Why are fragility fractures critical inflection points in a patient's health journey, highlighting the missed opportunity to manage underlying Osteoporosis (bone disease characterized by low bone mass and density) as a chronic condition following fracture?

From the Guidelines

Fragility fractures are critical inflection points in a patient's health journey, signaling underlying bone weakness and dramatically increasing the risk of subsequent fractures, functional decline, and mortality, and thus, necessitate a system-level response through coordinated post-fracture care programs to manage underlying osteoporosis as a chronic condition. These fractures demand immediate attention and intervention to prevent further complications. The current care gap, where approximately 70-80% of patients with fragility fractures do not receive appropriate evaluation or treatment for underlying osteoporosis 1, is a significant concern. This missed opportunity occurs despite effective medications being available, including bisphosphonates, denosumab, teriparatide or abaloparatide, and romosozumab. Implementing systematic approaches like Fracture Liaison Services can close this gap by identifying fracture patients, ensuring bone density testing, initiating appropriate osteoporosis medications, and providing follow-up care.

Key Points to Consider

• Fragility fractures are associated with significant morbidity and mortality, with a 20% first-year mortality rate and a 3- to 4-fold increased risk of mortality in the subsequent 5 years following any fragility fracture 1.
• The biological rationale is compelling—fragility fractures indicate compromised bone strength, and without intervention, bone loss continues and fracture risk escalates.
• Each fracture event provides a crucial opportunity to diagnose and manage osteoporosis as a chronic condition, potentially preventing the devastating cycle of recurrent fractures that lead to disability, loss of independence, and increased mortality.
• The estimated direct cost of managing fragility fractures worldwide is in excess of $100 billion USD, with indirect costs close to $200 billion 1.

Recommendations for Management

• Implementing systematic approaches like Fracture Liaison Services can close the care gap by identifying fracture patients, ensuring bone density testing, initiating appropriate osteoporosis medications, and providing follow-up care.
• Ensuring bone density testing and initiating appropriate osteoporosis medications, such as bisphosphonates (alendronate 70mg weekly, risedronate 35mg weekly), denosumab (60mg subcutaneously every 6 months), teriparatide or abaloparatide (daily injections for up to 2 years), and romosozumab (210mg monthly injections for 12 months).
• Providing follow-up care to prevent further complications and improve patient outcomes. The most recent and highest quality study, published in 2024 in the Mayo Clinic Proceedings 1, highlights the importance of addressing the osteoporosis care gap and implementing systematic approaches to manage fragility fractures and prevent subsequent fractures.

From the FDA Drug Label

Osteoporosis occurs in both males and females but is most common among women following the menopause, when bone turnover increases and the rate of bone resorption exceeds that of bone formation. These changes result in progressive bone loss and lead to osteoporosis in a significant proportion of women over age 50. Fractures, usually of the spine, hip, and wrist, are the common consequences From age 50 to age 90, the risk of hip fracture in white women increases 50-fold and the risk of vertebral fracture 15-to 30-fold. It is estimated that approximately 40% of 50-year-old women will sustain one or more osteoporosis-related fractures of the spine, hip, or wrist during their remaining lifetimes Hip fractures, in particular, are associated with substantial morbidity, disability, and mortality

Fragility fractures are critical inflection points in a patient's health journey because they are a direct consequence of osteoporosis, a chronic condition characterized by low bone mass and density. The occurrence of a fragility fracture significantly increases the risk of subsequent fractures, leading to substantial morbidity, disability, and mortality. Therefore, fragility fractures highlight the missed opportunity to manage underlying osteoporosis as a chronic condition, emphasizing the need for timely intervention to prevent further bone loss and reduce the risk of future fractures 2.

• Key points:
  • Osteoporosis is a chronic condition characterized by low bone mass and density
  • Fragility fractures are a direct consequence of osteoporosis
  • Fragility fractures increase the risk of subsequent fractures
  • Timely intervention is necessary to prevent further bone loss and reduce the risk of future fractures
• Main idea: Fragility fractures are a critical inflection point in a patient's health journey, highlighting the need for timely intervention to manage underlying osteoporosis.

From the Research

Importance of Addressing Fragility Fractures

• Fragility fractures are a significant public health concern, affecting an estimated 3 million people annually in the United States 3.
• These fractures are associated with a high mortality rate, emphasizing the need for prevention and proper management 3, 4.
• The elderly and individuals with certain medical conditions, such as thyroid disease, diabetes, hypertension, and heart disease, are at increased risk of fragility fractures 3.

Management and Treatment of Fragility Fractures

• Osteoporosis, a condition characterized by low bone mass and density, is often diagnosed after a fragility fracture has occurred 3.
• The National Osteoporosis Foundation recommends treating osteoporosis with pharmacotherapy in patients with a high risk for fracture or a history of fragility fracture 3.
• A multidisciplinary approach to care, involving orthopedic surgeons, geriatricians, and other healthcare professionals, can improve outcomes for patients with fragility fractures 4, 5.
• Clinical pathways and standardized approaches to care can help reduce variations in treatment and improve patient outcomes 4.

Preventing Subsequent Fractures

• Secondary prevention of fragility fractures is critical to preventing subsequent fractures and improving patient outcomes 6, 7.
• The Fracture Liaison Service (FLS) model of care has been shown to be effective in improving rates of bone mineral density testing, initiation of osteoporosis treatment, and adherence with treatment 7.
• Global and regional initiatives are underway to improve the care of individuals with fragility fractures and prevent subsequent fractures 6, 7.

Interdisciplinary Collaboration

• Fragility fractures represent an interdisciplinary challenge, requiring collaboration between orthopedic surgeons, geriatricians, and other healthcare professionals 5.
• Treatment should be based on consensus guidelines and adapted to local circumstances 5.
• Optimal care for patients with fragility fractures requires attention to perioperative management, surgical treatment, and rehabilitation 5.