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COMMENTARY
Year : 2020  |  Volume : 18  |  Issue : 4  |  Page : 351-352

Fracture liaison service


Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore, Tamil Nadu, India

Date of Submission07-Jul-2020
Date of Decision02-Aug-2020
Date of Acceptance05-Sep-2020
Date of Web Publication19-Oct-2020

Correspondence Address:
Dr. Thomas Vizhalil Paul
Department of Endocrinology, Diabetes and Metabolism, Christian Medical College and Hospital, Vellore - 632 004, Tamil Nadu
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/cmi.cmi_112_20

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How to cite this article:
Rajanl R, Cherian KE, Kapoor N, Paul TV. Fracture liaison service. Curr Med Issues 2020;18:351-2

How to cite this URL:
Rajanl R, Cherian KE, Kapoor N, Paul TV. Fracture liaison service. Curr Med Issues [serial online] 2020 [cited 2020 Nov 26];18:351-2. Available from: https://www.cmijournal.org/text.asp?2020/18/4/351/298582



India, with a population of about 1.3 billion, has about 50 million people living with either osteoporosis or low bone mass.[1] The morbidity and mortality associated with osteoporosis is high. About 20%–25% of postmenopausal women die within a year following an osteoporotic hip fracture.[2] However, poor awareness about osteoporosis and its treatment among people and physicians makes osteoporosis an under-recognized disease.[3],[4] Fracture prevention in the elderly is the need of the hour. Establishing a fracture liaison service (FLS) aids in preventing a second fracture in people with osteoporosis and thus may serve as the first step toward a secondary fracture prevention program.

After the detection of the index case in FLS, appropriate screening of at-risk family members may also enhance primary prevention of fractures, in addition to reducing the risk of another fracture in the index case. We have previously found that daughters of mothers with osteoporosis have a significantly lower bone mineral density as compared to daughters of mothers without osteoporosis.[5] Optimal replacement of calcium and Vitamin D in at-risk family members will further add another dimension to FLS centers in India.

Following a standard protocol is the key to having effective outcomes from a FLS program. The involvement of a multidisciplinary team, including an orthopedic surgeon, physician, nurse specialist, nutritionist, and physiotherapist, is important for successfully fulfilling the key objectives of any FLS.

FLS was initially conceived in Glasgow and then has been adopted in other countries including the United States of America, Australia, New Zealand, Singapore, and other South East Asian countries.[6] It has also been initiated in India in some centers in Mumbai, Delhi, and Chandigarh. It has been actively promoted by the International Osteoporosis Foundation since 2012 and thereafter by other national osteoporosis societies. Although several types of FLS models have been implemented, they have a common theme in identifying patients at high risk of fragility fracture and loop them through an FLS coordinator to this secondary prevention program. The key difference in some of these models as described by Ganda et al. was in relation to the extent of investigations and treatment offered to each identified high-risk individual.[7]

Moreover, a specific inclusion criterion has been delineated by some FLS centers wherein, in addition to having had a low trauma fracture and the age of the patient being more than 50 years, their place of stay and willingness to participate and be contacted periodically was also considered.[6],[8]

Several studies have been conducted to assess the utility of FLS in clinical care settings. These studies have shown benefit in several areas including frequency of subsequent fractures, adherence to treatment, and cost savings.[6],[8],[9] These programs have been run under several names, like the “Healthy Bones Program” run by the Kaiser Southern California Health Maintenance Organization, which resulted in the reduction of hip fractures by 37.2%.[9] In another California-based program called “The project healthy bones,” it was seen that a peer-led, lifestyle intervention resulted in significant improvement in calcium intake. They conducted classes at 6-month intervals to provide education on diet and exercise to improve bone strength and decrease the risk of fragility fractures.[10]

In another recently published study, based on a FLS initiated by the American Orthopedic Association, multiple risk factors were identified for detecting clinical vertebral fractures and nonvertebral low energy fractures. This project called “Own the Bone” aimed to provide a tool kit to set up a ten-step program to prevent fragility fractures.[11]

The FLS is a unique model that may address several risk factors to prevent a secondary fracture in individuals with previous fragility fracture. Several studies have shown that this could improve the screening, diagnosis, risk assessment, treatment, and health-related quality of life. It has also been shown to reduce the morbidity and mortality of patients with past fragility fractures and has huge implications in health economics related to this disease. A successful FLS requires efficient communication between multiple specialties and a multidisciplinary approach in the management of patients. As the population of India continues to age, managing and preventing life-threatening fractures secondary to osteoporosis has become an increasingly important issue. FLS has a significant role to play in the Indian setting in identifying and preventing subsequent fragility fractures.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Mithal A, Bansal B, Kyer CS, Ebeling P. The Asia-Pacific Regional Audit-Epidemiology, Costs, and Burden of Osteoporosis in India 2013: A report of International Osteoporosis Foundation. Indian J Endocrinol Metab. 2014;18:449-54.  Back to cited text no. 1
    
2.
Neuburger J, Currie C, Wakeman R, Tsang C, Plant F, de Stavola B, et al. The impact of a national clinician-led audit initiative on care and mortality after hip fracture in England: An external evaluation using time trends in non-audit data. Med Care 2015;53:686-91.  Back to cited text no. 2
    
3.
Thakur P, Kuriakose C, Cherian KE, Asha HS, Kapoor N, Paul TV. Knowledge gap regarding osteoporosis among medical professionals in Southern India. J Eval Clin Pract 2020;26:272-80.  Back to cited text no. 3
    
4.
Senthilraja M, Cherian KE, Jebasingh FK, Kapoor N, Paul TV, Asha HS. Osteoporosis knowledge and beliefs among postmenopausal women: A cross-sectional study from a teaching hospital in Southern India. J Family Med Prim Care 2019;8:1374-8.  Back to cited text no. 4
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5.
Shetty S, Kapoor N, Dian Bondu J, Antonisamy B, Thomas N, Paul TV. Bone turnover markers and bone mineral density in healthy mother-daughter pairs from South India. Clin Endocrinol (Oxf) 2016;85:725-32.  Back to cited text no. 5
    
6.
McLellan AR, Gallacher SJ, Fraser M, McQuillian C. The fracture liaison service: Success of a program for the evaluation and management of patients with osteoporotic fracture. Osteoporos Int 2003;14:1028-34.  Back to cited text no. 6
    
7.
Ganda K, Puech M, Chen JS, Speerin R, Bleasel J, Center JR, et al. Models of care for the secondary prevention of osteoporotic fractures: A systematic review and meta-analysis. Osteoporos Int 2013;24:393-406.  Back to cited text no. 7
    
8.
Nakayama A, Major G, Holliday E, Attia J, Bogduk N. Evidence of effectiveness of a fracture liaison service to reduce the re-fracture rate. Osteoporos Int 2016;27:873-9.  Back to cited text no. 8
    
9.
McLellan AR, Wolowacz SE, Zimovetz EA, Beard SM, Lock S, McCrink L, et al. Fracture liaison services for the evaluation and management of patients with osteoporotic fracture: A cost-effectiveness evaluation based on data collected over 8 years of service provision. Osteoporos Int 2011;22:2083-98.  Back to cited text no. 9
    
10.
Kathleen KS. “Project healthy bones: An osteoporosis prevention program for older adults.” J Ext 2001;39.  Back to cited text no. 10
    
11.
Robinson WA, Carlson BC, Poppendeck H, Wanderman NR, Bunta AD, Murphy S, et al. Osteoporosis-related vertebral fragility fractures: A review and analysis of the American orthopaedic association's own the bone database. Spine (Phila Pa 1976) 2020;45:E430-8.  Back to cited text no. 11
    




 

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