Challenges in Osteoporotic Fracture Management

8/22/2019 Challenges in Osteoporotic Fracture Management

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Challenges of Fragility Fracture

Treatment

Dr.A.Mohan krishnaM.S.Ortho., MCh Orth (U.K)

Consultant Orthopaedic surgeon,

Dr.N.Somasekhar Reddy

M.S.Ortho., MCh Orth (Liverpool)Sr.Consultant Orthopaedic surgeon


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Keep the patient alive

Fix the fracture

Keep patient mobile

Keep patient from returning

to your fracture unit

Acute medical management

Surgical challenges

Rehabilitation

Osteoporosis management

and secondary prevention

Management of fragility fracture patient:Goals, challenges and solutions


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Keep the patientalive


Optimal care of fragility fracture patient:Goals, challenges and solutions

Generalphysician cardiologist anaesthetist


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Keep the patient alive

Fix the fracture


Surgical challenges

Optimal care of fragility fracture patient:Goals, challenges and solutions


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Altogether, thesefactors lead to a higher

risk of failure at theimplant-bone interface

before healing achieved

Main surgical challenges

Impaired ability ofosteoporotic bone to

hold screws

Crushing ofcancellous bone withcreation of voids after

fracture reduction


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Some surgical solutions

Arthroplasty

Allow earlymobilisation

Improve implants forosteoporotic bone

Locking platesHydroxyapatite

coating ofscrews

Use IM nailinstead of onlay

devices


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Locking plates

Screw headthreaded engages with

hole in plate

Singlemechanical unit internal fixator

No compressiveforce on

periosteum


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Fixed angle plate for shoulder

Pullout from head less

likely with diverging, fixed-angle screws

Increases scope for ORIFas opposed to

hemiarthroplasty


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Standard Screw: Complications


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Proven arthroplasties relevant to challengingosteoporotic fractures

Hip Shoulder Knee Elbow


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Arthroplasty as an alternative to fixation: Hip

Hemiarthroplasty established

and widely preferred to ORIF indisplaced subcapital fractures

Economical, faster recovery

Total arthroplasty increasing

Keating et al. J Bone Joint Surg2006. 88A:249-60:THR greater initial cost but cheaperin the long run with better function.


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Arthroplasty as an alternative to fixation: Knee

Technically demanding

Revision components often needed

Complications common


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Arthroplasty as an alternative to fixation: Shoulder

Useful particularly for 3-part and 4-partfractures and fracture dislocations

Early treatment best

Good pain relief, movement and function

Soft tissues influence outcome


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Arthroplasty as an alternative to fixation: Elbow

distal humerus, belowcondyles, radial head

Probably better thanORIF


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Void Filling / Support of trabecular bonein metaphyseal fractures

Maintains radial length, avoids re-operation andincreases grip strength.

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Vertebroplasty and kyphoplasty

Vertebroplasty:

Filling void in

crushed vertebralbody with PMMA

transpedicularinjection of

cement

Kyphoplasty

Pre-insertion of

balloon to createa void for lowpressure injectionaiming for heightrestoration

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Balloon kyphoplasty : Can you uncrush abone?

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Kyphoplasty

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Multidisciplinary rehabilitation

Goals

Restore quality of life through mobility Prevent future fractures by preventing falls

Should be led by the appropriate

rehabilitationists

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Osteoporosis therapy and fracture healing

Theoretical concern:

Reduction of boneturnover by anti-resorptive drugs may

inhibit fracture healing

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Osteoporosis therapy and fracture healing

Calcium/Vitamin D Supplements

Calcitononin

Bisphosphonates

Teriparatide

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Calcium/Vitamin D Supplementation

Recommended for mostmen and women >50 years

Calcium

Age 50 -- 1,200 mg/day

Vitamin D

Age 51-70 -- 400 IU/day

Age >70 -- 600 IU/day

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Calcitonin

Inhibits bone resorption by inhibitingosteoclast activity

Daily intranasal spray of 200 IU orIntramuscular injection of 100IU twiceweekly

Trial demonstrated 33% reduction ofvertebral compression fractures with dailytherapy (ChesnutAm J Med2000)

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Bisphosphonates

Inhibits bone resorption by reducing osteoclastrecruitment and activity

Bone formed while on bisphosphonate therapyis histologically normal

Available formulations : oral & IVAlendronate

Risendronate

Ibandronate

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Teriparatide

Recombinant formulation of parathyroidhormone

Stimulates the formation of new bone byincreasing the number and activity ofosteoblasts

Once daily subcutaneous injection of 20 g

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Summary

Fragility fractures present a serious challenge to fractureservices, both because of the high volume andbecause of their medical, surgical and logistic complexity

Multidisciplinary working is the key to success and alliancebetween orthopaedics and geriatrics is particularly valuable

Surgical technique must be adapted to take account of

complications of fracture repair and healing in the elderly

It is absolutely necessary to deliver secondary preventionreliably to every patient

Challenges in Osteoporotic Fracture Management

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