As Hong Kong’s population ages, osteoporosis has emerged as a significant health concern, currently affecting an estimated 400,000 individuals. The rising incidence of osteoporotic or fragility fractures contributes to increased morbidity and mortality, creating a substantial burden on the healthcare system. At a scientific symposium, experts in cardiology, orthopaedic surgery, geriatrics, endocrinology, and anaesthesiology explored how a multidisciplinary approach can enhance the management of fragility fractures, particularly hip fractures. The discussions focused on optimizing care from the point of admission through to recovery, with an emphasis on postoperative prevention of imminent fractures using an osteoanabolic-first approach to improve patient outcomes.
Multidisciplinary care for fragility fracture
Fragility hip fractures are common in older adults, with approximately 95 percent of cases due to falls. The mortality rate after a hip fracture is 5–10 percent within the first month, and approximately one-third of patients die within a year. Previous fractures are the strongest predictor of future fractures, with most subsequent fractures occurring within 2 years of an initial event. [BMC Geriatr 2016;16:158; Hong Kong Med J 2019;25:235-42]
Orthopaedic surgical intervention is often necessary for hip fractures. As many of these patients are elderly with multiple comorbidities, a multidisciplinary approach involving anaesthesiologists, cardiologists, endocrinologists and geriatricians is needed to optimize surgical outcomes. [Osteoporos Int 2022;33:2049-2102; J Am Acad Orthop Surg 2022;30:e1291-e1296]
Postoperatively, preventing further fractures is crucial yet challenging, with barriers including lack of fracture liaison services (FLS) and low prescription rates for osteoporosis medications. These issues highlight a significant treatment gap, necessitating a collaborative multidisciplinary effort to enhance patient compliance and ensure secondary prevention with effective treatments. [Hong Kong Med J 2019;25:235-42]
Preoperative assessments
“When a patient with geriatric hip fracture arrives at the emergency room, baseline blood tests, an electrocardiography and a chest X-ray are conducted. Emergency doctors initiate pain management and aim to admit the patient within 4 hours. Orthopaedic surgeons utilize an orthogeriatric co-management approach, following standardized guidelines and clinical pathways. Same-day preoperative assessments involve communication with anaesthesiologists and other specialists regarding medical comorbidities. We also initiate FLS, coordinated by FLS nurses,” noted Dr Stephanie Liu, Specialist in Orthopaedics & Traumatology at Princess Margaret Hospital. “While fragility hip fractures are semi-urgent rather than orthopaedic emergencies, it is essential to coordinate with a multidisciplinary team, including allied health professionals, social workers and family members, before proceeding with surgery.”
Considerations for safe operations
Anaesthesiologists’ perspective
“For older patients undergoing hip fracture surgery, research indicates no significant reduction in mortality rates with regional anaesthesia [RA] vs general anaesthesia [GA]. However, RA may offer better postoperative outcomes, making it slightly preferable,” highlighted Dr Man-Shun Law, Specialist in Anaesthesiology from Kwong Wah Hospital (KWH). [J Orthop Surg Res 2023;18:428]
Cardiologists’ stepwise approach
Cardiologists evaluate risk factors in patients with cardiovascular disease to determine if surgery can proceed or if further evaluation is required. They use validated risk-prediction tools to estimate the likelihood of major adverse cardiac events perioperatively. Additional assessments, such as biomarkers, stress tests, CT angiography, and echocardiography, are conducted for symptomatic patients with poor functional capacity undergoing high-risk surgery. Low-risk patients typically proceed to surgery, while higher-risk patients may require further testing, optimization of therapy, or multidisciplinary consultations. [Circulation 2024;150:e351-e442]
“For patients on antiplatelets or anticoagulants, discontinuation of aspirin or clopidogrel is advised for 5–7 days, and direct oral anticoagulants [DOAC] should be withheld for 2 days before elective surgery. Reversal agents for DOAC may be necessary in urgent cases,” suggested Dr Carmen Chan, Specialist in Cardiology from Queen Mary Hospital (QMH).
Endocrinologists’ insights
Diabetes is a significant risk factor for hip fractures, increasing perioperative morbidity and mortality. Careful planning is essential, as hip surgery, especially in patients with poor glycaemic control, can potentially precipitate diabetic ketoacidosis (DKA). “Therefore, optimizing glycaemic control is vital. For adult patients with diabetes undergoing elective surgical procedures, guidelines suggest targeting preoperative HbA1c ≤8 percent or blood glucose levels of 5.6–10.0 mmol/L within 4 hours before surgery,” suggested Dr Paul Lee, Specialist in Endocrinology, Diabetes & Metabolism, University of Hong Kong (HKU). [Diabetes Care 2007;30:835-841; J Bone Miner Metab 2025;43:553-563; Br J Anaesth 2023;131:242-252; J Clin Endocrinol Metab 2022;107:2101-2028]
“Managing patients on antidiabetic agents, particularly sodium-glucose cotransporter 2 inhibitors [SGLT2i] and glucagon-like peptide 1 [GLP1]–based pharmacotherapy, requires careful consideration of when to stop and resume these medications to prevent complications. For elective surgeries, SGLT2i should be discontinued 3 days prior, whereas for urgent cases involving insulin or SGLT2i, a dextrose-potassium-insulin [DKI] drip should be administered to prevent DKA. Monitoring for DKA development postoperatively with high alertness is crucial,” emphasized Lee. [Br J Anaesth 2023;131:242-252; Diabetes Metab Syndr Obes 2014:7:255-264]
“Many heart failure patients are on SGLT2i even if they don’t have diabetes, and may develop ketoacidosis. For urgent surgery, a DKI drip should be given, but care must be taken to avoid fluid overload,” Chan echoed.
Postoperative care
“Optimizing bone health after surgery is paramount,” said Dr June Yeung, Specialist in Geriatric Medicine, KWH. “Our orthogeriatric team, including orthopaedic surgeons, geriatricians and nurses, collaborates with allied health professionals, the dental department and FLS nurses to ensure a smooth transition from inpatient care to the outpatient osteoporosis clinic. Before discharge, we will formulate an osteoporosis management plan for our patients and ensure that drug treatment for secondary prevention is initiated or arranged. We also develop holistic plans for discharge, rehabilitation and follow-up. Additionally, we provide education to patients and their families to optimize osteoporosis care after discharge.”
“QMH has also implemented a similar vertebral fracture pathway to foster collaboration between orthopaedic surgeons and endocrinologists in addressing osteoporosis, particularly as patients with diabetes are more likely to be lost to follow-up and have recurrent fractures when glycaemic control is suboptimal. Since implementation, the post–vertebral fracture osteoporosis treatment rate has markedly increased to approximately 80 percent upon discharge in the recent years,” noted Dr David Lui, Specialist in Endocrinology, Diabetes & Metabolism, HKU.
Superiority of osteoanabolic agents for secondary prevention
“Prior low-energy hip or vertebral fractures are strong predictors of imminent fractures, making osteoporosis treatment necessary regardless of bone mineral density [BMD] T-score,” emphasized Lui. “Even for morphometric vertebral fractures, we should consider initiating antiosteoporosis treatments, including antiresorptive or osteoanabolic agents. Significant decrease in body height may suggest the need to exclude vertebral fracture.”
Romosozumab, an osteoanabolic agent, is a humanized monoclonal antisclerostin antibody that increases bone formation and decreases bone resorption. Pivotal trials, FRAME and ARCH, have established romosozumab as an important option for patients at high fracture risk. [N Engl J Med 2016;375:1532-1543; N Engl J Med 2017;377:1417-1427]
In the phase III FRAME study involving 7,180 postmenopausal women with osteoporosis, treatment with romosozumab significantly reduced the risk of new vertebral fractures by 73 percent vs placebo (0.5 vs 1.8 percent; rate ratio [RR], 0.27; p<0.001). Romosozumab also significantly decreased the risk of clinical faracture vs placebo. [N Engl J Med 2016;375:1532-1543]
Similarly, the ARCH study, a phase III randomized controlled trial (RCT) involving 4,093 postmenopausal women with osteoporosis and fragility fractures, showed that treatment with romosozumab followed by open-label alendronate significantly reduced the risk of new vertebral fractures by 48 percent (6.2 vs 11.9 percent; RR, 0.52; p<0.001) and hip fractures by 38 percent (2.0 vs 3.2 percent; hazard ratio, 0.62; p=0.02) vs the alendronate-to-alendronate group. Risk reductions were consistently observed for clinical and nonvertebral fractures. A bone structure analysis revealed that romosozumab significantly improved bone density in both cortical and trabecular bone vs alendronate. [N Engl J Med 2017;377:1417-1427; J Bone Miner Res 2021;36:2139-2152]
“Notably, the dual effect of romosozumab makes it more potent than previous treatments, including teriparatide,” remarked Dr Raymond Yip, Specialist in Orthopaedics & Traumatology in private practice. [N Engl J Med 2014;370:412-420]
In a phase II RCT involving 419 postmenopausal women with low BMD, all five dose levels of romosozumab resulted in significant increases in BMD at the lumbar spine. Romosozumab 210 mg Q1M yielded the greatest BMD gains at the lumbar spine, total hip and femoral neck vs teriparatide, alendronate and placebo over 12 months. (Figure 1)
Furthermore, romosozumab demonstrated superior efficacy vs teriparatide in improving bone density. Over 12 months, romosozumab showed significant increases in mean vertebral cortical thickness (10.3 vs 4.3 percent), endocortical thickness (137.6 vs 47.5 percent), cortical BMD (2.1 vs -0.1 percent) and cortical mass surface density (12.4 vs 3.8 percent) vs teriparatide. [J Bone Miner Res 2022;37:256-264] “Romosozumab outperformed teriparatide in all cortical parameters, indicating comprehensive enhancement of vertebral bone structure,” Yip noted.
The most common adverse effects associated with romosozumab are nasopharyngitis and arthralgia. Use of romosozumab is contraindicated in patients with hypersensitivity to romosozumab or its excipients, hypocalcaemia, or a history of myocardial infarction or stroke. [Evenity Hong Kong Prescribing Information]
“Currently, the Hospital Authority [HA] reimburses romosozumab for postmenopausal women at very high fracture risk who maintain a reasonable quality of life. Eligible patients must have experienced a major osteoporotic fracture within the past 24 months and have a history of >1 previous fracture, with ≥1 occurring in the hip or spine. Reimbursement is available for a treatment duration of up to 12 months,” said Dr Kevin Mao, a geriatrics resident in United Christian Hospital.
Recommended strategy: An osteoanabolic agent first
“Evidence from ARCH and related sequential‑therapy analyses supports using an osteoanabolic agent first, followed by a potent antiresorptive, to maximize and maintain fracture risk reduction over time,” highlighted Mao.
A review article indicated that starting romosozumab de novo results in greater BMD gains than initiating treatment with prior alendronate or denosumab exposure. [J Clin Endocrinol Metab 2024;109:303-311] “This suggests that beginning with osteoanabolic agents before transitioning to an antiresorptive drug can maximize patient benefits,” Lui noted. (Figure 2)
“A recently published network meta‑analysis identified romosozumab as the most potent bone-forming option for rapid BMD gains and early fracture prevention, followed by anti-RANKL antibody, such as denosumab, as the most effective antiresorptive agent for long-term maintenance,” noted Mao. “This osteoanabolic-first strategy is recommended by the Osteoporosis Society of Hong Kong for individuals at very high risk of major osteoporotic fractures for achieving rapid BMD increases, improving bone microarchitecture, and reducing fracture risk.” [J Orthop Surg Res 2025;20:645; Hong Kong Med J 2024;30(Suppl 2):1-44]
This special report is supported by an education grant from the industry.
