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was highest in New Zealand (70%). Although a higher overall multinational response rate would have allowed a more accurate appraisal, the results provide valuable insights into the current state of practice. The survey reflects the opinion of surgeons, who each month treat at least 54 000 fragility fractures in their units, and prescribe medication for osteoporosis for 30 000 patients per month. In all countries, the majority of respondents believed that the orthopaedic surgeon should identify and initiate the evaluation of osteoporosis in patients with fragility fractures. However, only 10% always initiated a bone density test after surgically treating a patient for a fragility fracture. If osteoporosis is suspected, most surgeons in France, the UK and New Zealand (70% to 90%) would refer the patient to an osteoporosis specialist or general practitioner, while more than 80% of those in Germany and Italy initiate investigation and treatment themselves. More than half of the orthopaedic surgeons surveyed said they had received no or insufficient education in osteoporosis. In Italy and Spain this was lower but a third still felt that they were inadequately informed. Only 25% of the orthopaedic surgeons in France, the UK and NZ felt well informed about managing osteoporosis, while more than 80% in Germany and Spain were confi- 960 K. E. DREINHÖFER, J.-M. FÉRON, A. HERRERA, R. HUBE, O. JOHNELL, L. LIDGREN, K. MILES, L. PANARELLA, H. SIMPSON, W. A. WALLACE THE JOURNAL OF BONE AND JOINT SURGERY dent in their knowledge. Most of the surgeons in Germany, Italy and Spain felt competent in prescribing calcium/vitamin D and bisphosphonates, compared to less than 50% of their colleagues in France, the UK and New Zealand. Only 50% of orthopaedic surgeons in Southern Europe knew about the importance of external risk factors for hip fractures such as a cataract, poor lighting, uneven carpets and poor balance. There were also a number of misconceptions about the indications for bone mineral density in the countries (Germany, Spain) where surgeons considered themselves knowledgeable about osteoporosis. The majority of surgeons from all countries recommended that a baseline bone density test should be performed in a woman aged 50 without risk factors or fracture, indicating a lack of knowledge about the current indications for bone mineral density testing. Clearly there is a need for further education and improved training. Fortunately, the majority of orthopaedic surgeons in all countries were interested in learning more about the diagnosis and management of osteoporosisrelated fractures. The mode of learning which most surgeons preferred was through seminars or journals, followed by CD ROMs and website based information. E-based learning was the most popular in France. There was very little interest (less than 15%) by orthopaedic surgeons in all countries receiving direct information from pharmaceutical representatives. There is a need for orthopaedic surgeons to be more aware of the concerns of their patients regarding osteoporosis. The National Osteoporosis Society was wellknown in only two of the countries (UK and Germany). In the remainder more than half of the surgeons had not heard about their National Osteoporosis Society. This survey suggests that current practice is inadequate for the diagnosis and treatment of osteoporosis, especially in patients who have sustained a fragility fracture. We are aware that there may be a selection bias in the study since the surgeons who answered have already positively selected themselves, and therefore the lack of knowledge about osteoporosis is probably underestimated. Patients with fractures create a unique opportunity for treatment since the optimal care of fragility fractures includes fixing the fracture and the evaluation, diagnosis and treatment of its underlying cause.49 Pharmacological intervention has the potential to reduce the risk of future fracture by half in patients with existing fractures. Other measures such as fall prevention and individually-tailored exercise programmes have been shown to reduce falls among the elderly.4 How to improve care for the patient with osteoporosis Awareness. It is now recognised that insufficient priority is given to osteoporosis and the fractures it causes. The adherence to currently existing guidelines is not known, but is probably low. The outcome of surgical procedures should be followed on a large scale through appropriate audit studies to evaluate the standard of care. Fracture registries could monitor the size of the problem, assess the success of treatment and assist in planning adequate provision of resources. Additional awareness and general education programmes for orthopaedic surgeons and patients need to be established. Research. Research into better methods of managing these demanding fractures are needed to cope with the inevitable rise in their incidence and the surgical challenges which they pose. We need to improve further pharmacological and general management with strategies for primary and secondary prevention. We need to develop new surgical and/or biological techniques of repair for treating osteoporotic fractures.50 Education. Most orthopaedic surgeons felt that their education in osteoporosis was deficient. This needs to be improved in those
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