THE MANAGEMENT OF FRAGILITY FRACTURES OF THE HIP: A QUALITY ASSESSMENT PROJECT

Fragility fractures of the hip (FFH) constitute the most serious complication of osteoporosis, carrying a mortality rate of up to 30% in the first year after injury. Less than 50% of affected patients will regain their pre-injury activity level. Surgical fixation of the hip fracture within 48 hours of injury, multimodal pain management, deep vein thrombo-prophylaxis, early physical therapy and simultaneous management of osteoporosis and frailty in a multidisciplinary approach constitute the standard of care for FFH to keep the mortality and morbidity rates as low as possible and prevent future fragility fractures.  
AIM: To assess the standard of care of FFH at our institution and determine areas of management which require more attention and improvement.  
METHODS: A retrospective review of clinical and radiographic records of all patients admitted at our institution for FFH from 1 January 2014 to 31 December 2014. The waiting time from admission to surgical fixation of the hip fracture, pain control and thrombo-prophylaxis strategies, rate of geriatric referrals and extent of osteoporosis management were assessed.  
RESULTS: One-hundred-and-thirteen FFH were admitted from 1 January to 31 December 2014; 98 clinical records and 98 pelvis radiographs were included in the study. The other 15 clinical records were incomplete and were therefore excluded. The average waiting time from admission to surgery was 49 hours (range 9-120). All patients received low dose morphine, paracetamol and tramadol for perioperative pain control. Low molecular weight heparin and compression stockings were prescribed for thrombo-prophylaxis in all patients. Only two (2.04%) patients had some osteoporosis investigations ordered and none of the patients were referred to the geriatric department, and none were formally treated for osteoporosis.  
CONCLUSION: While the waiting time from admission to surgery was largely within the recommended time frame, there were no signs of a multidisciplinary approach to the management of FFH at our institution, leaving osteoporosis and frailty largely untreated.

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Published by the University of Cape Town (UCT) in terms of the non-exclusive license granted to UCT by the author.

Aim
To assess the standard of care of FFH at our institution and determine areas of care which need more attention and improvement.   recognised as complications of osteoporosis in its various forms. 1 The incidence of FFH is expected to continue rising due to the ever increasing life expectancy seen across developed and emerging countries worldwide.

Retrospective
It is estimated that 1 in 3 postmenopausal women and 1 in 5 men over the age of 75 will suffer a FFH in their life time. The rising global prevalence of FFH is estimated to reach 2.6 million in 2025 and 6.3 million by year 2050. 2 FFH constitutes the most serious complication of osteoporosis carrying a mortality rate of up to 20 -24% in the first year after injury and is associated with post injury decline in patients' level of activity in more than 50% of the cases. 2,3 The understanding that patients affected by FFH often present with a background of significant medical co-morbidities and frailty has led to the development of strict management guidelines with emphasis on a multidisciplinary approach to improve survival rate and clinical outcome after a FFH.
The American Academy of Orthopaedic Surgeons clinical practice guidelines stipulate that surgical fixation of the hip fracture within 48 hours of admission coupled with multimodal pain treatment, DVT prophylaxis, frailty care and osteoporosis management will ensure a positive clinical outcome. The presurgery waiting time should only be allowed for medical management of unstable or uncontrolled co-morbid conditions. 4 Studies have shown a tendency to neglect the management of osteoporosis and frailty in patients who have been treated for FFH at various orthopaedic centres across the world with only 2% to 8 % of these patients being referred for osteoporosis treatment. 3,5 The purpose of our study is to evaluate the standard of management of fragility fractures of the hip at our institution by determining the waiting time from admission to surgical fixation of the fracture, the common mode of analgesia and DVT prophylaxis and management of osteoporosis and frailty. Patient's details were obtained from our admissions records and matched with details on our surgical database. We were able to retrieve their folders from our records department and their radiographs were available on our digital PACS (Picture archiving and communication system).

Retrospective
Folders were examined to determine the waiting time from admission to surgical fixation of the fracture, the common mode of analgesia and DVT prophylaxis, the rate of geriatric referrals and the extent of management of osteoporosis and frailty.

Inclusion criteria
Hip fracture sustained from a fall from standing height or lower.
Availability of patient's folder with clearly documented mechanism of injury, date and time of admission, date and time of surgery and x-rays

III. STUDY RELEVANCE
This study is aimed at determining our level of care for fragility fractures of the hip. It will identify weaknesses in our management strategies and recommendations will be made to improve our current treatment protocol.

IV. REPORT OF FINDINGS
The results will be submitted for publication in a peer review journal (South African Orthopaedic Journal) and will also be discussed at the South African orthopaedic congress and research or faculty meetings.

V. BUDGET AND FUNDING
Costs not requiring funding: Departmental and personal computer usage.
Paper, stationery and photocopying supplied by the Orthopaedic department of the University of Cape Town.
Researchers will not be remunerated and will do the research as part of their current academic appointments.

VI. ETHICS
Informed consent is not applicable to this retrospective review, no patients identification will be linked to any of the raw data or results.

Risks/benefits:
There will be no risk or any potential benefit for the patients. The medical records will remain confidential. To gain knowledge and understanding of osteoporosis diagnosis, treatment and prevention.

II. SEARCH METHODOLOGY
Internet based search engines such as Pubmed, Medline and Google Scholar were used to identify articles relevant to the review. Articles were reviewed only if they were written in English and published in a peer reviewed journal.
Online relevant textbooks were also used.

III. INTRODUCTION
A fracture that is sustained following a minimal trauma such as a fall from standing height is defined as a fragility fracture. These fractures are caused by osteoporosis in its various forms. Fragility fractures of the hip constitute the most severe complication of osteoporosis because of the associated high mortality and morbidity rate. 1 The incidence of FFH is expected to continue rising due to the ever increasing life expectancy seen in developed and emerging countries across the globe. 2 It is estimated that 1 in 3 postmenopausal women and 1 in 5 men over the Studies have shown a tendency to neglect the management of osteoporosis and frailty in patients who have been treated for FFH at various orthopaedic centres across the world with only 2 to 8 % of these patients being referred for osteoporosis treatment. 4,6 While an in depth review of osteoporosis is outside the scope of this work, a summarized overview of osteoporosis is discussed in the subsequent sections of this review.
An integrated and multidisciplinary approach is highly desirable to ensure that medical co-morbidities are stabilised, the acute injury is adequately treated and simultaneously osteoporosis is investigated and treatment initiated before the patient is discharged. This comprehensive approach will help decrease mortality and morbidity but also serves as a secondary prevention of subsequent fragility fractures for the patient under treatment.
It has been shown that such an approach is also cost effective in terms of preventing future hospital admissions for future fragility fractures. 7 The orthopaedic surgeon is often the first point of contact and plays a key role in this multidisciplinary approach. He should think beyond surgical fixation of the fracture and invite relevant specialties on board at the initial patient's admission in the hospital.

IV. EATIOLOGY OF FRAGILITY FRACTURES OF THE HIP
The aetiology of fragility fractures of the hip (FFH) is multi-factorial.
Osteoporosis represents the main aetiological factor and many other risk factors act together to predispose patients with osteoporosis to a fall from standing height or lower and fracture their hips. 8,9 These risks factors can be classified as follow:

Definition
The term osteoporosis derives its etymology from a combination of 2 Greek words, osteo (bone) and poros (porous). It is used to describe a systemic skeletal disorder characterized by a decrease in bone mass and a progressive deterioration of the bone micro-architecture predisposing to fragility fractures. 10,11 The WHO has provided criteria for the diagnosis of osteoporosis and these criteria will be discussed under the diagnosis section of this overview.

Historical perspective
Sir

Risk factors for osteoporosis
It is important to recognize that the peak bone mass is achieved at age 25 to 30 and this is a crucial age group to maximize bone mass and strength. The peak bone mass achieved appears to be an important factor determining the severity and rate of bone mass decline in postmenopausal women after the age of 45 and men after the age of 50. 8,9 Factors negatively impacting on peak bone mass include extremes of weight range (underweight and obesity), inadequate physical activity, smoking, multiple pregnancies in women.
Regardless of the peak bone mass the following risk factors will predispose to osteoporosis: Age: after age 45 the ovarian function starts declining and oestrogen levels decline as well losing their protective effect on bone strength.
After the age of 75 the rate of fragility fractures increases significantly in both woman and men. 13 This is due to a higher rate of senile osteoporosis and frailty seen in this age group.
Sex: women are more affected by osteoporosis because of the combination of post-menopausal and senile osteoporosis.
Other factors: certain medical conditions such as celiac disease, renal disease, hyperparathyroidism, hypogonadism, inflammatory arthropathies and certain medications such as glucocorticoids will predispose patients to osteoporosis through various mechanisms. 10

Clinical presentation and Diagnosis
Osteoporosis is asymptomatic and patients will only present with fragility fractures. 8 Trabecular bones will be affected early on and in the most severe forms cortical bone will be affected severely enough to predispose to fragility fractures. Patients will then fracture their wrists many years before they get to fracture their hips. It has been shown that the most common pattern is to fracture the wrist first, followed by vertebral compression fractures and lastly hip fractures. This is why certain authors have described osteoporosis as a silent killer. 14 According to the WHO criteria, a diagnosis of osteoporosis is made when a patient has a T score lower than -2.5 or when a patient presents with a typical fragility fracture defined as a fracture occurring after a fall from standing height or lower and with clear osteopenia on plain radiographs.
A T score is obtained by measuring the patient bone mineral density (BMD) using a Dual-Energy X-ray Absorptiometry (DEXA) scan at the hip and the spine and comparing it to a mean of young healthy Caucasian women. 9 Bone strength depends on bone density and bone quality. Only bone density can be measured at this stage and it is expressed as grams of mineral per scanned area (g/cm 2 ). 10 Ideally Osteoporosis is diagnosed if the patient's T score is lower than -2.5 standard deviations below the mean of young healthy population matched for gender and ethnicity. 8,9 Due to lack of availability of data on mean bone mineral density for all ethnic groups the WHO allows matching the BMD of the patient to the mean BMD of young (21 to 29 year old) healthy white women. 8,9,10 According to the WHO, a DEXA scan report should classify the patient in one of the 3 categories as follows 8 : T score above -1 defines normal category T score between -1 and -2.5 defines the osteopenia category T score below -2.5 defines the osteoporosis category

Aetiological Classification of Osteoporosis
Osteoporosis is broadly classified in 2 major groups 10 : Primary Osteoporosis: this group is further classified in 2 types. Type I osteoporosis defines the group of postmenopausal osteoporosis and type II defines the senile osteoporosis which affects patients after the age of 75. 8,15 Secondary Osteoporosis: this group defines osteoporosis due to a medical condition such as inflammatory and connective tissue disorders (rheumatoid arthritis, systemic lupus erythematous, etc..) or malignancies such as multiple myeloma, endocrinopathies such as hyperparathyroidism from various causes, hypogonadism, celiac disease and chronic use of certain drugs such as steroids. 8, 10

Osteoporosis work-up
As a general rule osteoporosis investigations start with a DEXA scan which provides patient's T score to make a diagnosis and to have a baseline BMD to monitor the response to treatment.
Laboratory investigations will help exclude any possible causes of secondary osteoporosis and the following tests should be done for all patients under investigation for osteoporosis 10

General principles
Once the diagnosis has been made all efforts are directed at ruling out secondary causes of osteoporosis. The management plan will differ between the 2 main forms of osteoporosis namely primary and secondary osteoporosis.
General nutritional and lifestyle modifications will apply to both primary and secondary osteoporosis and include:

Regular physical activity
A daily intake of at least 1.2 g of calcium and 800 IU of vitamin D has been shown to reduce the relative risk of falls and fragility fractures mostly in the institutionalized elderly patients than in the community dwellers. 1,17 Adequate protein intake.
Smoking needs to be stopped and alcohol consumption moderated.
Pharmacological treatment will depend on the type of primary osteoporosis being addressed.
Postmenopausal osteoporosis will benefit from hormone replacement therapy early on but as senile osteoporosis sets in anti-resorptive therapy will be required to maintain adequate bone density.

Bisphosphonate therapy for osteoporosis
Bisphosphonates are synthetic, non-hydrolysable analogues of naturally occurring pyrophosphates that prevent loss of bone mass by interfering with osteoclastic activity.
The mechanism of action leading to inhibition of osteoclastic activity depends year probability or risk of a hip or other osteoporosis related fractures for each patient. The FRAX index is specific for each country. 19 Most common prescription include either Alendronate 70 mg weekly or zolendronic acid 5mg IV yearly. 16 The fracture risk reduction expected with the use of bisphosphonates has been widely studied on patients with vertebral fragility fractures. Alendronate has proven to reduce the vertebral fracture risk by 60%. 17 The most compelling data about the hip fracture risk reduction comes from the HORIZON(Health Outcomes and Reduced Incidence with zolendronic Acid Once Yearly) trial on the use of yearly 15 minute intravenous infusions of 5mg zolendronic acid started within 90 days after fixation of fragility fractures of the hip. 20 The pivotal HORIZON study showed a 70% risk reduction of morphometric vertebral fractures and 41% risk reduction of hip fractures at 36 months with an improved overall quality of life and a reduction in mortality rate. Patients treated with zolendronic acid were less likely to die of pneumonia and arrhythmias than placebo treated patients. 20 The mechanism underlying the later findings has not been clearly explained.
Beside the oesophageal and gastro-intestinal upset that oral bisphosphonates can cause, the most feared side effects of bisphosphonates include atypical femur fractures, osteonecrosis of the jaw and delayed or impaired fracture healing. 17,18 Atypical femur fractures

The 2013 American Society for Bone and Mineral Research Task Force
Revised Case Definition of Atypical Femur Fractures provides major and minor criteria for the diagnosis of atypical femur fracture. 17 Major criteria The fracture is a low energy fracture due to no trauma or minimal trauma as a fall from standing height or less.
The Fracture line starts from the lateral cortex and is essentially transverse in its orientation but can become oblique as it progresses to the medial cortex.
Complete fractures are not comminuted and may be associated with a medial spike and there is thickening of the lateral cortex at the fracture site.
The fracture must be located either in the sub-trochanteric area or in the diaphysis between the sub-trochanteric area and the supracondylar flare.

Minor criteria
Unilateral or bilateral prodromal groin or thigh pain Generalized increase in diaphyseal cortex thickness

Bilateral complete or incomplete fractures
Delayed fracture healing At least 4 major criteria need to be met to make the diagnosis of atypical femur fracture. Minor criteria will just strengthen the suspicion 15 .
The rate of these fractures varies in the literature but the known fact is that the incidence shows an exponential increase with the increase in the number of years of continuous treatment. Data from Kaiser California reported an age adjusted incidence of 1.8 per 100,000 with up to 2 years of bisphosphonates use, 16 per 100,000 with 4 -6 years of use and 107, 5 per 100,000 with more than 10 years of use. 18 To prevent the occurrence of atypical fractures the concept of "drug holiday" has been introduced. This concept is based on the fact that bisphosphonates activity last many years after the treatment has been interrupted. 15 It has been shown that after 5 years of Alendronate treatment osteoclastic activity remains inhibited for an additional 5 years 18 and zolendronic acid activity continues for an additional 3 years after 3 years of use. 18 The initiation time of drug holiday and its duration still is a debatable issue and this should vary with the particular bisphosphonate being used and patient's additional risk factors.

Recommendations for drug holiday from bisphosphonates
High risk: T-score ≤ -2.5 at the hip, previous fracture of the hip or spine or ongoing high dose glucocorticoid: drug holiday not justified but reassess the need for treatment at regular intervals.
Moderate risk: T score ≥ -2.5 at the hip, no prior history of hip or spine fragility fracture, consider drug holiday after 3 to 5 years of treatment with alendronate, risedronate and zolendronic Acid. 17

Osteonecrosis of the jaw
Osteonecrosis of the jaw is defined in 2 stages. In the preclinical stage the diagnosis is radiographic and based on the appearance of the mandible on plain radiographs. In the clinical stage the diagnosis is made on demonstration of an area of exposed bone in the oral cavity that fails to heal within 8 weeks of treatment. 18 The rate of osteonecrosis of the jaw is higher in the patients treated with bisphosphonates in the oncology department than for those treated for osteoporosis. This underlines the fact that the incidence is probably influenced by the combination of bisphosphonates and anti-neoplastic agents such as angiogenesis inhibitors and immuno-suppressors. In the osteoporosis treatment group the rate of osteonecrosis of the jaw is much lower than that of atypical femoral fractures. 18,20 Impaired fracture healing Bisphosphonates interfere with the course of continuous bone remodelling and it is logical to think that in so doing bisphosphonates may impair bone healing. This logical concern has not been validated in the literature.

VI. STANDARD OF CARE FOR FRAGILITY FRACTURES OF THE HIP
The aim of treatment of fragility fractures of the hip is to restore the patient's pre-injury activity level while minimizing morbidity and mortality and to lay out a plan for secondary prevention of future fragility fractures.
A multidisciplinary approach is required to cater for the wide variety of physiological disturbances that are often present and requiring treatment.
From the moment the patient is first seen in the emergency room all necessary investigations are conducted, hydration status corrected and comorbidities controlled with the aim to get the patient to theatre within 48 hours. In a prospective observational study Pioli et al have shown that the one year mortality risk increased by 12% per day of surgical delay. 25 The emergency physician would usually refer these patients straight to the orthopaedic surgeon and the latter becomes a key player in the multidisciplinary team that will be looking after these patients.
A review article by Ekman gives a check list of management priorities that the orthopaedic surgeon must satisfy while treating fragility fractures of the hip.
This check list ensures that the patient receives a holistic, comprehensive treatment for a positive outcome. 26 The multidisciplinary approach is aimed at reducing the perioperative complications seen in patients being treated for fragility fractures of the hip. A meta-analysis of prospective cohorts in Asian patients with hip fractures reported a DVT rate of 26% when prophylaxis was not used. 28 It is therefore recommended that all patients receive effective DVT prophylaxis.
A quarter of patients admitted with fragility fractures will develop delirium.
Predisposing factors for delirium include male gender, multiple comorbidities, low body mass index, prolonged surgery and general anaesthesia. 29 Although post-operative delirium is usually transient, it will persist for more than 4 weeks in 20% of patients. Importantly delirium is associated with lower functional recovery and higher mortality rate at 1 year. 30 Therefore the prevention of delirium becomes of paramount importance.
The literature supports that early referral to geriatricians is associated with lower rate of postoperative delirium. The geriatrician will also assess the risk of future falls and implement strategies to minimize or prevent falls. Factors such as delirium, use of psychoactive pain control agents, frequent change of care locations increase the risk of future falls and need to be addressed. 30,31,32 Sarcopenia is being increasingly recognized as an independent risk factor for falls and fragility fractures. It is defined by the presence of a low skeletal muscle mass and strength with poor physical performance. 33 Physiotherapists and dieticians work together to correct sarcopenia and optimize physical performance of these patients for a better clinical outcome.
It is the orthopaedic surgeon's responsibility to make early and appropriate referrals to geriatricians, physicians, endocrinologists, physical therapists and dieticians. These other team players will help optimize patient's medical condition to allow early surgery, early rehabilitation, optimal investigations, prevention and treatment of peri-operative complications and lay out a plan for osteoporosis treatment.
The orthopaedic surgeon is encouraged to go beyond the acute fracture care and ensure that osteoporosis is investigated and treated either by him/her or by his/her medical parteners. 34 The current literature shows that, for various reasons, less than 10% of patients presenting to major trauma centres with fragility fractures of the hip actually get a full evaluation and management of osteoporosis. 6,34,35,36 This outlines a need to increase awareness of osteoporosis management in orthopaedic trauma centres.
Further studies need to be directed at ways of preventing the first fragility fracture of the hip. Devices such as hip protectors are being developed and tested. 37 Newer pharmacological agents such as cathepsin K inhibitors are being slowly introduced for the management of osteoporosis. 38 Cathepsin K is the protease that is primarily responsible for bone matrix

Aim
To assess the standard of care of FFH at our institution and determine areas of management which require more attention and improvement. Studies have shown a tendency to neglect the management of osteoporosis and frailty in patients who have been treated for FFH at various orthopaedic centres across the world with only 2% to 8 % of these patients being referred for osteoporosis treatment. 5,6 Osteoporosis is broadly classified in 2 major groups 7 :

Retrospective
Primary Osteoporosis: this group is further classified in 2 types. Type I osteoporosis defines the group of postmenopausal osteoporosis and type II defines senile osteoporosis which affects patients after the age of 75. 8,9 Secondary Osteoporosis: this group defines osteoporosis due to a medical condition such as inflammatory and connective tissue disorders (rheumatoid arthritis, systemic lupus erythematosus, etc…) or malignancies such as multiple myeloma, endocrinopathies such as hyperparathyroidism from various causes, hypogonadism, celiac disease and chronic use of certain drugs such as steroids. 7,8 It is vitally important that osteoporosis, the main etiological factor of FFH be appropriately investigated and classified to initiate appropriate treatment.
Alongside osteoporosis many other risk factors play a significant role in causing FFH. These factors need to be identified at the initial admission and appropriate measures taken to prevent further falls and fractures. These risk factors include cognitive impairment, visual impairment, balance and gait disorders, sarcopenia, use of neuroactive medication, history of maternal FFH, patient's history of any fragility fracture. 8,10 An integrated and multidisciplinary approach is highly desirable to ensure that medical co-morbidities are stabilised, the acute injury is adequately treated and simultaneously osteoporosis is investigated and its treatment initiated before the patient is discharged.
This comprehensive approach will decrease mortality and morbidity and ensure secondary prevention of subsequent fragility fractures.
The purpose of this study was to assess the standard of care of FFH at our Institution and identify areas of management that require improvement.

Patients and methods
We conducted a retrospective review of clinical and radiographic records of all patients admitted with a fragility fracture of the hip at our level 1 trauma unit from 1 st January 2014 to 31 st December 2014.
Patients' details were obtained from our admissions records and matched with details on our surgical database. We were able to retrieve their folders from our records department and their radiographs were available on our digital PACS (picture archiving and communication system).
Only fractures sustained due to falling from standing height or lower (bed or chair) with radiographic osteopenia were included.
Pathological and high energy fractures were excluded.
Incomplete clinical records were excluded.
We examined clinical records to determine the waiting time from admission to surgery, pain control and thrombo-prophylaxis strategies, the rate of geriatric referrals and the extent of evaluation and management of osteoporosis.
Formal evaluation of osteoporosis meant that serum Vitamin D, calcium levels, erythrocyte sedimentation rate, thyroid function test and parathyroid hormone level were all requested with or without a DEXA scan.

Ethical approval was obtained from our institution's Human Research Ethics
Committee.

Results
We

Discussion
The results of this study have emphasised that fragility fractures are not only an injury of the female gender but males also can be affected. In our study 15% of cases were males. On further analysis 3% of the patients who were under 50 years of age were males. Despite their lower incidence of fragility fractures male patients tend to have poorer outcomes compared to postmenopausal women. 11 The aim of treatment of fragility fractures of the hip is to restore the patient's pre-injury activity level while minimizing morbidity and mortality and laying out a plan for secondary prevention of future fragility fractures.
To achieve this aim a multidisciplinary approach is required to cater for the wide variety of physiological disturbances that are often found in these patients.
The emergency physician would usually refer these patients straight to the orthopaedic surgeon and the later becomes a key player in the multidisciplinary team that will be looking after these patients.
Ekman in his review article gives a check list of management priorities that the orthopaedic surgeon must satisfy while treating fragility fractures of the hip. This check list ensures that patients receive a holistic treatment for a positive outcome. 12 The multidisciplinary approach is aimed at reducing peri-operative complications seen in patients being treated for fragility fractures of the hip. In a prospective observational study Pioli reported that the one year mortality risk increased by 12% per day of surgical delay. 13 It is therefore imperative that all unnecessary delays to surgery be proactively avoided to prevent morbidity and mortality.
All our patients had low dose morphine, tramadol and paracetamol prescription for pain control. This conservative approach undertreats pain and predisposes to pain induced delirium. In a single centre study, initiation of a standardized pain control program including the pre-operative use of femoral nerve blocks, avoidance of general anaesthesia and liberal use of oral intakes (food and oral fluids) pre-operatively resulted in much lower perioperative complications (pneumonia, urinary tract infection, delirium) compared to pre-programme rates. 14 Deep vein thrombosis (DVT) is another major complication that must be prevented in this fragile population of patients. A meta-analysis of prospective cohorts in Asian patients with hip fractures revealed that 26% of patients not on DVT prophylaxis developed a postoperative DVT. 15 It is therefore recommended that all patients receive effective DVT prophylaxis.
All our patients had low molecular weight heparin (Enoxaparin 40 mg once daily subcutaneously) prescribed for DVT prophylaxis. This was combined with a prescription of compression stockings for all patients.
Fifty-one percent of reviewed cases were patients above the age of 75. In this age group the incidence of fragility fracture rises significantly. 16 This probably due to a combination of frailty and senile osteoporosis. These patients need to be seen by a geriatrician who will optimise their medical condition while the orthopaedic surgeon focuses on surgical treatment. None of our patients were referred to a geriatricians.
A quarter of patients admitted with fragility fractures will develop delirium. 17 Predisposing factors for delirium include male gender, multiple comorbidities, low body mass index (BMI), prolonged surgery and general anaesthesia. 17 Post-operative delirium is usually transient but it can persist for more than 4 weeks in 20% of patients. Delirium is associated with lower functional recovery and higher mortality rate at 1 year. 18 Therefore the prevention of delirium becomes of paramount importance.
The literature supports that early referral to geriatricians is associated with lower rate of postoperative delirium. 19,20 Where the service of a geriatrician is lacking a specialist physician with interest in the field of geriatrics can be consulted for the management of these patients.
By definition a FFH implies a diagnosis of osteoporosis. According to the WHO criteria, a diagnosis of osteoporosis is made when a patient has a T score lower than -2.5 or when a patient presents with a typical fragility fracture defined as a fracture occurring after a fall from standing height or lower and has osteopenia on plain radiographs. 8  The management plan will differ between the 2 main forms of osteoporosis, namely: primary and secondary osteoporosis.
General nutritional and lifestyle modifications will apply to both primary and secondary osteoporosis and include regular physical activity, adequate intake of calcium, vitamin D and proteins.
A daily intake of at least 1.2g of calcium and 800 IU of vitamin D has been shown to reduce the relative risk of falls and fragility fractures more in the institutionalized elderly patients than in the community dwellers. 1,22 Sarcopenia is being increasingly recognized as an independent risk factor for falls and fragility fractures. 23 Physiotherapists and dieticians work together to correct sarcopenia and optimize physical performance of these patients for a better clinical outcome.
Smoking needs to be stopped and alcohol consumption moderated.
Pharmacological treatment will depend on the type of primary osteoporosis being addressed.
Postmenopausal osteoporosis may benefit from hormone replacement therapy early on but as senile osteoporosis sets in bisphosphonates therapy will be required to maintain adequate bone mineral density.
Once all causes of secondary osteoporosis have been excluded bisphosphonate therapy is indicated. High risk patients as determined by the applicable Fracture Risk Assessment Tool (FRAX index) are also eligible for treatment 22,24 . The FRAX tool combines patient's specific bone mineral density and clinical risk factors such as age, gender, body mass index(BMI), history of fragility fractures, history of maternal hip fracture and current smoking status to calculate a ten-year risk of hip or other osteoporosis related fractures for the patient being assessed. This tool is country specific. 24 Most commonly oral alendronate 70 mg weekly or zolendronic acid 5mg IV yearly is prescribed. 25 Alendronate has been proven to reduce the vertebral fracture risk by 60% and hip fracture risk by 30%. 25 Zolendronic acid once yearly study showed a 70% risk reduction of morphometric vertebral fractures and 41% risk reduction of hip fractures at 36 months. 26 The most debated side effects of bisphosphonates are atypical femur fractures, osteonecrosis of the jaw and delayed or impaired fracture healing. 22,25 The rate of atypical femur fractures varies in the literature but the known fact is that the incidence shows an exponential increase with the increase in the number of years of continuous bisphosphonates treatment. 25 Osteoclastic activity remains inhibited for a few years after discontinuation of bisphosphonates use. This allows for a "drug holiday" to minimise the rate of atypical fractures. 26 In the setting of osteoporosis treatment , the rate of osteonecrosis of the jaw is much lower than that of atypical femoral fractures. 25,26 A meta-analysis of 8 randomized controlled trials found that bisphosphonate treatment did not impair or delay fracture healing at short term (3 months) or long term (more than 12 months). 27 Other recent and not widely available pharmacological agents for the treatment of osteoporosis include parathyroid hormone (Forteo, Teriparatide), Denosumab (Prolia), Strontium Ranelate (Protos) and Cathepsin K inhibitors. 28,29,30,31 To simply provide a sound and early surgical fixation of the hip fracture and not address the underlying osteoporosis, frailty and certain possible causes of falls is in a way failing to provide the holistic and comprehensive management that these patients need.
The orthopaedic surgeon is most often the first specialist to see these patients and it is his or her responsibility to make early and appropriate referrals to geriatricians, physicians, endocrinologists, physical therapists and dieticians. These other team players will help optimize patients' medical condition to allow early surgery, early rehabilitation, optimal investigations, prevention and treatment of peri-operative complications and lay out a plan for osteoporosis treatment.
The literature shows that less than 10% of patients presenting to major trauma centres with fragility fractures of the hip are fully evaluated and managed for osteoporosis. This outlines the need to increase awareness of osteoporosis management in orthopaedic trauma centres worldwide. 4,6,32 This study was the first step of our quality assessment project for the management of fragility fractures of the hip at our institution. It has led to the development of a strict management protocol and the genesis of an orthogeriatric unit called GOGO (Geriatric Orthopaedic and Generalized Osteoporosis) that functions as our fracture liaison service for a focused and improved care for fragility fractures of the hip as the primary target.
The ortho-geriatric unit aims at providing an integrated service where orthopaedic surgeons and geriatricians provide an integrated care without the frustration of lengthy telephonic referrals. Geriatricians see these patients as their own patients and not as orthopaedic patients.
There are various models of integrated fragility fracture care available, each institution treating these fractures should adopt a suitable model that promotes an integrated multidisciplinary approach and optimal treatment of these fragile patients for secondary prevention of fragility fractures.

CONCLUSION
The vast majority of our patients had their hip fractures surgically fixed within the recommended time frame. Our management approach lacked the multidisciplinary integration that is recommended for these patients.
Osteoporosis and frailty were largely not addressed. The results of this study served as a platform to increase awareness of osteoporosis and frailty management as part of a multidisciplinary care for fragility fractures of the hip. We have subsequently formed a multidisciplinary unit in an effort to address our treatment deficiencies and to improve these patients' outcomes. 85% of patients were female and 15% were males.