December 1998 Bulletin

Focus on prevention, orthopaedists told

Specialty has unique opportunity to initiate diagnostic studies, push for research

Orthopaedic surgeons must deal with osteoporosis by preventing fractures, rather than only treating them once they occur.

Orthopaedists, as the recognized expert in bone injury and disease, have a unique opportunity to initiate effective preventative measures and treatments for osteoporosis, Laura L. Tosi, MD, and Joseph M. Lane, MD, said in an editorial in the November issue of The Journal of Bone and Joint Surgery.

Dr. Tosi and Dr. Lane, cochairs of the Academy's Oversight Panel on Women's Health Issues, urged orthopaedic surgeons to initiate diagnostic studies for osteoporosis and also to push for increased funding for osteoporosis research on diagnostic and treatment strategies.

They cite the dramatic mortality and morbidity rates associated with hip fractures, pointing out that a woman's risk for a hip fracture is equal to the combined risk for breast, uterine and ovarian cancer. Studies that show 10 percent of postmenopausal white women older than 50 years of age who sustain a hip fracture will become permanently functionally dependent in daily living activities and 19 percent will need long-term nursing home care. Further, many studies show the risk of fracture in men parallels that in women, although it occurs five to 10 years later.

"Historically, orthopaedic surgeons have readily treated fragility fractures, but they have rarely followed through and initiated care and treatment of the porous skeleton," Dr. Tosi and Dr. Lane said. "In these times of outcome analysis, fixation of fractures is not enough."

They observed that "orthopaedic surgeons, like most other clinicians, were not instructed during their training in the care of patients with osteoporosis; the literature offered a maze of conflicting protocols; and the cost of diagnostic work-ups was frequently not reimbursed by insurance companies."

However, three recent events have enhanced the opportunity for orthopaedic surgeons to initiate strategies for the prevention, diagnosis and treatment of osteoporosis, the authors said.

The national Osteoporosis Foundation's Physician's Guide to Prevention and Treatment of Osteoporosis, a comprehensive evidence-based guide that they believe reflects the experience of treating white postmenopausal women and provides an intellectual framework for assessing other populations.

The fact that the cost of bone-density analysis machines is declining and Medicare will pay for bone-density evaluations for beneficiaries who are at risk.

A thorough overview of the types of bone-density testing that appeared in the November 1998 issue of JBJS. The Current Concepts Review on "Bone Densitometry in Orthopaedic Practice" was written by E.C. Mirsky, MD, and Thomas A. Einhorn, MD.

Not all issues are resolved. The authors point out that Medicare does not pay for the medications to prevent the disease from progressing to the point of a fracture or other morbidity. Also, the best time for the first bone-density test is at the onset of menopause, but menopause usually occurs many years before the patient is eligible for Medicare. Further, many other health insurers do not pay for bone-density testing.

"Bone density measurement must not be seen as a generator of revenue or as an end unto itself, but rather as an important part of a total program of prevention, diagnosis and treatment of osteoporosis," said Dr. Tosi and Dr. Lane. "We must use our special expertise to argue for broader access to diagnostic testing for osteoporosis."

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