The hip joint is a well-known point of failure in the human body, especially as we age. It’s no wonder the problem is familiar: In the U.S. alone, someone fractures a hip roughly twice every minute; it happens 27 times a minute worldwide.

Most of us could correctly identify the typical patient. They’re in late life (the average age at time of fracture is 81). They’re more likely to be female than male. Whether they know it or not, they tend to have low bone density or osteoporosis. And in most cases, the fractures come after a fall.

Hip fractures could be understood as an inevitable risk that comes with advanced age — and, as our society ages, that more should be expected.

But the authors of a review article recently published in JAMA hope to shake us out of resignation.

They show that hip fractures are both terribly serious — with more than one in five patients dying within a year of their fracture — and at least partly preventable, both by preserving bone health and by avoiding the falls that cause them.

In her practice, co-author Joy Tsai, an endocrinologist and Harvard Medical School assistant professor of medicine at Massachusetts General Hospital, is continually reminded how hormonal changes in late life can cause serious degradation in bone quality that make fractures far more likely. (Tsai will discuss those changes at an Oct. 10 event on bone health at Boston’s Hynes Convention Center.)

In this edited conversation with the Gazette, Tsai explains why fractures are so common and so devastating, what people can do to prevent them, and what she hopes might follow from sounding the alarm in the world’s most widely circulated medical journal.

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Gazette: The top line number in your article shocked me: Roughly 22 percent of people who suffer a hip fracture die within a year. Why would that be the case?

Joy Tsai: That approximate number is a very familiar one to the clinicians and primary care doctors who are on the frontlines, seeing this. And it’s also just a number that has been passed down in medical schools for years. But it really wasn’t until I worked on this article that I wondered, “Why is that?”

Intuitively you understand it a little: Someone fell. They had a major fracture. And they have to learn to walk again. And then the hip is a big joint to repair or replace: Either they put in a large metal rod, or they take the whole thing out and replace the hip joint — and that can work. But if they’re doing that work in the aftermath of a hip fracture, the person is — first of all — probably older and relatively frail, and the recovery is not as quick: They may not make it home right away; they may have a pit stop in a rehab.

Obviously, we don’t put “frailness” as a cause of death, but I think this is where a lot of the mortality enters in. The leading causes of death, in the data that we cited in the paper, include pneumonia, sepsis, myocardial infarction, pulmonary embolism, and cancer. So it’s these other medical complications — maybe related, maybe not. But these are things that can come after you’ve had, say, a prolonged hospital stay, or experience reduced functionality, or end up suffering a refracture, which is very common. Many people just never make it back to their baseline.

It may be well-known in medical circles, but I’m not sure the broader culture has taken it on board — how disastrous hip fractures can be.

Yeah, to me, a hip fracture is the equivalent of a heart attack or a stroke. If people want to prevent heart attack or stroke, they manage their blood pressure, their cholesterol. But we don’t often talk about preventing hip fracture in the same terms or move as quickly to preserve bone quality.

This is part of why we were excited to publish this paper in JAMA: It has a much broader audience, with lots of primary care or family physicians. While bone-density scans may be high on many doctors’ checklists for their older patients, there’s definitely a “treatment gap” where even patients who are screened and confirmed as at high risk for osteoporosis are not always on prescription medications.

That’s partially from lack of time in the primary-care setting to address everything, and also from patient hesitancy: There’s a lot of bad press focusing on rare side effects of the medicines. So even when they’re known to have osteoporosis, they think, “I’m just going to be really active, and take calcium, and be careful not to fall.” But people are human — and falls happen.

I was surprised to find that you are an endocrinologist, having assumed that hip fractures are mainly an orthopedic problem. But the review shows the huge role that bone health plays in someone’s fracture risk.

Oh, absolutely. What I tell my patients is that absolutely you want an orthopedic surgeon when you have a broken bone. But — and this is no disrespect to them — you should kind of think of them like carpenters. You want a carpenter to rebuild the bone, or the joint — but you want someone else to help with the architecture, or the plumbing, the other things.

That’s where I come into play: by counseling patients on, first, preventing these fractures, as well as after one takes place. Orthopedic surgeons love to partner with us [endocrinologists], because after they’ve done their handiwork, they want it to last, right? They want recovery to go well; they don’t want you to break another bone.

To extend the analogy, though, if the body is like a machine or a house, the layperson almost expects bone to wear down or degenerate in later life.

Sure. And before I went to medical school, I thought of bone as this inanimate object — like an iron rod. Until you’re in a cadaver lab, that’s what you would think.

[At this point, Tsai holds up a model: a 3D-printed cross-section of her own tibia.]

I love to show this, because really that’s not what it’s like. There’s the outer rim, a shell we call cortical bone, and then these inner trabeculae: It looks like a sponge, but it’s actually hard — mostly mineral. And then there’s collagen and some other things too. It’s a matrix. My bone is relatively healthy, so it looks good. But bones can have pores, and its architecture will affect its quality. Mass is a big component — you want more bone — but the way it’s arranged matters, too.

And then bone is dynamic. You have cells building it up and breaking it down, like a life cycle. The medications I’m discussing work by influencing that cycle. Some slow down the breakdown, others improve the building aspect, and there’s one out there that does both. To your earlier question, endocrinology gets tied in because hormones can influence the cycle.

As estrogen falls in postmenopausal women, for example, you lose some protective effect — same with men and low testosterone. But there are other hormones involved, too, like parathyroid. And some of these medications are actually synthetic versions, or analogues, of that parathyroid hormone.

I want to be clear that medication is not the only intervention your report recommends. Lifestyle, posture, habits, and living space all have a role — preventing falls in the first place. What advice would you give there?

I’m glad you gleaned that from the article; it’s so important to us. I tell patients that our shared goal is for them not to break a bone — and if you just don’t fall, it will go a very long way toward achieving that.

In terms of practical points, I always tell my younger, more active patients not to multitask. You think you can do more than one thing at a time — you’re on the phone, walking the dog, turning your head — but you get distracted. Or: Slow down; it’s OK if you miss your train, catch the next one. Breaking those habits can be challenging, but I think it’s worth it.

And then for older patients, where their reflexes might be slower: You do want to declutter, remove loose rugs. But you try to tailor it to the patient. If they’re grandparents and they’re going to have a play area, try to keep it sequestered. And we don’t want them leaning over and picking up a heavy load, like a toddler that wants to be held up all the time. I always tell them, with a 2-year-old, you should have to insist that they stand up before lifting them.

There have been huge breakthroughs of late with inherited diseases, thanks to CRISPR technology. Here obviously there’s a more biomechanical problem, but the paper does suggest that hip fractures have a substantial genetic component, too.

Yes. Speaking as a non-epidemiologist, here, in our look at the databases, genetics always came out as a very strong risk factor. In one popular risk calculator, one of the inputs is, “Did a parent break a hip bone?” When patients say yes, they often add: “Oh, but they were 80, they fell,” and so on. We find that it doesn’t matter: It ends up being a significant predictor anyway.

It is a bit disappointing that we’re just in the early stages in terms of the genetic work of figuring out what precisely causes that pattern. I think there are so many environmental interactions at play that it’s really challenging to distill it down to one gene or one epigenetic factor. But there’s a connection.

I can see the difficulties of treating something that is, in the main, so much more of a risk for people in late life, and for people with osteoporosis. It could be tempting to say, “This is just part of getting older,” and to run the risk.

For sure. With a lot of patients, when they get a first-time bone-density scan that shows osteoporosis, it’s kind of devastating. It’s a silent disease; you don’t know you have it until something breaks. And so they’re often like, “Gosh, I’ve been exercising. I’ve always loved to drink milk. I’ve done all the right things.” They’re quite disappointed. But I try to tell them, “This doesn’t mean that you’re destined to break a bone; you can do something about this.”

We want patients to feel empowered, to feel that they can change their course and don’t have to just say, “Oh well, that’s part of the age-related process.” We have medications that can help, that are FDA-approved, and that are shown to reduce the chance of a broken bone. To be clear, they don’t cure osteoporosis. But you can at least get screened, find out your baseline risk, and talk it over with your doctors. I just want people to feel that they have power, have agency, to do something about it.

Editor’s note: Tsai included a disclosure in the paper acknowledging that her husband works for Amgen, which develops two major osteoporosis medications.