Fixation Options in Osteoporotic Bone Jeff Anglen, MD FACS Indiana University Special Thanks to Larry Marsh, MD

www.ota.org Baltimore, Maryland USA Orthopaedic Trauma Association 26th Annual Meeting 14 – 16 October 2010

Based on US Census Bureau Data

Age related changes in physiology Decreased bone mass Bone mineral density peaks age 25-30 Declines .3-.5% per year (variable) ↑ Falls + weaker bone = Fracture

Surgical Indications are different in Elderly Patients RISK BENEFIT Functional demands are different Long term results less important Surgery is more difficult, less predictable Risk of complications is higher Medical - systemic Surgical - local

Images courtesy of Larry Marsh, MD

Unpredictable or worse outcomes Example: ORIF of tibial plateau fx Schwartsman R, et al. Am. J. Orthop. 1998; 27:512-9 72% Unsatisfactory in pts > 50 yo Ali AM, et al. J. Orthop. Trauma 2002; 16:323-9 79% fixation failure in pts > 60 yo

60 yo female significant osteopenia Images courtesy of Larry Marsh, MD

3 months 6 months Post op Images courtesy of Larry Marsh, MD

Infected 1 year hardware removal ROM: 20o-90o terrible result Images courtesy of Larry Marsh, MD

76 yo female Tripped and fell Images courtesy of Larry Marsh, MD

Treated in cast brace 3 year follow up Slight valgus knee Assymptomatic Images courtesy of Larry Marsh, MD

Fractures in elderly patients Low energy mechanisms Different patterns: Metaphyseal compression Comminution Splinters or spikes Deeply impacted articular surfaces

Femoral artery Images courtesy of Larry Marsh, MD

Images courtesy of Larry Marsh, MD

Images courtesy of Larry Marsh, MD

The “Gull Sign” J Ortho Trauma Vol 17 2003

Alternatives to ORIF Closed management Fragment excision/soft tissue repair Olecranon Patella Arthroplasty Proximal humerus Femoral neck Distal humerus Acetabulum Knee

Femoral neck fracture ORIF has: Less blood loss Shorter op time Lower infection rate But Higher RE-operation rate! Bhandari et al. JBJS Am 2003

If you decide to ORIF - Nails rather than plates when possible Limited or Percutaneous approaches May accept a little shortening for cortical contact Longer plates, fewer screws Locking plates Allograft rather than autograft, consider BMP Augment fixation

Locking Plates

Biomechanics of Locking plates More stable fixation: Testing Data LOAD Low density foam simulating osteopenic Bone 4.5 mm Narrow LCP Apply a load and measure deflection Testing on traditional vs locked plate constructs.

Locked Plate and Screw Testing Osteopenic Bone Model (Low density foam) 1.7X 1.5X Notable points: Simulated osteopenic bone of low density foam Traditional and locking constructs tested Unicortical and bi-cortical constructs tested Lavendar line-(3) 4.5mm traditional cortical screws Loads at which these constructs begin to fail- First “tick” or Yield Point 1st review benefit of adding one locked screw to an osteopenic bone. Increases resistance to 1.5X greater axial loads 2nd note that load carrying capability of uni-cortical locking screws is similar to that of bicortical cortex screws.

Augmenting the bone PMMA Calcium Phosphate cement Allograft struts

Ca Phosphate cement as an aid to internal fixation of the proximal humerus Kwon et al JBJS 2002 Slide courtesy of Larry Marsh, MD

Ca-P cement in a 62 yo female with split depression plateau fracture Slide courtesy of Larry Marsh, MD

Intramedullary Fibular strut graft

Endosteal Plate

Summary Recognize different operative indications – use more conservative care Choose the right techniques Consider arthroplasty Fixation choices Nails Minimal exposures Locking plates Grafting Bone augmentation

Don’t Forget to Treat the Disease: Osteoporosis Calcium and Vitamin D Biphosponates when indicated Exercise counseling

Jeff Anglen, MD janglen@iupui.edu Thank You Jeff Anglen, MD janglen@iupui.edu