Management of Osteoperotic Fractures

Prof. Dr. Ashraf El-NahalFaculty of Medicine, Cairo University

THE PROBLEM

2 Months 6 Months

Fixation failure Malunion

F 81 yrs 3 MonthsF 83 yrs

The Problem

Osteoporotic bone has no impairment for fracture healing.

Impaired function due to inferior surgery in the elderly is unacceptable.

The Solution

Surgical procedures aimed at increasing fixation stability

Should be considered when treating osteoporotic fractures

In joint reconstruction in severely osteoporotic bone (shown by pre-operative DXA)

FIXATION AUGMENTATION TECHNIQUES(FATs)

Polymethylmethacrylate (PMMA: acrylic bone cement)

Bone grafts

Bone graft substitutes (calcium phosphate)

Joint replacement whenever feasable.

Intamedullary nailing is better than surface fixation

Modified implants

Pharmaceuticals

Combined FATs Moroni et al, Scand J Surg, 2007

Principles of FATs include:

Autografts

Allografts

BONE GRAFTS

Enhance osteogenic response Have osteoinductive and osteoconductive

potentialStructural support to maintain fracture

reductionGenerally harvested from patient’s iliac crestFinite quantity availableDonor-site morbidity

BONE GRAFTS AUTOGRAFTS

No osteogenic potential

Mechanically improve fracture stability

No donor-site morbidity

Possible disease transmission

BONE GRAFTS ALLOGRAFTS

BONE GRAFT SUBSTITUTESBONE GRAFT SUBSTITUTES

• Synthetic materials that possess

osteoconductive and structural properties

• Do not possess osteoinductive or osteogenic

potential

BONE GRAFT SUBSTITUTESCALCIUM PHOSPHATES

• Calcium phosphates account for most ceramic-based

bone graft substitutes

• Close chemical and crystal resemblance to bone mineral

• Biocompatible

• Scaffolds that induce a biologic response similar to bone

• The most widely used form of calcium phosphate is

hydroxyapatite (HA)

Better fixation No pin-tract infection

Level I Evidence (JBJS Classification)

4 cut-outs in the standard lag

screws

No cut-out in HA-coated lag screws

Better clinical outcomes in HA-

coated groupSHS

Standard screws

SHS HA-coated screws

Level I Evidence (JBJS Classification)

Joint Replacment whenever feasible:

Is a good option for osteoporotic patients with articular fractures where internal fixation is inappropriate.

Joint Replacment

Intramedullary Nailing Is always better than surface fixation as

they are load sharing devices It can be used in subtrochanteric fracture of

the femur, and unstable fractures of the proximal humerus.

Unfortunataly the ideal fracture for intramedullary nailing that is short, oblique or transverse diaphiseal fractures are rare in the elderly patients

Intramedullary Nailing

All available implants designed for fixation of normal bone

No implants specifically designed for fixation

of osteoporotic bone

Traditional implants do not perform optimally in osteoporotic

bone

MODIFIED IMPLANTS

WHY DO WE NEED MODIFIED IMPLANTS?

Screw holding power increased using screws with:

Smaller pitch

Greater screw thread angle

Smaller core diameter

MODIFIED IMPLANTS CHANGES IN SCREW DESIGN

Theoretical Advantages No focal necrosis of bone and soft

tissue deep to plate…improved local resistance to infection

Avoids early temporary bone losses under plate induced by vascular damage

Strength of fixation equals the sum of all the bolts (screws) ability to resist shear at the boltbone interface. Not that of a single screw’s thread purchase.

MODIFIED IMPLANTS Locking Screws

zPHARMACEUTICALS

ALENDRONATE SYSTEMIC ADMINISTRATION

Conclusions “ Weekly post-op systemic administration of alendronate for 3 months improves pin fixation in cancellous bone in elderly female

patients with osteoporosis.”

Implant Fixation Enhanced by Intermittent Treatment with Parathyroid Hormone

R.Skripitz, P. Aspenberg

From Lund University Hospital, Lund, Sweden

PHARMACEUTICALS PTH (1-34)

Conclusions “PTH increased the mean screw removal torquefrom 1.1 to 3.5 Ncm (p= 0.001)”

COMBINED FATsLCP AUGMENTED WITH HA-COATED SCREWS

5-fold greater fixation Better gap healing

JOT, 2008

Cements loaded with osteoinductive growth factors, cells and drugs

Coated fracture fixation implants loaded with osteoinductive growth factors, cells and drugs

COMBINED FATs

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