Bone deep... After a hip fracture here is what you should do to reduce the risk of a recurrence, says Jane E. Brody

TT, 24 Apr 2019: Just as lightning can strike the same target more than once in a given storm, hip fractures can and do happen again to the same person.

Yet, more often than not, people who fracture a hip do not get follow-up treatment that could prevent another fracture.

Studies have shown that after a hip fracture is repaired, patients often fall through the cracks, leaving them at risk of a recurrence. The surgeon's job ends with fixing or, more likely, replacing the broken hip. It is then up to the patient's personal physician to recommend and prescribe measures to help prevent a second fracture.

However, the typical 15-minute office visit is often focused on current medical issues, like diabetes and high blood pressure, rather than on a possible future problem, albeit one that can be life-threatening. In many cases, experts say, practicing physicians don't even know which of their patients have had a hip fracture.

Anyone who breaks a hip, unless from a severe trauma like a car accident, is considered at high risk for further fractures, including breaking the other hip. To reduce the risk, orthopaedic experts recommend that after a fracture, patients should have a bone density test, evaluation of calcium and vitamin D levels and, in nearly all cases, medication to protect against further bone loss.

Even without a bone density test, Dr Douglas C. Bauer, internist at the University of California, San Francisco, wrote in an editorial in JAMA Geriatrics in July, "There is almost universal agreement that individuals with documented hip or vertebral fracture have established osteoporosis, indicating that they are at high risk of future fracture, and appropriate drug therapy should be routinely offered. In an interview he said, "Every patient with a reasonable life expectancy who has a hip fracture should be offered treatment B auer was reacting to what he called "really depressing, shocking data" revealing that only a small -- and steadily declining -- fraction of hip-fracture patients are being treated with medication that might forestall future broken bones.

The distressing evidence comes from a national study of 97,169 patients who fractured a hip from 2004 through 2015. Published in JAMA Geriatrics, the study by Dr Rishi J. Desai, epidemiologist at Brigham and Women's Hospital, and co-authors showed a continuous decline in patients who started taking osteoporotic medications after the fracture, from 9.8 per cent of patients in 2004 to a dismal 3.3 per cent in 2015.

The decline in initiating treatment with any of the many medications known to reduce fracture risk is widely attributed to the outsize publicity given to the very rare risk of jaw necrosis and an uncommon fracture of the femur among patients who take bone drugs for many years. Yet the risk of a second hip fracture is far greater than either of these side effects, Bauer said. In Desai's study, treatment rates among those who broke a hip were even lower for men than for women, although men are nearly as likely to break another bone, including the other hip. In general, without preventive treatment, 15 per cent to 25 per cent of patients who suffer an osteoporotic fracture will experience another one within 10 years.

And with people living longer, hip fractures are increasingly likely. A report, published last year in the journal Osteoporosis International, revealed that, after a decade of declining rates of hip fractures, since 2012 the rates have plateaued in the United States, most likely because so many older adults, and their doctors, have turned their backs on bone-protecting med- ication. Among people enrolled in Medicare alone, Desai and co-authors wrote, this plateau "may have resulted in more than 11,000 additional estimated hip fractures between 2012 and 2015". The side effects of bone drugs "have gotten more hype than they should have," Desai said in an interview. "People worry about them, and with preventive therapy, they don't see the benefits right away." However, Bauer wrote, "hip fractures represent only the tip of the iceberg; timely evaluation and consideration of drug treatment are appropriate for many other individuals at high risk of fracture. M any people at risk of breaking a bone because of osteoporosis are reluctant even to take Vitamin D and calcium, nutrients critical to forming healthy bones. In a new national study reported recently by Dr Spencer Summers, orthopaedic surgeon at the University of Miami, to the American Academy of Orthopaedic Surgeons, fewer than one person in five known to have osteoporosis met the daily recommended intake of both Vitamin D and calcium. More than 10 million Americans have osteoporosis, and another 44 million are at increased risk of developing it. Osteoporosis, which means porous bones, is a chronic, progressive disease of increasingly fragile bones that can break from a relatively minor insult, like falling from a standing height. Sooner or later, osteoporosis results in half of white women and 20 per cent of white men breaking a bone (the risk is significantly lower in African- American and Hispanic adults); when that bone is a hip, the outcome too often is a tragic decline in quality of life, permanent disability or even death. Among elderly patients who break a hip, the mortality rate within a year is as high as 36 per cent.

In a blog post in August, Dr Farah Naz Khan bemoaned the fact that her grandparents' primary care doctor "never bothered to do bone density scans to see if they had osteoporosis." Khan's grandfather, then 89, fell in his home and broke his hip, which led to his death. Less than a year later, her grandmother fell in the same place at home, fractured her arm in three places and lost her ability to live independently.

I admit that, after taking the bone drug Fosamax for five years decades ago, I too resisted having my bones tested because I was reluctant to take another drug. But finally, in my mid70s, I decided I should know how my bones were doing, and, lo and behold, my left hip was on the cusp of osteoporosis. The examining doctor, a specialist in this all-too-common disease among older people, said, "I don't want to see you back here with a broken hip." So I took her advice. I've now had three annual infusions of zoledronic acid (Reclast) and my bone density has stabilised. Hopefully, that will be all I need, but I will have annual bone density tests from now on.

NYTNS Minus preventive treatment, 15-25 per cent of those who suffer osteoporotic fracture may experience another one.