Healthy Bones After Hip Fracture: From Guidelines to Practice

In this episode of Hipcast, we’re joined by Dr Angela Sheu, Staff Specialist Endocrinologist at St Vincent’s Hospital Darlinghurst, Conjoint Senior Lecturer at UNSW, and Research Officer at the Victor Chang Cardiac Research Institute, alongside Professor Jacqui Close, internationally recognised orthogeriatrician and co-chair of the ANZHFR.

Together, we unpack the updated Healthy Bones Australia recommendations and what they mean for clinicians caring for people after hip fracture. Angela and Jacqui discuss the persistent osteoporosis treatment gap, why the post-fracture period is a critical window for intervention, and how the latest evidence is shaping recommendations around treatment initiation and sequencing.

We also explore the practical realities of implementing these guidelines across hospital and community settings, including the role of fracture liaison services, shared care, and strategies to reduce the risk of patients being lost to follow-up.

Importantly, the conversation highlights that a hip fracture should be seen not only as an acute event requiring surgical management, but also as an opportunity to prevent the next fracture through timely, coordinated osteoporosis care.

🎙️ Hipcast is hosted by Dr Niamh Dove and produced by the Australian and New Zealand Hip Fracture Registry, dedicated to improving outcomes and experiences for people with hip fracture and those who care for them.

Transcript

SPEAKER_00 0:02

Hello and welcome to Hipcast, the podcast here to improve hip fracture care. I'm your host, Dr. Neave Dub. Join me today to welcome Dr. Angela Shu, staff specialist endocrinologist at St. Vincent's Hospital, Darlinghurst, conjoint senior lecturer at the University of New South Wales, and research officer at the Victor Chang Cardiac Research Institute, alongside Professor Jackie Close, Ortho Geriatrician at Prince of Wales Hospital, and co-chair of the ANS at HFR. Today's discussion focuses on the updated Healthy Bones Australia recommendations, osteoporosis treatment after hip fracture, and the ongoing challenges to improving secondary fracture prevention in real-world clinical care. We at the Australian and New Zealand Hip Fracture Registry acknowledge the Gadigal people of the Aura Nation as the traditional custodians of the lands on which we meet today. We pay our respects to elders past, present, and emerging, and extend that respect to any Aboriginal, Torres Strait Islander, or Maori people joining us today and listening on the podcast. Welcome to you both. Thank you for joining. Thank you for having me. Angela, I thought to start, could you briefly outline the key changes in the updated Healthy Bones Australia recommendations and what prompted the need for an updated guidance at this point?

SPEAKER_02 1:13

Yes, so the ROC GP, the Royal Australian College of GPs and Healthy Bones Australia, released these guidelines initially in 2010 and then there was an update in 2017, and then now again in 2024. So you can see that over this time it's been there's been actually many changes that have occurred over these years. They've not been updated that frequently. So these are agents that aim to build bone, and these are, as expected, superior to anti-resorptive agents, both in terms of bone mineral density gains and also in fracture risk reduction. So the 2024 guidelines really focused on that, how to incorporate osteoanabolic agents now that these were available, both on the PBS and on the PBS as well. As well as the new issue that had come about sort of in the prior seven years since the last guidelines 2017 of denosimab continuation or discontinuation, really. So in 2017, the biggest new thing at that point was that Denosimab had become available. And so it was sort of the new kid on the block, it was very exciting, excellent drug, very well tolerated, and very good uptake in the community in particular. And so now 2024, actually, it sort of was not the opposite message, but a different message of saying, well, now what do we do now that people have been on these medications, particularly Denosimab, for now five to seven to ten years and how to manage those patients. So I'd say that those were the two key changes and key focus of the guidelines. There are a few other nuances with specific medications, some special scenarios, but those were the two key things that needed to be needed to come out. And then since 2024, actually, 2026, there was a slight update to the summary flow chart because there were some changes with the PBS guidelines in terms of prescribing for rhomososiumab or osteoanabolic therapy. So really the main change of these updated guidelines was the concept of osteoanabolic therapy and the concept, sorry that I should say in particular, that these agents should be considered earlier in the management of osteoporosis. So previously they were sort of thought of as second-line therapy, partly due to the restrictions with funding. But now the concept that these agents, because of their superiority, should be used upfront in people, particularly at very high fracture risk. And that concept of very high fracture risk rather than just high fracture risk is also being introduced in these guidelines.

SPEAKER_00 3:49

Thank you. And I've included the updated guidelines in the bio of this episode for anyone wanting a deeper look. Jackie, from an orthogeriatric perspective, how significant is the treatment gap in osteoporosis care after hip fracture? And why is the post-fracture period such an important opportunity for intervention?

SPEAKER_01 4:06

So a few things to say on that, Neve. Like there is such good evidence that older people benefit from treatment for osteoporosis, both in terms of primary and secondary prevention, and that includes after hip fracture. And if we ignore the osteoanabolics just for now and look at where we are at this point in time after hip fracture, so the last report we released was at the end of 2025. And at that time, if you look across Australia and New Zealand, only 35% of patients leave hospital on treatment for osteoporosis after a hip fracture. That is woeful. The best performing hospitals manage to get over 80% of patients on treatment. Treatment that we know to be effective to substantially reduce their future fracture risk. And it is really important to remember that your risk of future fracture is greatest within that first year of hip fracture. So that's a huge gap. You can look at 120 days and you can use the argument that some people will use, well, actually, we don't get time to put them on treatment in hospital. We do it through fracture liaison services or we do it and the GPs will start them. Well, there's an element of truth to that. But if you look at our 120-day follow-up, and not all hospitals do 120-day follow-up, we specifically ask at that time point as well what percentage of people are on treatment for osteoporosis. It does go up, but it's still less than 50%. That's a huge gap where people are being left exposed to something that is potentially preventable. So I think we've got a major issue without the introduction of the complexity of the osteoanabolics, and I am not against the osteoanabolics. I think there's just so much more we need to do to get the basics right.

SPEAKER_00 6:10

Yeah, it seems like an issue with practicalities more than anything. Angela, what do the recommendations suggest around first line therapies, timing of treatment initiation and sequencing, particularly for older and frailer patients who have sustained a fragility fracture?

SPEAKER_02 6:24

Yes, I completely echo Jackie's sentiments here. I think that there is no lack of evidence of the benefit of these medications. And there's on the one hand, there's recommendations based on that evidence, which is what is good and what is best for patients. And then there's the real competing interest of what's actually the practicalities of it. And particularly, which I think we'll touch on a little bit later, is the issue of the PBS sort of substance subsidy and the requirements you need in order to initiate therapy. But if we put that aside first and say what are the recommendations, well, exactly as Jackie said, you know, we know that immediately after a fracture is the most high risk period of time for patients, particularly in older people who have suffered a hip fracture. They are at significantly elevated risk of a repeat fracture, subsequent fracture within the first two years. And really, it is such a critical time to initiate therapy, to think beyond just the broken bone that's been fixed, and to think about a person and how we can actually reduce their morbidity and mortality by protecting their whole skeleton. So the current recommendations for people who have suffered a hip fracture, which is a high-risk fracture, is to think about osteoanabolic therapy first line. That is reflected in the PBS, in that you can now get osteoanabolic therapy first line if you've suffered a hip fracture and have low enough bone mineral density. This was updated in 2024. But uh because that because that has been shown to show have the best BMD gains and fracture risk reduction. In a person, particularly who's just had a hip fracture, this is the exact person that needs the best care that they can get. If we can initiate that sooner rather than later, that is going to probably be better because then then it's actually been initiated. So ideally that would happen ASAP, ideally within the hospital admission, but even out to one year, which is still pretty bad, which is better than what a lot of people are already doing. So thinking about strategies how to actually initiate it sooner rather than later is definitely important. Um, the concept of sequencing is really a new concept as well. And this is that osteoanabolic therapies, those that build up bone, um, do better in terms of bone mineral density gains and fracture risk reduction if you initiate these agents prior to an anti-resorptive agent. So in people who've not been treated with an anti-resorptive agent, they will have better outcomes from a skeletal perspective if they uh initiate on osteoanabolics. And that was one of the reasons that the PBS were happy to move forward to increase the indications for use of osteoanabolics. However, and this is this is the issue with the practicalities, is that um if if the option is no treatment or anabolic and and and they don't get the anabolic, that means at the end of getting no treatment, these people will do far worse by not having any treatment. Um so although the guidelines do suggest that anabolics first would be are better, the big issue is the practicalities, particularly in these admitted patients who are complicated, often have fragmented care, often will see multiple different people before they make it home, and how to continue this care in the community. Um, so that that doesn't mean to say that anti-resorptives are not a useful agent. And certainly in the context of the practicalities, it can actually be still extremely useful to think about those medications for a patient's ongoing care because any treatment is still better than no treatment.

SPEAKER_01 9:58

It is about the practicalities. I don't think anybody is arguing about the potential benefits of the osteoanabolics. We should be welcoming them. They are here to stay, um, they're going to be around for a long time. It's getting the practicalities of assessment, investigation, initiation of treatment. That's that's where we're struggling. And the PBS has has added that layer of complexity. So for the hip fracture population, so so for me from a personal perspective, I use uh zolidronic acid for the majority of people that I see in hospital and know that they leave hospital on active treatment that would last at least a year, but maybe longer. And now we're trying to work through the logistics of um rhomosauziumab in particular, being available first line, but it requires us to do a bow mineral density. It's or some other way of measuring bow mineral density, of which a DEXA is the most common. Um but trying to get somebody who's just had a hip fracture onto a scanner table is complicated, it's painful, um, it is not straightforward. So then you will need to bring them back to an outpatient setting, do the DEXA at a later date, bring them back to an outpatient setting. There are a lot of um clinics where the waiting time for endocrinology and bone health are substantial, six to nine months. And for the that period of time, that individual is left without treatment. Um, and it is possible that their bone mineral density is not less than minus 2.5, um, and that they don't actually qualify for the PBS subsidized rhombososiumap. So it it's not the agent itself, it's the process that we have to go through and the time frame that it takes that is causing um some concern. And Angela's absolutely right. Something is better than nothing. Um and dysphosphanates and dinosiumap absolutely do still have a role in terms of managing osteoporosis. Um and so I still use quite a bit of that and bringing the younger patients back, but I've had to generate a new clinic to deal with some of these um issues.

SPEAKER_00 12:12

From I guess both of your perspectives, but maybe Jackie, for you to carry on, how should services navigate this in practice or how are you navigating it? And is the expectation that the responsibility and the treatment should be started by the hospital, if we're actually fractional liaison service or handed over to a community or specialist follow-up? Like how do we minimize that risk of patients being lost to follow-up so that we can make sure we're catching them in that transition?

SPEAKER_01 12:36

It probably needs to be done at a hospital stroke community level. Um, everybody's setup is slightly uh different. Um, some people have very comprehensive fracture liaison services that may be able to deal with this quite quickly and maybe streamline people into early BMD shortly after discharge, but but at a time when they're able to get on to a DEXA scanner table. Um some people will make a decision that they're gonna stick with the older agents if they don't believe that there's gonna be a significant um delay. So give consideration to people from residential age care facilities with cognitive impairment. These are often people that don't come back to fracture liaison um services, um, who don't often come back to outpatient services. They may be a group of individuals that you make a decision that you're gonna carry on using a clastor or an oral bisphosphonate or donoziomab. But but I think you have to work it out at a local level. Um but it is a pathway and everybody needs to sign up to the pathway. So it's going to be your geriatricians looking after the hip fractures in hospital, but it'll be your endocrinologists, metabolic bone specialists, etc. Um, to have a conversation with them. Well, actually, we'll say for the some of the younger ones potentially, but but that's an arbitrary um figure. Um how are you going to ensure there is a streamlined mechanism for getting them investigated early with treatment initiated early and not a year down the track?

SPEAKER_00 14:16

Angela, do you have any suggestions on how we minimize this risk of patients being lost to follow-up in the transition?

SPEAKER_02 14:21

This is this is a big problem. This is a really big issue. Um, and exactly the question of what would be the, again, what was the most optimal pathway, and then what is practical. There's no doubt that the number of patients exceed the number of um services sort of available. Um, that doesn't mean to say that we can't think of different strategies, but yeah, exactly as Jackie said, it's got to be individualized, and uh that comes down to both the local services but also the practicalities for the individual patient. Where I work in in a city, Sydney, um it's one of the most sort of connected but disconnected places in a lot of ways, um, in so much that you've got people who in theory can access lots of resources, but but it's it's not coordinated in a way where these people who are very vulnerable, they've just been discharged from hospital often and they don't know who they spoke to, let alone who they're following up with. Um, there's a bit of an assumption, and I think it's a fair assumption, that if you come into hospital, you will get good quality care and that you will be thought of holistically. And so when that isn't necessarily put that the plan or that transition isn't spelt out, I think it's very difficult in the community to pick up from there, um to really people in. We have a fractal liaison service that is inundated. Um, and you know, in terms of trying to exactly prioritize these people who are highest risk, um, is uh in theory very straightforward, but in practice not easy. Um, and as as we mentioned before, the issues of getting bone mineral density scared to fulfill the PBS criteria, a seemingly straightforward, just go get this test and then come. That doesn't, that that's not easy, particularly for an inpatient, multiple reasons for an inpatient, um, let alone an outpatient. Um, I guess an ideal setup would be a specific service that says these are the people that have come in, this is what we have initiated for for whichever reason. Um, and I again echo that you know the the big focus on the anabolics is is a good thing, but it doesn't mean that the anti-resorptives are a bad option. They're still good drugs. We actually have the benefit of multiple different options. Um, but with choice comes, you know, a decision-making process that isn't always clear and very individualized. So that's what can be hard. But nevertheless, I think a process which starts in hospital, we say this is what someone started on. This is the the very streamlined one-stop shop fits all type of place that you come to get all your testing and an assessment made. Um, and in theory, that's really straightforward, but in practice it's just so hard to do. Um, and we've been trying to work on how to do that in in our service, um, but it just hasn't been possible yet. So it does require good communication with the community um services, whether that's the GP or some sort of transitional service, um, to say, you know, you're gonna come back and forth, probably for whatever reason, sometimes to the orthopedic, sometimes to the geriatrician, sometimes to the physio, sometimes just to the hospital for something else. How come you keep coming and we never see you? How come we can't link you in? And part of it is just the fact that everyone is um, you know, we're just overstretched, particularly in the public health system.

SPEAKER_00 17:34

And I think as well, you know, for patients trying to navigate the system, it's so confusing. I think what's the um in general practice, it's like 40% of patients um find it overwhelming and difficult to coordinate their care. And then you want to add a hip fracture and all the complexities of that into the equation. Um, I guess um, one of my other hats I wear is in general practice. And so I was wondering, you know, where where can we be optimizing general practice because all these hospitals, clinics, and follow-up are so saturated. Is there a more of a role that where GPs could be stepping up into this role, or how do you see that in the future?

SPEAKER_02 18:07

I think one of the issues is because there are so many different options with medications now, I wonder if GPs find it a little bit overwhelming as well in terms of who what should I um commence this patient on? Say they've been a really great GP who's picked up that this person has come into hospital and been discharged without therapy, um, which is not that uncommon, you know, and they say, Oh, well, hang on, I would have started this, but I'm sure the the GP, the the doctors, sorry, in hospital thought of it and there must be a reason they didn't. I get that, I get that frequently that the patients finally come to see me and they say the GPs did think about it, but wasn't weren't sure or thought there must be a reason and so waited until they came that you were able to see me. And that's fine if we get to see those patients, but for the patients that take too long to see us or fall off because something else has happened, um, that's a real that's a real treatment gap and a real issue. And that's if we've even thought about it. Um, so that's one of the reasons I suppose the guidelines was supposed to try and help with that. But again, one of the issues is the anabolics have to be um physician initiated. So even if the GP knows and and has rightly um assessed this patient to be a person for this medication, they still can't even initiate it. Um, and that's uh just another, you know, it just is so many roadblocks along the way. Um but I I I think, you know, even just having been providing the GPs um to to even think about this, to have a referral pathway, um, that that I think would be a good start.

SPEAKER_00 19:29

I mean, we've touched on some of these, but what are like and I guess in addition to this barrier, what are other common barriers that clinicians are facing when trying to implement osteoporosis treatment recommendations across Australia?

SPEAKER_02 19:39

There's a lot of media about um the pros and cons of medications um for patients in general. Um, and it's right to be informed, it's good um to discuss this. Um, but I think there's again because there's so many different options, it makes it um tricky for someone to for a patient to sort of weed through all the differences and to say, you know, my friend did this, but I heard about this. And you know, ultimately we know that medicine should be practiced on an individualized level with consultation with a healthcare professional. Um and sometimes the there's a there are mixed messages coming out. Um, and then again, in an ideal world, you'd have a scenario where someone would have that discussion early on to, I suppose, uh frame the um management for that patient before they've sort of heard the things from other people. And really the hospital sometimes is a really good place for that, um, notwithstanding that often patients are there on their own and they might need you know good supports and and that sort of thing, which sometimes is lacking and because the hospital is such a chaotic environment, um, it can be tricky there.

SPEAKER_01 20:43

I think that's a really good point. I think public awareness is is part of our problem. We seem to be more aware of the complications of the drugs than the benefits of the drug. I mean, if you compare, so for example, hypertension is known to be a risk factor for stroke, but low BMD is a better predictor of fracture risk than hypertension is of going onto a stroke. Yet you would never dream of leaving somebody with high blood pressure for prolonged periods of time. And the public know that high blood pressure is bad, or having high cholesterol in ischemic heart disease is bad. There isn't the same awareness. There's not the same aware public awareness. Um, and that that's a real challenge um for us. So some of the barriers are between the ears, I'm afraid, and and we do need to do an awful lot more around public awareness.

SPEAKER_00 21:39

Well, sir, Jackie. Thank you to you both. To finish, what's one practical thing clinicians or services could do differently tomorrow to improve secondary fracture prevention after hip fracture? Just one. And it's one practical thing.

SPEAKER_02 21:51

Um at the top of your list. Um focusing on practical then, um, rather than one. Um I I think it's actually empowering the patient in hospital. I mean, if we're thinking about secondary fracture prevention after hip fracture, they're in hospital, empowering the patient to know that after discharge it doesn't end. There's there's all these people to follow up with and to encourage them to speak to their GPs and to come back. Um, because I think there's so much missed opportunity. Should be um in an ideal world, again, you know, we would have multiple ways to fill the gaps of where this is happening. Um but because there's such a bleed out, you know, we we don't even get that opportunity to come back. So I think empowering the patient to say, after discharge, you definitely need to see the person who put your bones together, but also remember every other bone pretty much. Um and then if we think about it in that way, then maybe we will think about systemic threat um treatment for these people.

SPEAKER_01 22:53

I think similar message for me. These these people in hospital provide that there is a window of opportunity to initiate treatment. I started off with the figures 35% leave hospital on treatment for osteoporosis. That's a national embarrassment. It's less than one and two at four months. As we navigate the complexities of how we build in the osteoanabolics into our treatment pathways, please don't forget that there are really good agents already available that we should be getting people on. And then as we get our pathways sorted out, we introduce the osteoanabolics in a way that just incorporates them over time. But doing nothing is not an option.

SPEAKER_00 23:40

Please, everyone, take that home. So thank you for joining us on Hipcast and for sharing your expertise and insights today. The listeners will include those links to the updated Healthy Bones Australia recommendations during the episode. So thank you once again.

SPEAKER_01 23:51

Thanks, Nathan. Thank you.