Reduced mortality and subsequent fracture risk associated with oral bisphosphonate recommendation in a fracture liaison service setting: A prospective cohort study.

OBJECTIVE: Osteoporotic fragility fractures, that are common in men and women, signal increased risk of future fractures and of premature mortality. Less than one-third of postmenopausal women and fewer men are prescribed active treatments to reduce fracture risk. Therefore, in this study the association of oral bisphosphonate recommendation with subsequent fracture and mortality over eight years in a fracture liaison service setting was analysed. MATERIALS AND METHODS: In this prospective cohort study, 5011 men and women aged >50 years, who sustained a clinical fracture, accepted the invitation to attend the fracture liaison service of the West Glasgow health service between 1999 and 2007. These patients were fully assessed and all were recommended calcium and vitamin D. Based on pre-defined fracture risk criteria, 2534 (50.7%) patients were additionally also recommended oral bisphosphonates. Mortality and subsequent fracture risk were the pre-defined outcomes analysed using Cox proportional hazard models. RESULTS: Those recommended bisphosphonates were more often female (82.9 vs. 72.4%), were older (73.4 vs. 64.4 years), had lower bone mineral density T-score (-3.1 vs. -1.5) and more had sustained hip fractures (21.7 vs. 6.2%; p < 0.001). After adjustments, patients recommended bisphosphonates had lower subsequent fracture risk (Hazard Ratio (HR): 0.60; 95% confidence interval (CI): 0.49-0.73) and lower mortality risk (HR: 0.79, 95%CI: 0.64-0.97). CONCLUSION: Of the patients, who are fully assessed after a fracture at the fracture liaison service, those with higher fracture risk and a recommendation for bisphosphonates had worse baseline characteristics. However, after adjusting for these differences, those recommended bisphosphonate treatment had a substantially lower risk for subsequent fragility fracture and lower risk for mortality. These community-based data indicate the adverse public health outcomes and mortality impacts of the current low treatment levels post fracture could be improved by bisphosphonate recommendation for both subsequent fracture and mortality.

Prospective, double blind, randomized, controlled trial of simvastatin in human fracture healing.

Although statins are widely prescribed as cholesterol-lowering drugs, a number of studies suggest that these compounds may have anabolic effects on bone. Our aim was to assess whether simvastatin affects the rate of fracture healing in humans. A prospective, double-blind, randomized controlled trial was performed. Individuals who had sustained an undisplaced, extra-articular fracture of the distal radial metaphysis were recruited from a trauma clinic. Patients were randomized to receive simvastatin 20 mg once daily or a placebo. Regular clinical and radiological follow-up was undertaken for a 12 week period. Dual-energy X-ray absorptiometry assessment of bone mineral density was conducted at 2 and 12 weeks postinjury. Biochemical markers of bone turnover were assayed during the study period. Time to fracture union was defined as the time to cortical bridging in four cortices on plain radiographs. In addition, the rate of trabecular union was assessed. Eighty patients were recruited, of which 62 completed the study (31 in each group). Study cohorts were matched for age and gender. For patients receiving simvastatin therapy, the mean time to fracture union was 71.6 days (SD 22.2 days, SEM 3.8 days). This compared to 71.3 days (SD 21.3, SEM 4.1 days) for the control cohort (p = 0.6481). There was no significant difference between bone mineral density or bone biochemical markers between groups (p > 0.05). Despite promising results from in vivo and in vitro animal studies, simvastatin at a treatment dose of 20 mg once daily does not affect the rate of fracture healing in humans.

Vertebral fracture assessment in patients presenting with incident nonvertebral fractures.

BACKGROUND: Patients with fractures should be prioritized for assessment for osteoporosis so that they can benefit from treatment for the secondary prevention of osteoporotic fractures. Assessment is seldom offered to patients with vertebral fractures because these fractures are typically not diagnosed. Vertebral fractures can be identified by vertebral fracture assessment (VFA) using current dual-energy X-ray absorptiometry (DXA) scanners. OBJECTIVE: The purpose of this study was to assess the prevalence of vertebral fractures, using VFA, in patients presenting with nonvertebral fractures and to assess whether this impacts on the management of these patients. DESIGN: A cohort study undertaken in 577 patients aged 50 years or over including 455 women, who presented with nonvertebral fractures and who underwent routine post-fracture assessment by a Fracture Liaison Service (FLS). MEASUREMENTS: The numbers and severity of vertebral fractures were assessed in evaluable vertebrae from TV4 to LV4 in addition to bone mineral density (BMD) assessment. RESULTS: Using DXA, 76% of vertebrae could be evaluated by VFA. Of the men and women with nonvertebral fractures, 19-20% had at least one vertebral fracture. The prevalence ranged from 6% in men with humeral fractures to 32% among women with hip fractures. The prevalence of vertebral fractures correlated most strongly with increasing age and with severity of reduction of BMD. Using local treatment protocols, VFA would result in only 3% more patients receiving treatment for fracture secondary prevention. CONCLUSIONS: In patients with nonvertebral fractures, VFA identifies a substantial burden of prevalent vertebral fractures that have not hitherto been recognized. Nevertheless, VFA seldom influences the need for treatment for fracture secondary prevention after a nonvertebral fracture.

A fracture liaison service for patients with osteoporotic fractures.

A fracture liaison service, led by a specialist nurse, has been set up in one trust to offer an assessment for osteoporosis to all men and women over 50 with new fractures. The aim is to identify those who have osteoporosis because they are at greatest risk of further fractures. The service delivers strategies to reduce future fracture risk, targeted at those patients at highest risk.

The fracture liaison service: success of a program for the evaluation and management of patients with osteoporotic fracture.

INTRODUCTION: Fracture care often represents the first opportunity for clinical management of osteoporosis; however, many patients do not receive any evaluation after a fracture. In Glasgow, Scotland, fewer than 10% of fracture patients underwent bone mineral density (BMD) testing. In an effort to better meet the needs of fracture patients by providing routine assessment and, where necessary, treatment for osteoporosis after their fracture, a novel service (The Fracture Liaison Service) was designed and implemented in two separate National Health Service trusts in Glasgow. METHODS: An agreed-upon standard of care for men and women 50+ years of age with fractures was established in collaboration with orthopedic surgeons and primary care physicians. The Fracture Liaison Service assumes responsibility for fracture case-finding and for assessing and performing diagnostic evaluations (including axial DXA), and making specific treatment recommendations for the secondary prevention of osteoporotic fractures. RESULTS: During the first 18 months of operation, more than 4,600 patients with fractures of the hip, wrist, humerus, ankle, foot, hand, and other sites were seen by the Fracture Liaison Service's osteoporosis specialist nurses. Nearly three quarters of these patients were considered for BMD testing; treatment was recommended for approximately 20% of the patients without need for BMD testing. Overall, 82.3% of patients who had BMD testing were found to be osteopenic or osteoporotic at the hip or spine. CONCLUSIONS: The Fracture Liaison Service has successfully identified and evaluated most patients with fractures. Only those patients who declined were not evaluated. The ultimate success of the program will be measured by the subsequent fracture experience of these patients, but clear improvements in diagnosing and treating low bone mineral density in patients with fracture have already been demonstrated.

Identification and treatment of osteoporosis in fractures.

Patients who present with osteoporotic fracture are at highest risk of further fractures and their associated morbidity. Despite the availability of several evidence-based therapeutic options, which have the potential to reduce the incidence of fractures by up to 50%, it is paradoxical that these high-risk patients are seldom assessed for osteoporosis and offered treatment. Secondary prevention of osteoporotic fractures should now be the priority for osteoporosis services; the challenge that remains is to devise new models of patient care that can deliver strategies for the secondary prevention of osteoporotic fractures in different healthcare settings.