The Clinical Impact of Fracture Liaison Services: A Systematic Review

Abstract

Introduction: A fracture liaison service (FLS) is a coordinated system of care that streamlines osteoporosis management in the orthopaedic setting and can serve as an effective form of secondary preventative care in these patients. The present work reviews the available evidence regarding the impact of fracture liaison services on clinical outcomes. Methods: The literature was reviewed for studies reporting changes in the rates of bone mineral density scanning (DXA), antiresorptive therapy, new minimum trauma fractures, and mortality between cohorts with access to an FLS or not. Studies including intention to treat level data were retained. A Medline search for “fracture liaison” OR “secondary fracture prevention” produced 146 results, 98 were excluded based on the abstract, 38 were excluded based on full-text review. Ten level III studies encompassing 48,045 patients were included, of which 5 studies encompassing 7,086 were analyzed. Odds-ratios for DXA and anti-osteoporosis pharmacotherapy rates were calculated from data. Fixed and random effects analyses were performed using the Mantel-Haenszel method. Results: Four studies reported, on average, a 6-fold improvement in DXA scanning rates (Figure 1). Six studies reported, on average, a 3-fold improvement in antiresorptive therapy rates (Figure 2). Four large studies reported significant reductions in the rate of new fractures using time-dependent Cox proportional hazards models at 12 months (HR = 0.84, 0.95), 24 months (HR = 0.44, 0.65), and 36 months (HR = 0.67). Five large studies reported mortality improvements using time-dependent Cox proportional hazards models at 12 months (HR = 0.88, 0.84, 0.81) and 24 months (HR = 0.65, 0.67). Conclusions: The findings suggest that fracture liaison services improve rates of DXA scanning and antiresorptive therapy as well as reductions in the rates of new fractures and mortality among patients seen following minimum trauma fractures across many time points.

Intravenous bisphosphonate therapy does not delay fracture healing in inter-trochanteric femur fractures – A randomised controlled study

“…Recent metaanalysis and reviews have also supported the safety and benefits of early administration of bisphosphonates in osteoporotic fracture scenarios. 39,40 There was no new fracture during the follow-up in any patient. The major factors associated with non-union and implant-related complications were fracture severity and technical errors in surgical fixation.…”

Novel Approach to Identify Patients With the Most to Gain From New Treatment Options Intended to Prevent Fragility Fractures

“…Fracture Liaison Services (FLS) are frequently regarded as a critical component of secondary fracture prevention efforts. 2 In combination with epidemiology-based fracture risk calculation tools such as FRAX or Garvan, FLS are considered state-of-the-art at identifying high-risk patients. They allow for stratification of patients into risk sub-groups, helping clinicians to tailor treatment strategies based on patients’ risk of fracture.…”

Secondary fracture prevention: global approaches

“…The fracture liaison service (FLS) model, initially described in 2003, [11] has since proven to be an efficacious, cost-effective multidisciplinary approach to systematically streamline preventative care for patients who have sustained a primary fragility fracture. [12] The degree to which FLS models have been implemented varies across countries. The models require significant organization, support, and funding.…”

“…The fracture liaison service (FLS) model, initially described in 2003, [11] has since proven to be an efficacious, cost-effective multidisciplinary approach to systematically streamline preventative care for patients who have sustained a primary fragility fracture. [12] …”