The management of osteoporosis.

Osteoporosis poses a significant orthopaedic problem of epidemic proportions. Clear guidelines for the management of osteoporosis presenting early or late are still being debated. Several recommendations, however, are now generally accepted. Measurements of BMD should be taken if the diagnosis is in doubt or as an adjunct to encourage patient compliance with treatment. Those with multiple risk factors and who are under the age of 65 years would benefit from a scan. Those with previous fractures and no obvious risk factors should also be sent for DXA assessment. The elderly with fractures and multiple risk factors do not need scanning and can normally be started on treatment. Mass population screening is not cost-effective. Prevention strategies should be targeted at high-risk patients and not offered to everyone. In the perimenopausal woman HRT is the first line of treatment and prevention, along with changes in lifestyle. Tibolone may be an option for those who find cyclical bleeding unacceptable. In the elderly, institutionalised patient, calcium and vitamin-D supplements should be considered to replace depleted levels, particularly for secondary prevention. Postmenopausal women with multiple risk factors and at least one insufficiency fracture should be treated. The most likely pharmacological agent will be a bisphosphonate with supplemental calcium if indicated. Each hospital should have a recognised link person through whom referrals can be channelled, either a clinical nurse specialist or physician. A protocol for treatment should be agreed locally and publicised among the primary health-care groups. The first step of identification of high-risk patients is most often in fracture clinics. Standardised letters attached to the clinic note to general practitioners are an easy way of 'getting these patients into the system'.