Internal Fracture Fixation in Patient with Osteoporosis Presenter: dr. Nicko Perdana Moderator: Dr. dr. Ismail, SpOT
Dec 30, 2015
Internal Fracture Fixation in Patient with OsteoporosisPresenter: dr. Nicko PerdanaModerator: Dr. dr. Ismail, SpOT
Osteoporosis
• A systemic disease.• Primary or secondary• Primary occurs in an individual who has no
endocrinopathy or other disease state that would account for the changes in bone mass.
• Characterized by:– Decreased bone mass.– Deteriorated bone microarchitecture.
• In the elderly (≥ 65 years): the most contributing factor (75%) fractures caused by low energy fall.**Lucas TS, Einhorn TA: Osteoporosis: The role of the orthopaedist. J Am Acad Orthop Surg 1993;1:48-56
Site of Fracture• Generally involves the metaphyseal region of
skeleton.• Why metaphyseal?
– Composed mostly of cancellous bone.– Greater surface for bone turnover rate (compared with
cortical bone).
• Proximal femur, distal femur, proximal tibia, distal radius, proximal humerus.
Principles of Fx Management
• The goal of definitive fracture care in elderly patients: early restoration of function.
• Timely treatment (best condition < 48 hr).*• Evaluation of concurrent illness.• Preoperative management to optimize the
condition.• Procedure should be simple & minimal.• Early weight bearing.
*Aharonoff GB, Koval KJ, Skovron ML, Zuckerman JD: Hip fractures in the elderly: Predictors of one year mortality. J Orthop Trauma 1997;11:162-165
Principles of Fx Management
• The principles of biologic fracture repair should be applied whenever possible:– Careful handling of the soft tissue.– Avoiding unnecessary stripping.–Minimizing exposure of fracture site.– Preservation of fracture hematoma.
Principles of Fx Management
• Decline in capacity of fracture repair is age related.*
• Disturbance of the development of strength within fracture callus:
*Silver JJ, Einhorn TA: Osteoporosis and aging: Current update. Clin Orthop 1995;316:10-20
Problems in Fx Management
• Bone failure NOT implant breakage.
• Bone mineral density correlates with holding power of screws.
• Osteoporotic bone lacks the strength to hold screw / plate securely. *
• Loosening of the screw & implant.
* Sjostedt A, Zetterberg C, Hansson T, Hult E, Ekstrom L: Bone mineral content and fixation strength of femoral neck fractures: A cadaver study. Acta Orthop Scand 1994;65:161-165
Solution for Fx Management
• Traditional internal fixation techniques must be modified.
• IF devices that allow load sharing is used to minimize stress at the bone-implant interface.– Sliding nail plate devices, – intramedullary nails, – antiglides plates, and – tension band constructs BETTER than more rigid techniques.
Implant Fixation
• Screws • Plates• Intramedullary nails• Tension band wiring• Augmentation
ScrewsResistance to
pullout depends on:• Length of the screw• Thread diameter• Quality of the bone
– Density – Trabecular orientation
• Direction of insertion*– Parallel BETTER than
perpendicular to the trabecular pattern.
*An YH, Young FA, Kang Q, Williams KR: Effects of cancellous bone structure on screw pullout strength. Medical University of South Carolina Orthopedic Journal 2000;3:22-26
Screws• Bone quality prime determinant of
screw holding.• When bone mineral content falls
below 0.4 gram/cm2, the effect of varying thread diameter is lost.*
• To prevent loosening:– Place it as parralel as possible.– Use the largest thread diameter
compatible with the fracture scale.*Turner IG, Rice GN: Comparison of bone screw holding strength in healthy bovine and osteoporotic human cancellous bone. Clin Mater 1992;9:105-107
Screws
• In cases of severe osteoporosis screw fixation may be augmented with Polymethylmethacrylate (PMMA).*
• (1)Once the cement components are mixed (2)injected into the stripped screw holes (3)place the screw but incompletely tightened (4)after the cement has set (5)the screw is fully tightened.
*Motzkin NE, Chao EYS, An K-N, Wikenheiser MA, Lewallen DG: Pullout strength of screws from polymethylmethacrylate cement. J Bone Joint Surg Br 1994;76:320-323
Plates• The strength of plate fixation is affected
by the degree of comminution & the resulting size of any gap at fracture site.
• The most important factor reducing strain in plated fracture is cortical contact.
• Screw spacing is more important than the number of screws used for fixation.**Törnkvist H, Hearn TC, Schatzker J: The strength of plate fixation in relation to the number and spacing of bone screws. J Orthop Trauma 1996;10:204-208
Plates • Ellis et al * concluded: three screws
should be placed adjacent in either side of fracture gap.
• Cortical contact at the fracture site is paramount.
• In certain conditions (e.g. moderate comminution) the fracture should be shortened to achieve contact. *** Ellis T, Bourgeault CA, Kyle RF: Screw position affects dynamic compression plate strain in an in vitro fracture model. J Orthop Trauma 2001;15:333-337** Blatter G, König H, Janssen M, Magerl F: Primary femoral shortening osteosynthesis in the management of comminuted supracondylar femoral fractures. Arch Orthop Trauma Surg 1994;113:134-137
Plates
• Plates act as tension band NOT as bridge.
• When comminution is extensive consider double-plating.
• In oblique or spiral plates act as antiglide.
Intramedullary nails• Treatment of choice for diaphyseal
fractures in osteoporotic bone (femur & tibia). *
• The advantages of nailing: **
– Providing broad area of purchase.– Allowing load sharing.– Sufficiently secure fixation to allow
immediate weight bearing.
* McConnell T, Court-Brown C, Sarmiento A: Isolated tibial shaft fracture. J Orthop Trauma 2000;14:306-308** Rodriguez Alvarez J, Casteleiro Gonzolez R, Laguna Aranda R, Ferrer Blanco M, Cuervo Dehesa M: Indications for use of the long Gamma nail. Clin Orthop 1998;350:62-66
Intramedullary nails• IM positioned closer to mechanical axis
smaller bending forces than plate (external surface).
• Less fatigue failure compared with plate.• Greater strength in axial loading but less
stable during bending & torsion. *• Better suited for fixation of severely
comminuted osteoporotic bone fracture.
* Ito K, Grass R, Zwipp H: Internal fixation of supracondylar femoral fractures:Comparative biomechanical performance of the 95-degree blade plate and two retrograde nails. J Orthop Trauma 1998;12:259-266
Intramedullary nails• Major weakness of interlocking medullary
nails loosening of locking screws.• It is likely in distal femur rotational
fragment varus / valgus deformity.• Locking screw fixation can be improved:– By using different planes of screw orientation
(anteroposterior & transverse placement).– By using cement.
Tension band wiring
• TBW is usually applied to transverse fractures, which are distracted.
• It provides strong & secure fixation early mobilization of involved joint.
• Fractures: patella, olecranon, medial malleolus, proximal humerus.
Augmentation
• Bone grafting– Autograft: iliac crest (most common).– Allograft: allograft bone, demineralized
allograft bone, synthetic osteoconductive materials. *
• Bone cement– PMMA (polymethylmetacrylate)– Calcium phosphate.
* Gazdag AR, Lane JM, Glaser D, Forster RA: Alternatives to autogenous bone graft: Efficacy and indications. J Am Acad Orthop Surg 1995;3:1-8
Augmentation
Bone autograft (using cancellous bone)• (+)
– Cancellous bone can encourage rapid fracture healing osteoinductive, osteoconductive, osteogenic. 30
– Osteoporotic bone is NOT an inferior graft material.
• (-)– There is morbidity associated with the harvest of
autogenous bone.– Requiring larger exposure to get more bone graft.
Bone Cement• PMAA (Polymethylmethacrylate)
– Replacement of severely comminuted areas.– Successfully used in femur supracondylar fx &
intertrochanteric fx.– But, it is NOT ideal material permanent, foreign body,
generating heat. – Can be used to augment screw fixation.
• Calcium phosphate– Adhere better to bone.– Capable of being resorbed & replaced by host bone.– Successfully used in intertrochanteric fx & distal radius fx.– Used to fill the voids, not for augmentation of screw
fixation.
Fracture Types• Intertrochanteric fractures• Supracondyler fractures of the distal
femur• Lateral tibial plateu fractures• Ankle fractures & the distal fibula• Proximal humerus fractures
Intertrochanteric fractures
Supracondyler Fx of distal femur
Lateral tibial plateu fx
Ankle fx & Distal fibula
Proximal humerus fx
Postoperative Care
• Physical rehabilitation & psychososial treatment.• Preinjury functional compromise + additional disability
associated with recovery + depression/hopelessness multidisciplinary service.
• Malnourished state Clinical evaluation of nutritional status.
• Any patient past middle age with low-energy metaphyseal fx:– Undergo BMD testing– Placed on regiment to combat further bone loss.
• Calcium 1000-1500 mg/day• Vitamin D• Biphosphonate therapy
THANK YOUfor your attention