Abstract
Over 70,000 hip fractures occur annually in the UK, most being osteoporosis associated fragility fractures that require surgical fixation. Established orthogeriatric intervention and standardised pre- and postoperative care improve outcomes. With 25% of patients sustaining another fracture within five years, post-operative bisphosphonate use is increasingly relevant. Periprosthetic hip fractures (PPFs), a growing form of fragility fracture, often lack orthogeriatric input and bone protection advice is not standardised, an issue seen at St Richard’s Hospital, Chichester.
Aim- This study aims to highlight discrepancies of bone health management between shared care (native fractures) and an orthopaedic-led approach (PPFs).
Methods
A cross-sectional bone health assessment review of 20 native and 20 PPFs was conducted in patients aged ≥60 at St Richards between 2024-2025. Native fractures received orthogeriatric care; PPFs were managed solely by orthopaedics. The standard for bone health assessment was set at 100% as per ROS Guidelines. Bone health assessment was defined as admission bone profile and review of fracture mechanism, alongside comorbidities. The proportion of patients who were assessed, identified as eligible, and initiated on bone protection therapy was calculated.
Results
Bone health assessments were conducted in 45% of PPFs versus 100% of native fractures. Of those assessed, 100% of PPFs and 84.2% of native fractures were eligible for treatment. 11.1% of eligible PPF patients commenced secondary prevention, compared to 100% of native patients. Pre-existing bisphosphonate use was noted in 10% of PPFs and 5% of native fracture patients, all of whom continued therapy post-discharge.
Discussion
Unlike NOF care, limited guidelines exploring bone protection in PPFs are available. Despite being an increasingly prevalent fragility fracture, fewer PPF patients (as well as non-NOF fragility fractures) have bone health assessments and are often undertreated with secondary prevention. Generally, non-NOF fragility fractures and PPFs are managed primarily by orthopaedic teams and there is currently no national standard for osteoporosis care in PPFs. NOF management heavily encourages early orthogeriatric intervention with the intention of optimising pre-operative state, as well as ensure secondary prevention is considered to avoid future fractures. Early orthogeriatric intervention in PPF care could ensure similar, appropriate decisions are made with regards to bone health. NOF management is also heavily audited by National Hip Fracture Database and relies on best practice tariffs and clear guidelines to ensure best outcomes for patients. By generating similar best practice tariffs for non-NOFs and PPFs, it is likely that bone health assessment and bisphosphonate utilisation would improve. Both locally and nationally, secondary prevention lacks consensus with regards to PPFs. Development of local and national guidelines and education, alongside incentivisation would increase assessment, instigation of bisphosphonate therapy and therefore overall bone health, as well as reducing patient mortality and re-fracture.
Conclusions
Bone health assessment and secondary prevention were significantly lower in PPFs. However, native fractures met ROS standards. Results suggest that a shared care approach with orthogeriatric care and a standardised protocol may improve patient outcomes and ensure a comprehensive bone health assessment for both native and PPFs.