Fracture Prevention in At-Risk Populations

In this podcast, Sameer Naranje, MD, from the University of Alabama at Birmingham, discusses which groups are most at risk for osteoporosis, best practices for mitigating fracture risk in these populations, and management strategies for patients who experience fractures.

Additional Resources:

• Preventing Fractures. National Osteoporosis Foundation. https://www.nof.org/preventing-fractures/. Accessed August 17, 2020.

Sameer Naranje, MD, is an assistant professor in the Department of Orthopaedic Surgery and the director of the fracture fragility care program at the University of Alabama at Birmingham.

TRANSCRIPT:

Consultant360:  Hi, everyone. I'm Michael Potts, Managing Digital Editor at Consultant360 Specialty Network. I'm here with Dr. Sameer Naranje, who is the Director of the Fracture Fragility Care Program at the University of Alabama at Birmingham.

Thank you for being here with us today, Dr Naranje.

Sameer Naranje, MD:  It's my pleasure, Mike. It’s good to be here.

C360:  What groups of people are considered at high risk for fracture, and why are they considered high-risk?

SN:  So, when it comes to fractures in this high-risk group of patients, it seems that every one of these patients has at least one or two of the many risk factors that are associated with osteoporosis. Age is definitely a major factor. The US Preventive Services Task Force recommends that women undergo screening at 65 years and above. In addition to age, there are various different risk factors, especially family medical history, race, tobacco smoking, alcohol consumption of more than three drinks per day.

If you have a small physique, you don't exercise often, or you have a thyroid disease, certain problems with premature onset of menopause, and anti‑estrogen treatment for breast or other cancers are some of the major risk factors.

There are numerous others minor risk factors that can contribute to osteoporosis and fractures in these patients.

C360:  What are the best practices for fracture prevention among these groups?

SN:  When it comes to prevention of fractures in this high-risk group, usually we need to follow certain rules, or you can say, to get adequate calcium, exercise, make sure that you don't fall or take good fall prevention precautions.

If there are some risk factors, like smoking, alcohol, or other modifiable risk factors, then one need to work on those to remove them from their habits to prevent fractures.

Usually, you get around 700 milligrams of calcium from our regular diet. I recommend that we need to supplement our diet with calcium, to around 1200 milligram per day. That's the recommended dose for a healthy person to keep their bone health well.

Other things we talk about are exercise, walking, weight training, working on your balance posture, keeping yourself flexible, are some of the things one can do to improve bone health and prevent these fractures.

Similarly, we talk about bad habits, or removing alcohol, smoking. These definitely have bad effects on your bones. If you avoid these habits, it can prevent these fractures.

C360:  Could you talk a little about how osteoporosis is usually diagnosed?

SN:  The most common way to diagnose osteoporosis is to do a DEXA study. It's a bone mineral density study.

The T‑score on your bone density report shows how much your bone mass differs from the bone mass of an average healthy 30‑year‑old adult.

The scores, usually, if they fall below ‑2.5, that's consistent with osteoporosis. If it's between ‑1.0 to ‑2.5, then it's considered as osteopenia. This is the basic test that helps diagnose osteoporosis in these patients.

C360:  How do you personally manage patients in these high-risk groups?

SN:  Me, as a surgeon, I specialize in adult reconstruction area of orthopedics, which deals with hip and knee replacements.

When I get patients mostly related to these fractures, high-risk group fractures, they are usually hip fracture patients. I treat them surgically most of the time, either fixing their fracture with plates or screws or putting a rod, which is an intramedullary nail, that goes to feed this fracture, or replacing their hip in partial or total hip replacements, is what these patients get.

Definitely, this is a surgical aspect I deal with. I pay a lot of attention to their bone health. I'm currently the director of the Fragility Fracture Care program at UAB.

Basically, our program deals with comprehensive management of this fragility fracture patients. Once they get surgery, or during their admission to a surgery, we evaluate them for any vitamin D deficiency, and then treat them appropriately with the help of calcium and vitamin D supplementation postoperatively.

Also, we arrange for follow‑ups with our rheumatology and osteoporosis specialists in these areas, or they can go to their primary care physician as follow‑up to make sure that their osteoporosis treatment is complete. This not only helps prevent further fractures, but also helps to heal their current injuries.

C360:  Do you have any tips that you could share with your peers regarding these best practices?

SN:  It is very common among my peers. I would say that, though they provide great care for the patients, often the bone part is neglected, or maybe you can say, not taking care of that well, as it regards to osteoporosis management.

As orthopedic surgeon, we all need to be careful managing these patients, not only to treat their injuries or fractures with surgeries that we do, but also to give appropriate attention to their bone health.

I understand not all centers may have appropriate infrastructure, or you can say programs like we have, which exclusively deal with osteoporosis management in orthopedic injury patients, so fracture patients. Whenever possible, a referral can be made to such specialty services, which are around town.

What I recommend to my peers is that not only when we treat, surgically, these fractures, we also need to medically treat their osteoporosis.

C360:  Vitamin D supplementation has been a cause for controversy. Where does that fall in the best practices?

SN:  I certainly feel that vitamin D is necessary in these patients, because, as we talked, a lot of these patients are already deficient on their vitamin D. If we implement a universal vitamin D supplementation in our diet, we don't need to routinely test these patients for vitamin D levels.

We can focus the testing mainly on the high-risk group and give them appropriate dosages if they're deficit. Definitely, I recommend around 1000 to 2000 international units of vitamin D and calcium appropriately to supplement these patients, so as to improve their bone health.

C360:  Thank you so much again for joining us today. SN.

SN:  It was my pleasure to be here, Mike.