Drugs & Aging

, Volume 19, Issue 1, pp 1–10 | Cite as

The Underuse of Therapy in the Secondary Prevention of Hip Fractures

  • Hosam K. Kamel
  • Edmund H. Duthie
Leading Article


There is strong evidence to indicate that individuals who sustain a hip fracture are at a greater risk of developing another. The management of such patients should include efforts to prevent future fractures, including prescribing medications that have been shown to lower hip fracture risk. Such therapies that are currently available include calcium and vitamin D supplementation, alendronic acid and risedronic acid. In addition, there is epidemiological evidence to indicate that estrogen may also decrease the risk of hip fracture. Parathyroid hormone is another agent that has shown promise in this regard and is likely to be available for clinical use in the near future. However, the rates of utilisation of these therapies among patients with hip fractures are low. It is important to emphasise that secondary prevention of hip fractures should be an integral part of the management of individuals who sustain hip fractures.


Bone Mineral Density Vertebral Fracture Nonvertebral Fracture Alendronic Acid Risedronic Acid 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.



There were no sources of funding used to assist in the preparation of this manuscript. There are no potential conflicts of interest that the authors may have that are directly relevant to the contents of this manuscript.


  1. 1.
    Cooper C, Campion G, Melton III LJ. Hip fractures in the elderly: a worldwide projection. Osteoporosis Int 1992; 2(6): 285–9CrossRefGoogle Scholar
  2. 2.
    Ray NF, Chan JF, Thamer M, et al. Medical expenditures for the treatment of osteoporotic fractures in the United States in 1995: report from the National Osteoporotic Foundation. J Bone Miner Res 1997; 12: 24–35PubMedCrossRefGoogle Scholar
  3. 3.
    European Commission. Report on Osteoporosis in the European Community-Action for Prevention. Brussels: European Commission, 1998Google Scholar
  4. 4.
    Hedlund R. Incidence and cause of femur fractures [thesis]. Stockholm: Karolinska Institute, 1985Google Scholar
  5. 5.
    De Laet CEDH, Van Hout BA, Pols HAP. Osteoporosis in the Netherlands: A burden of illness Study. Rotterdam: Institute for Medical Technology Assessment, 1996Google Scholar
  6. 6.
    Bacon WE, Maggi S, Looker A, et al. International comparison of hip fracture rates in 1988–89. Osteoporosis Int 1996; 6(1): 69–75CrossRefGoogle Scholar
  7. 7.
    Flffors I, Allander E, Kanis JA, et al. The variable incidence of hip fracture in Southern Europe: the MEDOS Study. Osteoporosis Int 1994; 4(5): 253–63CrossRefGoogle Scholar
  8. 8.
    De Laet CE, Pols HA. Fractures in the elderly: epidemiology and demography. Baillieres Clin Endocrinol Metab 2000; 14(2): 171–9CrossRefGoogle Scholar
  9. 9.
    Cumming RG, Nevitt MC, Cummings SR. Epidemiology of hip fractures. Epidemiol Rev 1997; 19: 244–57PubMedCrossRefGoogle Scholar
  10. 10.
    Cooper C, Atkinson EJ, Jacobsen SJ, et al. Population -based study of survival after osteoporotic fractures. Am J Epidemiol 1993; 137: 1001–5PubMedGoogle Scholar
  11. 11.
    Kamel HK. Osteoporosis and aging: etiology and current diagnostic strategies. Ann Long-Term Care 1998; 6: 352–257Google Scholar
  12. 12.
    Miller CW. Survival and ambulation following hip fracture. J Bone Joint Surg 1978; 60A: 930–4Google Scholar
  13. 13.
    Wolinsky FD, Fitzgerald JF, Stump TE. The effect of hip fracture on mortality, hospitalization, and functional status: a prospective study. Am J Public Health 1997; 87: 398–403PubMedCrossRefGoogle Scholar
  14. 14.
    Dolan P, Torgerson DJ. The cost of treating osteoporotic fractures in the United Kingdom female population. Osteoporosis Int 1998; 8: 611–7CrossRefGoogle Scholar
  15. 15.
    Gardsell P, Johnell O, Nillson BE. The predictive value of forearm bone mineral content measurements in men. Bone 1990; 11: 229–32PubMedCrossRefGoogle Scholar
  16. 16.
    Melton LJ, Ilstrup DM, Beckenbaugh RD, et al. Hip fracture recurrence: a population-based study. Clin Orthop 1982; 167: 131–8PubMedGoogle Scholar
  17. 17.
    Colon-Emeric CS, Sloane R, Hawkes WG, et al. The risks of subsequent fracture in community-dwelling men and male veterans with hip fracture. Am J Med 2000; 109: 324–6PubMedCrossRefGoogle Scholar
  18. 18.
    Wolinsky FD, Fitzgerald JF. Subsequent hip fracture among older adults. Am J Public Health 1994; 84: 1316–8PubMedCrossRefGoogle Scholar
  19. 19.
    Chui KY, Pun WK, Luk KDK, et al. Sequential fractures of both hips in elderly patients: a prospective study. Trauma 1992; 32: 584–7CrossRefGoogle Scholar
  20. 20.
    Stewart A, Walker LG, Porter RW, et al. Predicting a second hip fracture. J Clin Densitom 1999; 2(4): 363–70PubMedCrossRefGoogle Scholar
  21. 21.
    Smith EL, Tommerup L. Exercise: a prevention treatment for osteoporosis and injurious falls in the older adult. J Aging Phys Activity 1995; 3: 178–92Google Scholar
  22. 22.
    Madsen OR, Lauridsen UB. Knee extensor and flexor strength in elderly women after recent hip fracture: assessment by the Cybex 6000 dynamometer of intra-rater inter-test reliability. Scand J Rehabil Med 1995; 27: 219–26PubMedGoogle Scholar
  23. 23.
    Jarnlo GB, Thorngren KG. Standing balance in hip fracture patients. 20 middle-aged patients compared with 20 healthy subjects. Acta Orthop Scand 1991; 62: 427–34PubMedCrossRefGoogle Scholar
  24. 24.
    Consensus Development Conference. Prophylaxis and treatment of osteoporosis. Am J Med 1991; 90: 107–10CrossRefGoogle Scholar
  25. 25.
    Kamel HK. Pharmacological management of osteoporosis: current trends and future prospects. Ann Long term Care 1998; 6(12): 382–8Google Scholar
  26. 26.
    Cauly JA, Seeley DG, Ensrud K, et al. Estrogen replacement therapy and fractures in older women. Ann Intern Med 1995; 122: 9–16Google Scholar
  27. 27.
    Neer RM, Arnaud CD, Zanchetta JR, et al. Effect of parathyroid hormone (1–34) on fractures and bone mineral density in postmenopausal women with osteoporosis. N Engl J Med 2001; 344(19): 1434–41PubMedCrossRefGoogle Scholar
  28. 28.
    Chestnut CH, Silverman S, Andriano K, et al. A randomized trial of nasal spray salmon calcitonin in postmenopausal women with established osteoporosis: the prevent recurrence of osteoporosis study. Am J Med 2000; 109: 267–76CrossRefGoogle Scholar
  29. 29.
    Ettinger B, Blacm DM, Mitlak BH, et al. Reduction of vertebral fracture risk in postmenopausal women with osteoporosis treated with raloxifene: results from a 3-year randomized clinical trial. JAMA 1999; 282(7): 637–45PubMedCrossRefGoogle Scholar
  30. 30.
    LeBoff MS, Kohlmeier L, Hurwitz S, et al. Occult vitamin D deficiency in postmenopausal US women with acute hip fracture. JAMA 1999; 181: 1505–11CrossRefGoogle Scholar
  31. 31.
    Diamond T, Smerdely P, Kormas N, et al. Hip fracture in elderly men: the importance of subclinical vitamin D deficiency and hypogonadism. Med J Aust 1998; 169: 138–41PubMedGoogle Scholar
  32. 32.
    NIH Consensus conference. Optimal calcium intake: NIH consensus development panel on optimal calcium intake. JAMA 1994; 272: 1942–8CrossRefGoogle Scholar
  33. 33.
    Slavik DM, Adams JS, Neer RM, et al. Deficient production of 1,25-dihydroxyvitamin D in elderly osteoporotic patients. N Engl J Med 1981; 305: 372–4CrossRefGoogle Scholar
  34. 34.
    Armbrecht H, Zenser T, Davis B. Effect of age on the conversion of 25-hydroxyvitmain D3 to 1,25-dihydroxyvitamin D3 by kidney of rat. J Clin Invest 1980; 66: 1118PubMedCrossRefGoogle Scholar
  35. 35.
    Chapuy MC, Arlot ME, Duboef F, et al. Vitamin D3, and calcium to prevent hip fractures in elderly women. N Engl J Med 1992; 327: 1637–42PubMedCrossRefGoogle Scholar
  36. 36.
    Dawson-Hughes B, Harris SS, Krall EA, et al. Effect of calcium and vitamin D supplementation on bone density in men and women 65 years of age or older. N Engl J Med 1997; 337: 670–6PubMedCrossRefGoogle Scholar
  37. 37.
    Gillespie WJ, Avenell A, Henry DA, et al. Vitamin D and vitamin D analogues for preventing fractures associated with involutional and post-menopausal osteoporosis. Cochrane Database Sys Rev 2001; 1: CD000227Google Scholar
  38. 38.
    Black DM, Cummings SR, Karpf DB, et al. Randomized trial of effect of alendronate on risk of fracture in women with existing vertebral fractures. Fracture Intervention Trial Research Group. Lancet 1996; 348(9041): 1535–41PubMedCrossRefGoogle Scholar
  39. 39.
    Cummings SR, Black DM, Thompson DE, et al. Effect of alendronate on risk of fracture in women with low bone density but without vertebral fractures: results from the Fracture Intervention Trial. JAMA 1998; 280: 2077–80PubMedCrossRefGoogle Scholar
  40. 40.
    Rossini M, Gatti D, Zamberlan N, et al. Long-term effects of a treatment course with oral alendronate of postmenopausal osteoporosis. J Bone Miner Res 1994; 9(11): 1833–7PubMedCrossRefGoogle Scholar
  41. 41.
    Stock J, Bell NH, Chesnut III CH, et al. Increments in bone mineral density of the lumbar spine and hip suppression of bone turnover are maintained after discontinuation of alendronate in postmenopausal women. Am J Med 1997; 103(4): 291–7PubMedCrossRefGoogle Scholar
  42. 42.
    Tonino RP, Meunier PJ, Emkey R, et al. Skeletal benefits of alendronate: 7-year treatment of postmenopausal osteoporotic women. J Clin Endocrinol Metab 2000; 85(9): 3109–15PubMedCrossRefGoogle Scholar
  43. 43.
    Schnitzer T, Bone HG, Crepaldi G, et al. Therapeutic equivalence of alendronate 70 mg once-weekly and alendronate 10 mg daily in the treatment of osteoporosis. Aging Clin Exp Res 2000; 12: 1–12Google Scholar
  44. 44.
    Harris ST, Watts NB, Genant HK, et al. Effects of risedronate treatment on vertebral and nonvertebral fractures in women with postmenopausal osteoporosis: a randomized controlled trial. Vertebral Efficacy with Risedronate Therapy (VERT) Study Group. JAMA 1999; 282(14): 1344–52PubMedCrossRefGoogle Scholar
  45. 45.
    McClung MR, Geusens P, Miller PD, et al. Effect of risedronate on the risk of hip fracture in elderly women. N Engl J Med 2001; 344(5): 333–40PubMedCrossRefGoogle Scholar
  46. 46.
    Kamel HK, Perry III HM, Morley JE. Hormone replacement therapy and fractures in older adults. J Am Geriatric Society 2001; 49: 179–87CrossRefGoogle Scholar
  47. 47.
    Michaelsson K, Baron JA, Johnell O, et al. Variation in the efficacy of hormone replacement therapy in the prevention of hip fractures. Swedish Hip Fracture Study Group. Osteoporosis Int 1998; 8(6): 540–6CrossRefGoogle Scholar
  48. 48.
    Heart and Estrogen/progestin Replacement Study (HERS) research group. Randomized trial of estrogen plus progestin for secondary prevention of coronary heart disease in postmenopausal women. JAMA 1998; 280(7): 605–13CrossRefGoogle Scholar
  49. 49.
    Cauly JA, Black DM, Barrett-Connor E, et al. Effects of hormone replacement therapy on clinical fractures and height loss: the Heart and Estrogen/Progestin Replacement Study (HERS). Am J Med 2001; 110: 442–50CrossRefGoogle Scholar
  50. 50.
    Torgerson DJ, Bell-Syer SE. Hormone replacement therapy and prevention of nonvertebral fractures. JAMA 2001; 285(22): 2891–7PubMedCrossRefGoogle Scholar
  51. 51.
    Wren G. Megatrials of hormonal replacement therapy. Drugs Aging 1998; 12(5): 343–8PubMedCrossRefGoogle Scholar
  52. 52.
    Bauer E, Aub JC, Albright F. Studies of calcium and phosphorus metabolism: V. A study of the bone trabeculae as a readily available reserve of calcium. J Exp Med 1929; 49: 145–62PubMedCrossRefGoogle Scholar
  53. 53.
    Selye H. On the stimulation of new bone-formation with parathyroid extract and irradiated ergosterol. Endocrinology 1932; 16: 547–58CrossRefGoogle Scholar
  54. 54.
    Lauitzen JB, Petersen MM, Lund B. Effect of external hip protectors on hip fractures. Lancet 1993; 341: 11–3CrossRefGoogle Scholar
  55. 55.
    Harada A, Mizuno M, Takemura M, et al. Hip fracture prevention trial using hip protectors in Japanese nursing homes. Osteoporosis Int 2001; 12(3): 215–21CrossRefGoogle Scholar
  56. 56.
    Ekman A, Mallmin H, Michaelsson K, et al. External hip protectors to prevent osteoporotic hip fractures. Lancet 1997; 350(9077): 563–4PubMedCrossRefGoogle Scholar
  57. 57.
    Kannus P, Parkkari J, Niemi S, et al. Prevention of hip fracture in elderly people with use of a hip protector. N Engl J Med 2000; 343(21): 1506–13PubMedCrossRefGoogle Scholar
  58. 58.
    Parker MJ, Gillespie LD, Gillespie WJ. Hip protectors for preventing hip fractures in the elderly. Cochrane Database Syst Rev 2001; 2: CD001255Google Scholar
  59. 59.
    Gillespie LD, Gillespie WJ, Cumming R, et al. Interventions for preventing falls in the elderly. Cochrane Database Syst Rev 2000; (2): CD000340Google Scholar
  60. 60.
    Schroder HM, Petersen KK, Erlandsen M. Occurrence and incidence of the second hip fracture. Clin Orthop 1993; 289: 166–9PubMedGoogle Scholar
  61. 61.
    Dretakis E, Kritsikis N, Economou K, et al. Bilateral non-contemporary fractures of the proximal femur. Acta Orthop Scand 1981; 52: 227–9PubMedCrossRefGoogle Scholar
  62. 62.
    Boston DA. Bilateral fractures of the femoral neck. Injury 1982; 14: 207–10PubMedCrossRefGoogle Scholar
  63. 63.
    Kamel HK, Hussain MS, Tariq S, et al. Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fractures. Am J Med 2000; 109: 326–8PubMedCrossRefGoogle Scholar
  64. 64.
    Tariq SH, Iqbal MA, Makhdoom S, et al. The underuse of therapy in secondary prevention of hip fractures [abstract]. The Gerontologist. In pressGoogle Scholar
  65. 65.
    Torgerson D, Dolan P. Prescribing by general practitioner after an osteoporotic fracture. Ann Rheum Dis 1998; 57: 378–9PubMedCrossRefGoogle Scholar
  66. 66.
    Pal B. Questionnaire survey of advice given to patient with fractures. BMJ 1999; 318: 500–1PubMedCrossRefGoogle Scholar
  67. 67.
    Al-Allaf AW, Reid BP. An audit of post fracture rehabilitation with special emphasis on osteoporosis assessment and treatment. Clin Exp Rheumatol 1998; 16: 451–3PubMedGoogle Scholar
  68. 68.
    Sheehan J, Mohamed F, Reilly M, et al. Secondary prevention following fractured neck of femur: A survey of orthopedic surgeons practice. Irish Med J 2000; 93(4): 105–7Google Scholar
  69. 69.
    Zimmerman Si, Girman CJ, Buie VC, et al. The prevalence of osteoporosis in nursing home residents. Osteoporosis Int 1999; 9(2): 151–7CrossRefGoogle Scholar
  70. 70.
    Lauritzen JB. Hip fractures: incidence, risk factors, energy absorption, and prevention. Bone 1996; 18(1 Suppl.): 65S–75SPubMedCrossRefGoogle Scholar
  71. 71.
    Norton R, Campbell JA, Reid IR, et al. Residential status and risk of hip fracture. Age Ageing 1999; 28: 135–9PubMedCrossRefGoogle Scholar
  72. 72.
    Butler M, Norton R, Lee-Joe T, et al. The risks of hip fracture in older people from private homes and institutions. Age Ageing 1996; 25: 381–5PubMedCrossRefGoogle Scholar
  73. 73.
    Kamel HK, Phlavan M, Malekgoudarzi B. Underutilization of calcium and vitamin D supplements in an academic long-term facility [abstract]. J Am Med Director Assoc 2000; 1(2): A6Google Scholar
  74. 74.
    Abbasi AA, Rudman D, Wilson CR, et al. Observations on nursing home residents with a history of hip fracture. Am J Med Sci 1995; 310: 229–34PubMedGoogle Scholar
  75. 75.
    Scientific Advisory Board. Clinical practice guidelines for the diagnosis, and management of osteoporosis. Osteoporosis Society of Canada. CMAJ 1996; 155: 1113–33Google Scholar
  76. 76.
    National Osteoporosis Foundation of the US. Osteoporosis: Review of the evidence for prevention, diagnosis and treatment and cost-effective analysis. Osteoporosis Int 1998; 8Suppl. 4: S1–S3–6CrossRefGoogle Scholar
  77. 77.
    Royal College of Physicians of London. Osteoporosis. Clinical guidelines for prevention and treatment. London: Royal College of Physicians of London, 1999Google Scholar
  78. 78.
    Balas EA, Weingarten S, Garb CT, et al. Improving preventive care by prompting physicians. Arch Intern Med 2000; 160: 301–8PubMedCrossRefGoogle Scholar

Copyright information

© Adis International Limited 2002

Authors and Affiliations

  1. 1.Division of Geriatrics and GerontologyClement J. Zablocki Veterans Administration Medical CenterMilwaukeeUSA
  2. 2.Division of Geriatrics and Gerontology, Department of MedicineMedical College of WisconsinMilwaukeeUSA

Personalised recommendations