Resources

Care guidelines

Improving care for patients who have sustained a fragility fracture requires a coordinate approach that is identified through a Care Standard or Guideline. These have been developed and made available in many countries and often include resource tools for clinical management.

Spain

Sociedad Española de Fracturas Osteoporóticas (SEFRAOS). Libro Azul de la Fractura Osteoporótica en España. 2012.

http://www.actasanitaria.com/fileset/file__Libro_azul_fractura_osteopor_tica_23_7_12_82805.pdf

United Kingdom

National Institute for Health and Care Excellence (NICE). The Management of Hip Fracture in Adults. 2011. NICE Clinical Guideline 124.

https://www.nice.org.uk/guidance/cg124
Updated 2017: https://www.nice.org.uk/guidance/cg124/chapter/recommendations

NICE Quality Standard 16.
https://www.nice.org.uk/guidance/qs16

Scottish Standards of Care for Hip Fracture Patients 2018:
https://www.shfa.scot.nhs.uk/_docs/2018/Scottish-standards-of-care-for-hip-fracture-patients-2018.pdf

Guidance for the management of symptomatic vertebral fragility fracture

The guidance outlines how healthcare professionals can best support patients who present in the community or in hospital with symptoms of a vertebral fracture including assessment and management of symptoms, supporting self-management and promoting access to resources.

Download the document here

China

Guidelines for Diagnosis, Treatment, and Management of Hip Fracture in the Elderly

Download the document here.

Hong Kong SAR, China

Recommendations on the post-acute management of the osteoporotic fracture - Patients with “very-high” Re-fracture risk

https://pubmed.ncbi.nlm.nih.gov/36262963/

The aim of this clinical guideline from Fragility Fracture Network Hong Kong SAR, is to provide evidence-based recommendations on the post-acute treatment of the osteoporotic fracture patient that presents for clinical care at the Fracture Liaison Service (FLS).

Australia and New Zealand

Hip Fracture Clinical Care Standard 2023

The Australian Commission on Safety and Quality on Health Care has released updated Hip Fracture Clinical Standards 2023. The original Clinical Standards were launched in 2016 and have been measured using data collected in a registry. There are 7 updated Clinical Standards that address care at presentation to transition to the community.

Download the document here.

Bone and Joint Canada

http://boneandjointcanada.com/hip-fracture/hf-healthcare-professionals/

United States of America

Bukata SV, Digiovanni BF, Friedman SM et al. A guide to improving the care of patients with fragility fractures. 2011.

https://pubmed.ncbi.nlm.nih.gov/23569668/

American Academy of Orthopaedic Surgeons

https://www.aaos.org/quality/quality-programs/lower-extremity-programs/hip-fractures-in-the-elderly/

Ontario (Canada)

https://www.hqontario.ca/evidence-to-improve-care/quality-standards/view-all-quality-standards/hip-fracture

Canada Guidelines

Post hip fracture orthogeriatric care—a Canadian position paper addressing challenges in care and strategies to meet quality indicators

https://pubmed.ncbi.nlm.nih.gov/37014390/

A position paper outlines the clinical care for hip fracture patients across the continuum of care from the emergency department to returning to the community, including secondary prevention.

Recommendations on screening for primary prevention of fragility fractures

https://pubmed.ncbi.nlm.nih.gov/37156553/

The Canadian Task Force on Preventive Health Care developed and published guideline that provides evidence-based recommendations on screening to prevent fragility fractures in community-dwelling individuals aged 40 years and older who are not currently on preventive pharmacotherapy.

Japan

Policy Change increases access to osteoporosis management in Japan

In April 2022 the Ministry of Health in Japan changed the policy to increase access to evidence-based care for fragility fracture care including increasing access to osteoporosis management for fragility fractures.

Additional information can be found by contacting FFN Japan at ffn.or.jp

Care pathway

Tabu I, Goh EL, Appelbe D, Parsons N, Lekamwasam S, Lee JK, Amphansap T, Pandey D, Costa M; FERMAT collaborators and the Global Fragility Fracture Network Hip Fracture Audit Special Interest Group. Service availability and readiness for hip fracture care in low- and middle-income countries in South and Southeast Asia. Bone Jt Open. 2023 Sep 5;4(9):676-681. doi: 10.1302/2633-1462.49.BJO-2023-0075.R1.

https://www.ncbi.nlm.nih.gov/pmc/articles/PMC10477024/

The aim of this study was to describe the current pathways of care for patients with a fracture of the hip in five low- and middle-income countries in South Asia (Nepal and Sri Lanka) and Southeast Asia (Malaysia, Thailand, and the Philippines).

Principles for management of hip fracture for older adults taking direct oral anticoagulants: an international consensus statement

Click here for the infographic with the consensus statements.

Registries

Countries around the world collect and report data on the performance of their healthcare system in managing fragility fractures, with most countries focusing on hip fractures. Information on each country including their annual reports (where available) can be found here.

If you would like additional information about any of the registries you can contact through

communications@fragilityfracturenetwork.org.

Ireland

https://www.noca.ie/audits/irish-hip-fracture-database

United Kingdom (England and Wales)

National Hip Fracture Database:  www.nhfd.co.uk/

United Kingdom (Scotland)

www.shfa.scot.nhs.uk

Australia and New Zealand

ANZHFR: https://anzhfr.org/

Korea

Fracture Liaison Service in Korea: 2022 Position Statement of the Korean Society for Bone and Mineral Research

A position statement that reviews the implementation methods for institutions implementing FLS, and characteristics of services and activities of the FLS committee. The focus is to impel policy change to enable multidisciplinary and integrated FLS within the Korean healthcare system.

Download the document here

FFN MINIMUM COMMON DATASET

Johansen A, Ojeda-Thies C, Poacher AT, Hall AJ, Brent L, Ahern EC, Costa ML; Global Fragility Fracture Network Hip Fracture Audit Special Interest Group. Developing a minimum common dataset for hip fracture audit to help countries set up national audits that can support international comparisons. Bone Joint J. 2022 Jun;104-B(6):721-728. doi: 10.1302/0301-620X.104B6.BJJ-2022-0080.R1.

https://pubmed.ncbi.nlm.nih.gov/35638208/

This study explores the current use of the FFN Minimum Common Dataset (MCD) within established national hip fracture registries, and proposes a revised MCD to enable international benchmarking for hip fracture care.

Johansen A, Hall AJ, Ojeda-Thies C, Poacher AT, Costa ML; Global Fragility Fracture Network Hip Fracture Audit Special Interest Group. Standardization of global hip fracture audit could facilitate learning, improve quality, and guide evidence-based practice. Bone Joint J. 2023 Sep 1;105-B(9):1013-1019. doi: 10.1302/0301-620X.105B9.BJJ-2023-0281. 

https://pubmed.ncbi.nlm.nih.gov/37652448/

Following the publication of the revised minimum common dataset (MCD) in 2022 to improve consistency and interoperability between registries, this study compares the compatibility of existing registries with the MCD.

Rehabilitation

Programs

Bone Fit Canada

Evidence based exercise program for people with osteoporosis designed for health care and exercise professionals
https://bonefit.ca/

Bone Fit USA

BoneFit USA: BoneFitTM is an evidence-informed exercise training workshop, designed for healthcare professionals and exercise specialists to provide training on the most appropriate, safe and effective methods to prescribe and progress exercise for people with osteoporosis. BoneFitTM includes two different levels of workshops – BoneFitTM Basics and BoneFitTM Clinical. BoneFitTM Basics workshops are aimed at exercise and fitness professionals. BoneFitTM Clinical workshops are aimed at rehabilitation professionals. BoneFitTM was created and launched by Osteoporosis Canada in 2010. BHOF is working with Osteoporosis Canada and the founders of BoneFitTM to bring this training program to the United States. https://www.bonehealthandosteoporosis.org/bonefit-usa/

BoneFit directory: https://www.bonehealthandosteoporosis.org/bonefit-find-a-professional/

Own the Bone Registry

American Orthopaedic Association http://www.ownthebone.org/

Articles

Physical Therapy Management of Older Adults with Hip Fracture

https://www.jospt.org/doi/10.2519/jospt.2021.0301

Purcell K, Tiedemann A, Kristensen MT, Cunningham C, Hjermundrud V, Ariza-Vega P, Perracini M, Sherrington C. Mobilisation and physiotherapy intervention following hip fracture: snapshot survey across six countries from the Fragility Fracture Network Physiotherapy Group. DisabilRehabil. 2022 Nov;44(22):6788-6795. doi: 10.1080/09638288.2021.1974107 https://pubmed.ncbi.nlm.nih.gov/34514916/

Perracini MR, Kristensen MT, Cunningham C, Sherrington C. Physiotherapy following fragility fractures. Injury. 2018 Aug;49(8):1413-1417. doi: 10.1016/j.injury.2018.06.026. Epub 2018 Jun 21. PMID: 29958686.
https://pubmed.ncbi.nlm.nih.gov/29958686/

Dyer SM, Perracini MR, Smith T, Fairhall NJ, Cameron ID, Sherrington C, Crotty M. Rehabilitation Following Hip Fracture. 2020 Aug 21. In: Falaschi P, Marsh D, editors. Orthogeriatrics: The Management of Older Patients with Fragility Fractures [Internet]. Cham (CH): Springer; 2021. Chapter 12. PMID: 33347227.
https://pubmed.ncbi.nlm.nih.gov/33347227/

Sheehan KJ, Fitzgerald L, Lambe K, Martin FC, Lamb SE, Sackley C. Effectiveness of community-based rehabilitation interventions incorporating outdoor mobility on ambulatory ability and falls-related self-efficacy after hip fracture: a systematic review and meta-analysis. Arch Osteoporos. 2021 Jun 19;16(1):99. doi: 10.1007/s11657-021-00963-0. PMID: 34148132; PMCID: PMC8214580.
https://pubmed.ncbi.nlm.nih.gov/34148132/

Exercise

Exercise recommendations: Too fit to Fracture
https://osteoporosis.ca/exercise-recommendations/
 
Bone health and osteoporosis Foundation: Exercise resources
https://www.bonehealthandosteoporosis.org/?s=exercise
 
NIH Osteoporosis and Related Bone Disease National Resource Centre
https://www.bones.nih.gov/health-info/bone/bone-health/exercise/exercise-your-bone-health#b

 

Articles

Sherrington C, Fairhall N, Wallbank G, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb S. Exercise for preventing falls in older people living in the community: an abridged Cochrane systematic review. Br J Sports Med. 2020 Aug;54(15):885-891. doi: 10.1136/bjsports-2019-101512. Epub 2019 Dec 2. PMID: 31792067.
https://pubmed.ncbi.nlm.nih.gov/31792067/

M, von Stengel S, Kohl M, Schoene D, Kemmler W. Effects of dynamic resistance exercise on bone mineral density in postmenopausal women: a systematic review and meta-analysis with special emphasis on exercise parameters. Osteoporos Int. 2020 Aug;31(8):1427-1444. doi: 10.1007/s00198-020-05441-w. Epub 2020 May 12. PMID: 32399891; PMCID: PMC7360540.
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7360540/

Watson SL, Weeks BK, Weis LJ, Harding AT, Horan SA, Beck BR. High-Intensity Resistance and Impact Training Improves Bone Mineral Density and Physical Function in Postmenopausal Women With Osteopenia and Osteoporosis: The LIFTMOR Randomized Controlled Trial. J Bone Miner Res. 2018 Feb;33(2):211-220. doi: 10.1002/jbmr.3284. Epub 2017 Oct 4. Erratum in: J Bone Miner Res. 2019 Mar;34(3):572. PMID: 28975661.
https://pubmed.ncbi.nlm.nih.gov/28975661/

Giangregorio LM, Ponzano M. Exercise and physical activity in individuals at risk of fracture. Best Pract Res Clin Endocrinol Metab. 2022 Mar;36(2):101613. doi: 10.1016/j.beem.2021.101613. Epub 2022 Jan 6. PMID: 35210190.
https://pubmed.ncbi.nlm.nih.gov/35210190/

Secondary prevention programs

Fracture Liaison Services

New South Wales, Australia

NSW Agency for Clinical Innovation Model of care for Osteoporotic Refracture Prevention 2nd ed (2018) availableat:

https://www.aci.health.nsw.gov.au/__data/assets/pdf_file/0008/279350/MoC-Osteoporotic-refracture.pdf

Malaysia

FFN Malaysia have developed a Framework on how to provide a Fracture Liaison Service to support secondary fracture prevention in Malaysia. The Framework includes information on the benefits, best practices and clinical standards, the role of primary care and audits using registries and the minimum common dataset.

Download the document here

Falls Prevention

Montero-Odasso MM, Kamkar N, Pieruccini-Faria F, Osman A, Sarquis-Adamson Y, Close J, Hogan DB, Hunter SW, Kenny RA, Lipsitz LA, Lord SR, Madden KM, Petrovic M, Ryg J, Speechley M, Sultana M, Tan MP, van der Velde N, Verghese J, Masud T; Task Force on Global Guidelines for Falls in Older Adults. Evaluation of Clinical Practice Guidelines on Fall Prevention and Management for Older Adults: A Systematic Review. JAMA Netw Open. 2021 Dec 1;4(12):e2138911. doi: 10.1001/jamanetworkopen.2021.38911. https://pubmed.ncbi.nlm.nih.gov/34910151/

Sherrington C, Fairhall N, Wallbank G, Tiedemann A, Michaleff ZA, Howard K, Clemson L, Hopewell S, Lamb S. Exercise for preventing falls in older people living in the community: an abridged Cochrane systematic review. Br J Sports Med. 2020 Aug;54(15):885-891. doi: 10.1136/bjsports-2019-101512. https://pubmed.ncbi.nlm.nih.gov/31792067/

Bone Protection

Johansen A, Sahota O, Dockery F, Black AJ, MacLullich AMJ, Javaid MK, Ahern E, Gregson CL. Call to action: a five nations consensus on the use of intravenous zoledronate after hip fracture. Age Ageing. 2023 Sep 1;52(9):afad172. doi: 10.1093/ageing/afad172.  https://pubmed.ncbi.nlm.nih.gov/37776543/

Norway Guidelines

Secondary Fracture Prevention Guidelines (major revision 2022)

A guide for the investigation and treatment of osteoporosis in men and women > 50 years of age with fractures to make it easy for orthopedists to start treatment for osteoporosis in patients who have an increased risk of future fractures.

https://www.legeforeningen.no/foreningsledd/fagmed/norsk-ortopedisk-forening/faggrupper/faggruppe-for-osteoporose-og-benhelse/

 

Policy

USA Policy documents 

Policy Institute: https://www.bonehealthpolicyinstitute.org/

Medicare Cost Of Osteoporotic Fractures – 2021 Report: https://www.bonehealthpolicyinstitute.org/state-reports-2021

Fragility Fracture Network Innovations in Healthcare Improvement: a special supplement

FFN, under the leadership of the Fragility Fracture Recovery Research Special Interest Group, released of a supplement produced collaboratively with BMJ Open Quality. The special supplement ''Innovations in Healthcare Improvement'' showcases quality improvement work from around the world to support the management of fragility fracture patients. You can access the supplement articles here

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