December 2004 Bulletin

Orthopaedic surgeons and the Surgeon General’s Report

By Mary I. O’Connor, MD, and Laura L. Tosi, MD

On Oct. 14, 2004, U.S. Surgeon General Richard H. Carmona, MD, MPH, FACS, released Bone Health and Osteoporosis: A Report of the Surgeon General. More than two years in the making, the report highlights the tremendous burden of osteoporosis-related disease and calls for a national action plan to improve bone health. This report could have several ramifications for the practicing orthopaedic surgeon.

Increased awareness

The report has been widely publicized in the media; therefore we can expect increased patient awareness of the importance of bone health. As a result, patients may have elevated expectations of their orthopaedic surgeons in the management of poor bone quality.

These expectations may not always be met. Often we fail to recognize the significance of a fragility fracture, indicating increased risk for poor bone health. Both the AAOS position statement on fragility fractures and a current survey by the Bone and Joint Decade and the International Osteoporosis Foundation emphasize that a fragility fracture is the strongest indicator of risk of second fracture. Nonetheless, a majority of patients hospitalized with fragility fractures continue to be discharged without adequate evaluation of osteoporosis or appropriate referral for such an evaluation.

Orthopaedic surgeons are clearly missing an opportunity to help prevent the potential suffering and impairment of a future fragility fracture. This means that precious health care resources are wasted on preventable hospital and nursing home care.

Recommendations for care

The AAOS position statement on fragility fractures encourages orthopaedic surgeons to advise patients with fragility fractures that an osteoporosis evaluation may lead to treatment that can reduce the risk of repeat fracture. It also encourages orthopaedic surgeons to initiate an investigation of whether osteoporosis is an underlying cause of the patient’s fractures. The orthopaedic surgeon may conduct this evaluation or may refer the patient to another medical provider. The critical concept is that the patient, now known to be at risk, is evaluated.

To aid the orthopaedic surgeon in fragility fracture care, recommendations for evaluation and management of patients with a fragility fracture were published in the November/December issue of the Journal of the American Academy of Orthopaedic Surgeons (Vol. 12, #6). This evaluation should include a bone mineral density test. Potential secondary causes of osteoporosis should be investigated. Patients should be instructed regarding routine nutritional supplementation of calcium and vitamin D as well as fall-prevention measures. Physicians should provide patient-education materials outlining measures to promote bone health. Pharmacotherapy, particularly alendronate [Fosamax] and risedronate [Actonel], can increase bone mineral density and reduce risk of hip and vertebral fractures in postmenopausal women with osteoporosis.

Orthopaedic surgeons need to take a leading role in ensuring that patients with fragility fractures receive proper care. We must support the Surgeon General’s goal of increased quality and years of healthy life for our patients: Americans can live long and live well.

Mary I. O’Connor, MD, is chair of the Women’s Health Issues Committee. She can be reached at oconnor.mary@mayo.edu

Laura L. Tosi, MD, is a member of the AAOS Board of Directors and past chair of the Women’s Health Issues Committee. She can be reached at ltosi@cnmc.org

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