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

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

3. 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

4. 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

5. 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

6. 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):
Adapted from Cooper C, Campion G, Melton LJ 3rd (1992) Hip fractures in the elderly: a world-wide projection

7. 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

8. 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

9. 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.

10. 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

11. 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.

12. 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

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

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

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

16. 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.

17. 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.

18. “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.

19. 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.

20. 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.

21. 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

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

23. 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

24. 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

25. 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

26. 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

27. 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.

28. Augmentation in practice

29. If bone is very poor, consider prosthetic replacement

30. Don’t forget the soft tissues
Exposed implant = infection

31. 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

32. 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 weeks 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

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

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

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

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

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

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

39. 15 months Knee pain and can’t walk Nonunion Broken plate
Causes: Disturbed biology
No metabolic bone
assessment

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

41. Example of Reduction induced failure

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

43. Implant choice A nail is better here

44. Wrong Implant Choice

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

46. 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

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

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

49. Starting Point Error
Haidukewych,G , JBJS 2009

50. Plate on Wrong side of bone

51. Screws too close to joint

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

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

54. Cut Through

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

56. Cut out revised to tumor prosthesis -Too much surgery

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

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

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

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

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

62. Screw Penetration Revised to prosthesis

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

64. Failed DCS revised to augmented hip screw
Calcium phosphate cement augmentation

65. Avoid Failures correct Guide wire placement

66. Assess the fracture for stability
Fractured calcar
Varus position

67. Impact the Fracture for stability
3 months
9 months

68. Avoid Stress Concentration between implants

69. 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

70. Correct the deformity….. and metabolic problem
Preop Planning

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

72. 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

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

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

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

76. 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

77. 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

78. 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.

79. Hip Fracture Lifetime incidence in women 1:6

80. 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

81. 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

82. 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.

83. 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

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

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

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

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

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

89. 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!!!!!!

90. 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

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

92. 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

93. 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

94. Osteoporosis Medications
Antiresorptive drugs
Anabolic therapies

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

96. 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

97. 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

98. 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

99. 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

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

101. 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

102. 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

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

104. Treatment following Fragility Fractures
Published low rates %
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

105. 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