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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
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