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Barriers and Solutions to Osteoporosis Care in Patients with a Hip Fracture
John D. Kaufman, MD; Mark E. Bolander, MD; Andrew D. Bunta, MD; Beatrice J. Edwards, MD, FACP; Lorraine A. Fitzpatrick, MD; Christine Simonelli, MD
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Investigation performed at HealthEast Care System, St. Paul, Minnesota; McGaw Medical Center of Northwestern University, Chicago, Illinois; and the Mayo Clinic, Rochester, Minnesota

John D. Kaufman, MD
24355 Lyons Avenue, Suite 240, Santa Clarita, CA 91325. E-mail address: jdk2ca@yahoo.com

Mark E. Bolander, MD
Lorraine A. Fitzpatrick, MD
Department of Orthopedic Surgery (M.E.B.) and Department of Endocrinology (L.F.), Mayo Clinic, 200 First Street S.W., Rochester, MN 55905

Andrew D. Bunta, MD
Department of Orthopaedic Surgery, Northwestern University Feinberg School of Medicine, 645 North Michigan Avenue, Suite 910, Chicago, IL 60611

Beatrice J. Edwards, MD, FACP
Northwestern University, 676 North St. Clair Street, Suite 200, Chicago, IL 60611

Christine Simonelli, MD
HealthEast Osteoporosis Care, 1875 Woodwinds Drive, Woodbury, MN 55125

In support of their research or preparation of this manuscript, one or more of the authors received grants or outside funding from Merck and Company, Illinois Department of Public Health, and the Northwestern Memorial Foundation. None of the authors received payments or other benefits or a commitment or agreement to provide such benefits from a commercial entity. No commercial entity paid or directed, or agreed to pay or direct, any benefits to any research fund, foundation, educational institution, or other charitable or nonprofit organization with which the authors are affiliated or associated.

J Bone Joint Surg Am, 2003 Sep 01;85(9):1837-1843
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As the population ages, orthopaedic surgeons are treating an escalating number of patients who have a hip fracture. The total number of hip fractures worldwide was estimated to be 1.7 million in 1990 and is projected to climb to 6.3 million in 2050 1,2 . The number of men and women with disabilities directly related to these fractures is reaching epidemic proportions. Even small increases in lifespan will lead to large increases in the rate of hip fracture because the risk of hip fracture increases exponentially with age 3 . Approximately 50% of women who sustain a hip fracture lose the ability to walk normally, and complications directly related to the fracture cause a 20% increase in mortality during the six months after the fracture 4-7 . In the United States, substantial resources are needed for both acute and long-term treatment of hip fractures. It has been estimated that these costs range from seven to ten billion dollars annually 8 .
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    John D. Kaufman
    Posted on February 05, 2004
    Dr. Kaufman responds:

    Dr. Babbitt’s letter is appreciated and her points are well taken. Certainly the approach of establishing a protocol for evaluating and treating osteoporosis in hip fracture patients can and should be expanded to include other fragility fractures.

    Since hip fractures are the most severe of all osteoporotic fractures we felt this was a good starting point to try to establish a system for preventing the second hip fracture. The institutional setting also made it easier to standardize protocols.

    Dr. Babbitt also points out the great inconsistencies found in the area of bone density testing. Much of this comes from the fact that BMD testing and interpretation has been taken over by many different specialties from radiology to internal medicine to orthopaedic surgery. The ISCD Official Position document will help clarify and standardize the field of densitometry among the different specialties.

    John D. Kaufman, M.D., Mark Bolander, M.D., Andrew Bunta, M.D., Beatrice Edwards, M.D., Lorraine Fitzpatrick, M.D., Christine Simonelli, M.D.

    Ann M. Babbitt, M.D.
    Posted on January 14, 2004
    Increasing Awareness of the Importance of Recognizing Fragility Fractures
    Greater Portland Bone & Joint Specialists, 800 Main St., S. Portland, ME 04106

    To The Editor:

    It was with great interest and enthusiasm that I read the article "Barriers and Solutions to Osteoporosis Care in Patients with a Hip Fracture" (2003; 85: 1837-1843) by Kaufman, et.al. Integrating osteoporosis evaluation and treatment into the mainstream of orthopaedic care has definitely come of age.

    The HealthEast Care System, the McGaw Medical Center of Northwestern University and the Mayo Clinic are to be commended for instituting a new approach to evaluating patients with hip fractures which includes seven essential steps : 1) identification, 2) assumption of responsibility, 3) clinical testing, i.e., bone densitometry, 4) differential diagnosis, 5) treatment, 6) prevention of future fractures and 7) follow-up care.

    Two points warrant emphasis. First, this approach needs to be expanded to all fragility fractures. Personally, my awareness of any fragility fracture as a sign of osteoporosis heightened when my mind set changed from an attitude of "this is another broken bone" to "maybe there is something more to this".

    Second, it became apparent that we need a consistent approach to identify and treat patients at risk to fragility fractures. Although bone densitometry has been a powerful tool, it has become increasingly apparent that a greater standardization in the indications for and interpretation of bone density results was needed. Fortunately, improved standardization is occurring. Since 1995, the International Society for Clinical Densitometry (ISCD) has been the worldwide leader in promoting osteoporosis awareness, education and excellence through the field of densitometry.

    The ISCD has made substantial gains in our understanding of how to "quantify" bone mass, assess fracture risk, evaluate bone quality and develop parameters for osteoporosis treatment. The ISCD has also strived to continually seek better and more effective ways to assess the micro- and macroarchitecture of bone, and explore the concept of "bone quality" as it relates to research and the clinical setting of fracture.

    On two occasions, in 2001 and 2003, the ISCD has convened Position Development Conferences at which a panel of experts in the field of bone densitometry, with input from clinicians and technologists in attendance, has provided needed consistency in the field of densitometry. The ISCD is a not-for-profit multidisciplinary professional society with a mission to enhance knowledge and quality of bone densitometry among healthcare professionals, to provide continuing education courses for clinicians and technologists, to increase patient awareness and access to bone densitometry, and to support clinical and scientific advances in the field.

    The most recent PDC was held in Cincinnati, Ohio, on July 25-27, 2003. The key areas of interest from these Position Development Conferences are: indications for bone mineral density testing, which includes all women over age 65 and all men over 70; reference data bases for T-scores; uses for central and peripheral densitometry; diagnosis in pre and post menopausal women, children and men; indications for serial bone density testing; phantom scanning and calibration; precision assessment and cross calibration of densitometry machines; and guidelines for densitometry reporting and nomenclature.

    The complete review of the background and rationale for all ISCD Official Positions as well as the Positions themselves are published in the Journal of Clinical Densitometry (1-12) and Volume 5 Supplement 2002 and Volume 7 2004. A summary of the ISCD Official Positions is available online at the ISCD website (www.iscd.org), where there is also a viewable and downloadable slide presentation of the positions.

    As we move forward into this new era, as our population ages, and the fragility fracture becomes even more common, our understanding of bone densitometry will be all the more valuable.

    Ann M. Babbitt, M.D. Orthopaedic Surgeon Greater Portland Bone and Joint Specialists 800 Main Street South Portland, Maine 04106 ababbitt@maine.rr.com

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