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Objectives and questions: While International Osteoporosis Foundation (IOF) sets global standards via the Best Practice Framework, local success of a Fracture Liaison Service (FLS) depends on regional networks and stakeholder integration. These factors directly influence the “therapy gap” (TG). Our orthopedic department's FLS addresses all surgical inpatients, providing structured diagnostic and treatment recommendations for follow-up (FU) care.

Material and methods: We prospectively screen all inpatient fractures, excluding patients under 50, those with high-energy trauma and orthogeriatric patients who start therapy during hospital stay. The remaining undergo osteoporosis assessment, including dental status, laboratory findings, medical history, comorbidities, previous fractures, menopause, lifestyle, and family history. FLS offers individualized diagnostic and therapeutic proposals. During 1-year FU, we check whether recommendations had been implemented. Other questions concern DXA, specific therapy, new fractures, adverse events, mortality, and involved specialists.

Results: In 2024, we treated over 1.300 inpatient fractures. After excluding 291 orthogeriatric patients and others 484 underwent specific osteoporosis assessment (mean age 72.7), all having osteoporosis (37%). 335 (69.2%) were female. Lost to FU was 4/484 (0.82%). 55 (11.4%) died in the first year. 58 (12%) needed dental therapy. DXA was proposed in 444, performed in 208, (46.8%). 40 had no DXA indication. 34 (7.7%) declined DXA and in 80 it was not indicated due to further physicians (18%). In 122 reason for missing DXA remains unclear (27.5%). 180/484 (37.2%) had therapy. Non-initiation included patient refusal (41; 8.5%), contraindications despite willingness (7; 5.6%) and refusal by GP (119; 24.6%). Different human factors led to non-initiation in 20 (4.1%). Diagnostic gap (DG) was 53.2%; TG 62.8%. TG calculated with deceased patients, patients lost to follow-up, waiting for dental therapy, with contraindications and “overruled” indication by GPs was 27.4% (68/180). How DG and (estimated) first year mortality influence TG remains unclear.

Discussion and conclusions: TG is not just a service failure; it reflects complex correlations between human factors, clinical judgment, patient preferences, and contraindications. While FLS coordinates care, final decisions must involve primary care physicians and patient-centered context. Thus, the gap functions less as a rigid metric and more as a guiding framework for integrated, individualized treatment.