Invited papers: osteoporosis

Paradoxically, osteoporosis service providers traditionally target low-risk patients. Patients at highest risk of osteoporotic fractures are those who have already sustained a fracture; yet, while secondary prevention of fractures using treatments for osteoporosis is endorsed by national guidelines, this seldom happens in practice. To address this need, the Fracture Liaison Service (FLS), was created in West Glasgow in 1999 to offer routine assessment and treatment for osteoporosis and, where necessary, for fracture secondary prevention to all women and men over 50 years presenting to our orthopaedic and accident and emergency services with a new fracture at any skeletal site. Assessment for fracture secondary prevention is achieved 4–10 times more often in association with a FLS compared with alternative service models. During the first five years, the FLS offered assessment for osteoporosis to 6137 consecutive patients with 6755 fractures (97% of which were at non-vertebral sites), for fracture secondary prevention; 23% of fractures occurred in men. Seventy-nine per cent of patients underwent assessment; the other 21% either declined or were too unwell. Among women, the prevalence of osteoporosis ranged from 30% in those with ankle fractures to 76% among those with hip fractures. Thirty-seven per cent of patients were recommended a bisphosphonate, typically with calcium and vitamin D, and 35% were recommended calcium with vitamin D without any additional medication. About 4% were recommended either a selective estrogen receptor modulator or hormone replacement therapy. Drug treatment was deemed unnecessary for the remaining patients. During median follow-up of 28.3 months (range 0.5–60 months) 8.8% sustained a refracture. Refracture risk increased with age and was higher among women and varied with the site of the index fracture. Refractures occurred rapidly, 31% within six months of the original fracture. During follow-up, 15.9% of patients died. The FLS is the most efficient way of delivering assessment, targeting treatments of proven efficacy and achieving fracture risk reduction. To reduce the risk of refracture, patients with new fractures must routinely be offered assessment for osteoporosis, but the early refracture risk suggests that the assessment offered should also address falls risk to achieve optimal fracture secondary prevention.