An audit of the fracture liaison service at Helen Joseph Tertiary Hospital, Johannesburg, South Africa

Abstract

Summary

Fragility fractures are increasing worldwide, yet osteoporosis often remains underdiagnosed and untreated. This study found a high burden of osteoporosis risk factors among patients enrolled in a South African fracture liaison service, highlighting the need for structured secondary prevention. These findings support expansion of fracture liaison services to improve long-term patient outcomes in resource-limited settings.

Background

Fragility fractures (FF) driven by osteoporosis result in high morbidity and mortality and are a global health concern. Fracture liaison services (FLSs) are the gold standard for secondary prevention, yet data on their implementation and patient profiles in South Africa remain sparse. The Helen Joseph Tertiary Hospital (HJH) FLS was established to improve this care gap.

Objectives

To describe the clinical and demographic characteristics, risk factors for osteoporosis and falls, osteoporosis risk scores, and management of patients enrolled in the FLS at HJH.

Methods

This retrospective audit included 247 patients admitted to the orthopaedic ward and enrolled in the FLS between 03 October 2022 and 04 June 2024. Data on demographics, osteoporosis risk factors, investigations and management were analysed. Statistical significance was set at p < 0.05.

Results

The majority of patients were female (74.5%), aged 60–89 years (81.4%). Hip fractures predominated (59.9%), specifically neck of femur (38.8%) and intertrochanteric fractures (21.1%). Although 82.5% of patients received calcium and vitamin D supplementation, only 27.8% received in-hospital bisphosphonate therapy (Zoledronic acid). Medication shortages accounted for 60% of cases in which Zoledronic acid was not administered, while 12.4% were ineligible due to advanced chronic kidney disease. In-hospital mortality was 5%, and median length of stay was 18 days (IQR 11–28). Vitamin D insufficiency was prevalent (41.1%) and did not differ by ethnicity. Significant gender differences were observed: men had substantially higher rates of smoking (73% vs 46%) and alcohol use (48% vs 23%). Inadequate physical activity was a risk factor in both genders. Fall risks included a history of previous falls (42.0%) and cognitive impairment (Mini-Cog <3; 39.6%). Patients with hip fractures had significantly higher FRAX scores than those with fractures at other sites (p < 0.05).

Conclusions

This is the first South African Fracture Liaison Service study to report on fall risk, osteoporosis risk, and post-fracture management. Fragility fractures at Helen Joseph Hospital represent a substantial burden, with a high prevalence of clinical risk factors and notable gender-specific contributors, particularly alcohol use in men. While the FLS helps close the treatment gap, its impact is limited by inconsistent access to osteoporosis therapies. Improving outcomes in resource-constrained settings requires reliable medication supply and targeted interventions for fall prevention and modifiable risk factors.