Fragility Fractures- the problem, advances & treatment Stephen L. Kates, MD Professor and Chairman Department of Orthopaedic Surgery Virginia Commonwealth University Richmond, VA

What is covered Demographics Bone issues Mechanisms Basic Surgical considerations Avoiding failures Post fracture management

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

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

Incidence of Osteoporotic Fractures (United States) Annual Incidence in the United States Only 30% of morphometric vertebral fractures are “clinically apparent”. 750,000 750,000 500,000 350,000+ 300,000+ 250,000 200,000 Clinically Apparent Vertebral (Morphometric) Hip Wrist Other Fracture Site

Demography: projection of Hip Fractures growth from 1950 to 2050 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 KS: figure requires permission to reuse. Can data be summarized and cited?– done SK Fracture incidence is projected to increase 2- to 4-fold in the coming decades due to the aging of the population. Because the percentage of elderly patients grows, the number of projected fractures will rise dramatically. Without appropriate intervention, the growing number of elderly people combined with specific risk factors (eg, the former lack of diary products) will lead to catastrophic numbers of hip fractures for Asia in the future. Factors such as, genetic predisposition, demographics, and lifestyles all contribute to the scope of the problem within different regions. Source: Adapted from Cooper C, Campion G, Melton LJ 3rd (1992) Hip fractures in the elderly: a world-wide projection. Osteoporos Int; 2(6):285-289. Adapted from Cooper C, Campion G, Melton LJ 3rd (1992) Hip fractures in the elderly: a world-wide projection

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

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

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 KS – please confirm source for these images. If from a book or journal permission will be required to reuse.

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

Bone mass changes during life Peak bone mass is reached at age 25 Heredity Medications Diet, tobacco and alcohol Race / Weight Peak bone mass is obtained at age 25. The bone mass declines following this age and very rapid loss is experienced following menopause. As a person ages, they may eventually cross the „fracture threshold“ depending on how high their peak bone mass was in their youth. This peak bone mass is influenced by many factors listed above as well as others such as hormonal influences. Many osteoporotic fractures would be prevented if a higher peak bone mass could be obtained.

Bending Stiffness / Cross section Inner and outer Diameters increase KS – please confirm source for these images. If from a book or journal permission will be required to reuse. Authors may use images from Rockwood Adults or JOT complimentary. Fixed sk The human body increases the diameter of the osteoporotic bone to give some increase in it’s bending and torsional strength. The osteoporotic skeleton increases the outer diameter to increase the bending stiffness. With the reduced bone mass, the inner diameter is increased as well because the bony volume and bone mass may not be increased. However, because of the forth exponent in this equation, there is quite a lot of an net l effect. Here the rational explanation of our previous finding is presented. The formula describes the calculation of the bending stiffness of a tube. Let us assume a diaphyseal bone to be a tube. Bending stiffness depends on the inner and on the outer radius of the tube. Dependence is as strong as exponent 4. This is the rational behind osteoporotic bones with increased diameters and thinned cortices. That means, we have more likely fractures and the fractures are more difficult to fix. Cross section of normal bone Cross section through Osteoporotic bone F. Netter

Issues with Osteoporotic Bone Fixation in surgery Poor screw purchase Fragile cortices Difficult or impossible to get rigid fixation Initial deformity prone to recurrence

Conventional plate / screw failure Problem description Screws pull out of bone sequentially

Locked plate failure all screws fail at once Plate-screw connection Is solid Screw-bone interface Fails as a unit

Mono- vs. bicortical screw fixation 96 yrs. female Vancouver type C periprosthetic fracture in very osteoporotic patient is seen here. This is a typical fracture pattern seen. It is fixed with a LISS plate using all uni-cortical screws. The fracture has been nicely reduced but only five cortices are engaged proximally in this poor quality bone. A longer implant could have been used as well to overlap the femoral prosthesis above.

Choose screw diameter as large as possible 5 days later Monocortical screw fixation is not good in fragility fractures With thin cortices Choose screw diameter as large as possible Bi-cortical fixation KS – please confirm source for these images. If from a book or journal permission will be required to reuse. Authors may use images from Rockwood Adults or JOT complimentary. Five days later, the plate has pulled off the femoral shaft in a catastrophic failure mode. The limited cortical engagement of the five unicortical screws is the cause of this problem. A longer plate and bicortical screws can be used to avoid this type of failure.

“Working length“ of bicortical screws 3x More Stable Mono locked Std Bicortical Torsional stiffness KS – please confirm source for these images. If from a book or journal permission will be required to reuse. Authors may use images from Rockwood Adults or JOT complimentary. Gautier and Sommer, Injury 2003, 34 (Suppl) S-B63-B76.

5 days later 10 months postop. The problem is resolved by revising the fixation to bicortical screws proximally. The plate has not been changed. Alonger plate is a consideration here as well. One must also be careful when placing the LISS screws in this manner as the profunda femoris arey is clos tot he femur here. Approximately double the holding force on the plate is now obtained by changing to the bi-cortical screws and 10 cortices are engaged. Success will likely follow here.

Bridging with Locked Implant KS – please confirm source for these images. If from a book or journal permission will be required to reuse. Authors may use images from Rockwood Adults or JOT complimentary. If a plate is used in a so-called fracture bridging technique, the use of locking screws reduces the need for precise anatomical preshaping of the plate. Tightening the screws does not pull the bone to the plate.  

Concepts of Plate Fixation in Osteoporotic Bone Tough to employ compression technique Bridge plating useful Neutralization plates useful Long plate for bone protection LKC-Target audience is young residents. They will think this many screws is good. Can you use alternate image? Very osteoporotic bone is not amenable for standard compression plating techniques. The lack of cortical strength will result in intra-operative failures here. It is vastly preferable to reduce the fracture with atraumatic techniques and neutralize the forces across it with a locking implant. For the comminuted fractures often seen in this population, bridge plating the fracture is essential. This will require a longer implant to increase the plate’s working length and fixation strength. It is essential to not strip or touch the comminuted zone at all or it will not heal. The osteoporotic bone has reduced ability to heal and it also heals more slowly. A reduced number of mesenchymal stem cells is likely in part responsible for this. Imperfect reduction--but the fracture has Gone on to heal 21

Why is osteoporotic Bone a problem? Loss of cortical thickness Loss of bony tracebulae Loss of microarchitecture

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 A complete history and physical exam can yield important clues that your patient may have extremely poor bone quality. This may alter the surgical plans you make for fixation. If thereis a history of prior fixation failures, consider a completely different tactic to avoid falling into the same trap your colleague encountered before. Poor dentition is a very accurate tip for bad bone! 23 23

Osteoporotic Trabecular Bone: Clinical Consequences Cut out Loss of screw fixation Spontaneous fractures The osteoporotic cancellous bone has fewer trabeculae that are thinner and less interconnected to neighboring trabeculae. This has an effect of increased porosity and provides poor fixation for metallic implants including screws and blade type implants. Failure is not uncommon. This may be very frustrating to the surgeon who has tried his best to apply the implants correctly. Often a different approach to this type of bone is required for a successful outcome. 24

Choice of implant Many options, reduce the fracture first Both patient have very poor bone quality. The example on the left shows a 95 degree condylar blade plate used successfully to fix the fracture. The Xray on the right show the multiple fixed angles afforded by the distal femoral locking condylar plate. A longer implant is demonstrated here as well. This fixation is preferrred in the poor quality osteoporotic bone seen frequently with these fractures in the elderly. One Fixed angle with Blade plate Multiple fixed angles, longer implant

Varus collapse due to lack of medial buttress Failure to reduce the fracture and achieve a medial buttress will frequently result in varus collapse and failed fixation. Fracture reduction is essential in many osteoporotic fractures and will lead to improved results for the patient and surgeon. A locked implant applied incorrectly cannot make up for lack of fracture reduction. Reference: Owsley and Gorczyca, 2008 JBJS Am, March. 26

Technique: Impaction intraoperatively 3 mths. In this instance, the proximal humerus fracture is reduced with impaction in the operating room. The fracture is fixed with more fixed angle implants proximally, a longer implant and the use of the „calcar screws“ to help prevent a varus collapse from occurring. This technique will yield much better results when dealing weith bad bone quality.

Augmentation in practice

If bone is very poor, consider prosthetic replacement

Don’t forget the soft tissues Exposed implant = infection

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

Case Example: Female 82 years LKC: Please add explanation as to why you think it failed as target audience young residents. Also comment in this on plate length 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

What areas are at risk for Fixation Metaphyseal > Diaphyseal Bone Hip Distal Femur Proximal Humerus Ankle Proximal Tibia Distal Radius

Types of Failure Cut-out Cut through Plate pull –off Varus collapse Non-union

What Factors contribute to Fixation Failure? Poor bone quality Metabolic Bone problems Fracture Reduction quality Implant choice Implant Placement

Metabolic Bone Problems - secondary Vitamin D deficiency Steroids Hyperparathyroidism Dialysis All cause dramatically reduced bone quality and poor healing

Male 70 years, alcoholic “AP and Lateral” Fell while intoxicated

Fixed with Strut Graft and Rigid Long plate And Strut graft reduction Short working Length of plate

15 months Knee pain and can’t walk Nonunion Broken plate Causes: Disturbed biology No metabolic bone assessment

Fracture Reduction Quality matters! Bony apposition important – Avoid a gap Stable reduction Correct rotation Angular alignment

Example of Reduction induced failure

Implant Choice Correct length and working length Correct Principle Correct number of screws Correct stiffness

Implant choice A nail is better here

Wrong Implant Choice

Wrong implant Nail too large for canal Fracture distal to short nail used for Reverse obliquity sub-trochanteric fracture

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

Implant Placement Correct placement is often critical Tip – Apex distance – Hip Correct starting point for IM Nail Correct location on the bone

Poor Tip-Apex distance Baumgaertner, M JBJS(a) 1995

Starting Point Error Haidukewych,G , JBJS 2009

Plate on Wrong side of bone

Screws too close to joint

Follow the 4 AO Principles Accurate fracture reduction Stable Fixation Preserve Blood Supply Early mobilization of limb and patient

How to Fix the Failures Revision osteosynthesis Prosthetic Replacement Change Fixation method

Cut Through

Nail Cut-out Revised to Prosthesis Lateral bow Makes straight Stem rubs lateral cortex

Cut out revised to tumor prosthesis -Too much surgery

Cut through with second fracture Difficult Initial surgery Minor re-injury Revised to Prosthesis

Failed Revision Osteosynthesis Revised to Tumor prosthesis Third Revision osteosynthesis has failed

Female 83 yrs -Failed Plating Revised to Nail 14 months post plating 7 months after revision

Inadequate fixation Revision to prosthesis Ali, A. Et al. J Should Elbow Surg, 2010

Plate pull-off revised to Nail Male 65 years, alcoholic

Screw Penetration Revised to prosthesis

Early Screw Penetration Revised by shortening screws Preoperative 6 months 2 weeks, screw in joint

Failed DCS revised to augmented hip screw Calcium phosphate cement augmentation

Avoid Failures correct Guide wire placement

Assess the fracture for stability Fractured calcar Varus position

Impact the Fracture for stability 3 months 9 months

Avoid Stress Concentration between implants

Failed Fixation, 4 surgeries Broken plate Installed 5 months earlier Varus deformity Low Vitamin D level This is a metal fatigue failure of a good product. Obvious nonunion

Correct the deformity….. and metabolic problem Preop Planning

Don’t leave a void if possible Female, 73 years with osteoporosis

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

Basic Post Fracture Osteoporosis Workup : Metabolic 25-OH Vitamin D level Intact PTH Level Calcium Phosphate TSH Albumin level

Causes of Osteoporosis Primary Secondary Nutrition Lifestyle (Exercise, smoking, alcohol) Hormonal problems Age Medications (steroids, seizure meds)

Keeping the bone healthy Genetic factors – unclear transmission Moderate Physical activity Calcium Vitamin D Hormones Parathyroid hormone Calcitonin Estrogen Testosterone

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

Diagnosis of Osteoporosis DEXA Scan is best at present 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 T

Osteoporosis: a 2-Stage Disease With Without Fracture The main advantage of densitometry is that osteoporosis can be diagnosed before fracture. However, osteoporosis may also be diagnosed based on presence of a fragility fracture even if T-score is above 2.5. Fragility fracture is defined as a fracture resulting from the force of a fall from a standing height or less.

Hip Fracture Lifetime incidence in women 1:6

Diagnosis of Osteoporosis Using Central DXA WHO-Definition T-score Normal > -1 Osteopenia < -1 and > -2.5 Osteoporosis £ -2.5 Developed by a study group of the WHO in 1994 to help epidemiologists compare data from different countries and regions. Has been applied to clinical practice of bone densitometry, in particular to central DXA. Note that osteopenia does NOT include either –1 or -2.5 (-1 is normal; -2.5 is osteoporosis). NOTE: A FRAGILITY FRACTURE WITH ANY T-SCORE=OSTEOPOROSIS Not because this was part of WHO definition, but because this is a standard practice. Severe £ -2.5 with Fracture Osteoporosis Mainly for Spine and Hip in Women

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

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.

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

What about Men? Higher peak bone mass Fragility fracture Steroid use Forearm fracture Vertebral fracture

Osteoporosis is Treatable Nutrition Exercise Lifestyle changes Medications Fall prevention No treatment completely abolishes fracture risk

Nutrition Calcium requirements Young 1000mg / day in 2 doses Older 1500mg /d in 3 doses Calcium gluconate Calcium Citrate Calcium Carbonate Whichever is tolerated

Body weight Very low weight is a risk factor BMI< 18 Normal weight best Obesity predisposes to falls

Vitamin D3 Deficiency is common with age Lack of sunlight Deficiency = Osteomalacia Very common in Nursing homes May cause fracture not to heal

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!!!!!!

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

Fall Prevention Medications can cause falls Poor lighting Throw rugs Fall proofing the home Exercise, balance and strength training Correct the vision Pets

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

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

Osteoporosis Medications Antiresorptive drugs Anabolic therapies

Stimulators of bone formation Inhibitors of bone resorption Stimulators of bone formation Anabolic Osteoporosis Treatments Stimulators of bone formation Inhibitor of bone resorption

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

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

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

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

Calcitonin Hormone that regulates calcium, bone Synthetic Salmon calcitonin Decreases bone resorption Reduces pain from Vertebral fractures Nasal spray or injection

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

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

Teriparatide Contraindications PDR Black Box Previous Radiation therapy Paget’s disease Young patients open physes Very Expensive $$$$

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

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