Best Practice & Research Clinical Rheumatology 27 (2013) 709–710
Contents lists available at ScienceDirect
Best Practice & Research Clinical Rheumatology journal homepage: www.elsevierhealth.com/berh
Preface The only clinical manifestation of osteoporosis is fracture. To misquote Bill Clinton: it’s the fracture, stupid. In line with this, recent thinking has become organised more specifically around (a) the prevention and (b) the management of fragility fracture. Of course, the issue of prevention involves just as much as it ever did the biology of osteoporosis, its diagnosis, treatment and monitoring. But these aspects now stands on an equal footing with (a) falls prevention, since virtually all non-vertebral fractures follow a fall and (b) fracture healing since, whatever we do, there will be fractures and to minimise their impact on quality of life is to tackle the impact of osteoporosis. Furthermore, it has become clear that the most fruitful target for prevention of future fractures is the current fracture patient, because of their increased risk plus the fact that they are already captured in the health-care system. With the exception of certain groups, such as those receiving glucocorticoids, secondary prevention is more cost-effective than primary prevention. Similarly, as the patient recovering from a fragility fracture is likely to be at an even greater risk of falls, the potential value of integrating rehabilitation after fracture treatment with ongoing falls prevention measures is obvious. In all, prevention of the next fracture begins immediately after the first fracture has occurred, as the end result depends on optimising every step of the care pathway. These connections mean that the biggest gains are to be made among incident fragility fracture patients and that, to secure them, the deployment of a multidisciplinary team is essential. The main members of the team need to be the following: Orthopaedics – because that is where most patients present good surgery first time improves recovery of function and is cost-effective Geriatrics – because frailty usually coexists with fragility and needs to be tackled in rehabilitation co-morbidities present the greatest threat to life perioperatively Osteoporosis specialists – because of the proven reduction in fracture risk to be gained by treating osteoporosis the emerging possibility that anabolic drugs may enhance fracture healing Nurses – because they provide the best continuity and ortho-geriatric liaison in the acute episode they provide the best linkage between the fracture service, the falls and osteoporosis services and primary care for secondary prevention Allied Health Professionals – because the quality of rehabilitation and the discharge process are a huge determinant of the ultimate impact of the fracture on quality of life Furthermore, although not part of the acute team, the general practitioner or primary care doctor has a pivotal role to play. Osteoporosis and fragility fractures constitute a long-term condition, analogous to cardiovascular and chronic renal disease. The fractures can be regarded as acute exacerbations http://dx.doi.org/10.1016/j.berh.2014.03.001 1521-6942/Ó 2014 Published by Elsevier Ltd.
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Preface / Best Practice & Research Clinical Rheumatology 27 (2013) 709–710
and the end point of each fracture episode must be the return to surveillance and long-term preventive measures in primary care. Much international work is now under way based on the philosophy underlying this issue of Best Practice and Research Clinical Rheumatology (BPRCR). The International Osteoporosis Foundation with the Capture the Fracture campaign and, in the USA, the National Bone Health Alliance are leading the charge on the issue of reliable clinical systems for the provision of secondary prevention. To further drive change, this also includes a framework to evaluate best practice against standards. The Fragility Fracture Network of the Bone and Joint Decade is drawing many disciplines together to promote the necessary multidisciplinary management of the acute fracture episode. Hopefully, these efforts will have a substantial impact on our global ability to withstand the developing epidemic of fragility fractures. David Marsh*, Anthony Woolf, Kristina Åkesson
Corresponding author. E-mail address: [email protected] (D. Marsh)
Contents lists available at ScienceDirect
Best Practice & Research Clinical Rheumatology journal homepage: www.elsevierhealth.com/berh
Preface The only clinical manifestation of osteoporosis is fracture. To misquote Bill Clinton: it’s the fracture, stupid. In line with this, recent thinking has become organised more specifically around (a) the prevention and (b) the management of fragility fracture. Of course, the issue of prevention involves just as much as it ever did the biology of osteoporosis, its diagnosis, treatment and monitoring. But these aspects now stands on an equal footing with (a) falls prevention, since virtually all non-vertebral fractures follow a fall and (b) fracture healing since, whatever we do, there will be fractures and to minimise their impact on quality of life is to tackle the impact of osteoporosis. Furthermore, it has become clear that the most fruitful target for prevention of future fractures is the current fracture patient, because of their increased risk plus the fact that they are already captured in the health-care system. With the exception of certain groups, such as those receiving glucocorticoids, secondary prevention is more cost-effective than primary prevention. Similarly, as the patient recovering from a fragility fracture is likely to be at an even greater risk of falls, the potential value of integrating rehabilitation after fracture treatment with ongoing falls prevention measures is obvious. In all, prevention of the next fracture begins immediately after the first fracture has occurred, as the end result depends on optimising every step of the care pathway. These connections mean that the biggest gains are to be made among incident fragility fracture patients and that, to secure them, the deployment of a multidisciplinary team is essential. The main members of the team need to be the following: Orthopaedics – because that is where most patients present good surgery first time improves recovery of function and is cost-effective Geriatrics – because frailty usually coexists with fragility and needs to be tackled in rehabilitation co-morbidities present the greatest threat to life perioperatively Osteoporosis specialists – because of the proven reduction in fracture risk to be gained by treating osteoporosis the emerging possibility that anabolic drugs may enhance fracture healing Nurses – because they provide the best continuity and ortho-geriatric liaison in the acute episode they provide the best linkage between the fracture service, the falls and osteoporosis services and primary care for secondary prevention Allied Health Professionals – because the quality of rehabilitation and the discharge process are a huge determinant of the ultimate impact of the fracture on quality of life Furthermore, although not part of the acute team, the general practitioner or primary care doctor has a pivotal role to play. Osteoporosis and fragility fractures constitute a long-term condition, analogous to cardiovascular and chronic renal disease. The fractures can be regarded as acute exacerbations http://dx.doi.org/10.1016/j.berh.2014.03.001 1521-6942/Ó 2014 Published by Elsevier Ltd.
710
Preface / Best Practice & Research Clinical Rheumatology 27 (2013) 709–710
and the end point of each fracture episode must be the return to surveillance and long-term preventive measures in primary care. Much international work is now under way based on the philosophy underlying this issue of Best Practice and Research Clinical Rheumatology (BPRCR). The International Osteoporosis Foundation with the Capture the Fracture campaign and, in the USA, the National Bone Health Alliance are leading the charge on the issue of reliable clinical systems for the provision of secondary prevention. To further drive change, this also includes a framework to evaluate best practice against standards. The Fragility Fracture Network of the Bone and Joint Decade is drawing many disciplines together to promote the necessary multidisciplinary management of the acute fracture episode. Hopefully, these efforts will have a substantial impact on our global ability to withstand the developing epidemic of fragility fractures. David Marsh*, Anthony Woolf, Kristina Åkesson
Corresponding author. E-mail address: [email protected] (D. Marsh)
