Drug Shortages Undermine South Africa’s First Public Fracture Liaison Service

A broken hip in later life is often the first loud warning that bones have been quietly weakening for decades. Yet around the world, that warning is frequently missed: patients are patched up surgically, sent home, and left exposed to a second fracture that could have been prevented. A new audit from Helen Joseph Tertiary Hospital in Johannesburg, published in Archives of Osteoporosis, offers one of the most detailed looks yet at how a public hospital in South Africa is trying to break that cycle, and at the stubborn supply-side obstacles that keep getting in the way.

The service in question is a fracture liaison service, or FLS, a model of coordinated care widely regarded as the international gold standard for secondary fracture prevention. The concept is deceptively simple. When a patient arrives with a fragility fracture, meaning a break caused by low-energy trauma such as a fall from standing height, a dedicated multidisciplinary team screens the patient for osteoporosis and falls risk, initiates treatment, and arranges follow-up rather than allowing the person to disappear back into the community. International studies have shown that where such services exist, the initiation of bisphosphonate therapy can rise from roughly 45 percent to more than 72 percent, alongside reductions in subsequent fractures and mortality.

Helen Joseph, an academic public hospital in Gauteng serving a population of about one million people, established the first FLS of its kind in the Gauteng public sector. Researchers led by C. Van der Meer of the University of the Witwatersrand conducted a retrospective audit of the first 247 patients enrolled between October 2022 and June 2024, extracting data from standardised assessment forms covering demographics, fracture characteristics, laboratory results, risk factors, and treatment. The results paint a vivid portrait of a patient population whose skeletal fragility is entangled with cognitive decline, multimorbidity, and lifestyle risks.

The epidemiology is familiar in outline. Nearly three-quarters of patients were women, and more than 81 percent were aged between 60 and 89, with a mean age of 71.8 years. Hip fractures dominated, accounting for almost 60 percent of presentations, split between neck of femur fractures at 38.8 percent and intertrochanteric fractures at 21.1 percent. This aligns with global data identifying hip fracture as the most serious and costly consequence of osteoporosis. But the details are striking: 42 percent of patients had fallen at least once in the preceding year, 39.6 percent showed possible cognitive impairment on Mini-Cog screening, and more than a quarter had already suffered a previous fragility fracture before the one that brought them to hospital.

Laboratory findings added another layer of vulnerability. Vitamin D insufficiency was documented in 41.1 percent of patients, with no significant differences across self-identified ethnic groups, a notable result given longstanding assumptions that osteoporosis is less prevalent among people of African ancestry. Renal impairment was also common, with 11.3 percent of patients showing chronic kidney disease and 35.6 percent presenting with acute kidney injury. Comorbidities were the rule rather than the exception, led by chronic obstructive pulmonary disease in 25.5 percent and diabetes in 16 percent. Only 3.3 percent of patients had been receiving osteoporosis treatment before their index fracture, underscoring a vast untreated gap.

Perhaps the most distinctive finding concerns gender. Men in the cohort smoked at dramatically higher rates than women, 73 percent versus 46 percent, and consumed alcohol at more than three units per day at nearly double the female rate, 48 percent versus 23 percent. Physical inactivity was common in both sexes, affecting just over half of all patients. The authors suggest that men presenting with fragility fractures carry a heavier burden of modifiable lifestyle risk factors and may represent a particularly vulnerable subgroup requiring targeted prevention, a point with clear implications for how screening programmes should be designed in South Africa and similar settings.

On treatment, the audit reveals both progress and frustration. The FLS assessed patients quickly, with a median of just two days from admission, and prescribed calcium or vitamin D supplementation to 82.5 percent of patients. But only 27.8 percent received zoledronic acid, a potent once-yearly bisphosphonate, before discharge. The reasons are sobering: 12.4 percent of untreated patients were medically ineligible because of advanced chronic kidney disease, but a full 60 percent of the untreated cases were attributable to medication supply shortages. Patients with severe renal impairment could not be offered alternatives such as RANK ligand inhibitors or teriparatide, which are simply unavailable in the state sector. This matters because zoledronic acid has been shown in trials such as HORIZON to reduce vertebral fractures by roughly 70 percent and hip fractures by about 41 percent.

The systemic consequences are visible in the hospital statistics. The median length of stay was 18 days, more than double the five to eight days typically reported in high-income countries such as the United Kingdom and the United States, reflecting differences in health system resources and discharge pathways. In-hospital mortality was 5 percent, largely driven by pulmonary embolism and sepsis-related complications. The authors also note that DEXA scanning, the reference standard for measuring bone mineral density, was available to only 21 percent of patients during admission or the following year, limited to three inpatients and two outpatients per day, which forced the team to calculate FRAX fracture risk scores without bone density data.

Some findings invite careful interpretation. African patients made up 22.7 percent of the cohort compared with 45 percent who identified as Caucasian, a pattern consistent with published suggestions of lower osteoporosis prevalence among people of African ancestry. But the authors caution that fragility fractures in African patients may be under-recognised because of lower rates of diagnostic testing and referral, meaning the ethnic distribution may reflect patterns of healthcare access rather than true disease prevalence. The team also acknowledges the limitations inherent in a retrospective, single-centre design: reliance on clinical records, no long-term follow-up data on refracture or adherence, and the exclusion of outpatients, which likely underestimates distal radius fractures.

What emerges is a study that is less a celebration than a baseline. The Helen Joseph FLS has demonstrated that coordinated secondary prevention is feasible in a resource-constrained public hospital, and it has generated the first South African FLS data to incorporate detailed falls risk and osteoporosis risk assessment. But its impact is capped by forces beyond the ward: unreliable drug supply, scarce diagnostic capacity, and prolonged hospitalisation. The authors argue that reliable medication supply, wider access to DEXA scanning, routine falls and risk factor screening, and expansion of the FLS model to district hospitals and primary care are the levers that will determine whether the roughly 60 percent of patients currently missing out on bisphosphonates can be reached. Future research, they say, should track refracture rates, adherence, mortality, and cost-effectiveness, and directly compare outcomes between patients affected and unaffected by drug shortages. For now, the Johannesburg audit stands as both proof of concept and a warning: the clinical model works, but only if the medicines arrive.

Subject of Research: Implementation and outcomes of a fracture liaison service for secondary prevention of fragility fractures in South Africa

Article Title: An audit of the fracture liaison service at Helen Joseph Tertiary Hospital, Johannesburg, South Africa

Article References: Van der Meer, C., Daya, R., Bayat, Z., & Greenstein, L. S. (2026). An audit of the fracture liaison service at Helen Joseph Tertiary Hospital, Johannesburg, South Africa. Archives of Osteoporosis, 21(1), Article 142. https://doi.org/10.1007/s11657-026-01774-x

Image Credits: AI Generated

DOI: 10.1007/s11657-026-01774-x

Keywords: fracture liaison service, osteoporosis, fragility fractures, hip fracture, zoledronic acid, vitamin D deficiency, falls risk, FRAX, South Africa, secondary prevention, resource-limited settings, bone mineral density