Why Orthopaedic Surgeons Should All ‘Own the Bone’ This May

May is designated as National Osteoporosis Awareness Month, an effort to call public attention to a condition that goes unnoticed by patients and is all too frequently undetected by their physicians until it results in fractures. This condition is particularly concerning for the aging population, in whom these fractures lead to reduced mobility, diminished quality of life, and increased mortality. Osteoporosis Awareness Month, like many other national health observances, aims to both promote awareness and inspire action to counter an existing public health challenge. It is an opportunity to improve healthcare delivery.

A 2004 U.S. Surgeon General’s report highlighted the magnitude of the problem and an approximate 80 percent post-fracture osteoporosis treatment gap in regard to bone mineral density (BMD) testing, vitamin D and calcium supplementation, and drug therapy. Currently, 54 million older American adults have either decreased bone mass or osteoporosis, a condition associated with increased fracture risk and adverse orthopaedic surgical outcomes.

Fifteen years ago, in response to this challenge, the American Orthopaedic Association (AOA) launched the Own the Bone quality-improvement program to address osteoporosis undertreatment in patients who sustained a fracture. The initiative recognized the crucial role and responsibility of orthopaedic surgeons in advising their patients that fractures are a sentinel event. The AOA’s mission with Own the Bone was simple: provide a comprehensive, easy-to-understand quality-improvement program to equip orthopaedic surgeons to implement a systems-based approach to identifying, counseling, and treating patients for their bone health after an osteoporotic fracture. The program toolkit includes educational materials, best-practice resources, a patient registry, and annual recognition.

About the program
Since its launch in 2009, Own the Bone has provided a starting place for more than 300 hospitals and practice groups across the United States to establish programs to prevent secondary fractures or fracture liaison services (Fig. 1). These institutions have documented more than 110,000 bone-health patient visits in the registry. The program has helped shape and broaden the conversation on bone health within the specialty, and a growing number of orthopaedic surgeons are increasing their awareness of this imperative and advocating for action within their institutions.

In addition to building a case for why recognition of osteoporosis is important, the program has delivered hundreds of hours of education aimed at providing orthopaedic surgeons and their teams with the tools necessary to begin a program focused on preventing fragility fractures. Each year, the Own the Bone program delivers some 30 hours of expert content, including monthly online Extension for Community Healthcare Outcome (ECHO) sessions, a quarterly webinar series, and its annual Own the Bone Symposium.

In addition, the program includes a library of hundreds of hours of on-demand education focused specifically on the orthopaedic setting. For surgeon champions seeking to establish and staff a bone-health service for the first time, these educational activities provide support for onboarding new bone-health advanced practice providers (APPs).

Earlier this year, Own the Bone launched the Own the Bone APP/Coordinator Bootcamp, a new user group for those providing post-fracture patient education and care coordination in both inpatient and outpatient settings. These APP/Coordinator Bootcamp sessions provide an important resource to support those new to providing bone-health consultations, either from within an orthopaedic office or as part of a multidisciplinary service.

The program has also responded to the challenge of changing how orthopaedic surgeons are trained to think about bone health, exploring ways to augment residency education so that the next generation of orthopaedic surgeons is imbued with knowledge of metabolic bone disease and its impact on their practice and patient outcomes. In 2023, AOA’s C. McCollister Evarts Resident Leadership Forum included a session on bone health, during which nearly 200 orthopaedic surgery residents were challenged to consider this issue. In the future, the problems of bone-health diagnosis and treatment will continue to be presented to residents and their program directors as an opportunity to engage leadership skills and fulfill residency quality-improvement and research requirements.

Implications for orthopaedics
Osteoporotic fractures represent a significant and growing public-health burden, which will undoubtedly impact the practice of future generations of orthopaedic surgeons. Compared with levels in 2018, a 68 percent increase in osteoporotic fractures is expected by 2040, with related costs to the Centers for Medicare & Medicaid Services of more than $95 billion.

Value-based healthcare supports bone-health treatment for prevention of secondary fractures, with the number needed to treat to prevent one new fracture over 3 years estimated at just 20 patients, far below other widely treated conditions. AAOS, AOA, and the Orthopaedic Trauma Association have aligned with other medical stakeholder societies to bring the economic rationale and patient-care imperative to the attention of the Centers for Medicare & Medicaid Services and, most recently, the White House Initiative on Women’s Health Research.

The implications for orthopaedic surgeons, however, extend beyond osteoporotic fractures and prevention of secondary fractures. Each year in the United States, in addition to approximately 2 million osteoporotic fracture patients, approximately 1 million patients undergo elective hip and knee replacement surgeries. It is estimated that 50 percent of these patients have low bone mass.

Unaddressed poor bone quality can result in periprosthetic fractures and implant failures. The links between poor bone health and negative outcomes after orthopaedic surgery provide a particularly clear rationale for preoperative bone-health optimization for patients undergoing arthroplasty or spinal fusion.

Own the Bone challenges the orthopaedic specialty to act in the face of growing evidence that osteoporosis negatively affects outcomes after elective surgery and that preoperative optimization is both feasible and effective. Fracture liaison services for prevention of secondary fractures can also be used to provide preoperative diagnosis and treatment.

In 2018, the Own the Bone program formally adopted this important second objective for bone-health management of orthopaedic patients. Since participating centers began to document bone-health optimization in 2022, these patients have become the third largest demographic in the Own the Bone registry, after hip and spine fracture patients.

Setting up an Own the Bone program is not just about meeting standards; it is about elevating orthopaedic practice to improve patient outcomes. Orthopaedic surgeons play a critical role in their patients’ bone health. In diagnosing and ensuring the medical management of patients with underlying bone fragility, many have embraced the task of improved patient outcomes using the framework provided through the Own the Bone program. This May, remember that it is the orthopaedic surgery specialty’s responsibility to “own the bone”—not just during Osteoporosis Awareness Month but all year long. Doing so is more than just a professional commitment; it is a commitment to making a real difference in patients’ lives.

Kevin L. Kirk, DO, FAAOS, FAOA, is a partner with TSAOG Orthopaedics & Spine and president of the Medical Executive Board for Baptist Health System in San Antonio. An advocate for bone health and prevention of secondary fractures, Dr. Kirk is chair of the American Orthopaedic Association’s Own the Bone Steering Committee and has established fragility fracture programs through Own the Bone at both TSAOG and Baptist Health System.

References

1. Lewiecki EM, Ortendahl JD, Vanderpuye-Orgle J, et al: Healthcare policy changes in osteoporosis can improve outcomes and reduce costs in the United States. JBMR Plus 2019;3(9):e10192.
2. Nakayama A, Major G, Holliday E, et al: Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate. Osteoporos Int 2016;27(3):873-9.
3. Baaj AA, Lang G, Hsu WC, et al: 90-day readmission after lumbar spinal fusion surgery in New York State between 2005 and 2014: a 10-year analysis of a statewide cohort. Spine (Phila Pa 1976);42(22):1706-16.