The Orthopedic Surgeon’s Role in Osteoporosis Management: Optimizing Bone Health of Postmenopausal Patients Postfracture

The Orthopedic Surgeon’s Role in Osteoporosis Management: Optimizing Bone Health of Postmenopausal Patients Postfracture

Studies show that only a small minority of patients diagnosed with an osteoporotic fracture are adequately evaluated, diagnosed, and referred or treated for osteoporosis. According to the 2021 Milliman report, a research report commissioned by the National Osteoporosis Foundation to determine the human and economic toll associated with osteoporotic fractures, only 9% of women in the Medicare fee-for-service population received a bone mineral density test in the 6 months following an osteoporotic fracture.¹ Additionally, hip fractures are one of the most common types of fractures, accounting for 17% of all osteoporotic fracture cases in 2016.¹ Despite its prevalence, treatment rates after hip fractures are dismal at approximately 11%-14%, and overall treatment rates after all fracture types are low.

While orthopedic surgeons have shown improvement in their abilities to recognize osteoporosis as the underlying cause of fractures, there is often still a failure to connect disease recognition with treatment. It is imperative that fractures are recognized as a call to action for providers to proactively address osteoporosis and reduce the risk of future fractures.

Disconnect Between Fracture and Osteoporosis Identification and Treatment

There is a major disconnect between the occurrence of fracture and identification of osteoporosis as the underlying cause. To improve outcomes for patients, it is important that providers recognize signs of osteoporosis, investigate beyond attending to the acute fracture, and take action to provide appropriate care.

Knowledge gaps and a lack of clear consensus recommendations about who should be treated medically, when diagnostic testing should be performed, and the indications for various osteoporosis medications all contribute to this ongoing problem. While orthopedic providers should recognize their limitations when it comes to osteoporosis management, appropriate referral and handoff of care must be done to help prevent patients from being left to fall through the cracks.

Patients who experience a fragility fracture are at an 86% higher risk of a second fracture.² Additionally, as the number of fractures increases, the risk of additional fractures rises with them. Data from the Global Longitudinal Osteoporosis in Women (GLOW) study revealed that a fracture at any site (9 of 10 sites studied) increased the risk of fracture at multiple other sites.³

The occurrence of fracture in any individual over the age of 50 should be evaluated for underlying osteoporosis. Oftentimes, wrist, foot, or ankle fractures are harbingers of other major fractures, such as a hip or pelvic fracture, later in life. Identification of the risk of these more minor fractures provides a great opportunity for intervention and prevention of future fractures that could require surgery and hospitalization and end in significant disability.

The disconnect between fracture occurrence and adequate treatment is a major clinical challenge. It is imperative that orthopedic providers can identify the disease, fix the fracture, connect patients with appropriate osteoporosis care, and ensure they get diagnosed and receive treatment. These actions can help patients maintain their independence and avoid the necessity of a nursing home. A second fracture can be devastating to the quality of life of most patients, and by missing the important window to act quickly, providers can drastically impact their patients’ lives. It is vital that physicians do not underestimate the importance of early osteoporosis treatment when it comes to maintaining patient quality of life, independence, and mobility.

Pathophysiology of Osteoporosis

Patients develop osteoporosis because they cannot adequately build bone, inappropriately lose bone, or experience a combination of the two. Many factors can contribute to this dysfunction, including age, medications, and menopause. The pathophysiology can be simplified to a balance between 3 distinct cell types: (1) osteoblasts, or bone-building cells; (2) osteoclasts, or bone-cutting cells; and (3) osteocytes, or bone-maintaining cells. Osteoblasts and osteoclasts are very important to the building and constant remodeling of bone. When an imbalance between bone formation and resorption occurs, bone is lost. As this happens, bone begins to develop selective holes and weakened areas, making it more prone to fracture. Deficiencies in bone quantity and architectural quality combine to result in osteoporosis.

American Orthopaedic Association’s “Own the Bone” Program

The American Orthopaedic Association’s Own the Bone program is a national quality improvement, post-fracture, systems-based, multidisciplinary fragility fracture prevention initiative. This program was launched in 2009 to address the emerging epidemic of osteoporosis-related fragility.

Own the Bone helps bring together like-minded providers who are interested in improving care for osteoporosis patients. By utilizing the fracture liaison service model, fewer osteoporosis patients fall through the cracks. Without this program, patients are more likely to be discharged from the hospital without appropriate osteoporosis medication and/or bone density scan prescriptions. Fracture liaison services can be incredibly valuable because they act as a secondary follow-up and do not solely rely on the surgeon. This builds a supportive team around the provider, helping to connect patients with proper osteoporosis care. This multidisciplinary team approach is key to treatment success—to identifying patients, ensuring they are properly evaluated, and provided treatment as needed.

A number of recently released osteoporosis guidelines discuss this structured approach to secondary fracture prevention. The core message of these guidelines is consistent: after a fracture, patients need to be treated.^5-9 Providers must recognize that a recent fracture, as well as factors such as increased age, high-risk medications, and underlying conditions, puts individuals at higher risk of osteoporosis. Guidelines released by the American Association of Clinical Endocrinology (AACE), Endocrine Society, North American Menopause Society, and the National Osteoporosis Foundation Clinician’s Guide all focus on assessing baseline risk to help guide treatment decisions.^5-8

Osteoporosis Medication Considerations

Two major categories of pharmacologic agents for the treatment of osteoporosis are antiresorptive agents and osteoanabolic agents. Antiresorptive agents such as bisphosphonates and denosumab, the receptor activator of nuclear factor kappa B (RANK) ligand inhibitor, work primarily to inhibit bone turnover. The osteoanabolic agents, remodeling stimulators, and romosozumab primarily work to build new bone. The remodeling stimulators, teriparatide and abaloparatide, act as parathyroid hormone activators that increase formation and resorption of bone. Romosozumab is a dual-mechanism medication that stimulates bone modeling by increasing bone formation and decreasing bone resorption.

Available osteoporosis treatment guidelines recommend stratifying patients by risk. Recent fracture is a major factor that elevates the level of risk. Ultimately, the goal of treatment is to rapidly reduce fracture risk by building new bone, which is the role of osteoanabolic agents. Many guidelines recommend starting with an anabolic agent in patients with the highest risk, followed by an antiresorptive agent. Patients have a more robust response to an anabolic agent if it is used first as opposed to as an add-on therapy. Providers must recognize that both the individual agents and the sequence of medications matter.

Teriparatide and abaloparatide work quickly to rebuild bone. In head-to-head fracture trials, teriparatide has been demonstrated to be superior to risedronate; however, it can be costly and requires a daily injection. Both parathyroid hormone analogs have a boxed warning regarding rat osteosarcoma, though this is likely not an issue when used in humans.

The sclerostin inhibitor romosozumab has a unique dual-action mechanism that increases bone formation and decreases bone resorption. Head-to-head clinical trial results have shown that romosozumab is superior to alendronate in reducing hip fracture. Patients can also benefit from a monthly injection regimen that is given for a total of 12 doses. However, cost can be an inhibiting factor to romosozumab use, and it presents a possible increased risk of major cardiovascular events.

Some patients may begin therapy with antiresorptive agents. These medications are available for primary treatment and are excellent options for add-on therapy. Bisphosphonates, both oral and IV, have been the mainstay of antiresorptive treatment for many years and still play a major role in osteoporosis treatment. They are generally well-tolerated medications that have multiple formulations and are available in weekly, monthly, and even yearly (or less frequent) dosing. While this medication class does have side effects, in the right setting, the benefits of this treatment generally outweigh the risks.

Denosumab is a RANK ligand inhibitor that has the benefit of a prolonged dosing interval of every 6 months. Additionally, it has been studied for an extended interval of up to 10 years, and evidence throughout the 10-year time span has shown long-term safety and tolerability as well as progressive increases in bone mineral density. This medication also has a rapid reversal effect when it is stopped, which is similar to what is observed with most osteoporosis medications, with the exception of bisphosphonates.

When deciding on a medication regimen for patients with osteoporosis, physicians should look closely at the large store of choices available for treatment. Associated costs, expected outcomes, side effects, and dosing schedules should all be carefully considered to select unique treatments to achieve the best outcomes for each individual patient.

Table 2: Osteoporosis Treatment Considerations

AFF, atypical femoral fractures; ALN, alendronate; BMD, bone mineral density; BP, bisphosphonate; CV, cardiovascular; GFR, glomerular filtration rate; GI, gastrointestinal; IBN, ibandronate; MACE, major adverse cardiovascular event; MVF, multiple vertebral fractures; ONJ, osteonecrosis of the jaw; PTH, parathyroid hormone; PTHrP, parathyroid hormone-related peptide; RIS, risedronate; SC, subcutaneously; SERM, selective estrogen receptor modulator; VTE, venous thromboembolic disease; WHI, Women’s Health Initiative; ZOL, zoledronate.

Orthopedic providers should not shy away from starting treatment immediately. Data has disproven historical concerns that osteoporosis medications can interfere with the healing process, so it is not necessary to wait for healing to occur before initiating treatment. The longer a patient goes without treatment after the fracture, the more likely it is they will not receive appropriate osteoporosis care.

Orthopedic providers should also understand the challenges associated with hardware in the bone. In weaker osteoporotic bone, the bone is often not as strong as the hardware. As the bone heals, it is essentially a race between the bone and the hardware. In older patients, because the bones are weaker, the hardware can pull out of the bone. Osteoporosis management should be considered early on so providers can best optimize the results of surgery. The goal is to prevent the patient from experiencing a fall 6 months after major surgery and suffering a fracture next to the plates, which could severely impact the patient’s ability to function.

Key Takeaway

It is imperative that fractures are recognized as a call to action for orthopedic providers so they can proactively address osteoporosis and reduce the risk of future fractures. Many factors can contribute to the disconnect between fracture occurrence, the recognition of osteoporosis, and the initiation of treatment, but what is truly important is that patients are appropriately referred to follow-up care so they do not fall through the cracks. A variety of options are available for osteoporosis treatment, but cost, expected outcomes, side effects, and dosing regimens should all be carefully considered to create ideal medication regimens for each patient—leading to optimized bone health.

References

1. Hansen D, Pelizzari PM, Pyenson BS. Medicare cost of osteoporotic fractures: 2021 updated report. Milliman. March 2021. https://www.milliman.com/en/insight/-/media/milliman/pdfs/2021-articles/3-30-21-Medicare-Cost-Osteoporotic-Fractures.ashx
2. Kanis JA, Johnell O, De Laet C, et al. A meta-analysis of previous fracture and subsequent fracture risk. Bone. 2004;35(2):375-382.
3. Gehlbach S, Saag KG, Flahive J, Anderson FA, Hooven F; The GLOW Investigators. Previous fractures increase risk for subsequent fractures at multiple sites: global longitudinal study of osteoporosis in women. Bone. 2010;47(Suppl 1):S180.  
4. Van Geel TACM, Huntjens KMB, van den Bergh JPW, Dinant GJ, Geusens PP. Timing of subsequent fractures after an initial fracture. Curr Osteoporos Rep. 2010;8(3):118-122
5. Camacho PM, Petak SM, Binkley N, et al. American Association of Clinical Endocrinologists/American College of Endocrinology clinical practice guidelines for the diagnosis and treatment of postmenopausal osteoporosis—2020 update. Endocr Pract. 2020;26(Suppl 1):1-46.
6. Shoback D, Rosen CJ, Black DM, Cheung AM, Murad MH, Eastell R. Pharmacological management of osteoporosis in postmenopausal women: an Endocrine Society guideline update. J Clin Endocrinol Metab. 2020;105(3):dgaa048.
7. Management of osteoporosis in postmenopausal women: the 2021 position statement of the North American Menopause Society. Menopause. 2021;28(9):973-997.
8. Cosman F, de Beur SJ, LeBoff MS, et al; National Osteoporosis Foundation. Clinician’s guide to prevention and treatment of osteoporosis. Osteoporos Int. 2014;25(10):2359-2381.
9. Qaseem A, Forciea MA, McLean RM, et al. Treatment of low bone density or osteoporosis to prevent fractures in men and women: a clinical practice guideline update from the American College of Physicians. Ann Intern Med. 2017;166(11):818-839.