue transglutaminase, Vit B12, WBC, 24 hour urine calcium and phosphorus. Between 50 and 74% of the blood/urine analyses were within the normal range for: CRP (n = 30; 30% elevated), ESR (n = 173; 43% elevated), testosterone (n = 53; 25% of men below normal), bioavailable testosterone (n = 52; 40% of men below normal), N- telopeptide (n = 5; 30% of women elevated), RBC folate (n = 12; 33% elevated), 24 hour urine creatinine (n = 51; 27% below normal).

Conclusion: Half of the fracture patients were vitamin D insufficient. A standardized blood test protocol for all fragility fracture patients is in use.

Purpose: To evaluate the impact of the Osteoporosis Exemplary Care Program (OECP) on orthopaedic surgeons’ practice patterns at St. Michael’s Hospital.

Methods: A chart audit was performed to collect data on two groups of 54 patients identified with fragility fractures. The intervention group consisted of patients treated during the first four months of the OECP, while the control (pre-intervention) group consisted of age, sex, and fracture-type matched patients treated prior to implementation of the OECP. Characteristics of the intervention and control groups were compared using chi-square tests. Multivariable logistic regression analysis was then performed to identify significant correlates of OP care.

Results: Preliminary results from 54 matched pairs (108 patients in total) indicate that the OECP group was more likely to have OP risk or OP diagnosis documented (unadjusted OR 2.49; 95% CI 1.05–5.87), as well as to be referred for further investigation of OP (unadjusted OR 3.08; 95% CI 1.37–6.91) or to receive treatment or follow-up related to OP (unadjusted OR 9.01; 95% CI 3.77–21.54). As one surgeon was known to have been providing a high level of OP care prior to implementation of the OECP, the analysis was repeated after removing his patients. In addition, the analysis was repeated after removing patients who were already being treated for OP at the time of their fragility fracture. In both cases, larger increases in the likelihood of OP documentation and care were observed. Through multivariable analysis, age and fracture type (i.e. wrist vs. hip) were found to be significant correlates of having received OP care for patients with fragility fractures treated prior to implementation of the OECP. Following implementation of the OECP, there were no significant correlates of receiving OP care.

Conclusions: Preliminary results indicate that the OECP had a significant impact on orthopedic surgeons’ practice patterns. Following implementation of the OECP all patients were equally likely to receive appropriate referral, treatment, and follow-up whereas, prior to implementation of the program, age and fracture type affected the likelihood that a patient would receive such care.

Funding : Commerical funding

Funding Parties : The Osteoporosis Exemplary Care Program is funded by an unrestricted program grant provided by Merck Frosst Canada and Co. Dr. Beaton is supported by a New Investigators Award, from the Canadian Institute of Health Research.