Post-fracture Care: Not Just a Band-Aid

Fragility fractures are sentinel events in a patient's health trajectory, often signaling an inflection point that demands a paradigm shift in care. Yet, despite well-established evidence of the risks associated with osteoporotic fractures, post-fracture management often fails to address the long-term consequences.

The stats are sobering: One in four patients will experience another fracture within a year, and over 50% will re-fracture within five years. Mortality risk also doubles in the first 12 months post-fracture and remains elevated for years. As specialists, we know these fractures are not isolated injuries but warnings.

This month, I am reviewing the article “The Impact of Fracture Liaison Services on Subsequent Fractures and Mortality: A Systematic Literature Review and Meta-analysis.” This 2021 meta-analysis provides compelling evidence of FLS's impact on fracture recurrence, mortality, and treatment adherence. But as always, the devil is in the details.

Let’s examine the data more closely and explore how these findings should guide us as osteoporosis specialists.

Breaking the Cycle: What the Meta-Analysis Reveals

This meta-analysis synthesized data from 16 studies, representing over 50,000 patients in diverse healthcare settings. The results are a resounding call to action, but they also highlight key areas where FLS programs succeed—and where they fall short.

1. Subsequent Fractures: A 30% Risk Reduction

The headline finding is clear: FLS programs reduce the odds of subsequent fractures by 30% (OR: 0.70, 95% CI: 0.52–0.93).

• The reduction was particularly striking in studies with follow-up periods longer than two years, where fracture risk dropped by 43% (OR: 0.57, 95% CI: 0.34–0.94).

• However, shorter follow-ups (≤2 years) failed to demonstrate significant reductions, likely due to the time required for bone-strengthening therapies and adherence to fully take effect.

This underscores the critical role of long-term engagement. Fracture prevention is a marathon, not a sprint; our care plans must reflect this reality.

2. Mortality: Significant but Nuanced Benefits

The relationship between FLS care and mortality is less straightforward but equally important:

• Studies comparing pre- and post-FLS implementation reported a 35% reduction in mortality (OR: 0.65, 95% CI: 0.44–0.95).

• Conversely, studies comparing hospitals with and without FLS showed no significant difference in mortality (OR: 1.03, 95% CI: 0.92–1.15).

Why the discrepancy? Pre-post studies better capture the benefits of integrated, longitudinal care, while baseline differences in patient populations, care delivery models, and comorbidities often confound hospital-level comparisons.

The takeaway here is continuity. FLS must extend beyond episodic interventions to affect mortality outcomes and focus on sustained, proactive management of fracture risk and overall health.

3. BMD Testing and Anti-osteoporosis Treatment: Closing the Gap

The data also highlight a critical strength of FLS programs: their ability to drive action.

• BMD testing rates increased significantly in 8 of 9 studies, reflecting the effectiveness of systematic identification and risk assessment.

• Initiation of anti-osteoporosis treatment improved in 9 of 11 studies, demonstrating FLS’s ability to address the pervasive treatment gap.

Despite the availability of effective pharmacologic options, the treatment gap remains alarmingly wide. Across Europe, 25-95% of fracture patients remain untreated, and in Australia, fewer than 20% of postmenopausal women with fractures receive osteoporosis therapy in primary care. FLS provides a proven framework for addressing these missed opportunities.

Implementation Challenges: Where Do We Go From Here?

While the evidence is strong, implementing and sustaining FLS programs is not without hurdles.

1. Patient Engagement

Attendance rates in FLS programs varied dramatically, from as low as 20% to as high as 86%. Poor attendance is often attributed to logistical challenges, mobility limitations, and lack of awareness among patients and referring providers.
Action point: Streamline referral processes, integrate FLS into hospital discharge workflows, and consider telemedicine options to remove barriers.

2. Follow-Up Durations

Short follow-up durations (≤2 years) limit our ability to capture the full impact of FLS on both fractures and mortality.
Action point: Advocate for extending follow-up periods to at least 2-3 years, incorporating regular check-ins to reinforce adherence and reassess risk.

3. Competing Risks

Competing risks like mortality can skew fracture risk assessments in the geriatric population. Studies that failed to account for these risks likely overestimated fracture incidence.
Action point: Use advanced analytical methods like Fine and Gray competing risk regression to accurately quantify cumulative fracture risk in the context of competing mortality

Practical Strategies for Specialists

Here’s how we can integrate these findings into practice:

1. Prioritize High-Risk Patients

Focus FLS resources on patients at the highest risk for recurrence and mortality—particularly those with major osteoporotic fractures (e.g., hip, vertebrae).

2. Standardize Metrics and Benchmarks

Set clear targets for success:

• Aim for BMD testing rates >90% in eligible patients.

• Establish benchmarks for treatment initiation rates, ensuring at least 50-70% of patients begin therapy within 6 months of fracture.

3. Emphasize Multidisciplinary Coordination

An effective FLS requires seamless communication between orthopedists, primary care providers, endocrinologists, and rehabilitation specialists. Don’t let patients fall into the gaps between specialties.

4. Build for Sustainability

Advocate for healthcare system-level support, including funding for FLS coordinators and integration into electronic medical records (EMR). This ensures the program isn’t dependent on individual champions.

Looking Ahead

The evidence is clear: FLS is not just a Band-Aid—it’s a lifeline for patients at risk of recurring fractures and mortality. But its success depends on us: how we design, implement, and sustain these programs in the real world.

Let’s commit to going beyond episodic care. Investing in long-term, multidisciplinary post-fracture management can break the cycle of fragility fractures and save lives.