Orthopedics Surgeons' Out-Patient Practice in Saudi Arabia: Supplementation and Osteoporosis Management

Introduction:

With the increased specialization in the medical field, the specialist might lose sight of a significant issue facing his patient while is focused on the details of his specialty.¹ The orthopedics surgeon's outpatient clinic is a busy environment, and thousands of patients pass through it annually.² Nevertheless, the orthopedic surgeon is perfectly positioned to screen patients for relevant medical conditions, notably osteoporosis. As part of a multi-disciplinary team, the orthopedic surgeon plays a vital role in this regard 3. This role is not limited to osteoporosis screening, however. The orthopedic surgeon can suggest or prescribe a variety of nutritional and "health" supplements according to the patients' condition. Vitamins, calcium supplements, chondroitin & glucosamine, are often prescribed. The evidence supporting these practices-however-is weak.^4-6 Calcium supplementation may cause harm, and multivitamin supplementation is no longer recommended for healthy adults. 7, 8 Our goal in this study was to investigate the current trends in osteoporosis management -and the use of nutritional and other supplements- by orthopedic surgeons in our country.

Materials and Methods:

A structured electronic survey was designed to answer the questions posed by the author. It was distributed to members of the Saudi Orthopedic Association (SOA) by email and social media. The participants were completely anonymous as no personal identifying data was collected. The participants consented to their anonymous information being used for research purposes electronically. The first section was concerned with the participant and his practice environment. This included the number of years in practice and whether the participant's practice institution was public or private. The second section inquired about the pattern of prescribing specific supplements by the participant. This included multivitamins, vitamin B complex, vitamin D3, calcium, and chondroitin/glucosamine. The third section inquired about the participant's current practice with regard to osteoporosis management. The data was then coded and tabulated. Statistical analysis included descriptive statistics and the chi-square test using SPSS version 27(IBM, Armonk, NY, USA).

Results:

Fifty-one SOA members completed the survey. With regard to their practice type, thirty-one participants (60.8%) practiced in a public institution, while only 20 participants (39.2%) worked in a private institution. Most participants were in practice for 11-20 years (21 participants, 41.2%), some were in their first decade of practice (18 participants, 35.3%), and a few had more than 20 years of experience (12 participants, 23.5%).

When it comes to the provision of supplements, the variation in practice is shown in Figure 1. Apart from calcium and vitamin D, most participants did not prescribe supplements routinely. Multivitamins are rarely prescribed by most, but B complex vitamins showed wide variation in their prescription by the participants. Chondroitin and glucosamine had the largest percentage of participants who would not consider prescribing it under any circumstances (19 participants, 37.3%).

Figure 1: Prevalence of supplement provision by study participants.

There was no significant association between the type of practice and any of the supplements except for chondroitin and glucosamine. Chondroitin and glucosamine prescriptions were more prevalent in the private sector: Forty-five percent of participants from that sector would prescribe it frequently, and only 7% of public sector surgeons would do so (P=0.005). No significant association was found between supplement provision and experience (P=0.94).

Asked whether they would handle osteoporosis alone or involve others, most (28 participants, 54.9%) replied they would be happy screening only. They would then refer the positive cases to specialists (figure 2). Some would add initiation of treatment (14 participants, 27.5%), while a minority would manage the cases themselves and not involve others (7 participants, 13.7%).

Figure 2: Preferred osteoporosis screening and referral by study participants.

A significant association was found between the practice setting and osteoporosis screening preference: Public sector participants are more likely to screen and refer to experts (68%) than private-sector participants (35%), while 25% of private-sector surgeons would solely manage osteoporosis and only 7% of public sector surgeons would do so (P=0.035). No significant association was found between osteoporosis management and experience (P=0.34).

When asked about their current investigation(s) of choice when screening for osteoporosis, most replied that they would request dual-energy X-ray absorptiometry (DEXA) and follow established guidelines (figure 3). Some would request laboratory workup-such as a bone profile-and screening for vitamin D deficiency (29 participants, 56.9%). A minority felt comfortable investigating for causes of secondary osteoporosis (9 participants, 17.6%).

Figure 3: Osteoporosis screening investigation by study participants (any that applies).

When asked what their standard treatment for osteoporosis would be, the majority (21 participants, 41.2%) denied they would treat it (figure 4). The second largest majority (15 participants, 29.4%) would prescribe supplements and other medications, while around one-fifth of the participants (11 participants, 21.6%) would add bisphosphonates. A small minority (four participants, 7.8%) would prescribe supplements only. No significant association was found between osteoporosis treatment and practice location or experience (P=0.277&P=0.428).

Figure 4: Preferred osteoporosis treatment plan by study participants

Discussion:

The global burden of osteoporosis is large and expanding with the aging of the population.⁹ Increased morbidity and mortality following an osteoporotic fracture is well established.^{10, 11} Treatment of osteoporosis is effective in reducing fracture incidence. 12-14 Fragility fractures have been on the decline for years, but no longer.¹⁵ Screening by the orthopedic surgeon-as part of a broader management plan- has been shown to provide better outcomes.^{3, 16, 17} A recent publication showed that only 51% of eligible patients visiting the orthopedic clinic -in a local tertiary care hospital-had been screened for osteoporosis.¹⁸ A National Plan for Osteoporosis Prevention and Management in the Kingdom of Saudi Arabia was published in 2018 by the ministry of health, yet the national care gap continues, and the cost of fragility fracture management is over 2 billion Saudi Riyals annually. 19 In our study, 98% of participants would screen eligible patients, yet 88% reported that they would order bone density measurements for eligible patients. This percentage is similar to reports from Canada, Germany, and Italy. 20, 21 Reports from other countries paint a different picture, where orthopedic surgeons from the USA, France, and other countries are not willing as much to screen patients for osteoporosis. 20, 22, 23 The orthopedic surgeon's role in our community seems to vary by practice setting, as most public sector surgeons in our study screened and referred. In contrast, a sizable portion of private sector surgeons would manage osteoporosis solely. Discrepancies between the two sectors are not well established in the literature, but evidence is present.²⁴

An essential part of osteoporosis management is the provision of calcium and vitamin D supplements.²⁵ A recent meta-analysis found that daily calcium and vitamin D supplementation can help reduce hip fracture risk by 16%.26 In this study, most surgeons stated that they would frequently provide their patients with these supplements. A more controversial issue, however, would be the provision of multivitamins. Several reports have shown that no proven clinical benefit is associated with the daily multivitamin supplement.^27-29 Some have shown that self-reported health is better while no clinically measurable benefits exist.³⁰ A very recent systematic review showed that multivitamin supplementation might reduce fracture risk. 31 In our study, only 14% of the participants would routinely provide their patients with multivitamins.

Vitamin B supplementation in the outpatient orthopedic setting is controversial and has weak evidence supporting it.³² It is commonly provided without preceding bloodwork, proving deficiency. Widely prescribed for back pain and sciatica cases, yet most studies on the subject are on animals, except for one clinical trial.^33-37 In our study, slightly more participants would provide vitamin B complex supplementation than they would a multivitamin.

Supplementation with chondroitin and glucosamine has been studied. High-level evidence exists that shows that neither chondroitin nor glucosamine is effective in the management of osteoarthritis. 5, 38, 39 Only 22% of the participants in our study-mostly from the private sector- would frequently provide these supplements, and none reported that they would offer it routinely to eligible patients.

Summary:

The participants in this study are orthopedic surgeons from all over the country. Although the study sample size is small, the results show that the Saudi orthopedic surgeon is aware of his patient's medical management. Although significant variability in this matter exists internationally, the Saudi surgeons' practice is similar to his colleagues from developed countries20. As for the provision of supplementation, the percentage of participants who would provide supplements in our study is similar to other published reports. 40, 41

Acknowledgments:

The author would like to thank the president of the SOA -Dr. Abdulaziz AlJurayyan- and his administrative staff for their help in distributing the survey to their members.

Financial support:

The author did not receive any funding to conduct this research nor to prepare the manuscript

Disclosure of interest:

The authors have nothing to disclose.

References:

1. Spence D. Bad medicine: specialisation. Bmj. 2010;341.

2. Syed MA, Azim SR, Baig M. Frequency of orthopedic problems among patients attending an orthopedic outpatient department: a retrospective analysis of 23 495 cases. Annals of Saudi Medicine. 2019;39(3):172-7.

3. Queally J, Kiernan C, Shaikh M, Rowan F, Bennett D. Initiation of osteoporosis assessment in the fracture clinic results in improved osteoporosis management: a randomised controlled trial. Osteoporosis international. 2013;24(3):1089-94.

4. Guallar E, Stranges S, Mulrow C, Appel LJ, Miller III ER. Enough is enough: stop wasting money on vitamin and mineral supplements. Annals of internal medicine. 2013;159(12):850-1.

5. Train A, Moe S, Allan GM. Are glucosamine and chondroitin natural remedies for osteoarthritis? Canadian Family Physician. 2021;67(2):111-.

6. Chiodini I, Bolland MJ. Calcium supplementation in osteoporosis: useful or harmful? European journal of endocrinology. 2018;178(4):D13-D25.

7. Rautiainen S, Manson JE, Lichtenstein AH, Sesso HD. Dietary supplements and disease prevention - a global overview. Nat Rev Endocrinol. 2016;12(7):407-20.

8. Moyer VA. Vitamin, mineral, and multivitamin supplements for the primary prevention of cardiovascular disease and cancer: U.S. Preventive services Task Force recommendation statement. Ann Intern Med. 2014;160(8):558-64.

9. Johnell O, Kanis J. An estimate of the worldwide prevalence and disability associated with osteoporotic fractures. Osteoporosis international. 2006;17(12):1726-33.

10. Abrahamsen B, Van Staa T, Ariely R, Olson M, Cooper C. Excess mortality following hip fracture: a systematic epidemiological review. Osteoporosis international. 2009;20(10):1633-50.

11. Bass E, French DD, Bradham DD, Rubenstein LZ. Risk-adjusted mortality rates of elderly veterans with hip fractures. Annals of epidemiology. 2007;17(7):514-9.

12. Grey A, Bolland M. The effect of treatments for osteoporosis on mortality. Osteoporosis International. 2013;24(1):1-6.

13. Bolland MJ, Grey A, Avenell A. Effects of vitamin D supplementation on musculoskeletal health: a systematic review, meta-analysis, and trial sequential analysis. Lancet Diabetes Endocrinol. 2018;6(11):847-58.

14. Dell RM, Greene D, Anderson D, Williams K. Osteoporosis disease management: What every orthopaedic surgeon should know. J Bone Joint Surg Am. 2009;91 Suppl 6:79-86.

15. Lewiecki EM, Wright N, Curtis J, Siris E, Gagel R, Saag K, et al. Hip fracture trends in the United States, 2002 to 2015. Osteoporosis International. 2018;29(3):717-22.

16. Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM. Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. JBJS. 2006;88(1):25-34.

17. Edwards BJ, Koval K, Bunta AD, Genuario K, Hahr A, Andruszyn L, et al. Addressing secondary prevention of osteoporosis in fracture care: follow-up to “own the bone”. JBJS. 2011;93(15):e87.

18. Awwad WM, Almutair AS, Alsaleh KA, Aljomah NA, Alfouzan KA, Almutair OS. Rates of Osteoporosis Screening Among Patients Attending Orthopedics Surgery Clinics, Riyadh, Saudi Arabia. Merit Research Journal of Medicine and Medical Sciences. 2017;5(1):052-6.

19. Aziziyeh R, Garcia Perlaza J, Saleem N, Sadat-Ali M, Elsalmawy A, McTavish RK, et al. The burden of osteoporosis in Saudi Arabia: a scorecard and economic model. Journal of Medical Economics. 2020;23(7):767-75.

20. Dreinhöfer KE, Anderson M, Feron J-M, Herrera A, Hube R, Johnell O, et al. Multinational survey of osteoporotic fracture management. Osteoporosis international. 2005;16(2):S44-S53.

21. Bogoch ER, Snowden E. A sample of Canadian orthopedic surgeons expressed willingness to participate in osteoporosis management for fragility fracture patients. Can J Surg. 2008;51(1):8-13; quiz 4.

22. Skedros JG, Holyoak JD, Pitts TC. Knowledge and opinions of orthopaedic surgeons concerning medical evaluation and treatment of patients with osteoporotic fracture. J Bone Joint Surg Am. 2006;88(1):18-24.

23. Sorbi R, Aghamirsalim M. Osteoporotic Fracture Program management: who should be in charge? A comparative survey of knowledge in orthopaedic surgeons and internists. Orthop Traumatol Surg Res. 2013;99(6):723-30.

24. Siddiqi S, Hamid S, Rafique G, Chaudhry SA, Ali N, Shahab S, et al. Prescription practices of public and private health care providers in Attock District of Pakistan. The International Journal of Health Planning and Management. 2002;17(1):23-40.

25. Farmer RP, Herbert B, Cuellar DO, Hao J, Stahel PF, Yasui R, et al. Osteoporosis and the orthopaedic surgeon: basic concepts for successful co-management of patients' bone health. Int Orthop. 2014;38(8):1731-8.

26. Yao P, Bennett D, Mafham M, Lin X, Chen Z, Armitage J, et al. Vitamin D and Calcium for the Prevention of Fracture: A Systematic Review and Meta-analysis. JAMA Netw Open. 2019;2(12):e1917789.

27. Fortmann SP, Burda BU, Senger CA, Lin JS, Whitlock EP. Vitamin and mineral supplements in the primary prevention of cardiovascular disease and cancer: an updated systematic evidence review for the US Preventive Services Task Force. Annals of internal medicine. 2013;159(12):824-34.

28. Grodstein F, O’Brien J, Kang JH, Dushkes R, Cook NR, Okereke O, et al. Long-term multivitamin supplementation and cognitive function in men: a randomized trial. Annals of internal medicine. 2013;159(12):806-14.

29. Lamas GA, Boineau R, Goertz C, Mark DB, Rosenberg Y, Stylianou M, et al. Oral high-dose multivitamins and minerals after myocardial infarction: a randomized trial. Annals of internal medicine. 2013;159(12):797-805.

30. Paranjpe MD, Chin AC, Paranjpe I, Reid NJ, Duy PQ, Wang JK, et al. Self-reported health without clinically measurable benefits among adult users of multivitamin and multimineral supplements: a cross-sectional study. BMJ Open. 2020;10(11):e039119.

31. Beeram I, Mortensen SJ, Yeritsyan D, Momenzadeh K, von Keudell A, Nazarian A. Multivitamins and risk of fragility hip fracture: a systematic review and meta-analysis. Arch Osteoporos. 2021;16(1):29.

32. Dai Z, Koh W-P. B-vitamins and bone health--a review of the current evidence. Nutrients. 2015;7(5):3322-46.

33. Wang Z-B, Gan Q, Rupert RL, Zeng Y-M, Song X-J. Thiamine, pyridoxine, cyanocobalamin and their combination inhibit thermal, but not mechanical hyperalgesia in rats with primary sensory neuron injury. Pain. 2005;114(1-2):266-77.

34. Bonke D, Nickel B. Improvement of fine motoric movement control by elevated dosages of vitamin B1, B6, and B12 in target shooting. International journal for vitamin and nutrition research Supplement= Internationale Zeitschrift fur Vitamin-und Ernahrungsforschung Supplement. 1989;30:198-204.

35. Leuschner J. Antinociceptive properties of thiamine, pyridoxine and cyanocobalamin following repeated oral administration to mice. Arzneimittel-forschung. 1992;42(2):114-5.

36. Hakim M, Kurniani N, Pinzon RT, Tugasworo D, Basuki M, Haddani H, et al. Management of peripheral neuropathy symptoms with a fixed dose combination of high-dose vitamin B1, B6 and B12: A 12-week prospective non-interventional study in Indonesia. Asian Journal of Medical Sciences. 2018;9(1):32-40.

37. Mauro GL, Martorana U, Cataldo P, Brancato G, Letizia G. Vitamin B~ 1~ 2 in low back pain: A randomised, double-blind, placebo-controlled study. European review for medical and pharmacological sciences. 2000;4:53-8.

38. Simental-Mendia M, Sanchez-Garcia A, Vilchez-Cavazos F, Acosta-Olivo CA, Pena-Martinez VM, Simental-Mendia LE. Effect of glucosamine and chondroitin sulfate in symptomatic knee osteoarthritis: a systematic review and meta-analysis of randomized placebo-controlled trials. Rheumatology international. 2018;38(8):1413-28.

39. Singh JA, Noorbaloochi S, MacDonald R, Maxwell LJ. Chondroitin for osteoarthritis. Cochrane Database of Systematic Reviews. 2015(1).

40. Dickinson A, Shao A, Boyon N, Franco JC. Use of dietary supplements by cardiologists, dermatologists and orthopedists: report of a survey. Nutrition journal. 2011;10(1):1-7.

41. Dickinson A, Boyon N, Shao A. Physicians and nurses use and recommend dietary supplements: report of a survey. Nutr J. 2009;8:29.