Osteoporosis and Fragility Fractures Surgical Perpspective

8/8/2019 Osteoporosis and Fragility Fractures Surgical Perpspective

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Osteoporosis and

fragility fractures:An Expanding Epidemic


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a syste m ic ske le ta l d ise a sech a ra cte rized b y lo w b o n e m a ss

-a n d m icro a rch ite ctu ra l

,d e te rio ra tio n o f b o n e tissu e

le ad in g to e n h an ced b on e

fra g ility a n d a co n se q u e n t

.in cre a se in fra ctu re risk

Definition Of Osteoporosis

World Health Organization (WHO), 1994


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Fragility fractures arecommon

1 in 2 women and 1 in 5 men over age 50 will suffera fracture in their remaining life time1

55% of persons over age 50 are at increased risk offracture due to low bone mass

At age 50, a womans lifetime risk of fractureexceeds combined risk of breast, ovarian &uterine cancer

At age 50, a mans lifetime risk of fracture exceedsrisk of prostate cancer

Johnell et al. Osteoporos Int. 2005; 16: S3-7


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Osteoporot c ractures:Comparison with other

diseases

996 new,asesll ages84 300

50 000vertebral

50 000thersites

50 000forearm

50 000hip

0

500

1000

1500

2000

steoporoticfractures Heartattack Stroke Breastcancer

500 000nnualincidencell ages

13 000nnual estimate+omen 29

28 000nnual estimate+omen 30

American Heart Association, 1996American Cancer Society, 1996Riggs & Melton, Bone, 1995; 17(5 suppl):505S-511S


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Consequences of HipFracture

Cooper. Am J Med 1997; 103(2A):12s-19s.

%0

Unable to

walkindependently

%0Permanentdisability

%0Death within

one year

%0

Patients(%)

Unable to carry out at

least one independentactivity of daily

living

One year after hip fracture


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Consequences Of VertebralFractures

Acute and chronic pain Narcotic use, decrease mobility

Loss of height & deformity Reduced pulmonary function

Kyphosis, protuberant abdomen Diminished quality of life:

Loss of self-esteem, distorted body image, sleepdisorders, depression, loss of independence

Increased fracture risk

Increased mortality


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O'Neill et al. Osteoporos Int. 2001; 12:555-558

Consequences Of DistalRadius Fractures

The most common fracture in womenat middle age

Incidence increases just aftermenopause

The most common fracture in menbelow 70 years

Only 50% report good functionaloutcome at 6 months

Up to 30% of individuals suffer long-term complications

M t lit d t hi f t


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Mortality due to hip fracture vs.stroke(deaths per 100,000 in older

women)

Hip fracture data: age 80; Kanis. J Bone Miner Res. 2002; 17:1237Stroke data: ages 65-74; Sans et al. Eur Heart J 1997; 18:1231

H ip fra ctu re Stroke

S w e d e n 1 7 7 1 5 4D e n m a rk 1 5 4 1 8 0

G e rm a n y 1 3 1 1 9 0


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or a y a erOsteoporotic Fracture in

Men And Women

-A g e sta n d a rd ize d m o rta lity ra tio

Fra ctu re W o m e n M e n

Prox im a l fe m u r .2 2 .3 2

Vertebral .1 7 .2 4

O th e r m a jo r .1 9 .2 2

-year prospective cohort study

Center et al. Lancet 1999; 353:878-882


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.1 9.1 8.1 9.2 0Minor fracture

.2 4.3 3.1 7.1 9Forearm

.1 8.1 4.4 4.2 3Spine

.1 9.1 4.2 5.2 3Hip

Minor fractureForearmSpineHipSite of prior

fracture

Risk of subsequent fracture

Prior fracture increasesthe risk

of subsequent fracture

Klotzbuecher et al. J Bone Miner Res2000; 15:721-727

- -rior fracture increases the risk of new fracture 2 to 5 fo


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1.Eastell et al. QJM 2001; 94:575-592.Bouxsein et al. J Am Acad Ortho Surg. 2004; 12:385-95

Orthopaedic surgeons have aunique opportunity

Fragility fracture is often the first indication apatient has osteoporosis

Orthopaedic surgeons are often the first and may

be the only physician seen by fracture patientsand can serve a pivotal role in optimizingtreatment, not only of the fracture, but also ofthe underlying disease


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Multinational Survey ofOsteoporotic Fracture Management

Survey of 3422 orthopaedic surgeons from 6countries

90% do not routinely measure bone density following the firstfracture

75% are lacking appropriate knowledge about osteoporosis

Dreinhfer et al. Osteoporos Int 2005; 16:S44-S54


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Major Risk Factors ForFractures

Prior fragility fracture

Increased age

Low bone mineral density

Low body weight Family history of osteoporotic fracture

Glucocorticoid use

Smoking

O t ti F t


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Cooper et al. Trends Endocrinol Metab 1992; 3:224

755535

Men

Forearm

Vertebrae

Hip

Age

,4 000

,3 000

,2 000

,1 000

Women

Forearm

Vertebrae

Hip

55 7535

Osteoporotic FractureIncidence


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Typ e o f fra ctu re M e n W o m e n

Forearm.

4 6.

20 8

Hip .10 7 .22 9

Spine .8 3 .15 1

Proximal humerus .4 1 .12 9

Other .22 4 .46 4

Remaining Lifetime Fracture Risk (%) InCaucasian Population At The Age Of 50

Johnell et al. Osteoporos Int. 2005; 16 Suppl 2:S3-7


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u t is th a t e n o u g h ?

Millions of fragility fractures a year with current orthopaedicmanagement,

most fractures will heal


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Challenges InOsteoporosis

Awareness and knowledge about osteoporosis is lowamong fracture patients

Despite availability of therapies proven to reducefracture risk, even in patients who have alreadysuffered a fracture, diagnosis and treatment ofosteoporosis among fragility fracture patientsremains low


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Treatment Of Osteoporosis:Are Physicians Missing AnOpportunity?

Among 1162 women with distal radius fracture, at 6 mo

266 (23%) prescribed osteoporosis med

33 (2.8%) had bone density test

20 (1.7%) had bone density + OP therapy 883 (76%) received neither bone density test nor medical

treatment of osteoporosis

Among 1654 patients (age > 50 yrs) admitted to

hospital for a fracture resulting from a fall: ~ 50%hip fracture, at 1 yr 247 (15%) prescribed osteoporosis med

Women: 3 times more likely to receive treatment than men(19% vs 5%)

Freedman et al. J Bone Joint Surg 2000; 82-A:1063-70Panneman et al. Osteoporos Int. 2004; 15:120-4

A d k l d b t


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3 8 5 p a tie n ts w ith fra g ility fra ctu re s

H a ve yo u e ve r h e a rd of oste o p oro sis?

: % : %N O 2 0 Y E S 8 0

D o yo u th in k th a t th e fra ctu re yo u h a v e e x p e rie n ce dco u ld b e d u e to fra g ility o f yo u r b o n e s?

: % : %N O 7 3 Y E S 2 7

An Osteoporosis Clinical Pathway for the Medical Managementof Patients with Low Trauma Fracture

Chevalley et al. Osteoporos Int.2002; 13:450-455

Awareness and knowledge aboutosteoporosisin fracture patients is low


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Optimal care of the fragilityfracture patient

Diagnosis of fragility fracture Identify fragility fracture & underlying disease,

incorporate into existing workup

Influences treatment plan from the onset

General fracture management Stabilize patient, pain relief, fracture care

Rehabilitation Minimize dependence, maximize mobility

Secondary prevention Treat and monitor underlying disease, prevent future

fractures


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ia g n o se fra g ilityfra ctu re

ccid e n t p a tte rn

:D e fin itio n o f fra g ility fra ctu re

Fra ctu re d u rin g a ctivity th a t w o u ld n o t n o rm a lly in ju re( . .,yo u n g h e a lth y b o n e ie fa llfrom sta n d in g h e ig h t o r)le ss


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ra g ility fra ctu re ?

ccid e n t p a tte rn iska sse ssm e n t

R isk fa cto rs fo r p rim a ry a n dse con d ary O P

R isk fa cto rs fo r fra ctu re

R isk fa cto rs fo r fa ll

:M e ch a n ism o f in ju ry

Low trau m a ?

Fall fro m sta n d in gh e ig h t o r le ss ?

Fra g ility fra ctu re ?


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Fragility fracture patient assessment* In addition to routine pre-op or fracture evaluation

Family history of OP Menarche / Menopause Nutrition Medications

(past and present) Level of activity Fracture history Fall history & risk factors for falls Smoking, alcohol intake Risk factors for secondary OP Prior level of function

H isto ry


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Height Weight Limb exam

ROM, strength, deformity,pain, neurovascularstatus

Spine exam pain, deformity, mobility

Functional status

h y sica lE x a m

ra g ility fra ctu re p a tie n t a sse ssm e n tIn addition -to routine pre op or fracture evaluation


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Bone mineral density and spineradiograph for vertebral fractureassessment

Bone mineral density assessment by DXA Establish severity of osteoporosis

Baseline for monitoring treatment efficacy

Consider spine radiographs (thoracic and lumbar,AP and ML views) for patients with:

Back pain

Loss of height > 4 cm

Progressive kyphosis

Complexity Of Elderly


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Complexity Of ElderlyPatients Mean age hip

fracture = 80 yrs Comorbidities

Renal - dialysis

COPD - home O2 Diabetes

Delirium / dementia

Pseudo-obstruction

Alcohol abuse

Impaired metabolic

response to injury Hyponatraemia

Management problems Consent

Theatre scheduling Discharge planning

Polypharmacy Warfarin

Plavix

Neurotropics


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S i l id ti i


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Special considerations infixation

of fragility fractures Arthroplasty / Hemiarthroplasty

Also allows early mobilization, may be less painful

Implants designed for osteoporotic bone

Fixed angle locking plates Hydroxyapatite-coated screws

Use of IM nail instead of onlay devices(plates and screws) for diaphyseal fractures

Void filling with cement or bone graft

P ibl I di ti F


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Possible Indications ForArthroplasty

H ip S h ou ld er K n e e E lb o w

Images courtesy of John Keating


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Hiphemiarthroplasty

Establishedand widely

preferredto ORIF in

displacedsubcapital

fractures

But current

controversyTotal

arthroplasty use is

increasing

Keating et al. J Bone Joint Surg. 2006; 88(A):249-60

houlderarthroplasty

-Useful particularly for 3 part-and 4 part fractures and

fracture dislocations

Early treatment best

,Good pain relief but poormovement and function

Soft tissues influence outcome


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Female 82 yrs

YEARMONTHOST OP

Plecko and Kraus, Oper Orthop Traumatol.2005; 17:25-50

Example of fixed anglelocking plates

Screw head threaded engages with hole inplate

Single mechanical unit internal fixator

No compressive force onperiosteum


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Fixation augmentation withhydroxyapatite-coated screws

-OsteoTite HA coated external fixation pin

- /HA coated AO ASIF lag screw

- /HA coated AO ASIF cortical bone screw

- /HA coated AO ASIF cancellous bone screw

, . ; ( ): - Magyar G et al J Bone Joint Surg Br 1997 May 79 3 487 9

, . . ;( ): - Moroni A et al Clin Orthop 1998 Jan 346 171 77, . ( ): - Moroni A et al Clin Orthop 2001 Jul 388 209 17, . . . ; - ( ): - Moroni A et al J Bone Joint Surg Am 2001 May 83 A 5 717 21

, . . . ; ( ): - Sandn B al J Bone Joint Surg Br 2002 Apr 84 3 387 91, . . . ; - ( ): - Caja VL et al J Bone Joint Surg Am 2003 Aug 85 A 8 1527 31, . . ;( ): - Moroni A et al Clin Orthop 2004 Aug 425 87 92, . . . ; - ( ): - Moroni A et al J Bone Joint Surg Am 2005 May 83 A 5 717 21

HA t d d i hi i d t


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Moroni et al. J Bone Joint Surg Am 2005; 87:753-9

HA-coated dynamic hip screw improved outcomesin osteoporotic patients with hip fracture

DHS fixed with standard vs HA-coated AO/ASIF screws in

osteoporotic patients withtrochanteric fractures

Standard -H A coated. -1 H A co a te d scre w s m a in ta in e d b e tte r n e ck sh a ft a n g le a t 6 m o

. -2 Pa tie n ts w ith H A co a te d d e vice h a d b e tte r H a rris h ip sco re s a n dfa r le ss cu t o u t o f la g scre w


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MANIFESTATIONS

APPENDICULARAPPENDICULAR

AXIALAXIAL


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STRATEGIES

MINIMAL INVASIONMINIMAL INVASION

MIPPO SLIDING PLATEMIPPO SLIDING PLATE


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STRATEGIES

. . .AUGMENTATION WITH B M P. . .AUGMENTATION WITH B M P


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STRATEGIES

AXIALAXIAL

MINIMAL INVASION

AUGMENTATION

PAIN RELIEF

. .NEURO DECOMP

PREVENTION


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STRATEGIES

OPEN VERTEBROPLASTYOPEN VERTEBROPLASTY


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STRATEGIES

+ . .CLEAVAGE SIGN NEURO COMP+ . .CLEAVAGE SIGN NEURO COMP


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STRATEGIES

DELAYED NEURO NO KYPHOSISDELAYED NEURO NO KYPHOSIS


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STRATEGIES

+ .POSTERIOR DECOMP STAB IN SITU+ .POSTERIOR DECOMP STAB IN SITU


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1

1.Conservative (bed rest, pain medication and back braces).2.3.Vertebroplasty.4.5.Balloon Kyphoplasty.6.

7.B-Twin VBR (Vertebral Body Reconstruction).8.9.Sky Bone Expander System

re a tm e n tsO p tio n s


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V e rte b ro p la sty

Advantages Quick procedure Low cost Injection of

bone fillerreduces pain

D isad van tag esisa d va n ta g e s -B o n e fille r le a ka g e o f 3 0

% .7 0 re p o rte d R isk o f b o n e fille r

le a ka g e in to th e ca n a lo r b lo o d ve ssels

N o fra ctu re re d u ctio n o rh e ig h t re sto ra tio n


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Advantagesdvantages Relative correction of the

kyphosis Less risk of bone filler

leakage compared tovertebroplasty

Disadvantagesisadvantages Not directional The balloon may expand to the weak

parts of the vertebral body( )compliant balloon

%20 balloon rupture duringprocedure reported1.

May reduce only fresh fractures

1 Lieberman IH, Dudeney S, Reinhardt M- K, Bell G. Initial outcome and efficacy of 'kyphoplasty' in thetreatment of painful osteoporotic vertebral compression fractures. Spine 2001; 26( 14): 1631- 37.

alloon Kyphoplasty

Rehabilitation in the fragility


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Rehabilitation in the fragilityfracture patient

Goal is to improvestrength, balance,

position sense, reactionsto: Improve level of

function /independence

Decrease risk of falls Decrease risk of

fractures

( ,Balance position sense

)reaction

Mechanical vibration plate

Limb and core strength

Mobility in activities ofdaily living

Safety in gait and transfers

Sensory and visual limitations

Home safety evaluation andadaptation

Rehabilitation of fragility


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Rehabilitation of fragilityfracture patient: Fall

prevention

A multidisciplinary, multifactorial intervention programreduces postoperative falls and injuries after femoral neck fractureM. Stenvall et al, Osteoporosis International (2007) 18: 167-75

Guideline for the prevention of falls in older personsAmerican Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic SurgeonsPanel on Falls Prevention. J Am Geriatr Soc (2001) 49: 664-672

Interventions for preventing falls in elderly people (Review)LD Gillespie et al, Cochrane Database Syst Rev (2003)

Secondar Pre ention


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Secondary PreventionBasics

Further evaluation of underlying disease Bone mineral density

Rule out secondary causes of osteoporosis

Initiate osteoporosis therapy, as indicated

Fall prevention

Inform patient and primary MD doctor of probablefragility fracture and osteoporosis

Ensure patient has follow-up care with PT andphysician treating osteoporosis

I t ti t d


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Interventions to reducefuture fracture risk

Basics Nutrition, exercise, fall prevention strategies

Modify risk factors as able (smoking, excess alcohol)

Treat co-morbidities (i.e., endocrine disorder?)

Pharmacological agents

I t ti G l


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Interventions: Generalrecommendations

Regular physical activity Maintaining safe ambulatory status, indep ADLs

Daily limb and core home exercise routine

Sufficient intake of calcium and vitamin D

daily 1000-1500 mg calcium, 400-800 IU vitamin D by foods or foods and supplements combined

Adequate nutrition

Avoid cigarettes, excess alcohol


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Bisphosphonates Alendronate

(FOSAMAX)

Risedronate (ACTONEL)

Ibandronate (BONVIVA)

Zolendronate(ACLASTA)

Pharmacological agents

S E R M s

(R a lox ife n e E V IS TA )

S tim u la to rs o f b o n e fo rm a tio n - (rh P T H F O R T E O )

M ixe d m o d e o f a ctio n

(S tro n tiu m ra n e la te P R O T E LO S )

H o rm o n e th e ra p y

/E stro g e n p ro g e stin


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Conclusions

Fractures are common. Fractures will be morecommon

Osteoporotic fractures are associated with increasedmorbidity & mortality

A fracture is among the strongest risk factors forfuture fracture. Refracture rate is high

Majority of patients with fragility fractures are notevaluated or treated for osteoporosis

Effective treatments are available Orthopaedic surgeons are usually the treating

physician and can take an active role in optimizingcare of the fragility fracture patient

Osteoporosis and Fragility Fractures Surgical Perpspective

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