Medicolegal Issues

How can a patient with a hip fracture reduce the risk of repeat fractures?


 

Case

A 66-year-old female with a pack-a-day smoking habit is admitted to orthopedics with a hip fracture following a fall in her home. You are consulted to perform a pre-operative risk assessment and manage her heart failure. The following day, she undergoes an open reduction and internal fixation and does well following the surgery. She is scheduled to be discharged for rehabilitation in two days. She will continue taking her cardiac medications and the narcotics (as needed) for pain. What else can you recommend to reduce her chances of suffering another hip fracture?

Overview

Approximately 300,000 hip fractures occur each year in the United States.¹ The lifetime risk of sustaining a hip fracture is 18% for a woman and 6% for a man.2 One-year mortality after a hip fracture is 20% to 25%, and up to half of patients who live independently prior to their fracture cannot gain independence afterward.

In the late 1990s, inpatient care, nursing home care, and outpatient services associated with hip fractures totaled approximately $14 billion annually. These costs are predicted to reach $50 billion by the year 2040.3 Not surprisingly, second hip fractures are common, with up to 12% of patients suffering another fracture within one year of follow up.1 Risk of morbidity and mortality are even higher after a second hip fracture.

In most experts’ opinions, a fragility fracture indicates osteoporosis and warrants treatment—regardless of bone densitometry findings. Still, multiple studies have shown patients who sustain a hip fracture frequently are not diagnosed, evaluated, or treated for osteoporosis.4 This is analogous to treating an acute coronary syndrome without initiating treatment for a patient’s hypertension and hyperlipidemia prior to discharge. As such, providers clearly are missing an opportunity to begin effective measures at a critical stage in the disease.

Data Review

Physiology of bone strength: Bone minerals—in particular calcium hydroxyapatite—contribute to bone strength by making bone a hard tissue. Collagen adds flexibility and gives bone the ability to absorb energy. The degree of bone mineralization and the number of collagen crosslinks help determine how much stress a bone can tolerate before it breaks. Further, in response to daily stressors, bone accumulates microcracks. Remodeling is then accomplished by bone resorption and formation.5

Estrogen plays an important role in normal remodeling by controlling osteoclast action. Thus, estrogen deficiency leads to prolonged osteoclast activity and increased rates of bone resorption. This explains why bone remodeling typically favors bone resorption later in life and why women are at greatest risk for fracture.5

Key Points

1. The first step in treating osteoporosis is diagnosing it.

2. A patient who has had an osteoporotic fracture has a high risk of developing another fracture.

3. Start treatment before the patient leaves the hospital.

4. Ensure close follow-up with the patient’s primary care physician for further laboratory and bone mineral density testing.

The Bottom Line

Patients who have had a fragility fracture have osteoporosis. Initiate treatment for osteoporosis before they leave the hospital.

Vitamin D and calcium: Vitamin D, produced by the skin or ingested, is transported in the circulation by a binding protein to the liver, where it is converted to 25-hydroxyvitamin D. This form is inactive and must be converted by the kidneys to the active form, 1,25-dihydroxyvitamin D. The active form is needed for absorption of renal and intestinal calcium.6

Without vitamin D only 10% to 15% of dietary calcium is absorbed. In one study, serum levels of 25-hydroxyvitamin D directly were related to bone mineral density. When the level was 30 ng/mL or less, there was a significant decrease in intestinal calcium absorption and bone mineral density.6

Diagnostic evaluation: The “gold standard” for diagnosis of osteoporosis is bone mineral density (BMD) testing. The National Osteoporosis Foundation (NOF), the American Association of Clinical Endocrinologists (AACE), and the North American Menopause Society (NAMS) all agree, however, that the history of fragility fracture is diagnostic for osteoporosis, and all recommend initiating pharmacologic therapy in patients with this type of fracture. BMD testing is then used to track a patient’s response to therapy rather than as a diagnostic test.7 An osteoporosis diagnosis should always trigger a history, physical, and evaluation to identify the underlying cause.

Laboratory testing: All patients with osteoporosis should receive laboratory testing. As a baseline obtain chemistry studies, glucose, liver enzymes, albumin, total protein, alkaline phosphatase, and a complete blood count. Also, obtain a 25-hydroxyvitamin D level to help direct the immediate treatment.

Table 1 click for large version

click for large version

Management

Patients with previous fractures related to osteoporosis require aggressive nonpharmacologic and pharmacologic therapy. Physicians should encourage lifestyle changes that include regular weight-bearing exercise, fall prevention, and discontinuation of tobacco products. Minimizing alcohol ingestion and sedating medications also is recommended. Physical therapy should evaluate gait and balance prior to discharge. Hip protectors may be beneficial, although the data to support this practice is sparse. It also is helpful to arrange a home nurse/therapy visit to assess for hazards in the home that might contribute to falls.

In addition, patients should have adequate calcium and vitamin D intake. The Women’s Health Initiative study showed that calcium with vitamin D use lead to a statistically significant improvement in hip bone density and a 29% reduction in the risk of hip fracture.3 The NOF recommends adults 50 and older have a daily intake of 1,200 mg of calcium and 800 to 1,000 IU of vitamin D. While no definitive data exist to guide the doses of vitamin D and calcium for osteoporosis treatment, it’s reasonable to tailor treatment to the patient’s 25-hydroxyvitamin level.

Specifically, initiate bisphosphonates along with calcium and vitamin D in patients with mild vitamin D deficiency (levels 10 to 30 ng/mL). Patients with severe vitamin D deficiency (<10 ng/mL) should have two to three months of aggressive vitamin D replacement prior to beginning a bisphosphonate. Vitamin D deficiency often is associated with impaired bone mineralization, which potentially could worsen with a bisphosphonate.

Some of the FDA-approved pharmacologic therapies for osteoporosis include antiresorptive bisphosphonates, such as alendronate, risedronate, ibandronate, zoledronic acid, and raloxifene, as well as the human parathyroid hormone teriparatide. Morin et al., performed a population-based, retrospective cohort study using administrative databases to identify patients hospitalized for a hip fracture. They found patients exposed to antiresorptives had a 26% reduction in the rate of recurrent fractures.8

Bisphosphonates are the current first-line treatment of choice unless the clinical situation warrants otherwise. Do not prescribe oral bisphosphonates for patients with hypocalcemia, creatinine clearance lower than 30mL/min, esophageal stricture, or for those who cannot remain upright for 30 minutes.7

Recently, the use of the IV bisphosphonate zolendronic acid within three months of a hip fracture was evaluated. The study randomized approximately 2,100 patients to zolendronic acid 5 mg IV or placebo annually and followed them for a median of 1.9 years. Both groups received vitamin D and calcium supplementation. Those patients using zolendronic acid saw a statistically significant reduction in overall fracture (13.9% vs. 8.6%) and mortality (13.3% vs. 9.6%) rates. While these data support the timely use of bisphosphonate therapy, it is notable that only patients who refused or couldn’t tolerate oral bisphosphonate therapy received the drug, and it was generally not started in the hospital. Still, it’s reasonable to suspect that these beneficial effects would occur even if started in the hospital, as long as the vitamin D and calcium levels did not contraindicate commencement.9

Physicians Don’t Recognize Osteoporosis

In 2000, Kamel et al. retrospectively studied the charts of 170 patients age 65 and older who were hospitalized with a hip fracture, and found that fewer than 5% had been diagnosed with or treated for osteoporosis.7 Follin et al., noted similar results in 2003, reporting that only 14% of the patients were diagnosed with osteoporosis prior to discharge and 75% of patients received no therapy.10

Follin et al., also noted patients who received a diagnosis of osteoporosis prior to discharge were more likely to receive therapy. Sixty-five percent of patients diagnosed with osteoporosis received treatment as opposed to 20% of those not diagnosed. They surmised the lack of treatment may relate to the lack of recognition that a fragility fracture often means osteoporosis.10

Hospitalist Consult, Treatment of Osteoporosis in Hip Fracture Patients

A 2003 retrospective analysis from a university-based academic hospital aimed to determine whether hospitalist consultation during admission for a hip fracture resulted in improved treatment of osteoporosis. The results indicated 29% of patients received treatment for osteoporosis at the time of discharge. Twenty percent received calcium, and only 7% received a bisphosphonate. Those who received hospitalist consultation did not have a significant improvement in osteoporosis treatment, thus representing a huge missed opportunity.11

Back to the Case

You recognize that, because your patient has sustained a fragility fracture, she has osteoporosis and you wish to initiate treatment before she leaves the hospital. Her 25-hydroxyvitamin D level is 18 ng/mL. You commence 50,000 units of vitamin D once weekly and advise that she have her vitamin D level checked again in three months by her primary care provider. She has no contraindications, thus you also initiate a bisphosphonate and remind her to take 1,200 mg of calcium daily.

You encourage smoking cessation, decreased alcohol use, a simplified medication regimen, and weight-bearing exercises in the future. In addition, you ensure she has the proper gait stability items at discharge. You arrange a visiting nurse/therapist to assess her home for fall risks. Lastly, you schedule an outpatient bone mineral density scan and arrange a follow-up with her primary care provider. TH

Dr. Baker is a hospitalist at Ohio State University. Dr McDermott is professor of medicine and clinical pharmacy and endocrinology and diabetes practice director, University of Colorado Denver.

References

  1. Berry SD, Samelson EJ, Hannan MT, et al. Second hip fracture in older men and women. The Framingham Study. Arch Intern Med. 2007;167(18):1971-1976.
  2. Juby AG, De Gues-Wenceslau CM. Evaluation of osteoporosis treatment in seniors after hip fracture. Osteoporosis Int. 2002;13:205-210.
  3. Gardner MJ, Brophy RH, Demetrakopoulos D, et al. Interventions to improve osteoporosis treatment following hip fracture. The Journal of Bone and Joint Surgery. 2005;87-A(1):3-7.
  4. Gardner MJ, Flik KR, Mooar P, Lane JM.Improve-ment in the undertreatment of osteoporosis following hip fracture. The Journal of Bone and Joint Surgery. 2002;84-A(8):1342-1348.
  5. Seeman E, Delmas PD. Bone quality-the material and structural basis of bone strength and fragility. N Engl J Med. 2006;354(21):2250-2261.
  6. Holick, MF. Vitamin D Deficiency. N Engl J Med. 2007;357(3):266-281.
  7. Glauser T. Practical strategies for managing osteoporosis: An evidence-based approach to risk assessment and treatment. Dialogues in Clinical Practice. 2007.
  8. Morin S, Rahme E, Behlouli H, Tenenhouse A, Goltzman D, Pilote L. Effectiveness of antiresorptive agents in the prevention of recurrent hip fractures. Osteoporosis Int. 2007;18:1625-1632.
  9. Lyles KW, Colon-Emeric CS, Magaziner JS, et al. Zolendronic acid and clinical fractures and mortality after hip fracture. N Engl J Med. 2007;357:1799-1809.
  10. Follin SL, Black JN, McDermott MT. Lack of diagnosis and treatment of osteoporosis in men and women after hip fracture. Pharmacotherapy.2003;23(2):190-198.
  11. Jachna CM, Whittle J, Lukert B, Graves L, Bhargava T. Effect of hospitalist consultation on treatment of osteoporosis in hip fracture patients. Osteoporosis Int. 2003;14:665-671.

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