Our bones are a miraculous creation. As children, we run around and break one or two falling from a tree. As teenagers, it’s the adrenaline rush in football matches that leave us with twisted ankles and bleeding knees. As adults, we’re too busy worrying about bills and pills. All this while, our bones grow, learn and adapt to our bustling lives too.
Sadly, the health of our bones is rarely and barely talked about. The consequences are obvious in the elderly, especially after having a fall. We spoke to Dato’ Dr. Lee Joon Kiong, Consultant Orthopaedic Surgeon with the Bone Health Alliance Malaysia to understand the cruciality of bone health management and its future in the country.
What is fragility fracture?
Dato’ Dr. Lee Joon Kiong: From a definition standpoint, a fracture is simply a break in the continuity of a bone. The majority of fractures are caused by some sort of impact or stress, like when you hit something at high speed or something heavy falls on you. On the other hand, a fragility fracture is a broken bone caused by a fall from a standing height or less, and often affects the larger bones of the body such as the hip, spine or wrist.
Bones are strong and usually don’t break from a simple fall. Falling from a standing height certainly should not cause a fracture, otherwise you’d see children and sports people constantly experiencing a fracture. For there to be a fragility fracture, something must have weakened the bone first. Osteoporosis is a common factor.
Who is at risk of fragility fracture?
Dato’ Dr. Lee: Osteoporosis affects women and men of all races. One in three women and one in five men over the age of 50 will be affected by a broken bone due to osteoporosis.
Those at high risk include older persons, postmenopausal women, family history of osteoporosis or fracture, previous fracture history, or medical conditions such as rheumatoid arthritis.
Poor lifestyle habits such as leading a sedentary lifestyle, excessive alcohol consumption, and smoking also contribute to osteoporosis. Additionally, according to the Department of Statistics, Malaysia is well on its way to becoming an ageing society, with 14.5 percent of the population projected to be 65 years and above by 2040. The growing ageing population underscores the importance of stepping up for bone health and prioritising subsequent osteoporotic fracture prevention.
One in three women and one in five men over the age of 50 will be affected by a broken bone due to osteoporosis
How is fragility fracture linked to osteoporosis?
Dato’ Dr. Lee: Fragility fractures are a sign of underlying osteoporosis. These fractures arise following an event which would otherwise not be expected to result in a fracture. Importantly, one osteoporotic fracture leads to another. A prior fracture is associated with an 86 percent increased risk of any fracture and elevated risk in the first two years after an initial fracture.
Fracture prevention is an imperative measure to tackle this, be it the first fracture or subsequent osteoporotic fracture. Millions of men and women suffer from osteoporosis-related fractures every year, and almost half of the patients who break their hip have had a previous fracture.
Is fragility fracture often overlooked?
Dato’ Dr. Lee: Yes, it’s often overlooked largely due to the misconceptions that osteoporosis is a natural part of ageing, unpreventable, and untreatable. The reality is that most osteoporosis treatment is initiated only when a patient experiences a fracture.
Within the osteoporosis management landscape, it is reported that despite individuals being at heightened risk of osteoporotic fracture, only 12 percent were on bone health optimising medications and less than one-in-five received surgery within the recommended 48-hour timeframe from hospital admission, owing to the lack of awareness about bone health management. Hip fractures are associated with high morbidity and a mortality rate of up to 20 percent in the first year, with only 25 percent resuming normal activities while the majority are disabled.
Malaysians must also be aware of the bone health-related post-pandemic issues that need to be addressed. Reduced physical activity drastically increases the risk of falls and fractures, and reduced vitamin D levels due to the lack of sun exposure have a negative impact on bone health. Increased social isolation may also result in cognitive impairment among older persons leading to a lack of adherence to proper treatment or dietary care and engaging in activities that pose a greater risk of falling and fractures.
What is the role of the organisations within the Bone Health Alliance Malaysia?
Dato’ Dr. Lee: We have formed BHAM, with each partner bringing their respective expertise and capabilities in osteoporosis prevention and management. Together, we hope to pave way for bone health promotion with the purpose of improving patient outcomes. We will continue to prioritise bone health management and subsequent osteoporotic fracture prevention post-COVID-19 among Malaysians by encouraging them to recognise their risk factors, changing perceptions to place importance on appropriate management of fragility fractures, and driving action towards preventive measures to avoid secondary osteoporotic fractures.
Notably in the post-pandemic setting, Malaysians must adopt a positive behavioural change in bone health management by seeking treatment upon a fracture. Through our educational activities, we want to empower Malaysians to discuss bone health with their physician by sharing concerns and questions. Ultimately, BHAM aims to instil routine bone health screening for those aged 60 years old and above, and to facilitate timely diagnosis and treatment in the Malaysian healthcare system.
What is Fracture Liaison Service (FLS)?
Dato’ Dr. Lee: FLS is a coordinated model of care, which proactively identifies and treats individuals at risk of future fragility fractures. FLS is made up of a committed team of stakeholders, employing a dedicated coordinator to act as the link between the patient and the orthopaedic team, the osteoporosis and falls prevention services, and the primary care physician. It is an integral component in improving osteoporosis outcomes by evaluating bone health and initiating an ongoing treatment plan upon receiving care for a fracture at the hospital. Patients are encouraged to implement appropriate post-fracture care for secondary fracture prevention through FLS.
How will FLS aid patients with fragility fractures?
Dato’ Dr. Lee: For patients with osteoporosis at high risk for fracture; screening, DXA examination, diagnosis, and osteoporosis treatment are essential for both primary and secondary prevention of osteoporosis related fracture. Various organisations recognise the importance of osteoporosis testing and treatment, and clinical guidelines call for specific measures to be taken with patients with osteoporosis at high risk for fracture.
FLS will ensure all patients presenting with fragility fractures to the particular locality or institution receive fracture risk assessment and treatment where appropriate. The service will be comprised of a dedicated case worker, often a clinical nurse specialist, who works to pre-agreed protocols to case-find and assess fracture patients. FLS offers holistic treatment and prevention management, which are essential to patients who have experienced a fracture and are at high risk of another fracture.
FLS offers holistic treatment and prevention management, which are essential to patients who have experienced a fracture and are at high risk of another fracture.
FLS plays an important role in treating underlying osteoporosis in patients presenting with fragility fractures. FLS also provides education on minimising the risk of osteoporosis related fractures.
How will FLS contribute to secondary fracture prevention?
Dato’ Dr. Lee: FLS plays an important role in treating underlying osteoporosis in patients presenting with fragility fractures. FLS also provides education on minimising the risk of osteoporosis-related fractures. Physiotherapy, nutrition, and treatment continuity are equally important to prevent subsequent fragility fractures. Given that 9 in 10 hip fractures result from a simple fall from standing height or less, fall prevention is a critical intervention too.
Healthcare professionals also promote the widespread implementation of the FLS model of care to reliably deliver subsequent osteoporotic fracture prevention and ensure the best transition of care from hospital to community. FLS have been shown to dramatically improve osteoporosis treatment rates for fragility fracture patients and reduce secondary fracture incidence, in addition to potential beneficial effects on mortality outcomes.
How can patients acquire FLS?
Dato’ Dr. Lee: In Malaysia, FLS is currently available in seven locations within Klang Valley. An FLS program operates under the direction of your doctor and an FLS coordinator. We encourage those seeking treatment after sustaining a fragility fracture to speak to their doctor to find out more about FLS and its availability.
A key consideration moving forward is the implementation of FLS services on a much wider scale in Malaysia. Increasing the reach and network of FLS within our healthcare system is part of the alliance’s goals to prevent subsequent fractures for those who have already sustained an osteoporosis-related fracture.
Why is the multidisciplinary approach the new way to go in modern medicine?
Dato’ Dr. Lee: A multi-stakeholder partnership is an important aspect of tackling the multidimensional aspects of care for chronic diseases like osteoporosis. It allows us to scale up collective impact while enhancing the role and effectiveness of the efforts to drive action. It is clear that an integrated care approach for the management of bone health in Malaysia is essential, considering the ageing population.
The first step is recognising that bone health is a priority in any country-wide plan to improve the health outcomes of an ageing population. We are hoping to move the needle forward in making bone health a national priority, and then we can embark on orders at different levels; at the national, state and local levels, to bring different levels of awareness and initiatives. It is critical not just to get healthcare providers on board, but to enable public support for any evidence-based policies that may follow.
