The ageing of society is driving an enormous increase in fragility fracture incidence and imposing a massive burden on patients, their families, health systems and societies globally. [1] Disrupting the status quo has therefore become an obligation and a necessity. We call for implementation of a systematic approach to fragility fracture care with the goal of restoring function and preventing subsequent fractures without further delay.

There is an urgent need to improve:

  • Acute multidisciplinary care for the person who suffers a hip, clinical vertebral and other major fragility fractures
  • Rapid secondary prevention after first occurrence of all fragility fractures, including those in younger people as well as those in older persons, to prevent future fractures
  • Ongoing post-acute care of people whose ability to function is impaired by hip and major fragility fractures

Older people with fragility fractures often have pre-existing chronic diseases impacting their general management, short-term and long-term survival rate and functional recovery. Minimising delirium and avoiding complications is critical for achieving good outcomes. Appropriate pain management, rapid optimisation of fitness for surgery and early surgery improve morbidity and mortality. Adequate preoperative investigations should allow identification and treatment of acute medical illness or exacerbations of chronic medical conditions. [2]

Towards that goal it is increasingly recognised that people with fragility fractures should be managed in the context of a multidisciplinary clinical system, guaranteeing adequate and efficient preoperative assessment and preparation (Orthogeriatric Service - OGS). In people with hip fracture, the joint care model between geriatrician and orthopaedic surgeon on a dedicated orthogeriatric ward has been shown to drive shorter time to surgery, shorter length of inpatient stay and the lowest inpatient and 1-year mortality rate. [3]

People of all ages with a fragility fracture have an increased future risk for subsequent fractures. However, numerous studies conducted in all regions of the world have clearly documented a major and unacceptable treatment gap after the fracture. [4] Therefore, fracture risk evaluation should be mandatory to inform therapeutic decisions in these high-risk patients. Pharmacological and non-pharmacological treatment options are available and efficient to prevent further fractures – yet 80% of people presenting with fragility fracture remain unidentified and untreated. The organisation of post-fracture care through coordinator-led Fracture Liaison Services (FLS) has in many countries improved the delivery of secondary preventive care, comprising both osteoporosis management and falls prevention. These services have been shown to improve re-fracture prevention in the younger as well as older patient groups. [5,6]

As many as half of older people who were independent prior to sustaining a hip fracture fail to recover their pre-fracture ability to walk and carry out usual activities required to remain autonomous. Strategies for long-term rehabilitation that address these functional limitations also need implementation beyond the acute recovery period; these too require management by multi-disciplinary care teams working with patients and their families. [7]

To address this fragility fracture crisis, the undersigned organisations pledge to intensify their current efforts to improve the current management of all fragility fractures, prevent subsequent fractures, and strive to restore functional abilities and quality of life. The time is now and it requires we acknowledge that the status quo is no longer acceptable and that the opportunity starts with the next fractured patient!

In addition, they also call for specific actions in different sectors:

Patient and patient advocacy organisations
  • To call for access to care at the right time, in the right place and by the right health care professionals so as to optimise patient outcomes and recovery after a fracture and to prevent further falls and fractures
Individual Health Workers:
  • to seek, create and follow evidence-based best practice
  • to form multidisciplinary teams with colleagues to identify and address the needs of people with fragility fractures
Health professional societies
  • to collaborate nationally and locally to form alliances to speak with a unified voice to policy makers
  • to produce consensus guidelines setting clear standards for adequate care using the best available research evidence, and propose metrics to evaluate performance
  • to expand education and research programs that can establish best practice
Governmental organisations
  • to respond to the threat posed to their societies from fragility fractures
  • to recognise the critical role that they play in establishing health systems capable of addressing this challenge
  • to prioritise acute and long-term fragility fracture care and prevention in National Health Strategies
  • to increase funding available to develop, implement and test care models (i.e. OGS and FLS) designed to improve outcomes for people with fragility fractures
Insurers (private and public)
  • to reimburse the most effective services to improve the management and fracture prevention in people who sustain a fragility fracture
  • to incentivise where appropriate the delivery of best care
  • to provide additional resources for research on best practices for care of people sustain fragility fractures
Health systems and medical practices
  • to adopt and benchmark against quality standards
  • to incentivise clinicians and health systems to deliver optimal acute and long-term management and secondary prevention of fragility fractures
  • to provide additional resources for research on best practices for care of fragility fractures
  • to collect and analyse information on people who sustain fragility fractures, their care and long-term outcomes and to use this information to effect changes in care and to monitor their progress and clinical outcomes
  • to respond to care and service needs by developing and evaluating new products and technologies intended to improve patient outcomes through clear patient value
  • to work collaboratively with professional societies, government organisations, universities, insurers and health care systems in the development and evaluation of these products and technologies
  • to advocate globally for implementation of systematic approaches to fragility fracture care and fracture prevention like OGS and FLS.

The mandate is upon us to address the unacceptable crisis of under-recognised and undertreated people who have sustained an osteoporotic fracture. Our patients and society can no longer wait!


[1] Sànchez-Riera L, Wilson N. Fragility Fractures & Their Impact on Older People. Best Pract Res Clin Rheumatol. 2017;31(2):169-191.

[2] Wilson H (2017). Pre-operative management. In: Falaschi P, Marsh DR (eds). Orthogeriatrics. Springer

[3] Prestmo A, Hagen G, Sletvold O, Helbostad JL, Thingstad P, Taraldsen K, Lydersen S, Halsteinli V, Saltnes T, Lamb SE, Johnsen LG, Saltvedt I. Comprehensive geriatric care for patients with hip fractures: a prospective, randomised, controlled trial. Lancet 2015;385:1623–33

[4] Harvey NC, McCloskey EV, Mitchell PJ, Dawson-Hughes B, Pierroz DD, Reginster JY, Rizzoli R, Cooper C, Kanis JA.. Mind the (treatment) gap: a global perspective on current and future strategies for prevention of fragility fractures. Osteoporosis International 2017 May;28(5):1507-1529.

[5] Ganda K, Puech M, Chen JS, Speerin R, Bleasel J, Center JC, Eisman JA, March L, Seibel MJ. Models of care for secondary prevention of osteoporotic fractures: a systematic review and meta-analysis. Osteoporosis International 2013, 24, 393-406.

[6] Blain H, Masud T, Dargent-Molina P, Martin FC, Rosendahl E, van der Velde N, Bousquet J, Benetos A, Cooper C, Kanis JA, Reginster JY, Rizzoli R, Cortet B, Barbagallo M, Dreinhöfer KE, Vellas B, Maggi S, Strandberg T; EUGMS Falls and Fracture Interest Group; European Society for Clinical and Economic Aspects of Osteoporosis and Osteoarthritis (ESCEO), Osteoporosis Research and Information Group (GRIO), and International osteoporosis Foundation (IOF). A Comprehensive Fracture Prevention Strategy in Older Adults: The European Union Geriatric Medicine Society (EUGMS) Statement. J Nutr Health Aging. 2016;20(6):647-52.

[7] Dyer SM, Crotty M, Fairhall N, Magaziner J, Beaupre LA, Cameron ID, Sherrington C; Fragility Fracture Network (FFN) Rehabilitation Research Special Interest Group. A critical review of the long-term disability outcomes following hip fracture. BMC Geriatr. 2016;16:158