Author response to letter to the editor to ankle fractures: A pragmatic opportunity for osteoporosis case finding (OSIN-D-25–01889)
- Open Access
- 27.10.2025
- Invited Article (Response to the Letter to Editor)
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We would like to express our sincere gratitude for the thoughtful letter by Huang in response to our recent article,, 'Should we consider ankle fractures as osteoporotic fractures?' [1]. We are very grateful for the acknowledgement of the importance of our study and its contribution to the ongoing discussion about secondary fracture prevention.
We agree with the observation in the letter that ankle fractures are a critical yet often overlooked opportunity for osteoporosis case finding. The exclusion of ankle fractures from many osteoporosis screening guidelines, such as those of the German Osteological Society (DVO) [2], has indeed contributed to a significant care gap. However, we are encouraged by the recent update to the DVO guidelines, which no longer explicitly exclude ankle fractures from osteoporosis-related considerations [3]. While this does not yet constitute full inclusion, it is a positive step in the right direction and highlights a growing recognition of the potential value of these fractures in identifying individuals at risk of osteoporosis. Similar to well-accepted osteoporotic fractures, ankle fractures have prognostically relevant consequences, including an increased risk of subsequent fractures and excess mortality in men over five years [4].
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As the letter points out, although ankle fractures may not exhibit the same age-related peak as classic osteoporotic fractures, such as distal radius fractures, they still occur frequently in vulnerable cohorts, particularly among the elderly. Our study highlights this vulnerability: 85% of patients over 60 met the screening criteria for osteoporosis, independently of the fracture event. This reveals a significant failure to identify and treat individuals at risk [1]. The therapeutic gap, especially compared to distal radius fractures, is striking: 97% versus 84%, respectively. This discrepancy further emphasises the need to reconsider current clinical pathways for managing these injuries.
We also appreciate the suggestion to integrate ankle fractures into fracture liaison service (FLS) referral protocols, as this could be a practical and cost-effective way of addressing deficits in the diagnosis and treatment of osteoporosis. Recognising ankle fractures as potential triggers for FLS referral is consistent with current efforts to improve secondary fracture prevention and could play a crucial role in closing the treatment gap. Such initiatives would support broader efforts to optimise care for osteoporosis patients, particularly in the elderly population.
In conclusion, we are grateful for the authors’ positive feedback on our conclusions and their constructive suggestions. While ankle fractures may not meet the traditional definition of 'sentinel fractures', recognising them as an indicator for osteoporosis management represents a valuable opportunity to improve clinical care. We hope that our study, alongside the updated DVO guidelines, will encourage further discussion and lead to meaningful improvements in osteoporosis treatment strategies.
Declarations
Competing interests
Steffi S.I. Falk declare that she has no conflict of interest.
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