Improving patients’ outcomes after osteoporotic fractures

Osteoporotic fractures have become one of the most prevalent trauma conditions seen daily in clinical practice [1]. They are also known as ‘fragi lity fractures’ and they are defined as those occurring after a low-energy trauma, traditionally interpreted as a fall from a standing height or less [2]. Contributing factors are the susceptibility to falls and underlying osteoporosis, which is characterized by low bone mass and microarchitectural deterioration of bone tissue, leading to increased bone fragility [3]. Fractures of the vertebrae (spine), proximal femur (hip) and distal forearm (wrist) have long been regarded as ‘typical’ osteoporotic fractures with a substantial variation in their incidence between populations, sexes, different age groups and even between urban and rural areas [4]. In 2000, there were an estimated nine million new osteo porotic fractures worldwide, with approximately 1.7 million forearm fractures, 1.6 million hip fractures and 1.4 million vertebral fractures [5]. Overall, it has been forecasted that 20% of 50-year-old men and half of 50-year-old women will suffer from at least one osteoporotic fracture during their remaining lifetime [6]. As populations are aging, the incidence of osteoporotic fractures is also increasing [4], representing a major public health problem and a substantial burden to healthcare services [6]. For example, in 2005, fragility fractures in the USA resulted in 2.5 million medical office visits, 430,000 hospital admissions and 180,000 nursing home admissions, with a direct cost of US$17 billion [7]. In the UK, over 300,000 patients present to hospitals with fragility fractures, with a medical and social cost of approximately £2 billion each year, most of which is the result of hip fractures [8]. In addition to their significant medical costs worldwide [4], osteoporotic fractures also represent a major cause of morbidity in older people, often necessitating hospitalization and operative treatment, and resulting in loss of patient’s mobility and autonomy [4,6]. Hip fractures in particular are associated with high mortality [9]. Finally, besides the aforementioned main adverse outcomes of osteoporotic fractures including mortality, morbidity and cost of treatment [4], all fragility fractures, and particularly lumbar or multiple vertebral fractures and hip fractures, are also associated with pain and decrease of physical/social function and well being, compromising patients’ quality of life [10]. Therefore, the treatment of osteoporosis and the prevention of osteoporotic fractures is a major public health issue; and numerous treatments as well as fall prevention strategies have been developed to reduce the risk of fracture in patients with osteoporosis [3,11]. The aim is to minimize the associated mortality, morbidity and disability. Appropriate medical treatment for osteoporosis, adequate fracture fixation, rehabilitation and lifestyle modifications (e.g., calcium and vitamin supplementation, weightbearing exercises and minimizing the risk of falls) could facilitate optimal functional recovery, a reduction in future fracture risk and an overall improvement in health-related quality of life [12]. As populations are aging, osteoporotic fractures are common and they are associated with high rates of mortality and morbidity, disability, pain and a high cost of treatment. In addition to primary prevention strategies, efforts should be made to improve patients’ outcomes after a fragility fracture and optimize their overall management. Optimal surgical treatment of the fracture, when indicated, and high-quality postfracture care in terms of evaluation and appropriate medical treatment of osteoporosis, rehabilitation, lifestyle modifications and secondary fall prevention should be provided for optimal functional recovery, reduction of future fracture risk and improvement of overall quality of life. A multidisciplinary approach and the establishment of clinical pathways are mandatory to ensure optimization of treatment and adherence to prevention strategies of secondary fractures.