Orthopaedic surgeon attitudes a barrier to bisphosphonate use after fragility fractures

Orthopaedic surgeons appear reluctant to initiate early bisphosphonate therapy following fragility fractures due to misperceptions about bone healing, a Victorian study suggests.

According to a retrospective audit of practice at Boxhill Hospital, only 32 (18%) of 181 patients with fragility fractures likely to be due to osteoporosis were started on bisphosphonates.

A survey of orthopaedic attitudes from 17 registrars and 16 consultants also found none would commence bisphosphonates after fragility fractures.

“Seventeen (52%) believed early treatment would impair fracture healing and preferred physicians to start bisphosphonates 6 weeks post-fracture,” the researchers wrote in a letter to the editor of the Australian and New Zealand Journal of Surgery.

 “Although the sample size was small and reflects local practice only, there is a persisting view in orthopaedic practice that bisphosphonates impair fracture healing that is unsupported by evidence.”

They noted a 2015 systematic review and meta-analysis found early administration of bisphosphonates after surgery did not appear to delay radiologic or clinical healing time for fractures.

Instead, it found evidence bisphosphonates given immediately after surgical repair should reduce the rate of subsequent fractures.

The Boxhill audit found initiation of anti-resorptive therapy was more likely in patients with a history of osteoporosis, Caucasian ethnicity and femoral fractures.

However age, gender and osteoporotic risk factors did not influence the decision to initiate therapy.

Professor Christopher Gilfillan, director of endocrinology at Eastern Health, told the limbic all patients deserve early fracture prevention therapy.

“The treatment will still be effective given 6, 8 or 10 weeks later, but the problem is that because of that delay and lack of subsequent focus, the medication gets forgotten.”

He said some hospitals have consultative medical services which help look after orthopaedic patients and ensure bisphosphonates are started, usually in the rehabilitation phase following surgery.

However such services were variable across sites and probably non-existent in private facilities, he said.

“I think all ortho units should have medical liaison not only for the treatment of osteoporosis but for the management of patients in the perioperative period. They are a high-risk group of patients for medical complications and orthopaedic specialists and their registrars don’t have the time to do that job properly.”

“This study is demonstrating that they are not thinking about osteoporosis and they are not starting the medications. They don’t regularly do this even in their post-operative reviews and many of them don’t consider it their job to do so.”

He added that ‘fracture capture’ programs – where people with osteoporosis-related hip, spine, colles and rib fractures were picked up by surveillance of the medical record and dealt with appropriately – was another way that the electronic medical record can be used to improve patient care.

The audit also found while 41% of patients had a vitamin D deficiency, less than half of those patients were treated.


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