Table 1 Number of patients with subsequent fractures within two years

AAOS Now

Published 8/2/2022
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Brandon May

Older Hip Fracture Patients Often Experience Subsequent Fractures

A study suggests that bone-health evaluations are underutilized for patients following hip fracture, and many patients who experience a hip fracture sustain additional fragility fractures. Based on the research findings, reported at the AAOS 2022 Annual Meeting, the investigators said patients with osteoporosis-related fractures have critical unmet needs. The findings of the study were presented by Emily Pflug, MD, an orthopaedic surgery resident at NYU Langone Medical Center.

Dr. Pflug and her fellow researchers expected that both the presence of bone-health evaluation and the initiation of medications would reduce the risk of additional fractures. In contrast, the findings suggested there is no difference, at least in the two years following an index hip fracture, but the frequency of bone-health evaluation and osteoporosis care was low.

“One key takeaway from this study includes the post-injury follow-up rate with orthopaedic surgery, which, in our opinion, suggests that orthopaedic surgeons should take a more active role in managing bone health in an effort to capture the maximum number of patients,” Dr. Pflug explained. “Second, our study suggests there is a significant opportunity for further treatment of bone health following geriatric hip fractures given the high rate of additional fractures following the index admission.”

In the study, Dr. Pflug and researchers examined bone-health optimization among 837 outpatients with a mean age of 81.1 ± 10.0 years who underwent operative treatment at an urban academic medical center for a hip fracture between 2015 and 2019. The investigators performed a chart review to assess post-injury follow-up, with a focus on subsequent admissions, outpatient visits, bone-health evaluations, use of osteoporosis-related diagnostic and pharmacologic therapies, and subsequent fragility fractures.

Of the 837 patients, only 20.5 percent had a bone-health evaluation after a hip fracture. In the patients who underwent post-injury bone evaluation, 64.5 percent initiated pharmacologic therapy (vitamin D, calcium, bisphosphonates, or hormone therapy), and 73 patients underwent bone mineral density testing.

After hospital discharge, nearly 70 percent of patients were followed on an outpatient basis. Most of the patients who were followed after injury had established orthopaedic care (n = 559), but some patients were also seen by medicine (n = 116), rheumatology (n = 44), endocrinology (n = 32), and/or obstetrics and gynecology (n = 5) specialists.

In the two years after the index injury, 3.7 percent of patients sustained a contralateral hip fracture (Table 1). This injury occurred at a mean of 294.1 ± 197.7 days after the initial hip fracture. In that group of patients, 16 experienced a femoral neck fracture and 15 had an intertrochanteric hip fracture. Most patients (80.1 percent) with a subsequent hip fracture sustained the same type of hip fracture as the initial injury. Only six of 172 patients who received a bone-health evaluation had a second hip fracture after two years; however, no difference was observed in the rate of a subsequent hip fracture based on the presence of a bone-health assessment (3.5 percent versus 3.8 percent; P = 0.867). The same relationship was true for the incidence of subsequent fragility fractures (11.7 percent versus 15.1 percent; P = 0.230).

More than one in four patients (27.6 percent) had an additional ED visit that resulted in an inpatient admission over the two-year period. Patients with an additional inpatient admission had higher mean American Society of Anesthesiology scores (3.0 ± 0.6 versus 2.7 ± 0.7; P <0.001), were on average older (83.3 ± 8.8 years versus 80.2 ± 10.3 years;>P <0.001), and were less likely to have undergone bone-health assessments.>

A limitation of the study included the assessment of patients from a single urban academic center that consisted of a Level 1 trauma center, orthopaedic specialty hospital, and tertiary care center. The researchers explained that given this limitation, the patients in the study may not reflect patients from other institutions and across different geographic regions. The retrospective nature of the study represented an additional limitation.

The investigators wrote, “Next steps should include establishing centralized programs that make performing bone-health evaluations easier for physicians (orthopaedic and nonorthopaedic) logistically and financially.”

Dr. Pflug’s coauthors of “Lessons Learned from Bone Health Care: Gaps Remain in the Treatment of Osteoporosis-related Hip Fractures” are Ariana Lott, MD; Sanjit Konda, MD, FAAOS; and Kenneth Egol, MD, FAAOS.

Brandon May is a freelance writer for AAOS Now.