Estimating the Extent of Missed Opportunities for Osteoporosis Treatment Before Hip Fracture Occurrence

Hip fractures (HF) are among the most serious consequences of osteoporosis. Many individuals who subsequently sustain a HF may already fulfill recognized criteria for fracture risk assessment, bone mineral density (BMD) evaluation, or anti-osteoporosis treatment before the event occurs, yet remain unidentified and untreated. We aimed to quantify these missed opportunities for osteoporosis management prior to fragility HF occurrence. We performed a cross-sectional analysis of 1,103 patients aged ≥ 50 years hospitalized for fragility HF and evaluated within a Fracture Liaison Service. Pre-fracture fracture risk was retrospectively estimated using FRAX^® based on clinical risk factors only, excluding the index HF. Eligibility for anti-osteoporosis treatment and BMD assessment was evaluated according to international recommendations and national reimbursement criteria. Only 82 patients (7.4%) had received anti-osteoporosis therapy before the index HF. Female sex, rheumatologic diseases, chronic glucocorticoid therapy, and previous fractures were independently associated with prior treatment, whereas diabetes mellitus was negatively associated. Among patients aged 50-90 years, 69.6% would have been classified as being at high or very high fracture risk before fracture occurrence, yet only 10.2% had received anti-osteoporosis therapy. Among the remaining patients, 90.3% already met indications for BMD assessment. Most patients who sustain a HF already meet recognized criteria for osteoporosis assessment or treatment but remain untreated. These findings highlight substantial missed opportunities for fracture prevention and support earlier identification and management of individuals at increased fracture risk.