Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked...
Transcript of Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked...
![Page 1: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/1.jpg)
Fragility Fractures- the problem, advances & treatment
Stephen L. Kates, MD Professor and Chairman
Department of Orthopaedic Surgery Virginia Commonwealth University
Richmond, VA
![Page 2: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/2.jpg)
What is covered
• Demographics • Bone issues • Mechanisms • Basic Surgical considerations • Avoiding failures • Post fracture management
![Page 3: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/3.jpg)
Fragility Fracture
• Caused by a fall from a standing height or less
• Osteoporosis is most common cause • 33 to 50% of women will get a fragility
fracture • 15 to 33% of men get a fragility fracture • Likelihood increases with age
![Page 4: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/4.jpg)
Fragility Fractures- Risk Factors other than osteoporosis
• Women: Diabetes Previous fractures High BMI - ankle and prox
humerus
• Men: Diabetes Mental Health hospitalizations Holmberg et al; Osteoporosis Int. 2006
![Page 5: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/5.jpg)
Annual Incidence
in the United States
Incidence of Osteoporotic Fractures (United States)
Fracture Site
Hip
350,000+
Vertebral (Morphometric)
750,000
300,000+
Wrist 0
250,000
500,000
750,000
200,000
Other
Only 30% of morphometric vertebral fractures are “clinically apparent”.
Clinically Apparent
![Page 6: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/6.jpg)
Demography: projection of Hip Fractures growth from 1950 to
2050
6 Adapted from Cooper C, Campion G, Melton LJ 3rd (1992) Hip fractures in the elderly: a world-wide projection
Location 1950 2050N
North America 378,000 742,000
South America 100,000 629,000
Europe 400,000 668,000
Asia 600,000 3,250,000
![Page 7: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/7.jpg)
What is Osteoporosis?
Skeletal disorder with • Compromised bone strength • Increased risk of fractures • Deterioration of micro-architecture • Most common bone disease • Genetic basis (under study) • Uncoupling of osteoblastic & osteoclastic
activity
![Page 8: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/8.jpg)
Current Problem in US
• >5 million older women at high risk of fx • 1/3 of these have osteoporosis diagnosis • ¼ of these are on appropriate treatment
Gehlbach et al; Osteoporosis International 2007 June
![Page 9: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/9.jpg)
Osteoporosis
Loss of critical bony inter connections, thinner internal support
Trabecular bone loss and thinning of remaining bone is seen above
Osteoporosis is loss of bone mineral density and critical reduction in strength of bony architecture
![Page 10: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/10.jpg)
Bones change during Life
• Modeling as a child and adolescent • Remodeling throughout life • Peak bone mass reached in your 20’s • Remodeling allows bones to heal • Resorption in later years
![Page 11: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/11.jpg)
Bone mass changes during life
• Peak bone mass is reached at age 25 • Heredity • Medications • Diet, tobacco and alcohol • Race / Weight
![Page 12: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/12.jpg)
F. Netter
Bending Stiffness / Cross section
Cross section of normal bone Cross section through Osteoporotic bone
Inner and outer Diameters increase
![Page 13: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/13.jpg)
Issues with Osteoporotic Bone Fixation in surgery
• Poor screw purchase • Fragile cortices • Difficult or impossible to get rigid fixation • Initial deformity prone to recurrence
![Page 14: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/14.jpg)
Conventional plate / screw failure
Screws pull out of bone sequentially
![Page 15: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/15.jpg)
Locked plate failure all screws fail at once
Plate-screw connection Is solid Screw-bone interface Fails as a unit
![Page 16: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/16.jpg)
Mono- vs. bicortical screw fixation 96 yrs. female
![Page 17: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/17.jpg)
5 days later
With thin cortices
• Choose screw diameter as large as possible
• Bi-cortical fixation
Monocortical screw fixation is not good in fragility fractures
![Page 18: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/18.jpg)
Gautier and Sommer, Injury 2003, 34 (Suppl) S-B63-B76.
“Working length“ of bicortical screws
3x More Stable
Mono locked Std Bicortical
Torsional stiffness
![Page 19: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/19.jpg)
10 months postop.
5 days later
![Page 20: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/20.jpg)
Bridging with Locked Implant
![Page 21: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/21.jpg)
Concepts of Plate Fixation in Osteoporotic Bone
• Tough to employ compression technique • Bridge plating useful • Neutralization plates useful • Long plate for bone protection
Imperfect reduction--but the fracture has Gone on to heal
![Page 22: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/22.jpg)
Why is osteoporotic Bone a problem?
• Loss of cortical thickness • Loss of bony tracebulae • Loss of microarchitecture
![Page 23: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/23.jpg)
Signs your patient has bad quality bone
• Poor dentition: Teeth are formed similar to bone
• Multiple vertebral compression fractures • Previous hip, radius or tibial plateau fracture • End stage renal disease • On steroid therapy • Anticonvulsant use
23
![Page 24: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/24.jpg)
Osteoporotic Trabecular Bone: Clinical Consequences
• Cut out • Loss of screw fixation • Spontaneous fractures
![Page 25: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/25.jpg)
Choice of implant Many options, reduce the fracture first
One Fixed angle with Blade plate Multiple fixed angles, longer implant
![Page 26: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/26.jpg)
Varus collapse due to lack of medial buttress
![Page 27: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/27.jpg)
Technique: Impaction intraoperatively
3 mths.
![Page 28: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/28.jpg)
Augmentation in practice
28
![Page 29: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/29.jpg)
If bone is very poor, consider prosthetic replacement
![Page 30: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/30.jpg)
Don’t forget the soft tissues
30
Exposed implant = infection
![Page 31: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/31.jpg)
Incidence of Failures
• Hip: 3 to 5% • Distal Femur: 5%’ • Proximal humerus 30 to 40%” • Ankle 12%* • Distal Humerus 19%
*Srinivasan and Moran; Injury, 2001; ** Korner, J Osteoporosis Int 2004 “Oswley, K JBJS 2008; ‘ Smith, TO, Injury 2009
![Page 32: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/32.jpg)
Case Example: Female 82 years
One Day 3 weeks 6 weeks Lag screw cuts out because the screw is not inserted deeply in the head A 2 hole plate is also good enough, 4 hole plate is not needed
![Page 33: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/33.jpg)
What areas are at risk for Fixation
• Metaphyseal > Diaphyseal Bone • Hip • Distal Femur • Proximal Humerus • Ankle • Proximal Tibia • Distal Radius
![Page 34: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/34.jpg)
Types of Failure
• Cut-out • Cut through • Plate pull –off • Varus collapse • Non-union
![Page 35: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/35.jpg)
What Factors contribute to Fixation Failure?
• Poor bone quality • Metabolic Bone problems • Fracture Reduction quality • Implant choice • Implant Placement
![Page 36: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/36.jpg)
Metabolic Bone Problems - secondary
• Vitamin D deficiency • Steroids • Hyperparathyroidism • Dialysis
• All cause dramatically reduced bone quality
and poor healing
![Page 37: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/37.jpg)
Male 70 years, alcoholic
“AP and Lateral” Fell while intoxicated
![Page 38: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/38.jpg)
Fixed with Strut Graft and Rigid
Long plate And Strut graft
Short working Length of plate
reduction
![Page 39: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/39.jpg)
15 months
Knee pain and can’t walk Nonunion Broken plate Causes: Disturbed biology No metabolic bone assessment
![Page 40: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/40.jpg)
Fracture Reduction Quality matters!
• Bony apposition important – Avoid a gap • Stable reduction • Correct rotation • Angular alignment
![Page 41: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/41.jpg)
Example of Reduction induced failure
![Page 42: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/42.jpg)
Implant Choice
• Correct length and working length • Correct Principle • Correct number of screws • Correct stiffness
![Page 43: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/43.jpg)
Implant choice A nail is better here
![Page 44: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/44.jpg)
Wrong Implant Choice
![Page 45: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/45.jpg)
Wrong implant Nail too large for canal
Fracture distal to short nail used for Reverse obliquity sub-trochanteric fracture
![Page 46: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/46.jpg)
Femoral Bow Nails that are too straight….
• Watch anterior bow*
* Penetration of distal femoral anterior cortex during Intramedullary nailing for subtrochanteric fractures Ostrum and Levy, J Orthop Trauma April 2006 Haidukewych,G JBJS 2009
![Page 47: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/47.jpg)
Implant Placement
• Correct placement is often critical • Tip – Apex distance – Hip • Correct starting point for IM Nail • Correct location on the bone
![Page 48: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/48.jpg)
Poor Tip-Apex distance
Baumgaertner, M JBJS(a) 1995
![Page 49: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/49.jpg)
Starting Point Error
Haidukewych,G , JBJS 2009
![Page 50: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/50.jpg)
Plate on Wrong side of bone
![Page 51: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/51.jpg)
Screws too close to joint
![Page 52: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/52.jpg)
Follow the 4 AO Principles
1.Accurate fracture reduction 2.Stable Fixation 3.Preserve Blood Supply 4.Early mobilization of limb and patient
![Page 53: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/53.jpg)
How to Fix the Failures
• Revision osteosynthesis • Prosthetic Replacement • Change Fixation method
![Page 54: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/54.jpg)
Cut Through
![Page 55: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/55.jpg)
Nail Cut-out Revised to Prosthesis
Lateral bow Makes straight Stem rubs lateral cortex
![Page 56: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/56.jpg)
Cut out revised to tumor prosthesis -Too much surgery
![Page 57: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/57.jpg)
Cut through with second fracture
Difficult Initial surgery Minor re-injury Revised to Prosthesis
![Page 58: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/58.jpg)
Failed Revision Osteosynthesis Revised to Tumor prosthesis
Third Revision osteosynthesis has failed
![Page 59: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/59.jpg)
Female 83 yrs -Failed Plating Revised to Nail
14 months post plating 7 months after revision
![Page 60: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/60.jpg)
Inadequate fixation Revision to prosthesis
Ali, A. Et al. J Should Elbow Surg, 2010
![Page 61: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/61.jpg)
Plate pull-off revised to Nail Male 65 years, alcoholic
![Page 62: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/62.jpg)
Screw Penetration Revised to prosthesis
![Page 63: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/63.jpg)
Early Screw Penetration Revised by shortening screws
Preoperative 2 weeks, screw in joint
6 months
![Page 64: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/64.jpg)
Failed DCS revised to augmented hip screw
Calcium phosphate cement augmentation
![Page 65: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/65.jpg)
Avoid Failures correct Guide wire placement
![Page 66: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/66.jpg)
Assess the fracture for stability
Fractured calcar Varus position
![Page 67: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/67.jpg)
Impact the Fracture for stability
3 months 9 months
![Page 68: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/68.jpg)
Avoid Stress Concentration between implants
![Page 69: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/69.jpg)
Failed Fixation, 4 surgeries
Broken plate Installed 5 months earlier Varus deformity Low Vitamin D level
![Page 70: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/70.jpg)
Correct the deformity….. and metabolic problem
Preop Planning
![Page 71: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/71.jpg)
Don’t leave a void if possible Female, 73 years with osteoporosis
71
![Page 72: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/72.jpg)
Summary • Plan your cases
• Assess the bone quality • Proper implant choice and placement • Reduce the fracture • Impact the fracture if needed • Respect the bone biology • Bridging construct for comminution
![Page 73: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/73.jpg)
Basic Post Fracture Osteoporosis Workup : Metabolic
• 25-OH Vitamin D level • Intact PTH Level • Calcium • Phosphate • TSH • Albumin level
73
![Page 74: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/74.jpg)
Causes of Osteoporosis
• Primary • Secondary • Nutrition • Lifestyle (Exercise, smoking, alcohol) • Hormonal problems • Age • Medications (steroids, seizure meds)
![Page 75: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/75.jpg)
Keeping the bone healthy
• Genetic factors – unclear transmission • Moderate Physical activity • Calcium • Vitamin D • Hormones Parathyroid hormone Calcitonin Estrogen Testosterone
![Page 76: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/76.jpg)
Remember Metabolic Health
• Serum Albumin < 3 = higher mortality** • Vitamin D levels – often low * • Parathyroid Hormone level • Calcium level • Avoid malnutrition and Osteomalacia in
your elderly patients!
•Guisti, Barone, Razzano, Pizzonia, Oliveri, Palummmeri, Pioli; J Endocrinol Invest •Oct 2006, **Aging Clin Exp Res Oct 2006; Bukata et al, CORR 2011
![Page 77: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/77.jpg)
Diagnosis of Osteoporosis
• DEXA Scan is best at present •
T
T score
Compares density relative to peak bone mass (Normal healthy 25 year old) Matched to sex and race
Z score Compares density to peers
![Page 78: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/78.jpg)
Osteoporosis: a 2-Stage Disease • With • Without Fracture
![Page 79: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/79.jpg)
Hip Fracture Lifetime incidence in women 1:6
![Page 80: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/80.jpg)
T-score Normal > -1 Osteopenia < -1 and > -2.5 Osteoporosis ≤ -2.5 Severe Osteoporosis
≤ -2.5 with Fracture
Diagnosis of Osteoporosis Using Central DXA WHO-Definition
Mainly for Spine and Hip in Women
![Page 81: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/81.jpg)
Who Should be Tested ? • All women aged 65 and older regardless of
risk factors* • Younger postmenopausal women with one
or more risk factors (other than being white, postmenopausal and female).
• Postmenopausal women who present with fractures (to confirm the diagnosis and determine disease severity).
• Many women with osteopenia will fracture* *Pasco et al.; Osteoporosis International, 2006
![Page 82: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/82.jpg)
What Medicare covers DEXA every 2 years
• Estrogen deficient women at clinical risk for osteoporosis
• Individuals with vertebral abnormalities • Individuals receiving, or planning to receive, long-
term glucocorticoid (steroid) therapy • Individuals with primary hyperparathyroidism • Individuals being monitored to assess the response
or efficacy of an approved osteoporosis drug therapy.
![Page 83: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/83.jpg)
Workup for the Fragility Fracture patient
• Labs: Basic – Intact PTH – 25 vit D level – serum calcium
Advanced – serum alkaline phosphatase – 24 hour urinary calcium – urine N-telopeptide – TSH
![Page 84: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/84.jpg)
What about Men?
• Higher peak bone mass • Fragility fracture • Steroid use • Forearm fracture • Vertebral fracture
![Page 85: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/85.jpg)
Osteoporosis is Treatable
• Nutrition • Exercise • Lifestyle changes • Medications • Fall prevention • No treatment completely abolishes fracture
risk
![Page 86: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/86.jpg)
Nutrition
• Calcium requirements • Young 1000mg / day in 2 doses • Older 1500mg /d in 3 doses • Calcium gluconate • Calcium Citrate • Calcium Carbonate • Whichever is tolerated
![Page 87: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/87.jpg)
Body weight
• Very low weight is a risk factor BMI< 18 • Normal weight best • Obesity predisposes to falls
![Page 88: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/88.jpg)
Vitamin D3
• Deficiency is common with age • Lack of sunlight • Deficiency = Osteomalacia • Very common in Nursing homes • May cause fracture not to heal
![Page 89: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/89.jpg)
Vitamin D3
• Vitamin D3 -not D2- is best • Dose -Young 400units / d • Older 800 units / day - maintenance • If deficient, D2 50,000 units/ wk • 25 OH Vit D level to diagnose deficiency • Sunlight helps - Essential for bone
health!!!!!!
![Page 90: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/90.jpg)
Exercise
• Weight bearing exercise best • Low impact exercise can help prevent falls • Weight training • Tai Chi • Exercise helps other body systems too • Patients have control over this! • Helps to start young
![Page 91: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/91.jpg)
Fall Prevention
• Medications can cause falls • Poor lighting • Throw rugs • Fall proofing the home • Exercise, balance and strength training • Correct the vision • Pets
![Page 92: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/92.jpg)
Lifestyle
• Alcohol in moderation only • Alcohol can cause osteoporosis • Alcohol can cause falls • Cigarette smoking causes osteoporosis • Slows bone healing • Smoking cessation is the best plan
![Page 93: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/93.jpg)
Medications
• Many medications harm the bones • Steroids (Prednisone) • Seizure drugs • Elevated Thyroid hormone • Cancer drugs (Lupron) • Avoid these if possible • DEXA scans necessary with these
![Page 94: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/94.jpg)
Osteoporosis Medications
• Antiresorptive drugs • Anabolic therapies
![Page 95: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/95.jpg)
Stimulators of bone formation
Anabolic
Inhibitors of bone resorption
Stimulators of bone formation
Inhibitor of bone resorption
Osteoporosis Treatments
![Page 96: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/96.jpg)
Anti-resorptive Therapies
Bisphosphonates • Non hormone compounds • Bind to Hydroxyapatite crystals • Inhibit Osteoclastic activity • Cause Osteoclasts to die prematurely • Half life 6 to 10 years in bone • Can be taken by mouth or IV
![Page 97: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/97.jpg)
Oral Bisphosphonates
• Alendronate (Fosamax) • Risedronate (Actonel) • Ibandronate (Boniva) • IV bisphosphonates are used when oral
medications are not tolerated • Work for men and women • Best treatment for steroid osteoporosis
![Page 98: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/98.jpg)
Bisphosphonates - problems
• Reflux • Must be upright for one hour • Mostly GI symptoms • Rare: osteonecrosis of mandible • Long term effects not known • Need to take Ca, Vit D* • Compliance a problem*
*Adami et al.; J Bone Mineral Research, 2006 Oct
![Page 99: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/99.jpg)
Anti-Resorptive: SERM’s
• Raloxifene and Tamoxifen • Bind to Estrogen Receptor • Have a good effect on Bone density • For women only • Should be used with Calcium, Vit D • Reduces risk of breast cancer • Increases risk of DVT
![Page 100: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/100.jpg)
Calcitonin
• Hormone that regulates calcium, bone • Synthetic Salmon calcitonin • Decreases bone resorption • Reduces pain from Vertebral fractures • Nasal spray or injection
![Page 101: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/101.jpg)
Teriparatide (Forteo)
• Synthetic hormone like human Parathyroid hormone 1-34
• Builds bone mass • Improves bone quality • Increases the life span of osteoblasts • Injection for 2 to 3 years • May increase periosteal thickness, activity
![Page 102: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/102.jpg)
Teriparatide (Forteo)
• FDA approved for women with: • High fracture risk • Multiple fractures • Failure of other therapies • For men with: • Hypogonadal osteoporosis • High fracture risk men
![Page 103: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/103.jpg)
Teriparatide Contraindications PDR Black Box
• Previous Radiation therapy • Paget’s disease • Young patients open physes
• Very Expensive $$$$
![Page 104: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/104.jpg)
Treatment following Fragility Fractures
• Published low rates 15 -20% • Should be much higher - 50% plus* • Communication between hospital, MD’s
and patients essential** • CMS planning to penalize us for this
*Gidwani et al, Ann RCS Engl, 2007 ** Meadows et al; Osteoporosis Int ,2007 Feb
![Page 105: Fragility Fractures- the problem, advances & treatment...Screws pull out of bone sequentially Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone](https://reader036.fdocuments.net/reader036/viewer/2022071215/6045643f82d7763f093b7aff/html5/thumbnails/105.jpg)
The Orthopaedist’s Responsibility CMS guidelines
• Diagnose the Fragility Fracture as such • Obtain Lab tests • DEXA scan • Institute Therapy or Refer for treatment to PCP or Metabolic Bone
Clinic