St. Michael’s Hospital (SMH) in Toronto put into place the first Fracture Liaison Service (FLS) program – the first of its kind in Canada and the program has been a leader in the FLS movement across the country, and worldwide, since 2002.

The program’s success at SMH is attributed to its cohesive and dedicated multidisciplinary team. The program originated as a result of the leadership of Dr. Earl Bogoch with Dr. Dorcas Beaton, Clinical Epidemiologist as the scientific consultant who was succeeded by Dr. Joanna Sale, the current scientific lead.

Victoria Elliot-Gibson was and continues to screen all fracture inpatients and outpatients aged 50 and over at SMH to determine who is at high risk for future fractures. She also educates them on their risk level, coordinates the required imaging, bone densitometry and blood tests, arranges consultations with the internal medicine partners, arranges for prescriptions where indicated, collaborates with the family doctors, follows up with patients to ensure compliance with care and records the data in the comprehensive research database.  Ms. Elliot-Gibson also consults with Osteoporosis Canada to assist in the Ontario Fracture Screening and Prevention Program (FSPP). 

FLS focuses on secondary fracture prevention by identifying patients at risk for future fracture and initiating appropriate evaluation, risk assessment, education, and therapeutic intervention. From inception, data collection and analysis have been central to the program and approval by the Research Ethics Board was obtained to permit publication of quality assurance data.  The program is subjected to regular iterative modifications based on evolving risk assessment tools and treatment guidelines, performance outcomes and qualitative study results.

Data collection has enabled publication of manuscripts on program development, outcomes, cost-effectiveness, and patient perceptions. Publications have been included in the leading journals in orthopaedic surgery, such as the Journal of Bone and Joint Surgery, and in osteoporosis, such as Osteoporosis International.  The team has presented at local, national and international conferences. They have also published numerous book chapters on Fracture Prevention in Canada and post fracture care in general.

All University of Toronto orthopaedic residents receive training in post-fracture care at the St. Michael’s Hospital site. An ongoing goal of the program is to share the model with past residents and fellows, and researchers and physicians around the globe to support them in starting their own FLS programs.

The work at SMH was a key model that led to the development of the Ontario Osteoporosis Strategy (OOS), Fracture Screening and Prevention Program in 2006. Training of the Ontario Fracture Prevention Coordinators continues at St. Michael’s Hospital as well as continued work with Osteoporosis Canada’s OOS.  The research team led by Dr. Sale and Dr. Bogoch have published numerous publications on the provincial wide program.

In 2020, Dr. Bogoch was appointed the inaugural holder of the Brookfield Chair in Fracture Prevention – a global first of its type. The Chair has several goals, and its key clinical goal is to create Fracture Prevention Programs across Canada to mitigate the care gap in fracture prevention.

THE SMH FLS is listed on Osteoporosis Canada FLS Registry and the International Osteoporosis Foundation’s Capture the Fracture Initiative. SMH FLS continues to meet Osteoporosis Canada’s Essential Elements of an FLS. The success of this program is due to the cooperation and support of the Division of Orthopaedic Surgery (Surgeons and administrative assistants), Orthopaedic residents and fellows, Inpatient Team (Geriatricians, Geriatric clinical nurse specialists, Pharmacists, Case managers, Charge nurses and Clerical staff), Fracture Clinic Team and Martin Family Centre (Nurses, Orthopaedic technologists, Physical Therapists and Clerical staff), SMH Program Leadership, Musculoskeletal Health and Outcomes Research Unit, Nuclear Medicine Department (Managers, Technologists and clerical staff), Metabolic Bone Disease Clinic/Post Fracture Osteoporosis Clinic (Specialists, Nurses and Administrative Assistants), Osteoporosis Canada (Leadership and Ontario Osteoporosis Strategy), and the continued financial support of philanthropic funders.