Rates of osteoporosis and fractures associated with poor bone quality, which are known as fragility fractures, are at epidemic levels. It is estimated that osteoporosis affects approximately 200 million people world-wide. Currently, it is also estimated that 10 million individuals over age 50 in the United States have osteoporosis. Each year an approximately 2 million individuals suffer a fracture due to osteoporosis. The risk of a fracture increases with age and is greatest in women. Approximately 1 in 2 women and 1 in 5 men age 50 or older will experience a hip, spine, or wrist fracture sometime during their lives. Approximately 40% of individuals are unable to return to their homes following a fragility fracture and require relocation to a nursing facility. As many as 20% of individuals will die within 6 - 12 months of a fragility fracture. Also, an additional 33.6 million individuals over age 50 have low bone density or “osteopenia” and thus are at risk of osteoporosis and fragility fracture. 

Monitoring of the bone health is the foundation of fracture prevention in the way monitoring blood pressure is to stroke prevention and mammograms are to breast cancer prevention. The early detection of any of these conditions, allows for early treatment to be institutes to prevent the long-term consequences of the disease. Bone health assessment is looking for osteoporosis. Although, some may still consider developing osteoporosis an unfortunate part of growing older, it is now understood that fracturing due to idiopathic age-related bone loss is not an inevitable part of aging but a potentially preventable disease process. Nutrition and exercise fight against osteoporosis – monitoring makes sure that they are working.

The term for bone monitoring is known as bone densitometry – the measurement of bone density. Determining bone mineral density (BMD) has been the traditional method of diagnosing osteoporosis and predicting fracture risk. The most common way to measure BMD is by using Dual Energy X-ray Absorptiometry (DXA). DXA has been around for over 30 years and has been the backbone of Bone Healthcare. It is a method of measuring BMD by using low-energy x-ray and has been considered reasonably reliable for measuring BMD and diagnosing and treating osteoporosis.

There is another method of bone densitometry that not only determines BMD but also give a measure of the Bone Quality. Radiofrequency Echographic Multi Spectrometry (REMS) is a newer method of performing monitoring bone health that was developed and has been used in Europe for almost ten years and has replaced DXA as the official method of bone densitometry in Italy. REMS uses ultrasound to measure BMD. However, the ultrasound is also capable of measuring Bone Quality and therefore when REMS is used to assess bone, more information is obtained and there is a better way to predict fracture risk. REMS is still very new in the United States but its popularity is growing as more and more people are finding out about it.

In conclusion, it is important to remember that your bones need to be monitored and cared for like any other part of you and poor bone health can affect anyone. So, bone healthcare is an issue for everyone and something that we all need to be aware of. Everyone has a skeleton and we need to pay attention to and take care of our skeletons because if you ignore your bones, they will go away!

In 2004 the United States Surgeon General made a statement about bone health and osteoporosis:

“This first-ever Surgeon General’s Report on bone health and osteoporosis illustrates the large burden that bone disease places on our Nation and its citizens. Like other chronic diseases that disproportionately affect the elderly, the prevalence of bone disease and fractures is projected to increase markedly as the population ages. If these predictions come true, bone disease and fractures will have a tremendous negative impact on the future well-being of Americans.” 

Currently, it is approximated that 10 million individuals over age 50 in the United States have osteoporosis of the hip. An additional 33.6 million individuals over age 50 have low bone mass or “osteopenia” of the hip and thus are at risk of osteoporosis and its potential complication of fragility fracture later in life. Each year an estimated 1.5 – 2 million individuals suffer a fracture due to osteoporosis. The risk of a fracture increases with age and is greatest in women. Approximately 5 in 10 women and 2 in 10 men age 50 or older in the United States will experience a hip, spine, or wrist fracture sometime during the remainder of their lives. There is an estimated 20% mortality rate associated with a fragility fracture within the first year following the fracture and up to a 50% chance of sustaining a second fracture within the first 6 months following the sentinel fracture. It is estimated that up to 40% of individuals who sustain a fragility fracture are unable to return to independent living and require nursing home care. The lifetime risk of fractures will increase for all ethnic groups as people live longer. 

The life-time risk for osteoporosis-related morbidity than a women’s combined risk for breast cancer, endometrial cancer and ovarian cancer.

With an early diagnosis of this disease before fractures occur and by assessing the bone mineral density and with early treatment, osteoporosis can be prevented. Therefore, increasing awareness among doctors and the community will be the first step in curtailing this epidemic. 

And, as in most aspects of preventative medicine the whole person approach usually results in the most successful outcomes. A lifestyle balance that includes appropriate nutrition and understanding the need for a healthy and balanced diet, maintaining an active lifestyle including exercises directed at maintaining bone health and appropriate bone health monitoring and the appropriate medical treatment when indicated form the backbone of a complete Bone Health Program.  The Surgeon General also stated:

“But as this report makes clear, they need not come true: by working together we can change the picture of aging in America. Osteoporosis, fractures, and other chronic diseases no longer should be thought of as an inevitable part of growing old. By focusing on prevention and lifestyle changes, including physical activity and nutrition, as well as early diagnosis and appropriate treatment, Americans can avoid much of the damaging impact of bone disease and other chronic diseases.”

Bone Healthcare – is not just about fixing broken bones!

That might sound funny coming from an Orthopedic Surgeon. We have always been the “carpenters” of the medical world, using steel, titanium, cement and various other construction-like materials to fix broken bones. Our training focused on that aspect of bone care – putting things back together after they had broken apart. However, preventing the fracture before it ever happens, particularly in our older patients is becoming the goal of a bone healthcare program.

Central Carolina Orthopedic Associates have increased the scope of our orthopedic practice to include Bone Health and Fracture Prevention. We obtained Fracture Liasson Service certification from the National Osteoporosis Foundation and are star members of the AOA Own-the-Bone Program national fracture database. We have been the main orthopedic provider in the Sanford/Pittsboro for many years and now we are the FLS service for this area.

We have built our Bone Health program on the basis of a sound understanding of bone physiology and available medical treatment options. However, we have a focus on a full whole-person evaluation of our bone health patient including medical history, medication history, social and lifestyle habits, nutrition and vitamin history and physical activity assessment. All of our treatment recommendations will include recommendation for nutrition and exercise and we will consider medication only when necessary and medically indicated.

Another aspect of our practice that has differentiated us is our use of REMS (Radiofrequency Echographic Multi Spectrometry) technology for bone densitometry. Unlike DXA which is x-ray radiation based, REMS is an ultrasound technology that gives BMD measurements in accordance with the WHO standards. BMD is measured at the lumbar spine and hips and therefore it can be used to diagnose and treat osteoporosis as an equivalent method to DXA. Since it doesn’t use ionizing radiation, it can be done in an office setting – it is also portable and can be moved between offices. Another feature is the ability of REMS to give a Fragility Score – that is a measure of bone quality. Bone quality has been recently recognized as an important aspect of a bone’s ability not to break – its strength.

With REMS and our knowledge of bone physiology, and the training that we have received in Bone Health, CCOA is offering a comprehensive Bone Health program. We would like the opportunity to discuss the potential that a bone health program can bring to the medical services that you provide. Too often, bone health gets forgotten in routine medical healthcare and patients only find out when it’s too late that their bones are not healthy – by breaking a wrist, hip, vertebral body, pelvis or shoulder.

Please consider including bone healthcare along with the medical services that you are providing to your employees. We can work together to help Prevent the Fracture!

DXA densitometry has been the accepted standard for bone densitometry for over 30 years. It has helped healthcare providers include bone health as part of routine medical care. However, DXA has had limitations including a high error rate, lack of availability in many locations and repeated exposure to ionizing radiation during serial monitoring. It cannot be offered as an onsite service and requires a visit to an imaging center.

REMS densitometry is changing the bone heath landscape. REMS Radiofrequency Echographic Multi Spectrometry) is a newer method of performing standard densitometry which also offers the additional benefit of assessing microstructural properties of bone referred to as bone quality. The REMS bone quality assessment referred to as the Fragility Score provides the most accurate method currently available to assess fracture risk [Paola Pisani, Francesco Conversano, Fragility Score: a REMS-based indicator for the prediction of incident fragility fractures at 5 years, Aging Clinical and Experimental Research volume 35, pages 763–773 (2023]. Because REMS is an ultrasound (pulsed echographic sonography) it is safe and portable!

Healthcare is preventative medicine – it is the core of fracture prevention. Early screening is essential. Many in the bone healthcare field recommend perimenopausal bone densitometric assessment around the age of 50 yo, not 65 yo as is the current recommendation. By 65 yo a woman may have lost 30% of her skeleton and by that time treatment choices are significantly limited. With early bone assessment, a baseline can be established and then routine yearly monitoring would be recommended. This recommendation for bone health monitoring is very much in line with other healthcare monitoring - blood pressure, cholesterol, and diabetes screening.

CCOA and BH@SOS would like you to consider offering a mobile REMS service to your patients. We would like the opportunity to discuss the potential that a bone health program can bring to the medical services that you provide. Too often, bone health gets forgotten in routine medical healthcare and patients only find out when it is too late that their bones are not healthy – by breaking a wrist, hip, vertebral body, pelvis, or shoulder. Or patients may be unnecessary prescribed medication based only on a BMD value without any reference to their bone quality measure which is the best measure of fracture risk.