What’s New in Osteoporosis and Fragility Fractures

According to the American College of Surgeons1, “the surgeon is responsible for the preoperative diagnosis of the patient, for performing the operation, and for providing the patient with postoperative surgical care and treatment.” Stressing the first and last tasks, this article covers the trends toward more nonoperative treatment options and the importance of secondary fracture prevention. Nevertheless, performing high-quality surgery in patients carefully selected for the procedure certainly remains the core task for orthopaedic surgeons. The current and upcoming results from randomized controlled trials (RCTs) on the surgical treatment of fragility fractures are summarized as well. Surgical and Nonoperative Treatment Surgical treatment is indicated to varying degrees depending on the location of the fracture. The functional demands of the patients and their risk profiles influence the decision. Despite older age and frailty, patients with hip fractures are almost always treated surgically to obtain pain relief and mobility. In contrast, the discussion on which patients should have surgical treatment continues for upper-extremity fractures. Treatment for Hip Fractures A better understanding of the patient’s pre-fracture status and goal of care is essential for selecting a treatment that will be beneficial for both the individual and health-care economics. If the orthopaedic surgeon is able to provide advanced care planning together with the patient, family, and other involved physicians, individualized care respecting the life goals of the patient is obtained2,3. Recent studies from The Netherlands challenge the routine in most high-income countries to provide surgical treatment to everyone with a hip fracture4,5. The FRAIL-HIP study compared outcomes after 172 frail, elderly patients with hip fractures (or their proxies) opted for either surgery or nonoperative management. The health-related quality of life was similar in the 2 groups, and a “humane quality of dying” was reported. If orthopaedic surgeons should recommend that some individuals undergo nonoperative management rather than surgical care, it is necessary to correctly identify those patients who have a remaining life span of only days or weeks. Until now, different clinical scores have been the most popular way of doing so6. Still, statistical predictive values at a population level may not be reliable at the individual level. A more objective assessment may reduce the risk of misinterpreting the patient’s actual status. Basic biomarkers such as high lactate and/or low albumin, hemoglobulin, and glomerular filtration rate may predict death within 30 days. Thrombocytopenia and lymphocytopenia are associated with an increased risk as well7–11. More advanced analyses may be a future possibility. Studying the biological age in terms of DNA methylation clocks in intraoperatively harvested bone and whole blood in 12 patients with hip fractures, a recent U.S. study found mortality to be associated with the DNA methylation age. Bone and blood-derived methylation clocks were correlated with each other. The prevention of advanced DNA methylation was suggested to reduce hip fracture-related mortality following hip fracture12. To what degree decision-making in the future will rely more on predictive analytics than traditional science and proven experience is hard to foresee, but models are emerging13. The difficulties lie not just in correctly identifying the patients at extreme risk for early death after a fracture and ensuring their wishes. Abstaining from surgery also leads to ethical, legal, and logistic challenges. Using prompt surgery as part of palliative care is widely accepted. End-of-life care must be satisfying also for those opting out of surgery, and one can assume that most emergency care hospitals are poorly prepared for providing nonoperative palliative care. Pain control must be obtained, for example, by an indwelling femoral nerve catheter or even a phenol nerve block14. High treatment satisfaction was reported by next of kin in a Dutch study evaluating nonoperative management of a verified or suspected hip fracture in a total of 108 patients either entirely cared for in a nursing home or having a short stay in the hospital15. The smaller, selected group of 20 patients who were not hospitalized was assessed to have somewhat better quality of dying compared with patients who stayed in the hospital for 2 to 3 days. The differences were particularly in the aspects of symptom control, preparation, and transcendence. All patients who were not hospitalized and 83% of hospitalized patients died within 30 days. U.S. studies have reported better outcomes after hip fracture surgery for individuals with dementia, at least in terms of mortality16,17. The same was found for fracture of the odontoid18. The discussion of surgical treatment compared with nonoperative treatment of major fractures in frail, elderly patients will undoubtedly go on in the coming years, and a clear-cut rationale may be difficult to create19. Treatment for Upper-Extremity Fractures The debate on whether to manage upper-extremity fractures with surgery or nonoperative treatment may not be that controversial. Some meta-analyses have suggested that most proximal humeral fractures and distal radial fractures may be treated nonoperatively in frail, elderly patients, although recovery may be more rapid with surgery20,21. With regard to long-term outcomes, the available evidence is insufficient to select individuals and fracture types likely to benefit from surgery. Most proximal humeral fractures may be treated nonoperatively. For those that do need surgery, reverse total shoulder arthroplasty has gained popularity for the most displaced fracture patterns. In an RCT published in 2020, Fraser et al.22 compared reverse total shoulder arthroplasty with open reduction and internal fixation (ORIF) in 124 relatively healthy patients between 65 and 85 years of age. The main outcome measure was the Constant score, measuring pain, activities of daily living, range of motion, and strength. The mean score in the arthroplasty group was 13 points higher than in the ORIF group at 2 years, above the predefined minimally important difference of 10 points. Addressing the uncertainty about the long-term results of the reverse shoulder arthroplasty, the 5-year results were published and showed an unchanged 13-point benefit for the arthroplasty group. When comparing subgroups with the most severe fractures (type C2, according to the 2007 version of the OTA/AO classification), the mean Constant score of 73 after reverse shoulder arthroplasty was above the lower limit for a good score, whereas the score of 56 in the ORIF group was just on the threshold between a poor and mediocre score23. In addition, there were fewer adverse events in the arthroplasty group compared with the ORIF group. In a separate publication on cost-effectiveness, the mean reported cost was approximately 37,000 Euros for reverse shoulder arthroplasty compared with 32,000 Euros for ORIF24. Taken together, reverse shoulder arthroplasty seems to be the best surgical method after a 5-year follow-up as well23,25. The next natural step would be to compare nonoperative treatment and arthroplasty, and results from at least 2 such trials are expected in the near future26,27. The evidence regarding olecranon fractures is scarce. However, the first adequately powered trial randomizing displaced (Mayo type IIA and IIB) olecranon fractures in 64 patients who were 75 to 95 years of age was recently published28. At 3 months, the main outcome, the Disabilities of the Arm, Shoulder and Hand (DASH) questionnaire score, was significantly different by 12 points in favor of the operative group. At the 12-month follow-up, the groups no longer differed statistically, but the 95% confidence interval included a clinically relevant difference in the DASH score favoring operative treatment. The number of fracture-related complications was relatively low: 3 in the operatively treated group and 2 in the nonoperatively treated group. There were slightly more comminuted fractures (Mayo type IIB) in the operatively treated group. Again, we could speculate that there are subgroups who benefit from operative treatment. A larger trial or a trial focused on subgroups of patients or fracture patterns would help to answer that. Advantages and Disadvantages of RCTs on Surgical Methods The quality of historical RCTs in orthopaedics and trauma may be questioned29, for example, in terms of high risk of bias and low level of certainty20. However, the nature of traumatic injury, in terms of both patients’ characteristics and the immediate need for treatment, may explain why study design and follow-up cannot be impeccable. The rigid demands of pharmaceutical trials are likely not achievable in the study of fragility fractures. Traditionally, randomized trials on fracture treatment have often excluded older people, perhaps surprisingly, as they are at the highest risk for fracture. In addition, studies focusing on geriatric fractures (e.g., hip fractures) have excluded the frailest patients and patients with dementia. The obvious risk is that treatments proven to work in younger and healthier patients may not be the best choice for older and sicker patients. Fortunately, the body of evidence is improving for fragility fractures beyond the hip as well. Still, a better evidence base for surgical decisions is indeed needed, and the results from ongoing large-scale RCTs, for example, on shoulder fractures26,27 and acetabular fractures30 will be published in the near future. With regard to hip fractures, national RCTs on internal fixation compared with arthroplasty in nondisplaced femoral neck fractures31–33 and dual-mobility cups compared with conventional total hip arthroplasty for displaced femoral neck fractures34 are soon to be finalized. Periprosthetic Fracture Prevention and Arthroplasty Stem Design The success of hip arthroplasties, including in the treatment of fractures, has led to a rise in periprosthetic femoral fractures, a complication affecting older women in particular35. It is well established that cementless femoral stems have a higher risk of periprosthetic femoral fractures than stems fixed with bone cement, illustrated, for example, by a periprosthetic femoral fractures rate of 10.3% after use of uncemented stems compared with 2.6% after cemented stems in a substudy from the HEALTH RCT36. Cemented stems can also lead to better health-related quality of life37. No sufficiently powered randomized trials have yet compared different cemented stem designs, but registry trials have suggested an increased risk with polished tapered stems compared with composite beam stems38. Polished tapered stems have gained popularity due to the low risk of aseptic loosening. In the frail and elderly population, however, periprosthetic fractures may be a greater concern than loosening. As some orthopaedic communities are still hesitant to use bone cement, the clear recommendations from a recent U.S. study might be helpful: the Zimmer M/L Taper, DePuy Synthes SUMMIT Basic, and Zimmer Biomet VerSys LD/Fx prostheses ought to be avoided when treating femoral neck fractures with hemiarthroplasties performed without cement in frail patients, because of the higher risk of revision compared with other cementless stems39. In a commentary to the article, Keeney recommended that surgeons avoid low-demand stems and collarless single-wedge tapered stems in general40. Preoperative bone health optimization prior to elective orthopaedic and spine procedures has been advocated to avoid complications such as periprosthetic fractures41. Pasqualini et al. recommended actively searching for risk factors for poor bone health and ordering a bone density (dual x-ray absorptiometry [DXA]) scan if such risk factors are present41. Should a periprosthetic fracture occur, secondary-fracture prevention should be considered just as it is after other fragility fractures42,43. Secondary Fracture Prevention and Osteoporosis Drugs Besides age, a prior fracture is the most important risk factor for a recurrent fracture. The imminent fracture risk is high, so secondary fracture prevention should be performed as early as possible. A substudy of 2,520 patients with a femoral neck fracture from the FAITH and HEALTH trials showed that the treatment gap remains high even after a hip fracture44. Although the study protocols recommended secondary fracture prevention, only 25% of the patients received osteoporosis medication after a hip fracture. During the 2-year follow-up, 9% of patients had sustained a new fracture, most often a contralateral hip fracture (40%). “Own the Bone” has advocated and supported systematic secondary fracture prevention services45. A stepped-wedge randomized cluster trial examining the introduction of a Fracture Liaison Service (FLS) in 7 orthopaedic departments included 100,000 patients ≥50 years of age (mean age, 70 years), with a fracture (except in the fingers, toes, and skull)46. The FLS intervention included anti-osteoporosis drugs, lifestyle advice, and fall prevention. Seventy percent of eligible patients were assessed for fracture risk, and 56% of patients had anti-osteoporosis drugs prescribed. The patients were followed for up to 4.7 years for subsequent fractures and mortality. Outcomes were collected from national registers. A 13% reduction in new fragility fractures (distal forearm, proximal humeral, and hip fractures) was observed in women, and a 10% reduction was observed in men. The FLS was associated with a reduction in hip fractures of 25% in women and 21% in men. The observed mortality was 18% lower in women and 15% lower in men. For patients in whom the index fracture was a hip fracture, the risk of a second hip fracture was 20% lower in women and 26% in men. No change in mortality was observed after a hip fracture. Patients with hip fractures were most often offered zoledronic acid while admitted to the hospital for the index fracture. The idea of offering high-risk patients immediate treatment for osteoporosis is gaining popularity47. Those in favor of that approach have argued that the benefits of 100% adherence for at least a year by far outweigh the perceived risks. A further dose at 12 to 18 months will increase the benefit, but, for some patients, the single dose may be sufficient treatment. In a quality improvement report from a Level-I trauma center, the number of eligible patients with a hip fracture who received zoledronic acid went from 0 to 29 (35%) of 84 after Plan-Do-Study-Act cycle 1 and to 53 (75%) of 71 after Plan-Do-Study-Act cycle 2. The zoledronic acid was administered on postoperative day 2. No increase in hospital length of stay was observed48. Awareness of osteoporosis and the risk of subsequent fracture(s) followed by active assessment and medication will evidently be beneficial to our current and future patients. The Future Role of the Orthopaedic Surgeon The pressure on health-care spending and workforce challenges make it even more necessary for orthopaedic surgeons to demonstrate the benefit of what we do for our patients and for society. High-value care and treatment should be defined by the profession in a credible way, rather than by anyone else. Working in a multidisciplinary team around the orthogeriatric patient will call for orthopaedic surgeons to be team leaders, not isolated procedural experts. In particular, we should make sure that our patients are systematically offered secondary fracture prevention as an integrated part of fracture care. Due to the increasing proportion of older people in our societies, the best possible fragility fracture care and fracture prevention will continuously be stressed as our core undertaking. Focusing on musculoskeletal health as a whole, including prevention, cure, and palliation based on technological advances and value-based care, will most certainly be a future role for the orthopaedic surgeon. Evidence-Based Orthopaedics The editorial staff of JBJS reviewed a large number of recently published studies related to the musculoskeletal system that received a higher Level of Evidence grade. In addition to articles cited already in this update, 6 other articles relevant to osteoporosis and fragility fractures are appended to this review after the standard bibliography, with a brief commentary about each article to help guide your further in an in this Evidence-Based Orthopaedics The of preoperative the risk of postoperative in geriatric patients after hip fracture a systematic review and of randomized controlled Patients with hip fracture often a associated with a poor systematic review and the of preoperative in the prevention of after hip fracture surgery. The review included RCTs of patients who had surgical treatment for a hip fracture, were assessed for postoperative and were preoperative The results regarding the risk of and were RCTs were in study with a mean age of In the intervention of patients compared with of patients in the control group. The difference was The risk difference was and the number to was 7 patients. The not identify difference between groups regarding postoperative or results should be with as the studies may have been In addition, the rate between the included Although are to have including a risk of in frail older this not to be an when a single preoperative dose is In the risk of may be of this intervention pain, and of arthroplasty fixation and postoperative for proximal fractures in the a Shoulder the of arthroplasty type compared with reverse total shoulder arthroplasty humeral fixation method compared with and postoperative compared with for elderly patients with proximal humeral fractures treated with studies were only trials were and studies were The of reverse and early the best outcomes on the American Shoulder and and scores and In contrast, patients who with a cemented stem and had a range of had the Patients who reverse showed the highest reverse was associated with an increased risk of periprosthetic fractures, a with cementless but there was no statistical difference between and cemented in reverse in that reverse both and performed with cement, has important and that early is and may better stems cemented but this evidence was and further is needed, on humeral stem to postoperative and total arthroplasty a similar functional outcome for distal humeral fractures in patients years or a randomized controlled Shoulder In a RCT from to was compared with total arthroplasty in elderly individuals with distal humeral fractures in which internal fixation could not be The benefit of an is fewer postoperative than after including no on However, may be associated with and Patients were eligible if they were years of age, were and had an distal humeral fracture, and were followed for at least 2 The outcome measure was the DASH score, and other functional outcome were collected (Mayo the range of motion, and 20 were treated with and 20 were treated with and 18 in the group and in the group the had a mean age of around 75 years, and 3 of patients were The group had a somewhat higher mean DASH score at points compared with points for the but this difference was clinically The secondary outcomes not between the and There were 6 adverse events in each treatment periprosthetic fractures, or has gained likely because of for relatively more active patients. It is to speculate that performed well in this study because patients to use the as in daily of postoperative with more patients and longer follow-up are to on differences in complications and revision not postoperative pain in patients with femoral neck fracture treated with controlled Bone In an RCT including treated with of at the of surgery compared with was in terms of postoperative pain by a assessed as the to total and The study was and were from to There was no difference between groups with regard to the mean postoperative pain score in the group compared with in the The groups had similar outcomes in the other aspects as well. the cost and the The study was with regarding pain and the of in patients with hip fractures is because of the of and and However, the results with those of studies on in the younger and healthier population total hip after treated proximal a randomized controlled Shoulder RCT compared with in patients with nonoperatively proximal humeral fractures. patients from and were randomized either to 10 home or to after a single with a The mean patient age was 73 years, and of patients were The were relatively The outcome was the DASH score at 3 Secondary outcomes included the pain, health-related quality of and complication was The not report adherence to the At both 3 and 12 months, no clinically important or differences were found between groups for including and were low and indicated for most older with a proximal humeral fracture, a home with brief may be just as as a can guide clinical to and to and for elderly patients. hip fracture, hospital factors associated with of anti-osteoporosis medication on to imminent a Bone national study from patients 172 hospitals in and to to identify factors associated with anti-osteoporosis medication and risk after hip fracture. Despite clear only of patients received anti-osteoporosis medication at and a within 1 factors were associated with anti-osteoporosis medication and factors were associated with included care, bone health and early orthogeriatric and in were associated with risk, whereas increased risk by Although the study for is can but clinically Some factors may care to aspects of hip fracture care. the observed and for more and secondary fracture prevention.