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surgeons already practising and additional emphasis on these disorders needs to be introduced into university and postgraduate training. In a recent report, the World Orthopaedic Osteoporosis Organisation (WOOO) has summarised its “Recommendations for Care of the Osteoporotic Fracture Patient to Reduce the Risk of Future Fracture”, and developed a clinical pathway to ensure that optimal care is provided for patients with fragility fractures.3 The prevention of further fractures is based on three aspects: 1) the treatment of osteoporosis; 2) prevention of falls and 3) protection of the site of injury e.g. with hip protectors. These recommendations and the clinical pathway provide a useful resource for national orthopaedic associations to adapt for local use and implementation. This has already happened in the UK with the new booklet on “The Care of Fragility Fracture Patients” produced by the British Orthopaedic Association.51 Orthopaedic surgeons have to ensure that every patient with a fragility fracture has the appropriate operative treatment and appropriate evaluation, treatment and advice for the underlying disease so that they are aware of the further risks and the opportunities to reduce them. Service provision and further development. Each centre should guarantee that adequate access to measurements of BMD is available. A multidisciplinary meeting to agree on a standard protocol for the management of known osteoporosis both in pharmacological and general terms should be arranged. The concept of a fracture liaison nurse has been introduced with much success in several countries. The major role is to coordinate and develop productive working relationships with the diverse teams of healthcare professionals needed to ensure that the patient receives appropriate treatment and care in addition to the management of the fracture.52 Every patient should receive an appropriate and technically satisfactory operation and be evaluated and treated appropriately for the underlying disease. They should be ORTHOPAEDIC SURGEONS AND FRAGILITY FRACTURES 961 VOL. 86-B, No. 7, SEPTEMBER 2004 advised as to their susceptibility to falls and of the changes in lifestyle which will help prevent future fractures. In a number of countries “Care Pathways”, blueprints of the standard management of common conditions are being developed. It is hoped that this study combined with the WOOO Guidelines will allow each hospital involved to develop a “Fracture Care Pathway” which will include the treating surgeon, nursing and theatre staff, the general practitioner (Family Doctor), the social worker and the physicians providing the local “Bone Treatment management” and the “Falls Prevention Service”. By developing this care pathway we will reduce the number of patients returning to us with further fractures in the future, and thus reduce the deaths and severe disabilities which are a consequence. References 1. Consensus development conference diagnosis, prophylaxis, and treatment of osteoporosis. Am J Med 1993;94:646-50. 2. Delmas PD. Treatment of postmenopausal osteoporosis. Lancet 2002;359:2018-26. 3. Bouxsein ML, Kaufman J, Tosi L, et al. Recommendations for optimal care of the fragility fracture patient to reduce the risk of future fractures. J Am Acad Orthop Surg 2004:in press. 4. Woolf AD, Akesson K. Preventing fractures in elderly people. BMJ 2003;327:89-95. 5. Tosi L, Lane JM. Osteoporosis prevention and the orthopaedic surgeon: when fracture care is not enough. J Bone Joint Surg [Am] 1998;80-A:1567-9. 6. Stephen AB, Wallace WA. The management of osteoporosis. J Bone Joint Surg [Br] 2001;83-B:316-23. 7. Bellantonio S, Fortinsky R, Prestwood K. How well are community-living women treated for osteoporosis after hip fracture: J Am Geriatr Soc 2001;49-9:1197-204. 8. Castel H, Bonneh DY, Sherf M, Liel Y. Awareness of osteoporosis and compliance with management guidelines in patients with newly diagnosed low-impact fractures. Osteoporos Int 2001;12:559-64. 9. Freedman KB, Kaplan FS, Bilker WB, Strom BL, Lowe RA. Treatment of osteoporosis: are physicians missing an opportunity? J Bone Joint Surg [Am] 2000;82-A: 1063-70. 10. Gardner MJ, Flik KR, Mooar P, Lane JM. Improvement in the undertreatment of osteoporosis following hip fracture. J Bone Joint Surg [Am] 2002;84-A:1342-8. 11. Hajcsar EE, Hawker G, Bogoch ER. Investigation and treatment of osteoporosis in patients with fragility fractures. Cmaj 2000;163:819-22. 12. Harrington JT, Broy SB, Derosa AM, Licata AA, Shewmon DA. Hip fracture patients are not treated for osteoporosis: a call to action. Arthritis Rheum 2002;47: 651-4. 13. Juby AG, De Geus-Wenceslau CM. Evaluation of osteoporosis treatment in seniors after hip fracture. Osteoporos Int 2002;13:205-10. 14. Khan SA, de Geus C, Holyroyd B, Russell AS. Osteoporosis follow-up after wrist fractures following minor trauma. Arch Intern Med 2001;161:1309-12. 15. Kiebzak GM, Beinart GA, Perser K, et al. Undertreatment of osteoporosis in men with hip fracture. Arch Intern Med 2002;162:2217-22. 16. Simonelli C, Chen YT, Morancey J, Lewis AF, Abbott TA. Evaluation and management of osteoporosis following hospitalization for low-impact fracture. J Gen Intern Med 2003;18:17-22. 17. Torgerson DJ, Dolan P. Prescribing by general practitioners after an osteoporotic fracture. Ann
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