Osteoporosis – Role of the Surgeon

Reviewed by

Dr Sam Joseph
MBBS | Accredited Orthopaedic Registrar

Fragility Fractures

  • Osteoporosis = Bone mineral density T-score of <2.5
  • Common fragility fractures
    • Vertebrae
    • proximal femur
    • distal radius
  • 1-year mortality after hip fracture between 15 & 33%
  • Poor Prognostic Factors
    • Age
    • Comorbidities
    • Time to surgery
    • Subsequent Fracture risk as high as 45%
    • Low initiation of osteoporosis treatment 1-9%

Evaluating Fracture Risk

  • BMD is correlated to bone strength and is a predictor of future fracture risk
  • WHO algorithm for assessing risk FRAX assessment tool
  • National Osteoporosis Foundation (NOF) recommends treatment when 10 yr risk of hip fracture is >3%

Improving Bone Health & Reducing Fracture Risk

  • Diet
    • Calcium, Vitamin D (level 4 evidence)
  • Smoking cessation
  • Treating Alcoholism
  • Fall Risk Factors
    • Lighting, eyesight, postural hypotension
  • Bisphosphonates
  • Hormone replacement therapy
  • physiotherapy / exercise

Osteoporosis Medications

  • Bisphosphonates
    • Acts on the osteoclast to prevent bone resporption
  • Alendronate, risedronate, ibandronate and zoledronic acid have all been shown to reduce fracture risk (level III)
  • Better compliance with less frequent dosing

HORIZON Study

  • Multicentre RCT
  • Hip fracture patients mean age 73
  • N=2127
  • IV zoledronic acid 5mg yearly vs placebo
  • 5years
  • Treatment group 8.6% subsequent fracture
  • Placebo group 13.9% subsequent fracture

Safety of Bisphosphonates

  • GI symptoms
  • Osteonecrosis of the jaw
    • Recommend dental examination
    • <1/100,000 patient-years
    • More common in patients with metastatic bone disease
  • Bisphosphonate related fractures

Patient Preparation for Follow-up Care

  • All patients with fragility fractures shoulder be accessed by physicians / endocrinologists for suitability of bisphosphonates

References

The Role of the Orthopaedic Surgeon in Minimizing Mortality and Morbidity Associated With Fragility Fractures, JAAOS 2010;18:278-285