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Physicians Update

 
Spring 2010

When Presented with Fragility Fracture, Think Osteoporosis

03/01/2010

PhyUpdate-Spring2010 Orthopedic DoctorAmple evidence indicates that a fragility fracture — any fracture resulting from a fall from standing height or less — is a red flag for osteoporosis and the biggest risk factor for future fractures. But many physicians aren’t handling these cases with the appropriate diagnostic testing and follow-up, according to researchers at the Santa Monica-UCLA Osteoporosis and Metabolic Bone Disease Center.

In a survey published last year of patients in the emergency department at UCLA Medical Center, Santa Monica who presented with a fragility fracture, 40 percent were unaware they had osteoporosis, and only one in five were being treated for the condition.

“Primary care physicians have so much to cover in a short office visit that osteoporosis and fracture risk are often overlooked,” says Deborah Kado, M.D., a geriatrician at the Santa Monica- UCLA Osteoporosis and Metabolic Bone Disease Center and coauthor of the study with UCLA orthopaedic surgeon Benjamin Bengs, M.D. “As a result, we’re seeing many patients with recurrent fractures who haven’t even been treated with calcium and vitamin D.”

UCLA is spearheading an effort to assist physicians in being more proactive once their patients have experienced a fragility fracture. Aurelia Nattiv, M.D., director of the center, and colleagues have developed a fracture protocol that is being launched this year to assist physicians in ensuring that patients who experience fragility fractures are referred for a bone-density assessment and appropriate follow-up treatment.

Ideally, Dr. Nattiv notes, physicians should be proactive about their patients’ bone health well before that first fracture occurs. An estimated 44 million people in the United States — and more than half the population over age 50 — have osteoporosis or its precursor, osteopenia, accounting for approximately 1.5 million fractures each year that can be debilitating and sometimes fatal. Many of these people don’t know they are at risk until it’s too late. “This is a silent disease, like hypertension,” Dr. Kado says. “Until you measure for bone density, you might not know there is an increased fracture risk.”

The National Osteoporosis Foundation recommends that women age 65 and older and men starting at age 70 undergo bone-mineraldensity testing. Testing is also recommended for postmenopausal women and men older than age 50 who have increased risk factors. The gold standard for diagnosis, assessment of risk and monitoring of treatment is the noninvasive dual energy X-ray absorptiometry (DXA) scan. Additional tools have been added. Dr. Nattiv notes that the FRAX algorithm developed by the World Health Organization helps to determine patients’ 10-year fracture risk and can be useful in guiding decisions about whether to begin treating patients with osteopenia — a much larger group than the osteoporotic population. PhyUpdate-Spring2010 Osteoporosis BoneWhen treatment is indicated, an expanding armamentarium of medications can slow, and in some cases reverse, the process of bone loss. While the first-line treatment in most patients continues to be bisphosphonates, promising new drugs are on the horizon.

The most common contributor to osteoporosis and osteopenia in the U.S. population is vitamin D insufficiency (defined as less than 30 ng/mL in the 25-hydroxyvitamin D test), notes John S. Adams, M.D., vice chair for research and director of UCLA’s Orthopaedic Hospital Research Center. Dr. Adams, who is also a clinician at the Santa Monica-UCLA Osteoporosis and Metabolic Bone Disease Center, points to the most recent National Health and Nutrition Examination Survey (NHANES) findings that 80 percent of U.S. adults have insufficient levels of the hormone, which helps to maintain normal bone and muscle function. That’s double the prevalence found in the NHANES data just a decade earlier, Dr. Adams notes. Factors likely contributing to the dramatic increase include reduced sunlight exposure and higher rates of sunscreen use in response to concerns about skin cancer, increase in the population’s body-fat content (fat traps vitamin D and keeps it out of circulation), and reduced consumption of vitamin D-fortified dairy products and bread.

As with osteoporosis, vitamin D insufficiency tends to remain symptomatically silent until a fragility fracture occurs, Dr. Adams notes. “Measuring 25-hydroxyvitamin D in the blood is the fastest-growing endocrine test in the world, but it’s still underutilized when you consider that 80 percent of the U.S. population is now vitamin D insufficient,” he says, adding that intervening early, particularly in patients with a family history of osteoporosis, is critical. Therapy to return patients’ vitamin D levels to normal usually involves 500,000 to 1 million international units of vitamin D, followed by 1,600 to 2,000 IUs daily, on average, to maintain normal levels.

PhyUpdate-Spring2010 Fragility FractureDevelopments over the last decade have improved the outlook for patients who experience osteoporotic fractures, including those who sustain the fractures despite being on medication. Advances include enhanced surgical techniques, such as internal fixation using locking plates specially designed for fragile bones, as well as improvements in arthroplasty. “These techniques have revolutionized our ability to manage fragility fractures surgically,” says Dr. Bengs, who works closely with the medical physicians at the Santa Monica-UCLA Osteoporosis and Metabolic Bone Disease Center. “There is now less failure, less deformity, faster recovery and quicker ambulation.”

Dr. Nattiv believes that with the advances on both the medical and surgical sides, the comprehensive approach taken by a multidisciplinary team such as UCLA’s is important, particularly for the most complex cases — patients with very low bone density, those with complicated medical regimens (including cancer or transplant patients) and those who sustain recurrent fractures. “Beyond the new drugs and surgical techniques,” Dr. Nattiv says, “having the medical and surgical teams working together closely and approaching each case comprehensively is the best way to optimize the patient’s bone health.”





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