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2010 Clinical Practice Guidelines for the Diagnosis and Management of Osteoporosis in Canada. Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print]. 2010 Guidelines. Fragility Fractures and Care Gaps. Section Two. Fragility Fracture: Definition.

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2010 clinical practice guidelines for the diagnosis and management of osteoporosis in canada

2010 Clinical PracticeGuidelines for the Diagnosis and Management of Osteoporosis in Canada

Papaioannou A, et al. CMAJ 2010 Oct 12. [Epub ahead of print].

fragility fracture definition
Fragility Fracture: Definition
  • A fracture occurring spontaneously or following minor trauma such as a fall from standing height or less1,2
    • Excluding craniofacial, hand, ankle and foot fractures
  • Kanis JA, et al. Osteoporos Int 2001; 12(5):417-427.
  • Bessette L, et al. Osteoporos Int 2008; 19:79-86.
the majority of fractures in canadian women age 50 are fragility fractures

95%

91.8%

Overall: 81%

90%

85%

80%

% of all fractures that are fragility fractures

75.7%

75%

70%

65%

60%

50-59

60-69

70-79

80+

Age groups

The Majority of Fractures in Canadian Women > Age 50 Are Fragility Fractures

Bessette L, et al. Osteoporos Int 2008; 19:79-86.

consequences of fracture
Consequences of Fracture
  • Increased risk of
    • Hospitalization/institutionalization1,2
    • Death3-5
    • Subsequent fracture6-8
  • Decreased quality of life9-12
  • Economic burden on healthcare system2

1. Papaioannou A, et al. Osteoporos Int 2001; 12(10):870-874.

2. Wiktorowicz ME, et al. Osteoporos Int 2001; 12(4):271-278.

3. Ioannidis G, et al. CMAJ 2009; 181(5):265-271.

4. Papaioannou A, et al. J SOGC 2000; 22(8):591-597.

5. Tosteson AN, et al. Osteoporos Int 2007; 18(11):1463-1472.

6. Papaioannou A, et al. J SOGC 2000; 22(8):591-597.

7. Colon-Emeric C, et al. Osteoporos Int 2003; 14:879-893.

8. Lindsay R, et al. JAMA 2001; 285:320-323.

9. Sawka AM, et al. Osteoporos Int 2005; 16:1836-1840.

10. Cranney A, et al. J Rheumatol 2005; 32(12):2393-2399.

11. Pasco JA, et al. Osteoporos Int 2005; 16(12):2046-2052.

12. Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-715.

impact on function and quality of life
Impact on Function and Quality of Life
  • Loss of confidence and fear of falling have been reported with all types of fractures
  • < 40% of those who experience a hip fracture return to their prior walking abilities1,2
  • Clinical fractures negatively affect self-care and mobility, and are associated with chronic pain3

1. Cranney A, et al. J Rheumatol 2005; 32(12):2393-2399.

2. Pasco JA, et al. Osteoporos Int 2005; 16(12):2046-2052.

3. Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-715.

undertreatment of osteoporosis post fracture in women 1
Undertreatment of Osteoporosis Post Fracture in Women1

This care gap is even wider in men and those who reside in long-term care2,3

A fracture is to osteoporosis what a heart attack is to cardiovascular disease. BUT... The treatment gap is far wider post fracture than post MI.1,4

1. Bessette L, et al. Osteoporos Int 2008; 19:79-86.

2. Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587.

3. Giangregorio L, Osteoporos Int 2009; 20(9):1471-8.

4. Austin PC, et al. CMAJ 2008; 179(9):901-908.

looking beyond bmd
Looking Beyond BMD
  • Currently, low BMD is the primary trigger for initiation of therapy1-5. . . HOWEVER,
  • Most fragility fractures occur in those with a BMD in the non-osteoporotic range (T-score higher than -2.5)6

There is a missed opportunity to prevent future fractures due to over-reliance on BMD.6,7

1. Bessette L, et al. Osteoporos Int 2008; 19:79-86.

2. Papaioannou A, et al. BMC Musculoskelet Disord 2004; 5:11.

3. Elliot-Gibson V, et al. Osteoporos Int 2004; 15:767-778.

4. Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587.

5. Cranney A, et al. Osteoporos Int 2009; 20(9):1621-1625.

6. Cranney A, et al. CMAJ 2007; 177(6):575-580.

7. Langsetmo L, et al. J Bone Miner Res 2009; 24(9):1515-1522.

back up material

Back-up Material

Additional slides that can be accessedby hyperlinks on core slides

Section Two – Fragility Fractures and Care Gaps

fracture is a predictor of future fractures
Fracture is a Predictor of Future Fractures
  • The risk of experiencing another fracture in the year following a hip fracture*: 5% – 10%1,2
  • The risk of experiencing another vertebral fracture in the year following a vertebral fracture†: 20%3
  • Prevalent vertebral fractures also predict hip fracture*4,5
  • 40% of Canadians who experience a fracture have a history of prior fracture6

1. Papaioannou A, et al. JOGC 2000; 22(8):591-597.

2. Colon-Emeric C, et al. Osteoporos Int 2003; 14:879-893.

3. Lindsay R, et al. JAMA 2001; 285:320-323.

4. Ismail AA, et al. Osteoporos Int 2001; 12(2):85-90.

5. Melton LJ 3rd, et al. Osteoporos Int 1999; 10(3):214-21.

6. Hajcsar EE, et al. CMAJ 2000, 163:819-822.

* in men and women

† in postmenopausal women

Return to main presentation

one year mortality risk after hip fracture
One-year Mortality Risk after Hip Fracture

1

2

1. Ioannidis G, et al. CMAJ 2009; 181(5):265-271.

2. Papaioannou A, et al. J SOGC 2000; 22(8):591-597.

increased mortality risk after vertebral fracture
Increased Mortality Risk after Vertebral Fracture

1

2

Return to main presentation

Ioannidis G, et al. CMAJ 2009; 181(5):265-271.

hui3 deficits associated with fractures in women by fracture type

Multi (HUI2)

Mobility(HUI2)

Pain(HUI2)

Self-care (HUI2)

Multi(HUI3)

Ambulation(HUI3)

Pain(HUI3)

0

-0.05

-0.1

-0.15

-0.2

-0.25

Hip

Spine

Rib

Other

HUI3 Deficits Associated with Fracturesin Women, by Fracture Type

Return to main presentation

Papaioannou A, et al. Osteoporos Int 2009; 20(5):703-14.

increasing costs associated with hip fracture cdn
Increasing Costs Associatedwith Hip Fracture ($CDN)

Return to main presentation

Wiktorowicz ME, et al. Osteoporos Int 2001; 12(4):271-278.

therapeutic care gap most men do not receive treatment for osteoporosis after fracture
Therapeutic Care Gap: Most Men Do Not Receive Treatment for Osteoporosis after Fracture

Return to main presentation

Papaioannou A, et al. Osteoporos Int 2008; 19(4):581-587.

post fracture care gap comparison with heart attack
Post-fracture Care Gap:Comparison with Heart Attack

1. Bessette L, et al. Osteoporos Int 2008; 19:79-86.

2. Austin PC, et al. CMAJ 2008; 179(9):901-908.

Return to main presentation

most fragility fractures in postmenopausal women occur with low bone mass osteopenia
Most Fragility Fractures in Postmenopausal Women Occur with Low Bone Mass ("Osteopenia")

60

500

Fracture rate

No. of fractures

50

400

40

300

There is a missed opportunity to prevent fractures due to over-reliance on BMD.

Fracture rate, per 1000 person-years

30

No. of fractures

200

20

100

10

0

0

Normal

Osteo-penia

Osteo-porosis

> 0.0

0.0to -0.5

-0.5to -1.0

-1.0to -1.5

-1.5to -2.0

-2.0to -2.5

-2.5to -3.0

-3.0to -3.5

≤ -3.5

T-score

WHO category

Return to main presentation

Cranney A, et al. CMAJ 2007; 177(6):575-580.