DVO Guidelines Research Articles

Secondary fracture prevention/Update osteoporosis guidelines 2023 of the Umbrella Organization Osteology

The S3guidelines on the prophylaxis, diagnostics and treatment of osteoporosis 2023 were completely revised and updated between 2021 and 2023 in accordance with the Association of the Scientific Medical Societies of Germany (AWMF) regulations. The guideline committee consisted of delegates from the 20specialist societies of the Umbrella Organization Osteology (Dachverband Osteologie, DVO) as well as delegates from the German Society of General Medicine and Family Medicine (DEGAM), the German Society for Nephrology (DGfN) and the Federal Self-help Association for Osteoporosis (BfO).The guidelines focus on preventive measures, diagnostic procedures and treatment approaches for osteoporosis in men aged50 years and over and postmenopausal women. The main aim is the optimization of care processes, reduction of fracture incidences and maintenance or improvement of the quality of life and functional capacity of patients affected by fractures. Amajor update to the guidelines includes the introduction of anew risk calculator that can take more risk factors (n = 33) into account and that can estimate the risk of vertebral body and proximal femoral fractures for a3-year period (previously 10years). This results in new thresholds for diagnostics and treatment. The programmed app is currently not yet certified as a medical product and apaper version is therefore currently available for patient care with the planned integration of aweb-based version of the risk calculator. From the perspective of trauma surgery, the recommendations and innovations for manifest osteoporosis are of particular clinical importance. The focus of the DVO guidelines update is therefore on the implementation of secondary fracture prevention in trauma surgery, orthopedic and geriatric traumatology in the clinical and practical daily routine.

Update on the DVO Guideline 2023 "Prophylaxis, diagnosis and treatment of osteoporosis in postmenopausal women and in men aged over 50"-What's new for rheumatology?

In October 2023, the organization of the German-speaking scientific osteological societies (DVO) published the revised guideline on the "Prophylaxis, diagnosis and treatment of osteoporosis in postmenopausal women and in men aged over50." This review article reflects the new features of the guideline and their relevance in the care of patients with inflammatory rheumatic diseases.Akey innovation is the change from the 10-year fracture risk to the 3‑year fracture risk. Basic diagnostics are currently performed without adefined fracture threshold. Treatment thresholds for specific osteological therapy constitute another key innovation, defined as 3% to < 5%, 5% to < 10%, and from 10% for vertebral body and femoral neck fractures. If the 3‑year fracture risk is > 10%, osteoanabolic therapy should primarily be carried out and antiresorptive therapy is initiated following osteoanabolic therapy. In addition, patients with osteoporosis and prolonged glucocorticoid therapy should primarily be treated osteoanabolically with teriparatide. In summary, the changes to the DVO guideline reflect the latest scientific study findings in osteology and lead todetailed differential therapy for osteoporosis.

Discrepancies Between Osteoporotic Fracture Evaluations in Men Based on German (DVO) Osteoporosis Guidelines or the FRAX Score.

Established scores estimate 10-year fracture risk in osteoporosis to assist with treatment recommendations. This study compared the risk probabilities of major osteoporotic and hip fractures calculated by the FRAX tool with those of the DVO score, established in German-speaking countries. This seven-year retrospective study analyzed data of 125 male patients (mean age: 59.2±10.7 years) evaluated for osteoporosis. For the DVO score, the therapy threshold of>30% for vertebral and hip fractures suggested by DVO guidelines was implemented. We calculated fracture risks based on FRAX scores with aBMD and applied a common therapy threshold of≥3% for hip fracture and subsequently determined the "DVO-equivalent risk level" for FRAX-based assessment that would identify as many male patients as identified by the DVO score. Based on DVO score, 60.0% of patients had a 10-year risk of hip and vertebral fractures>30%. The recommendations for individuals based on FRAX scores for hip fracture with aBMD with risk≥3% overlapped with those based on DVO score in 36% of patients. Patients identified for treatment only by DVO score presented a higher percentage of spine fractures (65 vs. 41%). The thresholds for this "DVO-equivalent risk level" for 'FRAX with aBMD' was estimated to be≥6.7% for major osteoporotic fracture and≥2.1% for hip fracture.This study demonstrates that the DVO score was more sensitive than the FRAX score for patients with prevalent spinal fractures. We suggest considering the appropriate score and therapy threshold carefully in the daily care of male patients.

PMS13 - REAL-WORLD TREATMENT OF PATIENTS WITH OSTEOPOROSIS IN GERMANY: PREVALENCE AND INCIDENCE OF PATIENTS WITH OSTEOPOROSIS AT INCREASED FRACTURE RISK

Osteoporosis represents a major clinical burden worldwide and, with an increasing ageing population, the number of people affected is expected to increase. In Germany, there is a lack of recent osteoporosis epidemiology data. Therefore, we assessed the prevalence/incidence of osteoporosis in a cohort of patients in Germany insured by a sickness fund. The analysis was based on claims data from 3.2 million members (∼4.4% of the German insured population) of a regional German statutory health insurance fund. Patients with ≥1 inpatient/outpatient osteoporosis diagnoses (ICD10-Codes M80/M81) in 2016 were included. Osteoporosis prevalence/incidence were reported by age/gender and extrapolated to the German population, based on the overall national age/gender demographics. Extrapolating to the German population, the estimated prevalence of osteoporosis in 2016 was 2,997,243 (7%) women and 628,291 (2%) men. Of these, 2,829,538 (94%) were postmenopausal women ≥55 years of age, and 498,073 (79%) were men ≥60 years (using age thresholds defined per the German osteology [DVO] guidelines1). In 2016, an increased risk of fracture, defined as per DVO guidelines, was observed in 1,070,597 (36%) women (149,002 [24%] men). 331,970 (11%) women (65,469 [10%] men) had a prevalent vertebral/femoral fracture; 495,775 (17%) women (78,974 [15%] men) had major osteoporotic fractures; 664,953 (22%) women (59,337 [9%] men) had no fracture but received osteoporosis drug therapy; 73,674 (2%) women (24,196 [4%] men) were diagnosed with drug-induced osteoporosis. The incidence of osteoporosis in 2016 was 451,758 (1%) women (136,426 [0.4%] men) and the incidence of vertebral/femoral fracture in this osteoporosis population was 268,407 (57%) women (53,385 [39%] men). This study confirmed the previously reported 2009 data for the German population in terms of overall prevalence and incidence and female/male distribution. The analysis did not include asymptomatic/unreported fractures, and so may underestimate the actual numbers. 1. Neuerburg et al. Unfallchirurg 2015;118(11):905–12.

Value of a coordinated management of osteoporosis via Fracture Liaison Service for the treatment of orthogeriatric patients.

The prevalence of osteoporosis in female patients over 75years of age is 59.2%. In Germany ~6.3-7.8million patients are affected by osteoporosis. In 77% of german patients osteoporosis is not treated adequately. Even after fragility fractures only 16-21% of female patients and 3% of male patients are supplied with a specific osteoporosis therapy. Establishing a Fracture Liaison Services (FLS) is a possible addition to co-management for an efficient treatment of osteoporosis in orthogeriatric patients. According to a treatment algorithm adapted to the DVO guideline 2014, data of 251 (77 male, 173 female) patients were collected over 3months. For the assessment specific and standardized questionnaires were used. There was also a basic laboratory testing for osteoporosis done. The average age of female patients was 76.1years, in male patients 76.6years. Thirty-seven patients had vertebral fractures, 25 patients proximal humerus fractures, 18 distal radius fractures and a total of 78 proximal femur fractures were recorded. Eighteen percent of the 251 patients have already been treated with a basic and 11% with a specific osteoporosis medication. Approximately 40% of the orthogeriatric patients were diagnosed with osteoporosis for the first time in our clinic. Less than 1% of the patients had a vitamin D level over 40ng/ml and 32% had a vitamin D level under 10ng/ml. Sixty-five percent of the discharged patients received a basic osteoporosis therapy and 25% an additional specific therapy. Due to the demographic development osteoporosis-associated fractures steadily increase. In addition to the surgical treatment of fractures, osteological diagnosis and treatment are essential components of successful treatment and critical to the prevention of further fractures. A combination of orthogeriatric center and fracture liaison service allows a more efficient treatment of osteoporosis by close supervision of orthogeriatric patients by the physicians involved.

Diagnosing osteoporosis: what is new in the 2014 DVO guideline?

Suitable diagnostic strategies beyond general measures of fracture prevention which allow the identification of those individuals who are likely to benefit most from medical treatment are of utmost importance for an efficient treatment of osteoporosis. Since 2003 the "Dachverband Osteologie" (DVO) provides recommendations for the diagnostics and treatment of osteoporosis in German speaking regions. The most recent update was in November 2014. The DVO guideline provides detailed recommendations for a diagnostic examination depending on age, gender, and the presence and strength of clinical risk factors. The number of clinical fractures risks on which the diagnostic and therapeutic recommendations of the DVO guideline 2014 are based has increased in comparison to the DVO guideline 2009. In addition to the fracture risks listed in the previous version of the DVO guideline the list now also includes monoclonal gammopathy of unknown significance, ankylosing spondylitis, COPD, heart failure, celiac disease, type 2 diabetes mellitus, long-term treatment with proton pump inhibitors and a treatment with high-dose inhaled glucocorticoids. For all persons with an increased fracture risk the guideline recommends a diagnostic workup, comprising medical history, clinical examination including assessment of fall risk, DXA measurements at the lumbar spine, proximal total femur and femoral neck, blood analysis and, if indicated, appropriate imaging procedures. The trabecular bone score offers a new diagnostic option for fracture prediction.

New strategies for exercise training in osteoporosis

In the prevention and treatment of osteoporosis, movement with muscle strengthening and proprioceptive training plays a major role. This was taken into consideration in the guidelines by the governing body on osteoporosis (Dachverband Osteoporose, DVO) from 2014 on prophylaxis, diagnosis and treatment of osteoporosis and in the DVO guidelines from 2008 on physiotherapy and exercise therapy for osteoporosis. Increases in lumbar bone density of between 0.5 % and 2.5 % can be achieved in women by strengthening exercises with high resistance. With this combination and strengthening of the quadriceps muscle a reduction of falls and hence the fracture risk could also be achieved. In traumatology, training for muscle strengthening is not always possible, especially for elderly patients. Practically relevant alternatives are regular walking and aquatraining, which may also lead to a significant increase in bone mineral density. Furthermore, large effects can be achieved with alternating side whole-body vibration (WBV) training with whole body vibration plates with only 3 days of training per week and with short training periods (15-20min). Rates of increase in leg strength between 20 % and almost 40 % and in bone density between 0.5 % and 4 % in 6 months have been described. Whether and with what intensity whole body vibration therapy could be used for e.g. more rapid healing of fractures, is currently unclear. Initial positive results have been described in animal models.

New DVO guideline for osteoporosis management 2014 and its importance for trauma surgeons

Osteoporosis-associated fractures represent a growing challenge in the treatment of orthopedic patients. In November 2014 a new revision of the guidelines on osteoporosis by the German Osteology Society (Dachverband Osteologie DVO) was adopted, in which additional risk factors for fractures and further treatment options have been included. On the one hand the existing model used to diagnose osteoporosis and estimate a high fracture risk as a guidance for the use of specific anti-osteoporotic therapy in patients without a fragility fracture was maintained and further refined. On the other hand the guideline includes the option to initiate a specific osteoporosis therapy without a prior bone densitometry in patients with typical radiographs of a proximal femur fracture and higher grade vertebral fractures, suspicious for osteoporosis, depending on the overall clinical context. This may reduce the treatment gap of osteoporosis in Germany. In this paper the changes in the DVO guidelines 2014 on osteoporosis are summarized, focusing on the most important changes with practical relevance for orthopedic surgeons.

Radiofrequenz-Kyphoplastie – ein innovatives Verfahren zur Behandlung von vertebralen Kompressionsfrakturen – Vergleiche mit konservativer Behandlung

An evaluation of treatment protocols was used to expand the documentation of efficacy and safety of radiofrequency kyphoplasty (RFK). Additionally, a comparison of this new and innovative procedure with conservative treatment was carried out. Patients with painful osteoporotic vertebral fractures according to the common findings in an orthopaedic university hospital were included in the comparison study in which the indication for surgical intervention action according to the DVO guidelines was interdisciplinary confirmed. For the comparison group, patients with the same clinical and radiological findings were recruited who rejected a surgical intervention. For surgery, the StabiliT® Vertebral Augmentation System for a radiofrequency kyphoplasty by the company DFine was used. The cement was injected with a "multiplex controller". Thus, the results of the new method were compared to those of a group that was treated conservatively. The radiofrequency kyphoplasty (n = 114) resulted in an average decrease of VAS scores by almost 60 mm, which increased during the follow-up. Similarly, the Oswestry scores showed a marked improvement by 46 % points after 6 weeks. The mean increase in vertebral body height was 2.8 mm after radiofrequency kyphoplasty. In the conservatively treated group only very small changes compared to the initial findings were registered during the 6-week observation period. Accordingly, 33 of 67 patients decided after 6 weeks for surgery, which led to corresponding improvements (VAS, Oswestry, vertebral body height). Noteworthy is the low rate of cement leakage in the radiofrequency kyphoplasty group of 6 % (n = 7). Radiofrequency kyphoplasty offers a secure superiority over conservative treatment regarding clinical efficacy. In addition, the fractured vertebrae can be better targeted and erected, a longer processing time of the cement is ensured, a high interdigitation of the cement with the bone is guaranteed, the rate of cement leakage is low, the risk of radiation for the surgeon is minimised, and the operation time is shortened.

Medikamentöse Osteoporoseprophylaxe und -therapie bei Patienten mit rheumatoider Arthritis (ORA-Studie)

The aim of this study was to examine bone mineral density (BMD), frequency of osteopenia and osteoporosis in a representative sample of patients with rheumatoid arthritis (RA) and to describe chemoprophylaxis and treatment of osteoporosis compared to evidence-based guidelines. In 2005 and 2006, 532 patients with RA (98 men, 434 women) aged 23-87 years were recruited from 9 German rheumatology centers. Clinical examination included a detailed documentation of osteoporosis medication. Dual-energy X-ray absorptiometry (DXA) was used to measure BMD at the lumbar spine and femoral neck. Osteopenia and osteoporosis were defined according to the criteria of the World Health Organization. Of the RA patients 29% had normal BMD at the spine and femoral neck, 49% of the patients had osteopenia and 22% met the criteria for osteoporosis at any site. Of the patients 60% were receiving medication for prophylaxis or therapy of osteoporosis, 38% calcium/vitamin D alone, 20% as combinations mostly of calcium/vitamin D + bisphosphonate, 1% received bisphosphonate only and 1% hormone replacement therapy. Although the frequency of osteoporosis showed no significant differences between male and female patients, women with RA used osteoporosis medication more often than men (63% versus 49%, χ²-test, p <0.05). A total of 101 RA patients (83 menopausal women, 6 premenopausal women, 12 men) received corticosteroids in a daily dose of 7.5 mg or less for at least 3 months and had DXA T-scores below -2.0 at any site. In this patient group 41% of the menopausal women, 17% of the premenopausal women and 42% of the male patients were reported to receive medication with calcium/vitamin D + bisphosphonate. Calcium/vitamin D was used by 35% of the menopausal women, none of the premenopausal women and 50% of the male patients and 18% of the menopausal women, 67% of the premenopausal women and 8% of men received no prophylaxis or treatment for osteoporosis. According to the DVO (German Society for Osteoporosis) guidelines for osteoporosis (2009) menopausal women with corticosteroid therapy < 7.5 mg per day for at least 3 months and DXA T-scores below -2.0 should receive treatment with bisphosphonate and calcium/vitamin D. The data show that there were still deficits concerning prophylaxis and treatment of osteoporosis in RA.

DVO Guideline 2009 for Prevention, Diagnosis and Therapy of Osteoporosis in Adults

DVO Guideline 2009 for Prevention, Diagnosis and Therapy of Osteoporosis in Adults

The Diagnosis and Treatment of Primary Osteoporosis According to Current Guidelines: Living With a Dilemma

In principle it always makes sense to provide the colleagues at the coalface with a recommendation of how they might tackle the difficult pathology that is osteoporosis. Central to this are Professor Minne’s words, that every case of osteoporosis requires treatment, but also recommendations from the US (NAMS) www.guidelines.gov. However, difficulties arise if only those patients are to be treated who have a 30% risk of vertebral or femoral fracture over the coming 10 years. For example, women aged 50 to 60 whose T value is better than -4.0 will not receive treatment, although they are ill. Untreated osteoporosis is certain to advance, and these patients will end with a much lower T value over the following years. The treatment of osteoporosis is obviously rather costly if bisphosphonates are the only option under consideration. But the follow–on costs of osteoporosis related complications in Germany are in excess of five billion Euros per year. With regard to prophylaxis, the new recommendations of the International Menopause Society (www.imsociety.org) should be noted. I have personally been conducting DXA bone density scans since 1988 and unfortunately cannot confirm that treating of patients with T values of -4 yields sufficiently rapid improvements within a short time for a substantial reduction of the fracture risk to be expected. In heeding the DVO guidelines one has to live with the dilemma of conforming to the guideline and withholding treatment from patients and thus risking fractures that might have been prevented by early treatment.

Osteoporose und Sturz: medizinische Versorgung älterer Menschen mit einem erhöhten Frakturrisiko in Deutschland

Fractures are a considerable risk, especially in older patients. The fracture of the proximal femur is of particular relevance. Functional deficiency, an increased need for care and assistance and a limitation of the quality of life after a fracture lead to an increase in morbidity and mortality among patients who lived independently prior to the event in most cases. The risk of suffering a femoral fracture mainly depends on two risk factors: osteoporosis and falls. Both can be influenced and are therefore suitable for interventions. National and international guidelines for diagnosis and treatment have so far separately addressed deficiencies in bone stability and neuromuscular function. The current German DVO guideline is the first to consider both aspects simultaneously and develop an individual concept for diagnosis and therapy depending on a risk prediction of a fracture within the following 10 years. The evaluation of the current quality of health care in the field of osteoporosis and falls both nationally and internationally seems to be hardly possible. Merely the delivery of DXA measurements and medication for osteoporosis are assessable. In these sectors a deficiency in the delivery of care is apparent. Standardized evaluations of the implementation of guidelines are needed to assess deficiencies and reveal options for improving quality of care in the future.

Osteoprotektive Medikation: sinnvolles Monitoring, wie lange therapieren?

The improved options for effective treatment of osteoporosis and the shift to treatment strategies based on each patient's absolute fracture risk raise new questions in daily clinical care. Which patient should have what osteoprotective therapy and when and for how long? What techniques can be used to assess the individual effects of novel therapeuties? Are the results yielded by these techniques affected by concomitant factors? What specific characteristics need to be taken account of in rheumatological clinics and how should we deal with these? What is the impact of patient compliance on the assessment of therapeutic effects? This review is intended to shed some light on these questions and on the new DVO guidelines in daily practice with reference to the ambulatory setting.

Osteoporose - Ein Stiefkind der Orthopädie? Ergebnisse einer Befragung deutscher Orthopäden

Patients with fragility fractures have a significantly increased risk of sustaining additional fractures. Therefore one should consider avoidance of further fractures as the primary treatment principle. Since orthopaedic surgeons manage most of fragility fractures, but might not be well attuned to osteoporosis itself, it was the aim of the Bone and Joint Decade (BJD) and the International Osteoporosis Foundation (IOF) to survey orthopaedic surgeons in order to assess their knowledge of prevention, diagnosis, and treatment of osteoporosis. The multinational survey questionnaire was developed by a working group of national project co-ordinators in France, Germany, Italy, Spain, the United Kingdom, and New Zealand and based to some extent on an American survey. Following translation into the national language it was distributed in 2002 to the members of the orthopaedic societies to assess the management of prevention, diagnosis, and therapy of osteoporosis and fragility fractures, comparing both different health-care systems and different working environments. 5 700 questionnaires were distributed in Germany with a 20 percent response rate. As the main result of the German survey -- independent of the working environment -- a substantial deficit concerning training and knowledge about the management of prevention, diagnosis, and treatment of osteoporosis and fragility fractures was seen. In addition, the majority of participants requested educational opportunities to become qualified for a better disease control. In order to satisfy the increasing need for adequate management of prevention, diagnosis, and therapy of osteoporosis and fragility fractures, structured educational opportunities have to be offered to the German orthopaedic community. In the mean time first steps have been initiated: training courses to qualify as "Osteologe DVO" and the "White Book Osteoporosis", which was initiated by BJD and IOF and developed by several German medical societies and patient organisations it is based on the German DVO guidelines providing an evidence-based and structured overview concerning all relevant aspects of osteoporosis and fragility fractures.