1 Management of Current Osteoporotic Fracture During Medical Treatment Ppt

Management Of Current Osteoporotic Fracture

During Medical Anti osteoporotic Treatment

Hazem Abdel Azeem

ESOG workshop Alex , October 2012

Fractured under treatment

• Female• 78• Diabetic , Smoker , Chesty• On Alendronate for 3 years • Continued after the 1st fracture

• The occurrence of a fragility fracture while on osteoporosis treatment does not necessarily mean that the treatment was ineffective, as it is known that fracture rates are only reduced by 25–60% .

Fracture Healing & Remodeling process are natural phenomena

• Fracture Healing & Remodeling process are natural phenomena

Injury

Inflammation

Soft Callus

Remodeling

Hard CallusBiology

Stability

Types of bone healing :-Callus healing ( Natural )

-Direct healing: Contact Healing OR Gap healing

9

VIVII IIII

Stages of natural bone healing Cellular functions

9

10

I II III IV

Stages of natural bone healing – Stage 1

10

11

I II III IV V

Stages of natural bone healing – Stage 2

11

12

I II III IV V

Natural bone healing Stage 3 Granulation phase

12

Osteoblast

13

I II III IV V

Natural bone healing Stage 4

13consolidation

Remodelling

Osteoclast

14

I II III IV V

Natural bone healing Stage 5

14

RemodelingCortical fibres continuation Osteoclast

Splinting with a long plate, bendng forces equally distributed, no peak stresses

14 months postoperatively

17

Contact healing

&Osteoclast

Osteoblast & Collagen

Capillary bud

No fracture gapCutting cones directly cross fracture line

18

Gap Healing

• Small stable gaps <0.5 mm• Capillary ingrowth into

gap• This fills the gap so that

cutting cones can then start to penetrate across

• Followed by deposition of lamellar bone

• Capillary + Osteoclast + Osteoblast

19

No movement Osteonal remodelling

Rigid fixation “fools” the bone into “thinking” it Is wasn’t broken

19Chris van der Verkan

No callus , Bone building & Remodelling starts immediately , Osteoblast & Osteoclasts Coupled & functions Together

Direct or contact & Gap healing

Anatomical reduction & absolute stability

79-year-old female

Osteoclast … Bone catabolism and remodelling

The role of osteoclasts in fracture repair :•In the initial inflammatory phase and subsequent bone formation during the repair phase the osteoclast has no role • whereas in the remodelling phase : coupled remodelling of woven bone to lamellar bone at the end of fracture repair depends on osteoclast activity.

Injury

Inflammation

Soft Callus

Remodeling

Hard Callus

Fracture healing

• Female• 72• Not on

antiosteoporotic treatment

• Proximal femoral nailIssue of medical anti osteoporotic treatment

Questions

• Issues of osteoporotic fracture &medical treatment effects – Would bone anabolics help fracture healing – Would anti catabolics ( anti resorpatives ) help OR

impair fracture healing• When to start medical treatment after

fracture • Issue of medical treatment and implant

stabilisation

Evidence for anti-osteoporosis therapy in acute fracture situations—Recommendations of a multidisciplinary workshop of the International Society for Fracture Repair

Jörg GoldhahnSchulthess Klinik Zurich, Switzerland AO Clinical Priority Program Fracture Fixation in Osteoporotic Bone E-mail address: [email protected]. Corresponding author.David LittleThe Children's Hospital at Westmead, New South Wales, AustraliaPaul MitchellFaculty of Education Health and Sciences, University of Derby, Derby, UKNicola FazzalariBone and Joint Research Laboratory, SA Pathology and Hanson Institute, Adelaide, AustraliaIan R. ReidDepartment of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

Per AspenbergOrthopaedic Section, Department of Clinical and Experimental Medicine, Linköping University, SwedenDavid MarshInstitute of Orthopaedics and Musculoskeletal Science, UCL, Royal National Orthopaedic Hospital, Stanmore, UKon behalf of the ISFR working group drugs and fracture repair1

Study is done on animal model

1. to review the interaction of anti osteoporosis drugs and fracture healing 2. to review the interaction of anti osteoporosis drugs and internal fixation implants3. to review the issues around prevention of 2ry fragility fractures4. to discuss what clinical healthcare systems are required for effective delivery of care; and5. to identify research questions that need to be addressed to facilitate more effective secondary prevention.

Osteoporosis drugs and bone repair

• It is expected that anabolic agents used to treat osteoporosis would have a beneficial effect on fracture healing.

• However, most patients who need treatment for osteoporosis will currently receive anti- catabolic agents ( antiresorpative ), and it is important to know whether this may have any disadvantage for the healing of incident fractures.

Vitamin D- And Calcium Intake

• Good for fracture healing • Necessary for the use of anti osteoporotic

drugs • This maximises the effects of drugs and avoids

hypocalcaemia

Alendronate

• Alendronate did not interfere with initial union but led to increased callus size and decreased remodelling.

• Bisphosphonates have an effect on (callus- free) direct fracture healing . Direct healing in a mechanically rigid fixation relies on osteoclastic activity for the remodelling of the fracture surfaces.

Estrogen and Raloxifen SERM

• In a comparative study in ovariectomized rats, Cao et al. [21] found no major effect of raloxifene and oestrogen on fracture healing responses.

PTH Teriparatide

• In rodents, intermittent PTH stimulated fracture healing , with doses as low as 10 μg/kg/day having a positive effect , larger doses accelerated remodelling and improved material properties .

• It could promote healing during all phases through stimulating the osteoblasts as bone builders and osteoclasts as bone remodelers as well as regulating the their coupling functions

strontium ranelate

• Strontium ranelate, showed no effect on fracture healing in this animal study (in rats) .

When should the first dose be given after fracture?

WILL DEPEND UPON THE WAY YOU EXPECT YOUR FRACTURE TO HEAL : •Bone anabolic :

– Treatment may be initiated before discharge from the acute fracture ward in all types of fracture healing

•Anti resorpative may be in intravenous bolus of bisphosphonates only in callus haeling cases

96-year-old female postoperative

Fractured under treatment

Shall we continue medical treatment and how

• Female• 96• Diabetic , Smoker , Chesty• On Alendronate for 3 years • Continued after the 1st fracture

Medical treatment fractured patients already on osteoporosis treatment

• In these cases, the physician should take the opportunity to review the osteoporosis treatment and consider whether it remains appropriate or whether a change in therapy is justified.

• There have been recent reports of femoral diaphyseal fractures in patients on long-term bisphosphonate treatment. Schilcher and Aspenberg calculated an increased density for fractured patients while on bisphosphonate of 1/1000 per year . These subjects are unlikely to benefit from continuation of bisphosphonate treatment and may need consideration of an anabolic agent, either systemically (e.g. PTH)

Osteoporosis drugs and implant anchorage

• Biomechanical tests and clinical experience have shown that implant anchorage is impaired in osteoporotic bone. In animal studies, implants failed earlier (via cut-out or cut-through)

68 ys active lady

low energy trauma

Osteoporosis drugs ( Alendronates & PTH ) improved implant fixation in animal

models• This effect has been reproduced in a

patient level 1 study utilizing an external fixator for treatment of proximal femur fractures. Extraction torque was significantly higher in patients treated with bisphosphonate

• Peri-operative treatment have shown improvement the fixation of total knee replacements, measured as a reduction of the postoperative migration

• Thank you

5 days later 10 months postoperatively

Monocortical instead of bicortical screws

71-year-old male

Definition of OsteoporosisDefinition of Osteoporosis

Normal Osteoporosis

“Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture.”1

1. Consenses Development Conference, JAMA 2001; 285: 785-95.

Baseline 1 Year

Borah, et al. OI 2002 World Congress on OsteoporosisDufresne, et al. OI 2002 World Congress on Osteoporosis

Amount of Bone

Bone volume

Trabecula r Status

Trabecular

number

Trabecular

separation

Porosity

Marrow Star

Volume

Control Patients

Rapid Deterioration of Microarchitecture parameters