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opinion of orthopedic surgeons that medical follow-up and treatment is not inextricably linked to the surgical care of patients with osteoporotic fractures [16]. Additionally, orthopedic surgeons are reluctant to prescribe many forms of conventional pharmacological treatments because of their concerns about adverse events. Thus, in general, orthopedic surgeons appear to be at an impasse—they recognize the need for the initiation of medical treatment, yet they clearly seem concerned about the implications of the added responsibilities demanded by medical care. These possibilities, in addition to their concern about additional liability and potentially time-consuming responsibilities associated with medical treatment of such patients, seem to deter these surgeons from more aggressively seeking medical care for these patients. The fact that the orthopedic surgeons who participated in this study were not compelled to initiate medical treatment for patients with osteoporotic fractures is not inconsistent with their training. In the United States, there is currently no mandate that orthopedic surgeons have training for the medical treatment of patients with senescent or metabolic bone diseases such as osteoporosis. However, the American Academy of Orthopedic Surgeons (AAOS) is taking an active role in increasing the awareness of orthopedic surgeons about steps that can be taken of enhancing the care of patients with fragility fractures. Examples of this emphasis can be found on the AAOS Internet http://www.aaos.org/wordhtml/papers/position/1113. htm). Of the patients who saw a PCP within 84 days of fracture, nearly 50% were not prescribed an antiresorptive agent. Reasons for this apparent undertreatment were not evaluated. Recent studies have shown that inadequate medical treatment for patients with osteoporotic fractures is common [5]. Strides are being taken to increase the relatively low rate that PCPs currently prescribe anti-resorptive agents for patients with low-energy fractures [7]. These efforts include the education of health-care providers as to the importance of initiating treatment and possible work-up for probable osteopenia or osteoporosis in patients with lowenergy fractures. Additionally, there is an increasing prevalence of continuing medical education courses regarding the beneficial effects of exercise, calcium and vitamin D supplementation, as well as the risks and benefits of using anti-resorptive agents for these conditions. It is suggested that a standardized treatment/intervention program may be useful in helping orthopedic surgeons and PCPs facilitate effective medical treatment for the secondary prevention of osteoporotic fractures. For example, at any given healthcare facility, standard discharge orders could be given to patients who have a low-energy fracture and/or are noted to have other significant risk factors for osteoporosis. These orders would include: 1) a timely Osteoporosis, the Silent Disease Prevention and Treatment of Fragility Fractures in a Structured Program Rodney E. Brenneman, M.D. Orthopedic Associates of Lancaster Ltd. Physician Leader, Geriatric Fracture Program at Lancaster General Health The Journal of Lancaster General Hospital • Winter 2016 • Vol. 11 – No. 4 THE OSTEOPOROSIS CHALLENGE In 2001, the National Institutes of Health defined osteoporosis as “a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.”1 Bone mass and density are highest between the ages of 18 and 25, and they decline slowly and steadily thereafter. Current estimates suggest that 200 million people worldwide are affected by osteoporosis, resulting in 8.9 million fractures annually.2,3 The National Osteoporosis Foundation has estimated that 9.9 million Americans have osteoporosis.4 Osteoporosis has been labeled the “silent” disease, because its development is often unrecognized until a fracture occurs. Risk factors for such fractures include low body mass index, a history of osteoporosis-related fracture, early menopause, smoking, vitamin D deficiency or insufficiency, other endocrine abnormalities, use of glucocorticoids, excessive alcohol intake, immobility, and other factors.2 THE FRACTURE BURDEN Approximately 50% of women and 25% of men over the age of 50 will have a fragility fracture in their lifetime.5 Hip fractures are the most widely recognized type, though they comprise just a fraction of the burden of osteoporosis-related fractures, which can also occur at the proximal humerus, clavicle, distal radius, spine, pelvis, hip, knee, and ankle. There are more than 300,000 hospital admissions annually for hip fractures in patients over the age of 65 in the U.S.6 By 2040 that number could exceed 550,000,2 and by 2050 there could be more than 21 million hip fractures annually worldwide.2 The estimated cost of hip fracture care in the U.S. rose from $7.2 billion in 1984 to $20 billion in 1997, and it could reach $62 billion by 2040.7 Hip fractures may be only a fraction of all osteoporosis-related fractures, but they are the most easily studied due to their nearly universal requirement for surgical treatment. Their mandatory hospital admissions, operations, and associated services provide a captive population for research and quality improvement initiatives.5 Hip fractures also have a much more deleterious
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