50
Članek prispel / Received
16. 9. 2020
Članek sprejet / Accepted
2. 4. 2021
Abstract
Purpose: The aim of the study was to 
determine the prevalence of undiagnosed 
and untreated osteoporosis cases prior to 
hip fracture, to determine if there are 
more patients with diagnosed and trea-
ted osteoporosis from model family me-
dicine practices compared to standard 
family medicine practice patients, and 
to determine the proportion of patients 
initiating osteoporosis therapy after di-
scharge from hospital.
Methods: We conducted a retrospecti-
ve, qualitative study at the Department 
of Surgery, General Hospital of Dr. Jože 
Potrč Ptuj, Slovenia, using patient re-
cords from the period of January 1, 2015 
to December 31, 2016, including data 
analysis of patient discharge letters.
Results: The analysis used data from 
145 patients, 26 men (17.9%) and 119 
women (82.1%). The mean age was 
82.7 (±6.8) years. At discharge, 70.4% 
(81 out of 115) of patients were mobile 
and 28.3% (41 out of 145) of these were 
discharged and allowed to return home. 
Izvleček
Namen: Namen raziskave je bil ugo-
toviti delež neodkrite in nezdravljene 
osteoporoze pred zlomom kolka, ugo-
toviti ali imajo bolniki iz referenčnih 
ambulant odkrito in zdravljeno osteo-
porozo v večjem deležu kot bolniki iz 
ne-referenčnih ambulant ter ugotoviti 
delež uvedene terapije osteoporoze ob 
odpustu iz bolnišnice.
Metode: Opravljena je bila retrospek-
tivna kvantitativna raziskava na kirur-
škem oddelku Splošne bolnišnice dr. Jo-
žeta Potrča Ptuj za opazovano obdobje 
od 1.1.2015 do 31.12.2016 z analizo 
podatkov odpustnih pisem. 
Rezultati: V analizo je bilo vključenih 
145 bolnikov, med njimi je bilo 26 mo-
ških (17,9 %) in 119 žensk (82,1 %), 
povprečna starost bolnika je znašala 
82,7 (±6,8) let. Ob odpustu je bilo po-
kretnih 70,4 % (81 od 115) bolnikov, ki 
so bili v 28,3 % (41 od 145) primerov 
odpuščeni v domače okolje. Z raziskavo 
smo ugotovili, da je delež neodkrite in 
nezdravljene osteoporoze pred zlomom 
Ključne besede: 
osteoporoza, osteoporozni zlom 
kolka, družinska medicina, regijska 
bolnišnica 
Key words: 
osteoporosis, osteoporotic hip 
fracture, family medicine, regional 
hospital
Odkrivanje in zdravljenje osteoporoze pri 
bolnikih z osteoporoznim zlomom kolka 
Diagnosis and treatment of osteoporosis in 
patients with osteoporotic hip fracture 
Avtor / Author Mateja Krajnc1, 2, Vojislav Ivetić2, 3
Ustanova / Institute 1ZD dr. Adolfa Drolca Maribor, Maribor, Slovenija; 2Univerza v Mariboru, Medicinska 
fakulteta, Katedra za družinsko medicino, Maribor, Slovenija;  3SAVA MED, d.o.o., Spodnji 
Duplek, Slovenija; 
1Dr. Adolf Drolc Health Centre Maribor, Maribor, Slovenia; 2University of Maribor, Faculty 
of Medicine, Department of Family Medicine, Maribor, Slovenia; 3SAVA MED, d.o.o., 
Spodnji Duplek, Slovenia;  
Klinična študija / Clinical study
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2021; 14 (1): 25–37
Naslov za dopisovanje /  
Correspondence
doc. dr. Vojislav Ivetić, dr. med.
SAVA MED d.o.o.
Cesta k Dravi 8,
SI–2241 Spodnji Duplek, Slovenija
Telefon +386 51336036
Fax +386 26202492
E-pošta: vojislav.ivetic@um.si 
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INTRODUCTION
Osteoporosis is a progressive systemic skeletal 
disease characterized by reduced bone mass and 
micro-architectural deterioration of bone tissue (1). 
Osteoporotic fractures are very common, considerably 
decrease the patient's quality of life and increase 
mortality (2). Osteoporosis treatment is aimed at 
preventing osteoporotic hip fractures (2, 3). A previous 
fragility fracture increases the patient's risk of another 
osteoporotic fracture by up to five times (4). Of all 
fractures reported worldwide, the studies show that 
osteoporotic fractures account for 34.8%, with women 
comprising 85% of all cases (4). In 2010, approximately 
22  million women and 5.5  million men aged 50–84 
years had osteoporosis in Europe (5). The level of 
undiagnosed osteoporosis remains extremely high in 
the developed countries, and treatment is not initiated 
early enough (5, 6).
Screening of patients at high risk for osteoporotic 
fracture is performed at family medicine practices 
during preventive cardiovascular examinations. These 
are performed in line with the management protocol 
for patients with osteoporosis and using an upgraded 
model of primary care where the standard family 
practice team (family physician and a nurse) is expanded 
by a registered nurse (model family medicine practices) 
(7, 8, 9). Using a computer-driven FRAX (“Fracture 
Risk Assessment Tool”) model we can calculate the 
absolute risk in all postmenopausal women and men 
aged 50 and older of experiencing one of the four most 
common osteoporotic fractures (vertebra, hip, wrist or 
humerus) over the next 10 years (8, 10, 11). 
Osteoporotic vertebral and hip fractures are two 
most important complications of osteoporosis which 
considerably increase the risk of new fractures. 
kolka 94,5 % (137 od 145) in da je de-
lež uvedbe terapije za osteoporozo ob od-
pustu iz bolnišnice 7,1 % (10 od 140), 
delež priporočil za uvedbo terapije za 
osteoporozo ob odpustu pa 15,0 % (21 
od 140). Med bolniki iz referenčnih 5,5 
% (5 od 91) in ne-referenčnih ambulant 
8,1% (3 od 37) ni pomembne razlike v 
deležu zdravljene osteoporoze pred hospi-
talizacijo zaradi zloma kolka (p>0,05). 
Zaklju~ek: Z raziskavo smo ugotovili, 
da je delež neodkrite osteoporoze zelo 
velik in da ostaja obravnava osteopo-
roznih zlomov kolka kljub priporočilom 
in smernicam velik izziv za multidisci-
plinaren pristop na vseh nivojih zdra-
vstvene oskrbe.
The study showed that osteoporosis pri-
or to hip fracture was undiagnosed and 
untreated in 94.5% (137 out of 145) 
of cases. Osteoporosis therapy was initi-
ated at discharge in only 7.1% (10 out 
of 140) of patients, and recommenda-
tions to initiate osteoporosis therapy at 
discharge were provided in 15.0% (21 
out of 140). There was no significant 
difference between model family medici-
ne practice patients (5 out of 91; 5.5%) 
and patients from standard family me-
dicine practices (8.1%; 3 out of 37) in 
the proportion of patients treated for 
osteoporosis prior to hospitalization due 
to hip fracture (p>0.05).
Conclusion: The study concluded that 
the prevalence proportion of undiagnosed 
osteoporosis is quite high and that, despi-
te all recommendations and guidelines, 
management of osteoporotic hip fractures 
still remains a major challenge at all le-
vels of healthcare.
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Hence, any of these conditions are sufficient for the 
diagnosis of severe osteoporosis and initiation of 
treatment regardless of the DXA (“Dual-energy X-ray 
absorptiometry”) result and the FRAX risk calculation 
(1, 12). All hip fractures are treated surgically and 
therefore require first-line inpatient treatment (12). 
More than 50% of hip fracture patients are unable 
to live independently and as many as 33% of these 
patients die in the first year following the fracture (13). 
The 5-year risk of a secondary hip fracture is estimated 
to range between 13% and 43%. Initiation of therapy 
after osteoporotic fracture has been shown to benefit 
patients (14).
Osteoporosis therapy should be initiated during 
hospitalization to improve patient compliance 
and reduce mortality (15). Inclusion of a primary 
care physician and patient education also improve 
compliance (16). In clinical practice, most patients 
still do not receive any osteoporosis medication 
after hip fracture (17, 18). This is mainly due to the 
following: ambiguity as to who was supposed to 
perform osteoporosis treatment (endocrinologist, 
rheumatologist, traumatologist or family physician), 
insufficient knowledge (by both physicians as well as 
patients) about the evidence as to the post-hip fracture 
osteoporosis treatment type and success, fear of adverse 
effects, and cost of therapy (19). 
Although osteoporosis and its associated fractures is 
one of the most pressing social and economic issues, its 
management is still far from adequate in the Republic 
of Slovenia.
The aim of the study was to determine the prevalence 
of undiagnosed and untreated osteoporosis prior to 
hip fracture, to determine if there are more patients 
with diagnosed and treated osteoporosis from model 
family medicine practice compared to standard family 
medicine practice patients, and to determine the 
proportion of patients undergoing osteoporosis therapy 
after hospital discharge. 
MATERIALS AND METHODS
Study Type 
A retrospective, quantitative study was performed in 
which we analysed discharge letters from the MEDIS 
Hospital Information System of the General Hospital 
of Dr. Jože Potrč Ptuj, Slovenia, for the period from 1 
January 2015 to 31 December 2016.
Subjects
The sample consisted of hospitalized and operated 
patients with hip fracture (ICD-10 diagnostic codes: 
S72.00, S72.04, S72.05, S72.10, S72.11, S72.2, 
S72.40 and S72.9) from the General Hospital Ptuj 
with a history of a fall from standing height.
To be included in the study, the patients had to 
meet all four eligibility criteria: (1) age >65 years, (2) 
a fracture of the neck of femur (treated surgically as 
partial/total hip arthroplasty or osteosynthesis), (3) a 
history of a fall from standing height, and (4) data on 
therapy that was in progress prior to hip fracture.
The exclusion criteria were: (1) suspected secondary 
osteoporosis (ongoing glucocorticoid therapy, 
rheumatic disease, chronic kidney disease, alcohol 
dependence syndrome) or (2) confirmed high-energy 
trauma (road traffic collision, fall from >2m).
Collection of data
Data was provided by the General Hospital Ptuj’s 
analytics office following our request for records on 
all patients treated at the Department of Surgery for 
hip fracture in the observation period under the ICD-
10 code S72.XX. Based on the review of 287 discharge 
letters and eligibility criteria we obtained a sample 
of 145 patients whose data was further analysed in 
this study. For eligible patients, additional data was 
obtained from the MEDIS system about their family 
physician of choice (FPOC). Their environment type 
was determined based on their residential postal code.
The NIJZ (National Institute of Public Health) 
provided a list of model family practices (20) 
operating since the start of our project, namely from 
April 2011 to February 2017, which included the 
names and surnames of family physicians working at 
a model family practice, data on their employer, and 
date of their inclusion in the project. With the help 
of this data we were able to establish if the FPOC 
had a model family practice. An FPOC code was 
provided for each patient. We collected these for 128 
out of 145 (88.3 %) patients, whereby we recorded 42 
different codes.
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To establish if the patient received any prescribed 
osteoporosis therapy before hip fracture, we analysed 
data on their medical history obtained at hospital 
admission. A review of discharge letters was conducted 
to establish the patient’s condition at discharge and to 
determine if they were prescribed therapy at discharge 
or received recommendations for osteoporosis therapy 
initiation.
Statistical Analysis
Data entry and analysis were performed using 
IBM SPSS 22.0. Basic patient characteristics were 
shown categorized according to standard descriptive 
methods. Proportions and differences were tested 
using nonparametric tests, such as the chi-square test. 
The statistical significance level was set at 5% (p≤0.05). 
Due to the observed frequencies of less than five, we 
further performed the Fisher’s exact test, which also 
failed to confirm statistically significant differences. 
The study was approved by the National Medical Ethics 
Committee on 18 July 2017 (No. 0120-342/2017/4).
RESULTS 
The analysis included 145 patients; 26 men (17.9%) 
and 119 women (82.1%). The mean age of patients 
in the reference year of 2016 was 82.7 (±6.8) years 
(Table 1).
Data shows that the majority of patients who 
received osteoporotic hip fracture treatment in the 
observation period at the General Hospital Ptuj live 
in rural environments; they represented nearly three 
fourths of all study subjects (107 out of 145; 73.8%). 
(Table 2).
The results show that the majority of patients (91 out 
of 128; 71.1%) had selected a FPOC who also works 
at a model family medicine practice (Table 2). 
The majority of patients (137 out of 145; 94.5%) did 
not receive any osteoporosis therapy prior to hospital 
admission. The remaining 8 out of 145 (5.5%) 
patients were receiving osteoporosis therapy for their 
osteoporotic hip fracture at hospital admission.
Only 1 out of 145 enrolled patients had been 
receiving triple therapy (bisphosphonate/denosumab, 
Table 1. Patient age (years)
Age in 2016
Mean 82.74
Standard deviation 6.812
Modus 85
Median 83.00
Minimum 65
Maximum 100
N 145
Table 2. Patient’s residence environment type, model fa-
mily medicine practice of the FPOC, pre-admission oste-
oporosis therapy, triple therapy (bisphosphonate/denosu-
mab, cholecalciferol, calcium) prior to admission
Number (N) Proportion (%)
Environment 
type
urban 38 26.2
rural 107 73.8
total 145 100
Model family 
medicine 
practice
yes 91 71.1
no 37 28.9
total 128 100
Pre-admission 
osteoporosis 
therapy
yes 8 5.5
no 137 94.5
total 145 100
Triple therapy 
prior to 
admission
yes 1 0.7
no 144 99.3
total 145 100
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cholecalciferol, calcium) prior to hospital admission, 
which is 0.7% of all patients (Table 2). Additionally, 
the analysis also showed that two out of 145 (1.4%) 
patients had already been taking calcium for their 
osteoporotic hip fracture prior to hospital admission.
Cholecalciferol had been used by 7 out of 145 (4.8%) 
patients, bisphosphonate/denosumab by 4 out of 145 
(2.8%) patients, and only 1 (0.7%) patient had been 
taking other medication (calcitriol) (Table 3).
The obtained data revealed that most patients were 
either discharged to home care or had a prolonged 
hospital stay (41 out of 145; 28.3% in both cases) 
(Table 4).
A comprehensive adequate medical status at discharge 
was defined in 115 out of 145 (79.3%) subjects; we 
were unable to determine the status of other patients 
at discharge based on discharge letter analysis only. 
The majority of our patients (81 out of 115; 70.4%) 
were mobile at discharge (Table 5).
We were able to obtain data on osteoporosis therapy 
initiation during hospitalization for 140 out of 145 
(96.6%) patients. The majority, namely 130 out of 
140 (92.9%) of these patients did not receive any 
osteoporosis therapy during hospitalization (Table 5). 
Triple therapy was not recorded for any patient (Table 
5). We found that 8 out of 140 (5.7%) patients were 
taking calcium at the time of discharge; 13 out of 140 
(9.3%) patients were taking cholecalciferol, and 1 out 
of 140 (0.7%) patients was taking bisphosphonate/
denosumab. Apart from these three medications, 
there are no reports of any other medications used.
 The collected data showed that 21 out of 140 
(15.0%) patients also received recommendations for 
osteoporosis therapy initiation (Table 5). Among these, 
3 patients had a prescription issued in accordance 
with authorizations which is 14.3% (N=21). We also 
found that, despite recommendations, 18 out of 21 
(85.7%; N=21) patients did not obtain a prescription 
(Table 5).
The results also revealed that there was a smaller 
proportion of patients from model family medicine 
practices who received osteoporosis treatment prior 
to hospitalization (5 out of 91; 5.5%) compared to 
patients from standard family medicine practices (3 
out of 37; 8.1%), but this difference was not statistically 
significant (p>0.05) (Table 6). This finding led to a 
Table 3.  
Pre-admission medication, medication at discharge
Pre-admission medication Number (N) Proportion (%)
calcium 2 1.4
cholecalciferol 7 4.8
bisphosphonate/
denosumab 4 2.8
other (calcitriol) 1 0.7
no medication 131 90.3
total 145 100
Medication at discharge 
calcium 8 5.7
cholecalciferol 13 9.3
bisphosphonate/
denosumab 1 0.7
other - -
no medication 118 84.3
total 140* 100
*five patients deceased during the hospitalisation
Table 4. Discharge type
Number (N) Proportion (%)
home care 41 28.3
health resort 8  5.5
prolonged 
hospital 
treatment
41 28.3
Discharge type nursing home 14 9.7
Department 
of Internal 
Medicine 
at General 
Hospital Ptuj
3 2.1
non-acute 
hospital 
treatment
33 22.8
death 5 3.4
total 145 100
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conclusion that there is no statistically significant 
difference between model family medicine practice 
patients and patients from standard family medicine 
practices in the proportion of patients receiving 
osteoporosis treatment prior to hospitalization due to 
hip fracture (Table 6).
DISCUSSION 
We found that the proportion of patients with 
undiagnosed and untreated osteoporosis prior to 
hospital admission for osteoporotic hip fracture 
is 94.5% (137 out of 146 patients) (Table 2). The 
results show that osteoporosis therapy was initiated 
at discharge in only 7.1% of patients (10 out of 
140), and recommendations to initiate osteoporosis 
therapy at discharge were provided in 15.0%  of 
cases (21 out of 140), meaning that osteoporosis 
remains undiagnosed and untreated in the majority 
of cases after hospitalization and remains untreated 
even after surgical treatment of osteoporotic hip 
fracture. We found that, considering patients whose 
osteoporosis remains undiagnosed and untreated, 
there is no statistically significant difference between 
model family practice compared to standard family 
practices (chi-square test: χ2=0.307, df=1, p=0.580) 
(Table 6). 
Foreign literature suggests that it would be 
reasonable to formulate recommendations not only 
for osteoporosis detection and treatment, but also 
for the management of patients after osteoporotic 
hip fracture in the context of secondary prevention 
(21, 22). Fokner et al. in their research from 2003, 
found that primary prevention (building sufficient 
peak bone mass at younger age) in Slovenia, was 
shown to be inadequate as well (28).Slovenia 
has adopted recommendations for hip fracture 
treatment, osteoporosis treatment after hip fracture 
and medical rehabilitation of elderly patients with 
hip fracture (23). After surgical treatment, patients 
often do not recover to the level that would allow 
them to live the same quality life as they did before 
the injury (24). After surgical treatment is completed, 
patients in Slovenia can be referred for rehabilitation 
treatment at a tertiary institution (the University 
Table 5. Patient status at discharge, osteoporosis therapy 
initiated during hospitalization, triple therapy at discharge, 
recommendations for osteoporosis therapy at discharge, pre-
scription issued in accordance with authorizations
Number (N) Proportion (%)
Patient status at 
discharge
mobile 81 70.4
immobile 34 29.6
total 115 100
Osteoporosis 
therapy 
initiated during 
hospitalization
yes 10 7.1
no 130 92.9
total 140 100
Triple therapy at 
discharge
yes - -
no 140 100
total 140 100
Recommendations 
for osteoporosis 
therapy at discharge
yes 21 15.0
no 119 85.0
total 140 100
Prescription 
issued in acc. with 
authorizations
yes 3 14.3
no 18 85.7
total 21 100
Table 6. Chi-square test by family medicine practice type 
(model or standard)
Practice type
model standard total
Prescription 
issued in acc. with 
authorizations
yes 5 (5.5%) 3 (8.1%) 8 (6.3%)
no 86 (94.5%)
34 
(91.9%)
120 
(93.8%)
total 91 (100%)
37 
(100%)
128 
(100%)
chi-square test: χ 2=0.307, df=1, p=0.580
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Rehabilitation Institute Soča), natural health resort 
(secondary level), nursing hospital or the Prolonged 
Hospitalization Department, or alternatively, they 
can be transferred to a nursing home or discharged 
to the home environment (25). Patient referral 
depends on the patient’s medical condition, their 
comorbidities and the information about their 
functional independence prior to the fracture (23). 
Our findings further show that after hospitalization 
most patients were discharged to home care, or that 
they had a prolonged hospital stay (Table 4). This 
increases the total cost of hospitalization for hip 
fracture, which was observed by Ferk in 2002 (27). 
Osteoporotic fractures directly affect mortality and, 
most of all, the quality of life (3). Approximately 
25% of patients become wholly dependent on 
others after a hip fracture, as was also observed 
in our study (Table 4), and approximately 50% of 
them never regain their pre-injury activity level (4, 
12, 24). Initiation of osteoporosis therapy after hip 
fracture should also be considered due to the risk of 
additional fractures (23, 24).
A study performed between 2003 and 2005 on a 
much larger sample at 318 hospitals in the USA, 
which included 51,346 patients with osteoporotic 
hip fracture, showed a very low rate of in-hospital 
initiation of osteoporosis therapy (18). Only 6.6% 
of patients received a combination of calcium and 
vitamin D, 7.3% of patients received antiresorptive 
drugs, and only 2% of patients were prescribed triple 
therapy after discharge (18), which is comparable to 
our results (Table 3). Foreign studies also showed that 
in-hospital treatment represents an ideal opportunity 
to initiate osteoporosis therapy in patients who had 
not received it before (15, 16, 17, 18). Slovenia 
issued guidelines for the management of hip fracture 
patients in 2012. These guidelines recommend 
that therapy be initiated in a hospital environment 
as follows: initiation of therapy with vitamin D to 
replenish stocks, the initiation of therapy with 
calcium - if serum calcium levels are not elevated and 
finally recommendation to family physician to treat 
osteoporosis with bisphosphonate or denosumab 
after 14 days to 1 month after discharge from 
hospital (after sufficient replenishment of Vitamin 
D and calcium) (23). 
A study conducted at the University Clinical Centre 
Maribor from 1 January 2015 to 31 December 2016 
included an analysis of patients with osteoporotic 
hip fracture aged >65 years and treated at the 
Department of Traumatology (12). Besides the basic 
demographics, the study also collected data on the 
patients’ ages and the proportion of patients who 
had a recorded diagnosis of osteoporosis or received 
instructions on osteoporosis therapy, as well as 
data on the number of patients with prior typical 
osteoporotic fracture (12). The study included 561 
patients older than 65 who experienced a typical 
osteoporotic hip fracture (a fall from a standing 
height) (12). A total of 418 (74.50%) women and 
143 (25.49%) men were treated in the study (14). 
The mean age of patients was 82.3 (±7.0) years (12). 
These demographics are similar to the ones in our 
study (Tables 1, 2). The proportion of patients with 
undiagnosed osteoporosis prior to hip fracture was 
92.7% , which is also similar to our findings (94.5%) 
(12). This related relevant study revealed that only 
15 out of 561 (2.67%) patients received instructions 
or osteoporosis therapy at discharge which is also 
comparable to our results showing that osteoporosis 
therapy was initiated at discharge in 7.1% of cases 
and that recommendations to initiate osteoporosis 
therapy at discharge were provided in 15.0% (12). 
A study performed in the USA in 2005 showed that 
patient education and inclusion of a primary care 
physician improve the rate of osteoporosis treatment 
(16). Patients who received a 15-minute education 
and instructions from their FPOC also received 
therapy in 42% compared to the control arm where 
osteoporosis therapy was initiated in 19% (16). In 
Slovenia, the necessary additional education could 
be provided at the primary level by a suitably trained 
graduate nurse.
Another Slovenian study performed at the University 
Clinical Centre Ljubljana on secondary prevention 
of osteoporotic fractures introduced measures aimed 
at improving the management of such patients (26). 
These measures included an admission checklist 
introduced for patients with hip fractures, and their 
FPOCs received instructions for further treatment 
of osteoporosis at patient discharge (26). Before this 
checklist, only 5% of patients were diagnosed with 
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osteoporosis at discharge, and only 1.1% of patients 
received instructions for osteoporosis treatment at 
discharge, which is similar to our findings. After 
the introduction of the checklist, 50% of patients 
were discharged with the diagnosis of osteoporosis, 
and instructions for osteoporosis treatment were 
provided in 56%. However, we could not find a 
simplified version of the proposal for measures that 
would be more appropriate for smaller regional 
hospitals in Slovenia. Hence, we decided to propose 
simplified measures to improve secondary preventive 
management of patients with osteoporotic hip 
fractures at admission as well as at discharge from 
hospital treatment. In preparing this proposal, we 
derived guidelines from the existing literature and 
strived to summarize and simplify the most relevant 
content to make it more useful in everyday clinical 
practice (26).
We suggested that upon admission to hospital 
for hip fracture treatment, anamnestic diagnosis 
of osteoporotic hip fracture can be made during 
the history taking (unrecognized osteoporosis 
in the elderly, fall from a standing height), that 
basic laboratory tests can be performed during 
hospitalization to exclude secondary osteoporosis, 
and that Vitamin D is added to osteoporosis therapy 
(Appendix 1). It is necessary that osteoporosis is 
coded according to the ICD-10 at discharge, and an 
auto-generated text should be added for the FPOC 
(Appendix 2).
One of the weaknesses of this study was the sampling 
method, for it was subjectively conditioned by the 
investigator's assessment due to unclear medical 
records. Another weakness was the sample itself, 
which was defined based on a patient’s medical 
history obtained at admission and relative to the 
course of hospital treatment. For some patients it was 
impossible to determine exactly whether the patient 
actually fell from standing height, concluding based 
on their medical history that this was a low-energy 
fall (e.g. falls occurring in the kitchen, bathroom, 
backyard, church, etc.). We encountered even 
more problems in obtaining data about patients' 
therapy prior to hospitalization and chronic 
diseases, as their medication history was often not 
recorded at admission. Thus, we had to collect this 
data from previous hospitalization records, their 
anesthesiological treatment records, and sometimes 
also from records of their further care (mainly from 
records on prolonged hospitalization). We excluded 
all patients who did not receive surgical treatment, 
regardless of whether they experienced osteoporotic 
hip fracture. Patients for whom we were not able to 
collect sufficient key data were also excluded from the 
study. Repeating the same study will probably allow 
the possibility of choosing a different sample, due to 
prior clinical knowledge and subjective assessment of 
the investigator. The sample was obtained from only 
one regional hospital, which is the main weakness 
of the study; subsequently, we cannot extrapolate 
the results to all of Slovenia. Nevertheless, other 
studies were performed at the two Slovenian clinical 
centres with similar duration, both of which gave 
comparable results to ours, and we did not find any 
other similar study performed at a regional hospital 
only (14, 16).
CONCLUSION 
The results of our study show that, despite the 
recommendations from 2012 and guidelines for the 
diagnosis and treatment of osteoporosis adopted in 
2013, management of osteoporotic hip fractures still 
remains a major challenge at all levels of healthcare. 
Within the multidisciplinary approach, the family 
physician is the one playing the role of a coordinator 
and providing continuous patient management 
after hip fracture. Inclusion of a graduate nurse in 
the family medicine team is a major plus, as their 
professional approach and education can contribute 
significantly to the treatment of these patients. 
According to our findings, more studies are needed 
to improve the management of patients with 
osteoporotic hip fractures, and healthcare workers 
and the general population should also receive more 
education on this subject. 
The proposed measures for smaller regional hospitals 
are only one of the factors that can contribute 
to improving management of patients after 
inpatient treatment. discharge back to their home 
environment or a nursing home.  After discharge 
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back to their home environment or a nursing home, 
these patients still require further medical care which 
can be provided by family medical practices using an 
integrated and holistic approach. 
ACKNOWLEDGMENTS 
We thank our colleagues Dr. Darko Jazbec, 
MD, General Surgery Specialist, and Dr. Borut 
Kostanjevec, PhD, General Surgery Specialist, for 
their professional assistance and help in obtaining 
the data used for this study. We are also very grateful 
Mrs Dolinar and Ms Hadler for reviewing the English 
language of the manuscript.
APPENDIX: Proposed measures for secondary 
prevention of osteoporotic hip fractures – a checklist to 
be completed at admission, reminder for discharge letter
ADMISSION CHECKLIST FOR HIP 
FRACTURE PATIENTS (WITH SUSPECTED 
OSTEOPOROTIC HIP FRACTURE)
AT ADMISSION
BASIC LABORATORY TESTS for exclusion of second-
ary causes of osteoporosis (on a temp. list)
HISTORY YES NO
Fall from a standing height X
Undiagnosed osteoporosis X
age >65 years X
Hip fracture confirmed on an X-ray X
CBC
Ca, P
AF
AST, ALT
creatinine
TSH
Plivit D 3 sol. 10gtt/day (2,000 IU/
day) = 70 gtt/week (14,000 i.e./week)
AT DISCHARGE
A letter to the FPOC with included diagnosis of 
osteoporotic hip fracture (icd-10 code: m80.9)
Dear colleague!
Your patient was treated at our hospital’s 
Department of Surgery for low-energy hip fracture. 
Since the patient fell from standing height, this 
type of fracture is in terms of diagnostic criteria 
for OSTEOPOROSIS, considered as a severe 
osteoporotic fracture. 
At admission, the patient underwent basic laboratory 
tests to exclude secondary osteoporosis (hemogram, 
calcium, phosphates, alkaline phosphatase (ALP), 
creatinine, transaminases, and TSH), and we 
also initiated primary treatment with vitamin 
D supplementation (initial therapy to restore 
sufficiency: 2,000U/day or 14,000U/week - Plivit 
D3: 10gtt/day or 70 gtt/week).
We recommend that the patient receives primary 
osteoporosis treatment with medication according 
to the guidelines (Kocjan T, Preželj J, Pfeifer M, 
Jensterle-Sever M, Čokolič M, Zavratnik A. Smernice 
za odkrivanje in zdravljenje osteoporoze. Zdrav Vestn 
2013; 82:207-17) and that you comply with the 
prescribing limitations. The graduate nurse in your 
team must ensure the patient and their family receive 
appropriate education about a healthy lifestyle, the 
importance of a calcium-rich diet and prevention of 
additional falls. 
Osteoporosis and the associated osteoporotic hip 
fractures are an increasing social and economic 
issue. With comprehensive patient management we 
want to improve the quality of life of hip fracture 
patients, and secondary prevention should decrease 
incidence of further osteoporotic fractures. 
Sincerely, ...
INCLUSION 
OF VITAMIN D 
(on a temp. list)
59
Klinična študija / Clinical study
ACTA MEDICO-BIOTECHNICA
2021; 14 (1): 25–37
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