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© 1999 The Journal of Bone and Joint Surgery, Inc.
CorrespondenceTO THE EDITOR: We thank Dr. Tosi and Dr. Lane for their rousing "Editorial. Osteoporosis Prevention and the Orthopaedic Surgeon: When Fracture Care Is Not Enough" (80-A: 1567–1569, Nov. 1998) and for their leadership in placing this important disease on the agenda of the American Academy of Orthopaedic Surgeons. The recent medical literature is replete with high-quality studies demonstrating reduced rates of fracture when preventive care is used for women who have risk factors for osteoporosis or its complications. Among the most prominent of these risk factors is a history of a previous osteoporotic fracture. Of all medical specialists, orthopaedists are perhaps best suited to identify patients who have an osteoporotic fracture. Given that we are in a position to prevent additional fractures, pain, disfigurement, and disability, are we not ethically obligated to go beyond treatment of the complication (the fracture) and to see to it that the disease itself is brought under control? One would think that the obvious answer is yes, but orthopaedists have been slow to act, both as individual practitioners and as a whole2. There appear to be two sources of acquiescence on the part of individual orthopaedists. The first is a (falsely) fatalistic opinion that, once the patient has a fracture, it is too late to do anything about the osteoporosis. The second, and perhaps more fundamental, reason is that orthopaedists believe that they are ill trained, and they are therefore disinclined to discuss the treatment of osteoporosis with patients. As a group, we have done no better. The Academy has been slow to act, especially in view of its strong leadership in other areas of prevention and education. This is an unglamorous and complicated issue, but it cries out for decisive leadership by the Academy. Perhaps there is a sense among some orthopaedists that a reduction in the risk of fractures about the hip may somehow jeopardize our future job security given the current industry environment and government predictions of a glut of orthopaedists. The current revolution in health-care financing and staffing is determined not by quality of or access to care but by budgetary considerations alone1. Given financial realities, that is not likely to change in the foreseeable future. So the question is, how do we want to spend our time as the baby boomers age? It is a matter of simple arithmetic. If we cannot reduce the frequency of fractures among the elderly, we may well be repairing fractures to the exclusion of all other activities by the year 20305. However, implementing programs for the screening, prevention, and treatment of osteoporosis within a defined population is not straightforward. One of the problems that we have encountered has been the cost and inefficiency of central dual-energy x-ray absorptiometry scanners for the screening and follow-up of patients. Realistically, we can screen only a small fraction of patients who could be tested under one proposed guideline. Needless to say, under the same guideline, follow-up testing is out of the question for all but a few. Newer alternatives, such as peripheral dual-energy x-ray absorptiometry and ultrasound, are cheaper and more efficient, but, as stated by Tosi and Lane, their utility has not been universally accepted as a standard for screening and follow-up testing. The unavailability of resources limits universal testing at this time. It is clear that treatments are available that can help patients to avoid the disabling complications of osteoporosis. Testing and treatment guidelines have been established by the National Osteoporosis Foundation4 and other organizations. What has not been determined is whether any of these guidelines will be effective in improving the health of the population. Widespread screening for and treatment of osteoporosis will involve a costly investment of limited health-care resources. Therefore, the question is not whether the treatment and prevention of osteoporosis should be a priority but how to invest the available resources so that the maximum health benefits can be realized. Models of treatment and prevention, based on current guidelines, are needed in order to help us to determine how best to control the osteoporosis epidemic. This effort will require an overall strategic plan and a focus on research that will provide scientific evidence to support one approach or another. We applaud the efforts of the Academy's Oversight Panel on Women's Health Issues, and we strongly support its important work in bringing this issue to the forefront.
Donald C. Fithian, M.D.; Alexandra E. Page, M.D.: Kaiser Permanente, 4647 Zion Avenue, San Diego, California 92120
Dr. Tosi and Dr. Lane reply: We thank Dr. Fithian and Dr. Page for their enthusiastic support of our recent Editorial. We would like to respond to four of their points. First, we heartily agree that orthopaedists can and should take an active role in the detection and treatment of osteoporosis. Patients come to the orthopaedic surgeon specifically for musculoskeletal care. All of our attention is focused on the musculoskeletal system. This gives us a special authority when we speak on bone health. Patients are more likely to listen to the message when it is not lost among the many other messages of primary care. Orthopaedists are also the physicians who come into contact with the most deleterious form of osteoporosis—namely, fragility fractures. Simply treating the fracture without addressing the underlying weakened skeleton leaves the patient at risk for other mishaps. The methods used to diagnose and treat osteoporosis have moved forward to the point that most individuals should respond favorably. Orthopaedists should now know that there is no need for fatalism regarding this disorder. Second, we recognize that many orthopaedists may not be comfortable with trying to keep up to date with the vast range of treatment options for osteoporosis and may want to partner with clinicians in the medical field to perform diagnosis and treatment. The field is changing rapidly, and it is difficult to remain current. However, the American Academy of Orthopaedic Surgeons has recognized this problem and has moved rapidly to provide support in the following ways. (1) The Academy is a sponsor of and an active participant in the National Osteoporosis Foundation. This organization has actively changed the federal support for efforts related to the diagnosis and treatment of osteoporosis, as evidenced by the hundredfold increase in federal support of research as well as Medicare payment for dual-energy x-ray absorptiometry. The Academy collaborated with the National Osteoporosis Foundation in the development of the Physician's Guide to Prevention and Treatment of Osteoporosis4, which was recently distributed to the entire membership of the Academy. In addition, the American Academy of Orthopaedic Surgeons Board of Councilors has partnered with the National Osteoporosis Foundation to sponsor America Walks for Strong Women. Although this walk is a fund-raising project for the National Osteoporosis Foundation, it also raises awareness. We are hoping that orthopaedic surgeons in the cities where this annual event is held will encourage their patients to participate and will use this opportunity to speak to their patients about the importance of osteoporosis prevention, diagnosis, and treatment. (2) The Academy has partnered with the American Academy of Pediatrics, the National Institute of Child Health and Human Development, and the Milk Processors Education Program to produce the Calcium Coalition and the Milk and Me educational programs. These programs focus directly on educating children about good bone health. (3) The Academy has made the prevention and treatment of osteoporosis a major theme for the Annual Meeting in 2000. It has established a task force to work on upgrading its osteoporosis educational program. James Heckman, the immediate past president of the Academy, has urged orthopaedists to broaden their practice profile to include osteoporosis care. (4) The Academy established the Task Force on Women's Health Issues (which became the current Oversight Panel on Women's Health Issues) in 1995. The leadership of the Academy recognized that women have substantial musculoskeletal health-care needs and that their presentation and care are often unique. The Oversight Panel initiated our Editorial and is responsible for the Instructional Course Lecture on osteoporosis3. In addition, the Oversight Panel has provided testimony on the importance of musculoskeletal heath (for both men and women) in numerous government and private forums. Third, we believe that there is little risk that osteoporosis care will "jeopardize our future job security." Even if we could manage all of the patients who have osteoporosis, the current medications only reduce the risk of fracture by 50 percent. The continued aging of the population will still result in an increasing number of fractures about the hip, and it is anticipated that more than 50 percent of the orthopaedic effort in the year 2015 will be directed solely to repairing fractures about the hip. Finally, Dr. Fithian and Dr. Page also speak to the need for more research to determine the best protocols and treatments for the prevention, diagnosis, and treatment of osteoporosis. The United States is facing a substantial shift in its demographic profile. Senior citizens, particularly women, make up a growing share of the population. Osteoporosis or, more specifically, osteoporotic fractures are a major source of pain and disability for senior citizens. Musculoskeletal wellness will largely define the quality of the last years of life in our senior population. We strongly agree that more dollars are needed for musculoskeletal research.
Laura L. Tosi, M.D.: Department of Orthopaedics, Children's National Medical Center, 111 Michigan Avenue N.W., Washington, D.C. 20010 Joseph M. Lane, M.D.: The Hospital for Special Surgery, 535 East 70th Street, New York, N.Y. 10021
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