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In response to a multi-country survey showing that orthopaedic surgeons are poorly trained to recognise and treat osteoporosis, an international organisation of orthopaedic surgeons unveils a set of recommendations to reduce the risk of successive fractures in patients with osteoporosis.

June 9, 2003

A multinational study of orthopaedic surgeons finds that these specialists often do not recognise osteoporosis as a cause of fractures, nor do they consistently offer appropriate treatment or referrals. The study was presented in Helsinki at the annual congress of the European Federation of Orthopaedic Surgeons and Traumatologists (EFORT), which devoted a special symposium to the findings.

"It is vital for orthopaedic surgeons to understand that the occurrence of a fragility fracture increases two- to five-fold the risk of another fracture within the next year," said Prof. Lars Lidgren, chairman of the international steering committee for the Bone and Joint Decade (BJD), which co-sponsored the study with the International Osteoporosis Foundation (IOF).

Also presented at the symposium-entitled Orthopaedic surgeons ARE missing the fracture opportunity. Can we change this?-was a rapid response from the World Orthopaedic Osteoporosis Organization (WOOO), which issued a set of recommendations for how orthopaedic surgeons should approach fracture patients in order to identify and treat those with osteoporosis.

Worldwide, the lifetime risk for osteoporotic fractures is between 30% and 40% for women and 13% for men. Although there is no cure for osteoporosis, there are treatments and lifestyle changes that can stop further bone loss and reduce the risk of fractures.

"Since orthopaedic surgeons / traumatologists are often the first and only physicians to see fracture patients, they are in a unique position to identify untreated cases of osteoporosis," said Prof. Olof Johnell of the IOF, who led the development of the WOOO guidelines.

Multinational Survey of Orthopaedic Surgeons

Mounting evidence that orthopaedic surgeons are not well attuned to osteoporosis led the BJD and IOF to survey 3500 orthopaedic surgeons in France, Germany, Italy, Spain, the United Kingdom, and New Zealand.

Among the key findings of the study, presented by Dr. Karsten Dreinhöfer of the BJD:

  • About half the orthopaedic surgeons surveyed said they received no or insufficient training in osteoporosis.
  • Only about 1 in 4 orthopaedic surgeons in France and the UK feel knowledgeable about managing osteoporosis in their patients.
  • Only in Germany are the vast majority of fracture patients referred for a bone density test.

In another striking example of national differences, German, Italian, and Spanish surgeons were likely to diagnose and treat osteoporosis themselves, whereas their counterparts in France, the UK, and New Zealand were more likely to refer patients to a general practitioner or osteoporosis specialist.

"However, the most important thing is not which specialist diagnoses and treats osteoporosis-related fractures, but rather that patients are adequately served," said Prof. Nikolaus Boehler, president of EFORT.

Perhaps the most encouraging finding was that the majority of orthopaedic surgeons in all the countries surveyed felt that orthopaedic surgeons / traumatologists had a responsibility to identify and initiate evaluation of patients with fragility fractures. Simililarly, most of the survey respondants wanted to learn more about the diagnosis and management of osteoporosis-related fractures.

Beyond Fixing the Fracture

The key recommendation of the WOOO panel was that all fracture patients between the ages of 50 and 80 years of age should, if possible, have their bone density measured. In their opinion, the evaluation for osteoporosis can be performed either by a knowledgeable orthopaedic surgeon / traumatologist, or by a physician specialising in osteoporosis.

For national associations of orthopaedic surgeons-many of which are already developing country-specific guidelines and educational measures to improve care-a particularly important feature of the WOOO guidelines is a treatment algorithm that condenses the assessment and treatment of fracture patients down to a simple flow chart, including options for diagnostic tests, referral, and therapeutic interventions to reduce the risk of subsequent fractures.

It is fitting that the survey results and recommendations are being presented in Finland, which has taken some of the most far-reaching steps to identify osteoporosis among fragility fracture patients.

"The Finnish Ministry of Health is actively supporting the training of healthcare professionals to improve the care of patients with fragility fractures. In addition, we recommend that every hospital and health centre have a trained nurse dedicated to the diagnosis and management of patients with fragility fractures," said Dr. Liisa Hyssälä DSc, MSocSc, Finnish Minister of Health.

The concept of a fragility fracture nurse is one that has been tried with much success in several countries. By having primary responsibility for this process, the nurse is able to develop productive working relationships with the various healthcare professionals who are needed to ensure that the individual with a fragility fracture is diagnosed and receives appropriate treatment and care.

But orthopaedic surgeons agree that this innovation should not relieve the surgeon of overall responsibility in the process.

"Just as we routinely prevent problems such as deep vein thrombosis after surgery, we have to prevent new fractures after we treat the first fracture in patients with osteoporosis," said Prof. Jean-Marc Féron of France, who participated in the EFORT symposium on behalf of La Société Française de Chirurgie Orthopédique et Traumatologie.


EFORT, BJD and IOF are grateful for the cooperation and input of the national organisations that participated in the survey:

  • France. La Société Française de Chirurgie Orthopédique et Traumatologie (SOFCOT)
  • Germany. Deutsche Gesellschaft für Orthopädie und Orthopädische Chirurgie (DGOOC)
  • Italy. Società Italiana di Ortopedia e Traumatologia (SIOT)
  • New Zealand. New Zealand Orthopaedic Association
  • Spain. Sociedad Española de Cirurgia Ortopédica y Traumatologia (SECOT)
  • United Kingdom. British Orthopaedic Association (BOA)

Special acknowledgement is due to Dr. John Kaufman and the Osteoporosis Interest Group of the American Academy of Orthopaedic Surgeons for providing the survey questionnaire prototype, and the WOOO for developing the recommendations for fracture care.

EFORT, BJD and IOF invite other countries to conduct the survey if they have the resources to do so.

E-mail enquiries: Mary Anderson BSc (Hons) Pharm, IOF board member and project co-ordinator.


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