Osteoporosis is a global public health problem affecting an estimated 200 million people worldwide . Bone loss in osteoporosis is usually gradual and silent. Unless carefully sought, the disease may manifest itself with an acute event such as a fracture. It is leading cause of fractures of the hip, spine, and wrist in people above the age of 50 years. Approximately 1.6 million hip fractures occur worldwide each year and by 2050 this number could reach between 4.5 million and 6.3 million [2, 3, 4]. Hip fractures not only cause morbidity but also mortality with reported rates up to 24% in the first year after fracture [5, 6] Greater risk of dying may persist for at least 5 years afterwards . Loss of function and independence among survivors is profound, with 40% unable to walk independently and 60% requiring assistance a year later [8, 9]. Because of these disabilities, 33% are totally dependent or are in a nursing home in the year following a hip fracture.
Osteoporosis is a global public health problem affecting an estimated 200 million people worldwide . Bone loss in osteoporosis is usually gradual and silent. Unless carefully sought, the disease may manifest itself with an acute event such as a fracture. It is leading cause of fractures of the hip, spine, and wrist in people above the age of 50 years. Approximately 1.6 million hip fractures occur worldwide each year and by 2050 this number could reach between 4.5 million and 6.3 million [2,3,4]. Hip fractures not only cause morbidity but also mortality with reported rates up to 24% in the first year after fracture [5,6] Greater risk of dying may persist for at least 5 years afterwards . Loss of function and independence among survivors is profound, with 40% unable to walk independently and 60% requiring assistance a year later [8,9]. Because of these disabilities, 33% are totally dependent or are in a nursing home in the year following a hip fracture . In addition, a prior fracture is associated with an 86% increased risk of fracture in future [2,11]. Financial burden to manage osteoporotic fractures on healthcare budgets around the world is huge. In USA alone, estimated cost of treating osteoporotic fractures in year 2008 was $22 billion . Significant proportion of people who sustain an osteoporotic fracture, was not diagnosed prior to their fracture and received no appropriate treatment . Similarly a great majority, as high as 80%, of individuals who already had atleast one osteoporotic fracture, are neither identified nor treated for osteoporosis . This is especially true among males. The reason for this dismal scenario is probably manifold. An International Osteoporosis Foundation (IOF) survey conducted in 11 countries identified that this may be largely due to lack of awareness among high risk individuals and physicians or due to limited access to diagnostic facilities. The situation is grim in Asia . One of the main reasons is under-appreciation of the problem on the part of the contact clinician. Nearly all Asian countries fall far below the FAO/WHO recommendations for calcium intake of between 1000 and 1300 mg/day. The median dietary calcium intake for the adult Asian population is approximately 450 mg/day, with a potential detrimental impact on bone health in the region . Studies carried out across different countries in South and South East Asia showed widespread prevalence of vitamin D deficiency/ insufficiency in both sexes and all age groups of the population . In a study among Indian women aged 30-60 years from low income groups, BMD at all the skeletal sites was much lower than values reported from developed countries, with a high prevalence of osteopenia (52%) and osteoporosis (29%) in both males and females and that too at a younger age . In our own unpublished series, we did DEXA scan on all patients above the age of 50 years who presented with a fracture of proximal femur in orthopedic emergency. Patients with risk factor for osteoporosis i.e. sedentary lifestyle, smoking, excessive alcohol consumption, family history of fractures, loss of endogenous sex hormones, BMI<21 and chronic glucocorticoid use were excluded. 80% Patients had osteopenia (31%) or osteoporosis (49%). In a similar pilot study conducted on patients undergoing joint replacement at our institute, 22% (44/200) had either osteopenia or osteoporosis. The patients with known risk for osteoporosis were also excluded from this study. No worldwide data of incidence of fractures in people above the age of 50 years or total number of patients undergoing total joint replacement is available. However a study has shown that it can be as high as 53.2% among women and 20.7% among men  and more than 1 million people undergo total hip or total knee replacements annually in USA alone . It indicates that number of people in whom the diagnosis of osteoporosis is being missed may be staggering. Second main reason, especially in developing countries, is lack of diagnostic facilities. In 2008, Indonesia had a total of only 34 DEXA machines, half of them in Jakarta, for a population of 237 million (0.001 per 10,000 populations) . .Likewise in most of the countries including many European countries, this falls far below the recommended number of 0.11 per 10,000 populations . The third and probably the most important reason is absence of region specific guidelines for preemptive evaluation for osteoporosis. Treatment of osteoporosis has been shown to increase bone-mineral density (BMD) leading to decrease in the incidence of future fracture by almost 50% as compared to untreated patients [21,22,23]. Studies have also established that in patients undergoing lower limb arthroplasty, use of bisphosphonates was associated with an almost twofold increase in implant survival time . While primary fracture prevention is the goal, secondary prevention is also critical to prevent the future costs to the patient and society.
To conclude, primary care physicians and other specialists who come in contact with patients who are at high risk of developing osteoporosis should work diligently to participate in prevention and treatment of osteoporosis and fragility fracture care. The morbidity, mortality and resulting cost of managing fragility fractures can at least be decreased if not fully avoided if timely diagnosis and intervention is carried out. It is recommended that region specific fresh guidelines be formulated so as to evaluate all potential patients for osteoporosis. Evaluation, of all trauma patients (>50years) and patients undergoing joint replacement, for osteoporosis is a golden opportunity and should not be missed. Orthopedic surgeons should own the bone and take the lead. It should be emphasized that it is never too late to diagnose and treat established osteoporosis at any opportunity.
- Osteoporosis Society of India (2003) Action Plan Osteoporosis: Consensus statement of an expert group. New Delhi: Osteoporosis Society of India.
- Gullberg B, Johnell O, Kanis JA (1997) World-wide projections for hip fracture. Osteoporos Int.7: 407-413.
- Kanis JA, Johnell O, De Laet C, Oden A, Delmas P et al. (2004) A meta-analysis of previous fracture and subsequent fracture risk. Bone 35: 375-382.
- Cooper C, Campion G, Melton LJ 3rd (1992) Hip fractures in the elderly: a world-wide projection.Osteoporos Int. 2: 285-289.
- Cooper C, Atkinson EJ, Jacobsen SJ, O’Fallon WM, Melton LJ 3rd (1993) Population-based study of survival after osteoporotic fractures. Am J Epidemiol 137: 1001-1005.
- Leibson CL, Tosteson AN, Gabriel SE, Ransom JE, Melton LJ (2002) Mortality, disability, and nursing home use for persons with and without hip fracture: a population-based study. J Am Geriatr Soc. 50: 1644-1650.
- Magaziner J, Lydick E, Hawkes W, Fox KM, Zimmerman SI et al. (1997) Excess mortality attributable to hip fracture in white women aged 70 years and older. Am J Public Health. 87: 1630-1636.
- Magaziner J, Simonsick EM, Kashner TM, Hebel JR, Kenzora JE (1990) Predictors of functional recovery one year following hospital discharge for hip fracture: a prospective study. J Gerontol. 45: 101-107.
- Gold DT (2001) The nonskeletal consequences of osteoporotic fractures: psychologic and social outcomes. Rheum Dis Clin North Am. 27: 255-262.
- Kanis JA, Johnell O, Laet CD, Jonsson B, Oden A (2002) International variations in hip fracture probabilities: implications for risk assessment. J Bone Miner Res.17: 1237-1244.
- International Osteoporosis Foundation. (2000) How fragile is her future?. Switzerland: International Osteoporosis Foundation.
- Blume SW, Curtis JR (2011) Medical costs of osteoporosis in the elderly medicare population.Osteoporos Int. 22: 1835-1844.
- Freedman KB, Kaplan FS, Bilker WB, Lowe RA. (2000) Treatment of osteoporosis: are physicians missing an opportunity?. J Bone Joint Surg Am. 82: 1063-1070.
- Nguyen TV, Center JR, Eisman JA (2004) Osteoporosis: underrated, underdiagnosed and undertreated. Med J Aust. 180:18-22.
- International Osteoporosis Foundation (2009) The Asian Audit: epidemiology, costs and burden of osteoporosis in Asia. Switzerland: International Osteoporosis Foundation.
- Mithal A. Wahl DA, Bonjour JP, Burckhardt P, Dawson-Hughes B et al. (2009) Global vitamin D status and determinants of hypovitaminosis D. Osteoporos Int. 20: 1807-1820.
- Shatrugna V, Kulkarni B, Kumar PA, Rani KU, Balakrishna N (2005) Bone status of Indian women from a low-income group and its relationship to the nutritional status. Osteoporosis Int. 16: 1827-1835.
- Van Staa TP, Dennison EM, Leufkens HG, Cooper C (2001) Epidemiology of fractures in England and Wales. Bone. 29: 517–522.
- United States of America. Number of all-listed procedures for discharges from short-stay hospitals, by procedure category and age: national hospital discharge survey (2010) Centers for Disease Control and Prevention.
- Kanis JA, Johnell O (2005) Requirements for DXA for the management of osteoporosis in Europe.Osteoporosis Int. 16: 229-238
- Riggs BL, Melton LJ (1992) The prevention and treatment of osteoporosis. N Engl J. Med.327: 620-627.
- Harris ST, Watts NB, Genant HK, McKeever CD, Hangartner T et al. (1999) Effects of risedronate treatment on vertebral and non vertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. Vertebral Efficacy with Risedronate Therapy (VERT) Study Group. JAMA. 282: 1344-1352.
- Karpf DB, Shapiro DR, Seeman E, Ensrud KE, Johnston CC Jr et al. (1997) Prevention of nonvertebral fractures by alendronate: a meta-analysis. Alendronate OsteoporosisTreatment Study Groups. JAMA. 277: 1159-1164.
- Prieto-Alhambra D, Javaid MK, Judge A, Murray D, Carr A, et al. (2011)Association between bisphosphonate use and implant survival after primary total arthroplasty of the knee or hip: population based retrospective cohort study. BMJ.343: d7222.