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expected to be US $131.5 billion worldwide by 2050.29 Osteoporotic fractures are associated with an increase in morbidity and mortality. The negative impact on quality of life after a hip or vertebral fracture is a major concern. Up to a third of patients who sustain fracture of the hip will die as a result,30 4% die during their initial hospitalisation31 and 10% to 24% within the first year.32,33 In addition to mortality, these fractures are associated with substantial morbidity and loss of function. Half of these patients do not regain their previous level of ORTHOPAEDIC SURGEONS AND FRAGILITY FRACTURES 959 VOL. 86-B, No. 7, SEPTEMBER 2004 mobility. They may become severely handicapped, unable to walk unaided or climb stairs and 25% will require longterm residential care.34 Many patients lose their ability to live independently and often depend on other family members for support. The annual cost of treating patients with fractures of the hip in the US is between $10.3 and $15.2 billion.35 The annual cost in the UK now exceeds £800 million.36 The costs to patients, family members and society occurring because of lifestyle changes and lost productivity are not known. A fragility fracture is the strongest indicator of risk of future fracture. Patients who have had a fracture at any site have approximately twice the risk of sustaining a future fracture compared with individuals who have never experienced such an injury as an adult.37,38 Patients with a low-energy fracture of the wrist, hip, proximal humerus or ankle have nearly a fourfold greater risk for future fractures than individuals who have not.38 Up to 50% of patients with a vertebral fracture will experience additional vertebral fractures within three years, many within the first year.39,40 A patient with a vertebral fracture has nearly a fivefold increased risk of a future similar injury and double the risk of hip and other non-vertebral fractures.37,41 Patients who have sustained a fracture of the distal radius have nearly twice the relative risk of a future hip fracture,35,42 and have both site-specific and generalised decreased bone-mineral density when compared with young adults and age-matched controls.43,44 Fractures of the distal radius start to occur approximately 15 years earlier than those in the hip and warn of a high risk of these latter fractures. Fractures of the distal radius are therefore good indicators for investigation of osteoporosis. In a cohort of 22 494 low-energy fractures, the relative risk of a fracture of the hip following a fracture of the wrist, proximal humeral, ankle or hip was 3.22, 5.76, 1.30 and 9.79, respectively.38 A contralateral hip fracture may occur in as many as 10.6% of patients with a fracture at the hip.45 The majority of patients with fragility fractures are discharged without adequate evaluation of osteoporosis. Despite the evidence in support of appropriate management of patients with osteoporosis after they have sustained a fragility fracture, up to 95% are discharged without adequate assessment as to the cause of the fracture and very few are prescribed medication.7-17 Gardner et al10 retrospectively analysed 300 randomly selected patients with fractures of the femoral neck. Only 58 (19.3%) had received a prescription for medication targeting osteopenia at the time of their discharge. However, 40 of these patients (13.3% of the overall group) had been prescribed calcium but only 18 (6.0% of the overall group) had received medication to actively prevent bone resorption and to treat osteoporosis. The remaining 81% of patients were discharged without proper medication and none had a bone density scan while in hospital.10 Freedman et al9 analysed 1164 patients with fractures of the distal radius and found that few had been assessed or treated for osteoporosis. Only 2.8% had been tested for bone density, and only 22.9% were treated with at least one of the drugs approved for managing established osteoporosis.9 Torgerson and Dolan17 found that, following an osteoporotic fracture, the majority of patients were not prescribed any suitable medication. Only 39% of patients with vertebral fractures received antiresorptive medication, and patients with fractures of the hip did not receive any.17 A survey of 56 Danish departments of orthopaedic surgery showed that only seven (12.5%) referred their patients with a low-energy fracture for a bone density scan and only six (10.7%) gave treatment for those with osteoporosis.46 Multinational survey The Bone and Joint Decade and the International Osteoporosis Foundation (IOF) initiated a multinational survey of the current care of patients with osteoporotic fractures in a range of countries with different health care systems (UK, Germany, Spain, Italy, France and New Zealand) in order to assess the levels of practice. In association with the respective societies (BOA, DGOOC, SECOT, SIOT, SOFCOT and NZOT), a working group of national project coordinators was convened and a questionnaire developed, partly based on an American survey in 2000.47 This questionnaire was then translated into the national language. The national project coordinator determined the optimum method of distributing the survey. Anonymous responses were collected nationally and then analysed centrally.48 Results. Overall 3422 surgeons responded, representing approximately 25% of all society members. The response rate
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