1. The Different Modalities of Treatment of Osteoporosis Fracture Kuo-Ti Peng, M.D. Kuo-Ti Peng, M.D. Department of Orthopedics, Chang Gung Memorial Hospital at Chia-Yi

2. Osteoporosis § A common chronic condition § Aged populations, especially postmenopausal women women § Risk of fragility fracture § Socioeconomic burden

3. Fragility Fracture § Cause ··· low energy trauma event, like a fall from standing height, lifting a goods,… from standing height, lifting a goods,… § Aged population, usually post-menopausal women women § Incidence : when Age > 50 yo Female ··· 50% / Male ··· 30% Female ··· 50% / Male ··· 30% Female ··· > 1/3 throughout whole life Female ··· > 1/3 throughout whole life § Usually associated with osteoporosis

4. Most of the Osteoporosis Fractures § Managed by orthopedic surgeons  usually the first and frequently the only  usually the first and frequently the only physician to see the patients physician to see the patients § Primary advocator  proper management § Need “Osteoporosis evaluation”

5. AAOS Recommendation for Fragility Fracture § “Osteoporosis” is a predisposing factor § To evaluate and treat underlying osteoporosis  to reduce the risk of future additional fracture  to reduce the risk of future additional fracture § To investigate the relationship between osteoporosis and fragility fracture § To establish partnership within the medical and nursing community  facilitate the management § To establish the clinical pathway

6. Fracture in the Elderly § Pain § Loss of function § Financial burden - direct vs indirect health care cost - direct vs indirect health care cost

7. 1995 Osteoporosis Fracture (U.S.A) § 432,000 hospitalization § 2.5 million physician visit § 180,000 nursing home admission § 17 billion, Annual direct cost § The “previous fracture” is the “strongest” risk factor for “new fracture”

8. Clinical Pathway for Management of Osteoporosis Fracture (N=385) § 2/3 antiresorption agents § > 80% Calcium and with Vitamin D - Chevalley et al …Osteoporosis Int - Chevalley et al …Osteoporosis Int 2002;13:450-455 2002;13:450-455

9. Scope of the Problems § To occur at many skeletal sites - Hip - Hip - Spine - Spine - Wrist - Wrist - Proximal humerus - Proximal humerus

10. Hip Fracture § The major causes of complications associated with osteoporosis § 25% ··· die within 1 year § 50% ··· long-term disability § 25% ··· long-term nursing home care § Complications ··· pressure sore, pneumonia, UTI and depression § M : F = 1/3 to 1/2 of similar age, yet higher mortality in male

11. Osteoporosis Hip Fracture Hip fracture is the major adverse clinical and public health consequence associated with osteoporosis. As populations are aging the incidence of hip fractures is increasing. The lifetime risk for sustaining hip fracture is estimated at 18% in women and 6% in male. - Annals of the Rheumatic Diseases. January 2006 -

12. Epidemiology of hip fractures There were an estimated 1.7 million hip fractures in 1990, and it has been projected that up to 6.3 million hip fractures will occur annually by 2050. - Jan 2005 J Bone Joint Surg Am. -

13. Risk Osteoporotic fractures are an important cause of disability. Osteoporosis was associated with a hip fracture rate approximately 4 times that of normal BMD (95% CI, 3.59-4.53) Osteopenia was associated with a 1.8-fold higher rate (95% CI, 1.49-2.18). - Dec 2001 JMMA - - Dec 2001 JMMA -

14. Mortality Hip fracture is associated with a 17-31% mortality in the year following fracture. - Jan 2005 J Bone Joint Surg Am. - - Jan 2005 J Bone Joint Surg Am. -

15. Kaplan-Meier Survival Curves After Hip Fracture - Annals of the Rheumatic Diseases. January 2006 -

16. Lancet Ltd. May 18, 2002 Survival Probability

17. CGMH Experience From Jan 2006 to Dec 2007 Proximal femoral fracture : 346 cases (femoral neck and intertrochanteric fracture) Sex : Male : Female = 121 : 225 Age : Mean = 76.6 (Range: 44~99)

18. Proportion in Orthopaedic admission: 0.073 (346 / 4760), 95% CI=(0.066, 0.080) Proportion in CGMH admission numbers 0.006(346 / 55282), 95% CI (0.006, 0.007) CGMH Experience

19. Management

20. Femoral neck fracture Intertrochateric fracture Bipolar 81 (23.4%) Moore 74 (21.4%) DHS 138 (39.9%) Cannulated screws 28 (8.1%) Recon nail Gamma nail 24 (6.9%)

21. Other fracture episode in follow-up Case numbers Proportion (95% CI) (95% CI) Contralateral femoral fracture 180.052(0.033,0.081) Spine compression fracture 20.006 (0.002,0.021) (0.002,0.021) Distal radial fracture 20.006(0.002,0.021)

22. Case Presentation

23. A 90 y/o male, right intertrochanteric fracture

24. Treated by hip compression screw

25. 65 y/o male patient, left femoral neck fracture Garden type 3, treated by multiple cannulated screws

26. A 84 y/o female, left intertrochanteric fracture

27. Treated by cemented hip compression screw

28. A 70 y/o female, left intertrochanteric fracture

29. Treated by Gamma nail

30. 65 y/o male patient, left femoral neck fracture Garden type 4, treated by cemented Bipolar hemiarthroplasty

31. A 82 y/o male, left femoral neck fracture Garden type 4, treated by cemented Moore hemiarthroplasty

32. A 79 y/o femoral, L1 compression fracture for months, OPD treatment

33. Left femoral neck fracture, 2 weeks later

34. Treated with Bipolar hemiarthroplasty

35. Combined surgery, L1 Vertebroplasty

36. A 79 y/o male, left femoral neck fracture

37. Treated with Bipolar hemiarthroplasty

38. 5 months later, right intertrochanteric fracture

39. Treated with DHS and derotation screw

40. A 93 y/o female s/p left Moore hemiarthroplasty 5 years ago

41. Right femoral neck fracture

42. Treated with Moore hemiarthroplasty

43. Complication of Hemiarthroplasty Case numbers Proportion (95% CI) (95% CI) Dislocation20.013(0.004,0.046) Superficial wound infection (medical treatment and subsided 10.006 (0.001,0.036) (0.001,0.036)

44. Complication of ORIF Case numbers Proportion (95% CI) (95% CI) Failed fixation 3/1910.016(0.005,0.045) Wound infection (need debridment) 3/1910.016 (0.005,0.045) (0.005,0.045)

45. Hemiarthroplasty VS. ORIF More surgical complications and reoperations occur after internal fixation than after arthroplasty. Reoperation rates after arthroplasty of 7%, 11%, and 11% compared with 40%, 35%, and 33% for internal fixation. Postoperative pain, function, and quality of life, without showing any difference between the treatment groups. - BMJ. 2007 December 15; 335(7632): 1251–1254.

46. Complication of Hemiarthroplasty Hemiarthroplasty may cause dislocation, loosening, and peri-prosthetic fracture, which together have an overall incidence of 5–15%. - BMJ. 335(7632):1220-1221, December 15, 2007.

47. Complication of ORIF In all, 94% of the patients in the sliding hip screw group healed without complication. Complication including femoral head necrosis, one lag screw cutout, and hip pain. - J Trauma. 2006 Feb;60(2):325-8

48. A 72 y/o female Left femoral intertrochanteric fracture

49. Treated with DHS ( non-cemented)

50. Failed fixation, 2 weeks later

51. Treated with Bipolar hemiarthroplasty

52. A 81 y/o female, left femoral neck fracture Cemented Moore hemiarthroplasty

53. Fell accident with hip dislocation 3 weeks later

54. Closed reduction without periprosthetic fracture

55. A 74 y/o female, left femoral neck fracture

56. Osteoporosis and iatrogenic proximal femoral fracture, periprosthetic fracture Need cement and wire fixation

57. General Recommendations § To reduce risk factors § To participate weight-bearing exercise ··· walking § To quit smoking § To reduce or stop alcohol intake § To prevent falling § Calcium > 1200 mg/day § Vitamin D 800 IU/day § Antiresorption agents § ………………

58. Prevention of Falls § Exercise § Reduction of medications § Environment modification § Balance and strengthening training

59. Conclusions (I) § The patients with osteoporosis fracture have a risk of suffering a new fracture § Optimal care of osteoporosis fracture includes treatment of presenting fracture as well as prevention of subsequent fracture

60. Conclusions (II) § The proper treatment of osteoporosis proved to reduce the risk for new fracture § The orthopedic surgeon can substantially improve the long-term outcome for these patients

61. Thank You For Your Kind Attention!!!