Embedded Files
with medication increased significantly from 11% to 29% between 1997 and 2000, and, while this trend is encouraging, treatment rates remain suboptimal. Furthermore, we did not determine if these patients continued to take the medication after discharge. Many patients in the study had been taking calcium or vitamin D prior to admission. While these agents are recommended for treatment and have been shown to be efficient for decreasing the rate of bone loss and preventing fractures24-29, patients who are hospitalized with a femoral neck fracture should be treated with a prescription antiosteoporotic agent such as estrogen, calcitonin, a bisphosphonate, or raloxifene. Of the thirty patients in the study who were already taking a medication at the time of admission and for whom no change was made at the time of discharge, sixteen (53%) were taking calcium, although additional treatment with an antiresorptive medication was indicated. Furthermore, in the other fourteen patients who were taking prescription medications at the time of admission, an additional medication or a change in medication or dose may have been justified. Thus, although these patients were considered “treated” in our data analysis, this group may not reflect true physician awareness of osteoporosis as an active problem. Although medical care of the patient may ultimately reside with the primary-care physician, it is the obligation of the orthopaedic surgeon to ensure that osteoporosis has been addressed. The National Osteoporosis Foundation has constructed guidelines regarding the risk factors, diagnosis, and treatment of osteoporosis30. We have incorporated these guidelines into specific recommendations for the treatment of osteoporosis following a fragility fracture (Table II)31 . Calcium supplementation and vitamin-D repletion are crucial aspects of care following an osteoporotic fracture. Calcium citrate is the preferred form of calcium, as it enhances the likelihood of gastrointestinal absorption. A randomized telephone survey of households in the United States demonstrated that only half of adults between the ages of sixty and ninety-four years drink at least one glass of milk per day32, suggesting that this specific population may be calcium-deficient. Treatment with calcium has been shown to substantially retard femoral neck bone loss in the elderly and to positively affect the total body calcium balance24,25. In addition to preserving bone density, supplemental calcium reduces the risk of future osteoporotic fractures in postmenopausal women26-28. The National Institutes of Health recommend a daily intake of 1500 mg of calcium33 . Vitamin D facilitates both absorption of dietary calcium and bone mineralization. Serum vitamin-D levels decrease with age, mainly as a result of restricted exposure to sunlight, a reduced capacity of the skin to produce vitamin D, and reduced dietary vitamin-D intake29, which ultimately leads to bone loss and an increased risk of fracture. Van der Weilen et al.34 found vitamin-D deficiency among elderly European women, regardless of geographic location. LeBoff et al.29 found that 50% of women in the United States who sustained an TABLE II Recommendations for the Treatment of Osteoporosis Following a Fragility Fracture* 1. All patients presenting with a low-energy hip fracture should be considered as having primary or secondary osteoporosis. 2. All patients should be placed on 800 IU of vitamin D and 1200 to 1500 mg of elemental calcium (preferably calcium citrate) daily. 3. Before discharge, all patients should be started on alendronate (70 mg per week), risedronate (30 mg per week), or pamidronate (30 mg administered intravenously every three months). Pamidronate is the agent of choice if the patient has a history of gastrointestinal dysfunction. 4. Within six weeks after discharge, all patients should undergo a dual-energy x-ray absorptiometry scan and a metabolic workup to rule out secondary causes of osteoporosis. *Based on National Osteoporosis Foundation guidelines 30,31 . Downloaded from www.ejbjs.org on October 16, 2006 acute hip fracture had occult vitamin-D deficiency and recommended a daily intake of 400 IU for patients between the ages of fifty-one and seventy years and of 600 IU for those older than seventy years. To analyze the reduction in the risk of hip fracture among elderly women, Chapuy et al.27 studied 3270 healthy postmenopausal women who were able to walk and found a 43% decrease in the prevalence of hip fractures among those who were treated with vitamin D. In a similar well-controlled study, Dawson-Hughes et al.28 reported that 700 IU of vitamin D per day combined with calcium reduced femoral and vertebral bone loss and substantially decreased the prevalence of fracture. Some studies have shown that calcium and vitamin D, while necessary elements of treatment, should in no way be considered sufficient to prevent future fractures in patients with established osteoporosis35-39. Many other agents have been tested extensively, are effective and safe, and are now available for
Google Sites
Report abuse