Osteoporosis Evaluation and Treatment

There were two moderate strength studies (Lyles et al¹⁶¹ and Majumdar et al¹⁶²) and one low strength studies (Gardner et al¹⁶³) that support this recommendation. Lyles et al¹⁶¹ studied the effectiveness of zoledronic acid versus placebo combined with pre-treatment vitamin D repletion and found that the treatment group exhibited statistically significant reductions in mortality rates, rates of any new fractures, rates of new non-vertebral fractures, or the rates of new vertebral fractures.All participants who had very low 25-hydroxyvitamin D levels or no blood level available  received 50,000 to 125,000 units of vitamin D₂ or D₃ (orally or intramuscularly) 14 days before the treatment intervention.  All participants then received supplemental calcium and vitamin D daily. Majumdar et al¹⁶² was upgraded from a low strength study to a moderate strength study due to a large effect size. Majumdar, et al studied the effectiveness of an osteoporosis case manager for post-discharge hip fracture care.  In this study, those patients who received the intervention had increased chance of osteoporosis evaluation by bone mineral density testing and osteoporosis-specific treatment with bisphosphonates. The Gardner et al¹⁶³study found no significant differences in mortality or osteoporosis addressed with bone density scan and/or bisphosphonate therapy between the group who received a discussion regarding osteoporosis risks post-surgery and the group who received a fall prevention pamphlet. Hip fractures are a sign (symptom) of osteoporosis, but most patients with hip fractures are not currently evaluated and treated for their underlying osteoporosis.
  
 
Risks and Harms of Implementing this Recommendation
A hip fracture is a sign of osteoporosis, but most patients with hip fractures are not currently evaluated and treated for their underlying osteoporosis. Patients who have fractured a hip are at high risk for subsequent fracture and increased mortality. There are very effective osteoporosis therapies that lower the risk of fractures. There are potential benefits for identification of secondary causes of osteoporosis with no known harm associated with this osteoporosis evaluation. There is the potential for “atypical femur fractures” that may be associated with prolonged bisphosphonate therapy. All medications including osteoporosis therapies have potential harms.
 
Future Research
Cost-effectiveness research on use of a fracture liaison service in open health care systems would be helpful for evaluation and treatment of osteoporosis and to test whether a fracture liaison service reduces the risk of hip fracture readmission rates after a hip fracture.  Further investigations of the long term patient specific outcomes of bisphosphonate therapies are also appropriate, including assessment of alternative osteoporosis treatments. In addition, the relative roles of the orthopaedic surgeon and the patient's primary care provider in evaluating and treating low bone mass after hip fracture, and how these compare to the use of a fracture liaison service, should be studied.