Data for 50 consecutive patients with femoral neck fractures were collected during the periods pre-UK lockdown, post-UK lockdown, and after the “MRS BAD BONES” intervention. During data collection, a number of patients were excluded from analysis: 8 patients with periprosthetic fractures, 8 patients who were managed nonoperatively, 12 patients who were taking bone-sparing treatment preadmission, 9 patients for whom it was documented as inappropriate to commence bone-sparing treatment due to a palliative approach, and 14 patients who died while in hospital. The demographics of the patients can be seen in Table 1. The percentage of patients who were reviewed by the orthogeriatric team prelockdown was 88% (n=44), but this fell to 0% following the lockdown, due to redeployment in response to COVID-19 pressures. During the postintervention period, this rose to 38% (n=19) as the orthogeriatric team returned to the T&O wards with the easing of local COVID-19 pressures.

The percentage of patients who had blood tests performed per local guidelines, which includes eGFR, adjusted calcium, and vitamin D, was high (96%-100%), with no significant difference between all 3 phases (P=.78) (Table 2). However, only 5 PTH blood tests were performed, all in the prelockdown period, with an average of 7.0 (range 4.3-10.8). This represents just 10% of the prelockdown population sample, which is just over 3% of the total sample population.

Average vitamin D, adjusted calcium, and eGFR serum levels for the cohorts can be seen in Table 3. Results show deficiency in serum vitamin D but normal adjusted calcium levels and eGFR, when adjusted for age, sex, and ethnicity.

The purpose of this audit was to assess whether the correct bone health management procedures had been initiated following the UK-wide COVID-19 lockdown. This was broken down into the steps advised by local guidelines, with the following treatments: vitamin D/calcium supplementation, bone-sparing medications, and DEXA scanning. We also noted a subgroup of patients who met the criteria for a DEXA scan but did not have a DEXA requested and instead started bone-sparing treatment. The frequencies and percentages of patients who received the correct osteoporosis management is displayed in Table 4, and Figure 3 to Figure 6.

The number of patients receiving the correct vitamin D/calcium treatment following the lockdown was significantly reduced (P=.02) with a drop from 81.6% (n=40) to 58% (n=29). Following the implementation of the “MRS BAD BONES” mnemonic, it was found that prescriptions increased to 85.7% (n=42) (P=.003), and this was significant when compared to the postlockdown data (Figure 3). However, there was no significant difference between the postintervention and prelockdown findings (P=.69).

As seen in Figure 4, following the UK lockdown, only 18.2% (n=4) of patients, compared to 60.7% (n=17) of patients prelockdown, were prescribed bone-sparing medication. This represents a significant drop (P=.004). However, following the implementation of the “MRS BAD BONES” mnemonic, the prescription of these medications significantly increased to 72.4% (n=21) compared to post lockdown (P<.001).

There was a significant drop (P=.003) in DEXA scan requests from 40.1% (n=9) to 3.6% (n=1) among eligible patients in the postlockdown period despite a normal service. In the postintervention phase, this number increased to 60% (n=12) and was of significance (P<.001) compared to the postlockdown data, as represented in Figure 5. While the percentage of patients with DEXA scans requested increased from 40.1% (n=9) in the prelockdown period, to 60% (n=12) in the postintervention period, this was not statistically significant (P=.37). A number of patients were eligible for a DEXA scan as per the guidelines but did not have one requested. Alternatively, they were treated with bone-sparing medication. As seen in Table 3 and Figure 6, prelockdown, 69.2% (n=9) of this subgroup had bone-sparing medication prescribed. Following the lockdown, this dropped to 7.4% (n=2), which was a significant drop (P<.001). Post intervention, this significantly increased to 88.9% (n=8) (P<.001) when compared to the postlockdown figures.

A significant percentage of the patients with a femoral neck fracture who attended UHCW did not receive the correct secondary fragility fracture prevention treatment following the UK lockdown due to the COVID-19 pandemic. Other than PTH, blood testing was performed per guidelines during the 3 phases, but these serum results were not actioned appropriately post lockdown. The redeployment of the orthogeriatric team, who primarily action these results, was the biggest factor leading to this. Clinical management of patients with fragility fractures is often suboptimal even under normal circumstances; a prior study on the secondary prevention of fragility fractures showed that despite steps being taken to increase awareness among junior doctors and nurse practitioners, improvements were still below target [11].

The direct implications on patients who did not receive adequate bone protection are unclear; a follow-up of this cohort may be useful for outcome studies. However, the literature suggests a 10%-13% overall risk of sustaining a secondary contralateral femoral neck fracture, which leads to a 1-year mortality of 31.6% compared to 27.3% for the index fracture. Furthermore, a risk of 28.6% is seen for any other osteoporosis-related fractures. It is clear this injury causes a significant morbidity and mortality among the elderly, as well as financial burden to the NHS [12,13].

The blood tests revealed deficiencies in serum vitamin D, which is to be anticipated in this population [9], but normal adjusted calcium levels and eGFR. No PTH measurements were performed post lockdown, with very few prior; no particular reason for this was identified. Parathyroid pathologies are relatively common endocrine disorders, particularly in elderly women [14]. PTH is vital for the maintenance of calcium homeostasis through its catabolic and anabolic actions that regulate bone remodeling. Hypoparathyroidism can lead to osteoporosis. PTH replacement therapy has been shown to remedy this abnormality [15]. Equally, patients suffering with primary hyperparathyroidism, particularly the normocalcemic variant, have more skeletal complications than is classically seen in hypercalcemic primary hyperparathyroidism. One study found osteoporosis in 57% of a population with normocalcemic primary hyperparathyroidism [16]. Hence, measuring serum PTH, per local guidelines, is important in this cohort and needs to be improved.

NICE recommendations to consider DEXA scanning and treatment of target groups to prevent fragility fractures are based on the extensive evidence that they reduce the risk of hip fractures and are cost-effective when compared to untreated osteoporosis [17,18]. In younger patients, bone mineral density assessment is needed to confirm the diagnosis of osteoporosis since high-energy trauma is often required to fracture the proximal femur. However, appropriate treatment can be commenced in elderly patients with a fragility fracture without the requirement for a DEXA scan [19]. Hence, it is good clinical practice to address this while the patient is still in hospital.

This study highlighted the positive impact on patient care that can be achieved by service changes implemented at a junior level. Following the dissemination of our findings and implementation of the “MRS BAD BONES” mnemonic, there was a significant improvement in the management of bone health compared to the postlockdown period, and was comparable to the prelockdown data. Mnemonics are used in various sectors for teaching purposes. Though used in a hospital environment here, this acronym has the potential to be beneficial in a wider setting, including primary care and medical education. Studies have demonstrated the role of mnemonic strategies in reshaping brain networks and improving memory performance [20]. Finally, though utilized during the COVID-19 pandemic, the use of this mnemonic has the potential to have an ongoing positive impact in the post–COVID-19 era.

Not all parameters included in the “MRS BAD BONES” mnemonic were assessed in this study due to restricted access in requesting archived written documents during the pandemic. Consequently, data were primarily collected using information available from electronic patient records. Those parameters not assessed include medication review, rheumatology/renal advice, smoking cessation, alcohol limits, nutrition, and exercise. The authors opted to use “MRS BAD BONES” despite this limitation because of the importance of each parameter as well as being a memorable acronym that provides a holistic approach to managing fragility fractures as endorsed by NICE. Drugs, particularly glucocorticoids, can induce osteoporosis, which makes a medication review an important assessment. Rheumatology or renal advice can be sought in complex cases where specialist treatment input is required, particularly in patients with severe renal impairment or intolerance of first-line bisphosphonates. Lifestyle changes, including smoking cessation, drinking alcohol within recommended limits, optimizing nutrition, and regular exercise, can all improve bone health and reduce the risk of fragility fractures [17]. Further research may provide insight into whether these factors were significantly affected by the use of the mnemonic. Furthermore, the return of the orthogeriatric team to the orthopedic unit will have contributed to improvements. Due to the unpredictability of the pandemic, their arrival was an unforeseen factor during the intervention phase. However, 62% of the patients in the postintervention phase did not receive an orthogeriatric review because they were discharged prior to their return. Hence, a large proportion of these patients had optimized management prior to the gradual return of services. Another limitation is that the guidelines state all male patients, as well as female patients <75 years old, should have a DEXA scan. Our results showed a significant proportion of patients eligible for DEXA scanning were instead treated with bone-sparing medications. The local guidelines do not take into consideration the experience and clinical judgment made by the orthogeriatric team who on occasions will commence all male patients and female patients <75 years old deemed high risk for osteoporosis onto bone-sparing medications without the need for bone density assessment. An update on the local guidelines to reflect this should be considered when next reviewed. A final limitation of this study is that 50 consecutive patients with femoral neck fractures were collected during 3 phases over a 5-month period. This may be considered a small population over a short duration. A longer period of analysis including the recruitment of patients with nonhip fragility fractures may be useful to further evaluate the findings. Additionally, dissemination of this mnemonic to other orthopedic units might be useful to further validate our results.

Management of bone health is an important consideration for patients with femoral neck fractures due to the morbidity and mortality osteoporosis poses, and the significant financial burden fragility injuries cause the NHS. Orthogeriatric team input is invaluable in coordinating secondary prevention of fragility fractures. However, with the uncertainty of future COVID-19 outbreaks, subsequent orthogeriatrician redeployment may be required. Despite this, ensuring that fragility fracture management is not forgotten is vital. Here, we present the use of a mnemonic, “MRS BAD BONES,” aimed at junior doctors, advanced nurse practitioners, and medical students, which could be used to improve awareness of major areas of assessment and management of secondary prevention of fragility fractures, and maintain optimal quality of care.