In general, fragility fractures can reveal osteoporosis that have significant consequences on the lives of those concerned, particularly in terms of loss of autonomy. After a break in the femoral neck, less than half of the patients over 60 years old regain their previous level of activity. The economic burden of osteoporosis is also considerable: the annual cost of these fractures is an estimated 5.4 billion euros.
To combat this condition effectively, the first step is to recognize it for what it really is: a disease that can be detected and treated, not an inevitable physiological evolution related to aging.
Osteoporosis, a long-standing asymptomatic disease
According to the World Health Organization, osteoporosis is a "widespread skeletal disease, characterized by a decrease in bone density and alterations in the trabecular microarchitecture of the bone, leading to exaggerated bone fragility and therefore at risk high for fractures". It occurs when the activity of certain bone cells is changed.
During the bones are renewed and repaired continuously during a person’s lifetime. This remodeling, which maintains bone strength, mainly involves two types of cells, osteoclasts and osteoblasts. Osteoclasts create gaps in the old bone, and these holes are filled by other cells, the osteoblasts. This balanced process is influenced by many factors, including hormonal factors.
If bone renewal and repair is less effective with age, resulting in a loss of bone density, in osteoporosis, it becomes pathological. Bone remodeling accelerates, and osteoclasts destroy too much bone tissue without replacement. The bone becomes less resistant, which increases the risk of fracture.
The cellular mechanisms of bone remodeling.
Although this pathological mechanism is known, there is a general denial of the reality of this disease, by patients, but also by some health professionals. This disease evolves without symptoms until the occurrence of the complication, the first fracture called "fragility".
Following a minor trauma, such as a fall, the resulting fracture from the accident reveals the disease. Frequently, it can happen spontaneous in the vertebrae. Most often, these vertebral compression fractures are not painful. However, they lead to a significant decrease in size (up to 3 or 4 cm), and can also cause the back to hunch, when several occur successively.
A disease that is revealed with age
In 2017, there were 380,000 fragility fractures reported in France, of which 20% were in the hip and 15% in the spine.
These fragility fractures are correlated with age. Practitioners should be aware of the risks from the age of 50 or 55. Due to an increase in life expectancy, it is estimated that the number of fractures will reach 470,000 in 2030. The current cost of 5.4 billion euros would then go to 6.8 billion euros.
The French High Authority of Health and other learned societies have made recommendations for diagnosing osteoporosis. Nevertheless, screening by measurement of bone mineral density (the bone is exposed to a very small amount of x-rays, the denser it is, the more x-rays it absorbs), an evaluation of the risk factors for new fractures as well as the specific anti-osteoporosis treatment is only performed in less than 20% of cases.
This state of affairs is not specific to France, and despite the considerable efforts made in recent years by many international organizations to raise awareness of the problem and improve the management of patients with fragility fractures, the hoped-for improvements remain quite insufficient.
Early screening for more effective treatment
The first fragility fracture is the most predictive factor for the occurrence of other fractures. After a first fracture, a patient increases the risk of having another fracture a short time, from six months to one year. The risk is highest during the first 2 years after the initial fracture, when the patient is five times more likely to have another fracture. The risk increases exponentially after each fracture.
This "imminent" risk of fracture following a first accident requires early detection of osteoporosis, in order to treat it quickly. Detecting bone fragility as soon as possible is all the more important as treatments only take effect after a few months.
Different specific treatments are available depending on the individual assessment of the patient. The most commonly used drugs (bisphosphonates) are aimed at curbing the activity of osteoclasts in order to limit bone loss. Concomitant calcium and vitamin D supplementation is often necessary, but remember that it is not a preventive treatment for the risk of fracture.
On the other hand, if certain risk factors cannot be modified (age, female, family history), the observation of rules of hygiene of life can have beneficial effects. Physical exercise has a positive effect on bone mineral density, while alcohol and tobacco promote bone loss.
Set up "fracture pathways" for better management
A "call to action" was launched in 2016, during the 5th Fragility Fracture Network congress supported by the international and national organizations of all stakeholders (including geriatricians, orthopedic surgeons, medical internists, rheumatologists, and rehabilitation therapists). It aims to promote multidisciplinary management of patients who suffer from fragility fractures and to ensure effective prevention at the first fracture.
The solution involves the establishment of fracture networks, based on the model initiated in the United Kingdom, which has proven its effectiveness in other countries both on the quality of life for patients and on the economic level.
These models determine patient treatment between different departments (most often emergency services, orthopedic surgery, rheumatology, rehabilitation, geriatrics) of the care facility that treated the patient for the first fracture, which revealed or suggested bone fragility. The associated organization ensures effective communication with the attending physician and health professionals monitoring the patient.
Systematic implementation of osteoporosis screening and treatment recommendations would bridge the gap between a fragility fracture and preventative treatment of other fractures, avoiding approximately 700,000 fractures by 2025.
Recently announced by the government, the "My Health 2022" plan, a strategy for transforming the health system, has listed as a first recommendation of its 54 measures:
"The development of guidelines/references, which are relevant, co-constructed and validated by health professionals: for heart failure and osteoporosis by the end of the year and which will encompass, within 12 months, the approach to the main chronic pathologies"
This step, which should be specified at the beginning of 2019, is of the utmost importance to combat this major public health problem, which leads to an excess of mortality, has a serious impact on the quality of life for the patients and causes a very serious heavy economic burden on society.
Pour en savoir plus :
For more information:
- The site of the GRIO (Research and Information Group on Osteoporosis); (in French)
- The AFLAR website (AFLAR French Association for the fight against rheumatism); (in French)
- The website of the International Osteoporosis Foundation | Bone Health. (in English)
Jean-Marc Féron, University Professor - Hospital Consultant, Sorbonne University