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William M. Ricci, MDChief Orthopaedic Trauma Service

Hospital for Special Surgery & NewYork-Presbyterian Hospital

Professor and Vice-Chair of Orthopaedic SurgeryWeill Cornell Medical College

Deputy-Chief of OrthopaedicsNewYork-Presbyterian Hospital

Disclosures• Ownership Interest: Cable Fix LLC, CrookedFoot Medical

LLC, McGinley Orthopaedic Innovations, LLC, Primo MC LLC

• Royalties: MicroPort, Smith & Nephew, Wolters-Kluwer• Potential Royalties: SMV Orthopaedics• Consultant: Smith & Nephew• Institutional Support: AONA• Board Memberships: OTA, JOT, HSS

Thank You

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Disclosures

• Institutional Support-Smith & Nephew, AONA, COTA

• Consultant-Smith & Nephew, Biomet, Stryker

• Royalties-Smith & Nephew, Wright (MicroPort)

• Board -OTA• Editor-Rockwood & Green• Reviewer-JBJS-A, JBJS-Br, JOT, CORR

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Bisphosphonate Fx’s

William M. Ricci, MD

Professor of Orthopaedic Surgery

Washington University School of Medicine

St. Louis, MO

Evidence

• Meta Analysis – Liu et al 2015• 5 Studies - Alendronate

• Use < 5years no association• Use > 5 years association with femur fractures

Risk

Task Force of American Society for Bone and Mineral Research - 2014• 3.2 to 50 cases per 100,000 person years• Increased risk with long-term use

• >100 per 100,000 person-years• 1/1,000 person-years

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Stress Fx’s Displaced Fx’s Nonunions

Treatment Options

• Watchful waiting• IM nail• ORIF• Other?

Diagnosis?

Prophylactic Nailing

• Egol et al JOT 2013• 43 incomplete fx’s in 31 patients

• 21 Rx w/ surgery• 81% pain free• 100% healed at 7.1 months

• 22 Rx non-op• 64% pain free• 18% radiographically healed at 11 months

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Strategy• If symptomatic

• Reamed IM nail

• 7 months after IM nailing• Asymptomatic

CAUTION!!!

• Brittle bone• Risk of displacement• Prasarn et al CORR 2012 – 21%

• Long nail• Anterior perforation

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LC

• 59 yo F• R Thigh Pain• Bisphosphonates x 6

years

• Good to be lucky!• Piriformis starting

point

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RG

• 63 yo F• L > R thigh pain

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Add Flouro Shots Of Starting Points

Acute Fx

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Plating

Prasarn et al CORR 2012• 25 patients• 3/10 (30%) treated with plate had plate failures• 2/15 (13%) treated with nails had nonunions

Acute Fx

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Healing after Nailing

Egol et al CORR 2014• 41 complete atypical fx’s in 33 patients• 98% healed by 1-year• Healing impaired if malaligned

Weil et al J Trauma 2011• 17 complete fx’s in 15 patients• 54% healed after index nailing

55 yo Female• RA

• MTX, Arava, Prednisone, Humira• Severe osteoporosis

• T-score -2.5• Multiple fragility fracture• Forteo (Teriparatide): 8/2004 to 9/2006• Actonel (Risedronate): 11/2006 to 7/2007• Forteo: 11/2007 to present

55 yo Female• Low energy fracture• Completed stress

fracture?• Acute IM nail• Exchange nail 7 months

later• Dynamization 8 months

after exchange nail

• Presents 5 months after dynamization with persistent pain with WB

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NU work-up• +/- Imaging• Infection

markers• Vit D

Work-up

• WBC - nl• CRP - nl• ESR - nl• Vit D – Low

• 50,000 IU q week x 6 weeks

• Repeat nl

Treatment?• Repeat

exchange nail

• ORIF

• Compression

• Bridge

• Graft

• BMP

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NU Repair• ORIF

• Compression• ICBG• Gram stain and

culture (-)

6 months after NU repair

• Healed?

• Criteria

7 months after L NU repair5 months after R IM nailing

• Fall from standing height

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• 7 mo s/p nonunion repair

Fall

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Now what?

• ORIF• IM nail• Graft• BMP

Strategy

• Fibular strut

• Double plate

• BMP-2

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Fibular strut

Double plate

BMP-2

• 3 mo s/p peri-implant fx

• 10 months after NU repair

Medical Management

• Biphosphonates vs PTH

• Stress fractures• Associated to prolonged BP therapy• Not described with PTH

CC

• 63 yo female• Fosemax x 3 years

• Displaced stress fracture• IM Nail

• Dynamized @ 6 mo• Exchange nail & ICBG @

10 mo

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8/08

9/09

• 3 months after ICBG• Bilateral thigh pain

10/09

• 3 mo after prophylactic nailing• L thigh pain

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SE

• 64 yo F hxbisphosphonates

• Hx L Displaced Femur Fx

• 10 mo s/p IM nail• L thigh pain

• No R thigh pain

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Pain

Follow R Side

Risk

• RR after 4 years = 126• Alendronate higher risk than risedronate (RR 1.9)• Risk decreases by 70% per year after last use• Varus Neck Shaft Angle

• 129.5° with fx• 133.8° w/o fx

Schilcher et al, Acta Orthop, 2015; Hagen et al, JBJS 2014

Summary• Evaluate both sides• Stress fractures

• Asymptomatic – observe• Symptomatic – nail

• Meticulous technique

• Displaced fractures• Nail

• Avoid deformity, gaps

• Nonunions• Plate entire femur• Nail if hypertrophic AND well aligned