Secondary Fracture Prevention: Consensus Clinical Recommendations from a Multistakeholder Coalition

Abstract

Osteoporosis-related fractures are undertreated, due in part to misinformation about recommended approaches to patient care and discrepancies among treatment guidelines. To help bridge this gap and improve patient outcomes, the American Society for Bone and Mineral Research assembled a multistakeholder coalition to develop clinical recommendations for the optimal prevention of secondary fracture among people aged 65 years and older with a hip or vertebral fracture. The coalition developed 13 recommendations (7 primary and 6 secondary) strongly supported by the empirical literature. The coalition recommends increased communication with patients regarding fracture risk, mortality and morbidity outcomes, and fracture risk reduction. Risk assessment (including fall history) should occur at regular intervals with referral to physical and/or occupational therapy as appropriate. Oral, intravenous, and subcutaneous pharmacotherapies are efficacious and can reduce risk of future fracture. Patients need education, however, about the benefits and risks of both treatment and not receiving treatment. Oral bisphosphonates alendronate and risedronate are first-line options and are generally well tolerated; otherwise, intravenous zoledronic acid and subcutaneous denosumab can be considered. Anabolic agents are expensive but may be beneficial for selected patients at high risk. Optimal duration of pharmacotherapy is unknown but because the risk for second fractures is highest in the early postfracture period, prompt treatment is recommended. Adequate dietary or supplemental vitamin D and calcium intake should be assured. Individuals being treated for osteoporosis should be re-evaluated for fracture risk routinely, including via patient education about osteoporosis and fractures and monitoring for adverse treatment effects. Patients should be strongly encouraged to avoid tobacco, consume alcohol in moderation at most, and engage in regular exercise and fall prevention strategies. Finally, referral to endocrinologists or other osteoporosis specialists may be warranted for individuals who experience repeated fracture or bone loss and those with complicating comorbidities (e.g., hyperparathyroidism, chronic kidney disease).

Muscle density is an independent risk factor of second hip fracture: a prospective cohort study

“…This is the first study summarizing the strength of bone and muscle parameters for the prediction of second hip fracture. According to current osteoporosis guidelines, 13 , 25 , 26 all low‐trauma hip fracture patients should receive second hip fracture prevention treatment, but the prevalence of a lack of proper medical management remains high. 2 , 13 Therefore, it is important to identify patients at high risk of a second hip fracture.…”

“…Areal BMD (aBMD) assessed by dual‐energy X‐ray absorptiometry is an established parameter for the prediction of hip fracture risk. However, risk of a second fracture is significantly elevated for patients with hip or vertebral fractures independent of BMD 13 . Thus, aBMD measurements of the hip may have limited value for predicting the risk of a second hip fracture.…”

“…However, risk of a second fracture is significantly elevated for patients with hip or vertebral fractures independent of BMD. 13 Thus, aBMD measurements of the hip may have limited value for predicting the risk of a second hip fracture.…”

Compliance of functional exercises in school-age children with limb fractures: implication for nursing countermeasures

“…Children with limb fractures will still have obvious pain, swelling and movement dysfunction in the early postoperative period. The children will be disturbed by physical discomfort or emotional state of tension and fear [ 32 , 33 ]. The older the school-age children can be more adapt well to the postoperative state of fractures and better cooperate with functional exercises.…”

Textbook process as a composite quality indicator for in-hospital hip fracture care

“…In the systematic review of Voeten et al, seven process indicators were recommended to measure the quality of hip fracture care: assessment of malnutrition, time to surgery, orthogeriatric management during admission, time to mobilization after surgery, future fracture prevention assessment, systematic pain assessment and prevention/assessment of pressure ulcer [7]. In addition, operation by an orthopaedic trauma certified surgeon is also used as an indicator in the Netherlands [12].…”