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Pelvic Fragility Fractures an Opportunity to Improve the Undertreatment of Osteoporosis

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Pelvic Fragility Fractures an Opportunity to Improve the Undertreatment of Osteoporosis 213 COPYRIGHT Ó 2020 BY THE JOURNAL OF BONE AND JOINT SURGERY,INCORPORATED A commentary by Paul A. Anderson, MD, is linked to the online version of this article at jbjs.org. Pelvic Fragility Fractures An Opportunity to Improve the Undertreatment of Osteoporosis Christian T. Smith, MS, David W. Barton, MD, Amit S. Piple, BS, and Jonathan J. Carmouche, MD Investigation performed at the Virginia Tech Carilion School of Medicine, Roanoke, Virginia Background: Osteoporosis is often undiagnosed until patients experience fragility fractures. Pelvic fractures are com- mon but underappreciated sentinel fractures. Screening patients with a pelvic fracture for osteoporosis may provide an opportunity to initiate appropriate treatments such as anti-osteoporosis therapy to prevent additional fractures. Methods: This retrospective cohort review examined the management of osteoporosis after pelvic fractures at a large tertiary care center without an established secondary fracture prevention program. Data were extracted from electronic medical records of all new patients with a pelvic fracture who were ‡50 years of age from this center and its affiliated community hospitals from 2008 to 2014. Outcome measures included the initiation of anti-osteoporosis therapy before the fracture, within the year following the fracture, >1 year following the fracture, or never and new osteoporotic fractures within 2 years after a pelvic fracture. Results: From 2008 to 2014, 947 patients presented with pelvic fractures. Of these patients, 27.1% (257 patients) were taking anti-osteoporosis medications before the fracture. Four percent of treatment-na¨ıve patients began anti- osteoporosis therapy within 1 year of fracture, with 1.2% (11 patients) starting after 1 year. Of the treatment-na¨ıve patients, 92.3% (637 patients) were never prescribed anti-osteoporosis therapy. Treatment rates were consistent over time. Within 2 years, 41.0% (388 patients) developed fragility fractures at secondary sites: 12.0% (114 patients) experienced a hip fracture, and 16.4% (155 patients) experienced a vertebral fracture. Conclusions: Osteoporosis screening and initiation of secondary fracture prevention after a pelvic fracture were inad- equate in the study population. Of the patients in this study, 909 (96.0%) never underwent a dual x-ray absorptiometry (DXA) scan during the study period. Of the 690 treatment-na¨ıve patients, 637 (92.3%) were never administered anti- osteoporosis medications. Within 2 years, 41.0% of all patients developed additional osteoporotic fractures. This study demonstrates an opportunity to improve bone health by screening for and treating osteoporosis in patients with a pelvic fragility fracture. Level of Evidence: Prognostic Level IV. See Instructions for Authors for a complete description of levels of evidence. steoporosis remains undertreated and causes substantial insufficiency fractures may be more directly associated with long-term morbidity, mortality, and health-care expen- osteoporosis than traditional osteoporotic fractures. Morris O 3 diture. Fifty percent of women and 20% of men will et al. found that 115 patients (93%) with pelvic fractures experience a fragility fracture1. Osteoporosis often goes undi- had a Singh index of £4, consistent with osteopenia or agnosed and untreated until after fractures occur, sometimes in osteoporosis, compared with 67.9% of patients with femoral multiple locations. Vertebral, wrist, and hip fractures are tra- neck fractures in a separate study by Pogrund et al.4.Pelvicfrac- ditionally recognized fragility fractures; however, 40% of fra- tures are therefore an underappreciated sentinel fracture in the gility fractures occur at other sites. Pelvic fractures account geriatric population. for 7% of annual fragility fractures in the United States, the Pelvic fracture is a heterogeneous fracture category that largest percentage of these other fractures2.Further,pelvic can occur from both high-energy and low-energy fracture Disclosure: The authors indicated that no external funding was received for any aspect of this work. The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G219). J Bone Joint Surg Am. 2021;103:213-8 d http://dx.doi.org/10.2106/JBJS.20.00738 214 T HE J OURNAL OF B ONE &JOINT SURGERY d JBJS. ORG PELVIC FRAGILITY F RACTURES VOLUME 103-A d NUMBER 3 d F EBRUARY 3, 2021 mechanisms. Although more attention has been devoted to usual care, definedasosteoporosiseducationbytheirpri- studying high-energy unstable pelvic ring injuries in young mary care physicians, and patients for whom an in-house patients, 64% of pelvic fractures are low-energy and osteopo- assessment of osteoporosis was initiated by an orthopaedic rotic in nature. In patients who were >60 years of age, 94% of surgeon(withfollow-uptreatmentatadedicatedosteopo- pelvic fractures were low-energy5. The incidence of pelvic in- rosis clinic). The study found that the percentage of these patients sufficiency fractures is increasing alongside the increasing age prescribed pharmacological therapy for osteoporosis at 6 months of the population6. Projections by Burge et al. have predicted an after the fracture was significantly higher when the evaluation overall increase in osteoporotic fracture incidence in the United was initiated by an orthopaedic surgeon and the patient was States by >48% (>3 million fractures) and an increase in managedinanosteoporosisclinic(58%)comparedwiththeusual associated costs from $209 billion from 2006 to 2015 to $228 referral to the primary care physician for osteoporosis manage- billion from 2016 to 20252. Among all osteoporotic fracture ment (29%)6. This highlights the importance of an active role by types, the largest increases have been predicted in pelvic frac- the orthopaedic service in managing osteoporosis after sentinel tures, with incidence increasing by 56% and costs rising by 60% fractures. between 2005 and 20252. Given that any fragility fracture doubles the risk of ex- Materials and Methods periencing future fragility fractures, osteoporosis screening in his retrospective cohort review examined the management patients with a pelvic fracture provides an opportunity to Tof osteoporosis after a pelvic fracture at a large tertiary care intervene before additional fractures occur. Despite the success center with 6 affiliated community hospitals without a of programs to improve osteoporosis management after a frac- formal secondary fracture prevention program. Institu- ture and secondary fracture prevention, the 2014 Medicare tional review board approval was obtained. Data were National Committee for Quality Assurance (NCQA) reported retrospectively extracted from the electronic medical rec- that, nationally, <30% of patients presenting with a fragility ords of all patients presenting with a pelvic fracture to the fracture were diagnosed with or were treated for osteoporosis. emergency department at the age of ‡50 years. The re- Further elucidation of the osteoporosis care gap following pelvic sulting data set contained both inpatient and outpatient fractures is therefore warranted. In this study, we explore osteo- recordsfortheentirehealthsystemovera7-yearperiod, porosis screening and treatment following pelvic fractures, which including >1,000 physicians and a large majority of dual we believe to be an underappreciated fragility fracture type. We x-ray absorptiometry (DXA) scanners within a 2-hour hope that this research might allow better recognition of osteo- radius. porosis in a previously missed subset of patients, thereby nar- Incident pelvic fractures were defined as any code from rowing this care gap. the International Classification of Diseases, Ninth Revision One element of this care gap that has been explored is (ICD-9) beginning with 808. Only the first recorded pelvic the composition of the care team involved in the workup fracture visit was counted as the incident pelvic fracture. Of and management of osteoporosis following a fragility note, the code contains pelvic ring and acetabular fractures, but fracture. In a 2008 prospectiverandomizedtrial,Mikietal.6 not sacral fractures, which are commonly associated with pelvic investigated the difference in the rates of early osteoporosis fracture. Data were captured from July 2008 (the implementation treatment after hip fracture between patients given the of the current electronic medical record system) to September Fig. 1 Fig. 2 Fig. 1 Incidence of DXA scanning £2 years prior to the fracture (2.3% [22 patients]), £1 year after the fracture (0.8% [8 patients]), >1 year after the fracture (0.8% [8 patients]), or never (96.0% [909 patients]). s/p = status post. Fig. 2 The rate of pharmacotherapy with an FDA-approved medication for osteoporosis and the distribution of the documented start times of anti-osteoporosis pharmacotherapy using a medication approved by the FDA for osteoporosis relative to the incident pelvic fracture. Individuals were classified on the basis of whether they received their first documented treatment with an FDA-approved medication £2 years prior to the fracture (27.1% [257 patients]), £1 year after the fracture (4.4% [42 patients]), >1 year after the fracture (1.2% [11 patients]), or never (67.3% [637 patients]). s/p = status post. 215 T HE J OURNAL OF B ONE &JOINT SURGERY d JBJS. ORG PELVIC FRAGILITY F RACTURES VOLUME 103-A d NUMBER 3 d F EBRUARY 3, 2021 2014, 2 years before the transition to the International Classifi- cation of Diseases, Tenth Revision
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