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Challenges of Fragility Fracture Challenges of Fragility Fracture TreatmentTreatment

David MarshInstitute of OrthopaedicsUniversity College of LondonRoyal National Orthopaedic HospitalStanmoreEngland

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Keep the patient alive

Fix the fracture

Keep patient mobile

Keep patient from returningto your fracture unit

Quality control of process

Acute medical management

Surgical challenges

Multidisciplinary rehab

Osteoporosis managementand secondary prevention

Optimal care of fragility fracture patient:Goals, challenges and solutions

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Keep the patient alive Acute medical management

Optimal care of fragility fracture patient:Goals, challenges and solutions

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Complexity of elderly patients• Mean age hip fracture = 80 yrs

• Comorbidities (median ASA 3) – Murmurs

– Renal - Dialysis

– COPD - home O2

– Diabetes

– Delirium / dementia

– Pseudo-obstruction

– Alcohol abuse

• Impaired metabolic response to injury– Hyponatraemia

• Management problems– Consent

– Theatre scheduling

– Discharge planning

• Polypharmacy– Warfarin

– Plavix

– Neurotropics

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Acute medical management

• Slow but steady rise in age of patients presenting with fragility fractures. Many have multiple co-morbidities

• Difficult judgement – balance between medical optimisation and prompt surgery

• Inexperienced surgical trainees not the best people to look after such people and prepare them for surgery

• Ideal solution is close supervision by senior physicians having expertise with elderly patients– pre- and peri-operatively, not just for rehabilitation

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Senior medical backup desired

• Can come from different specialists, depending on health care system – Anaesthesia - Geriatrics

– Cardiology - Respiratory medicine

– Internal medicine

• Orthogeriatrics may play larger role in future

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Quality service is cheaper in the endQuality service is cheaper in the end

The pay-off from orthogeriatric care in the acute phase

• Superior medical care

• Optimal scheduling of fracture surgery

• Better communication with patients and relatives

• A leader for the multidisciplinary team

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Alternative models for orthogeriatric care

• Orthopaedic doctors and nurses supported by visiting medical specialist

• Nurse specialists on fracture wards, supervised by geriatricians

• Geriatricians employed on fracture wards

• Elderly fracture patients admitted to geriatric wards

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Keep the patient alive

Fix the fracture

Acute medical management

Surgical challenges

Optimal care of fragility fracture patient:Goals, challenges and solutions

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Altogether, these factors lead to a higher risk of failure at the implant-bone interface before healing achieved

Main surgical challenges

• Impaired ability of osteoporotic bone to hold screws

• Crushing of cancellous bone with creation of voids after fracture reduction

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Some surgical solutions

• Avoid the problem with arthroplasty– Allow early mobilisation

• Improve implants for osteoporotic bone– Fixed angle locking plates

– Hydroxyapatite coating of screws

• Use IM nail instead of onlay devices for diaphyseal fractures

• Fill voids with cement

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Proven arthroplasties relevant to challenging osteoporotic fractures

Hip Shoulder Knee Elbow

Images courtesy of John Keating

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Arthroplasty as an alternative to fixation: Hip

• Hemiarthroplasty established and widely preferred to ORIF in displaced subcapital fractures– But still controversial

• Total arthroplasty increasing– Keating et al. J Bone Joint Surg 2006. 88A:249-60:

THR greater initial cost but cheaper in the long run with better function.

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Arthroplasty as an alternative to fixation: Knee

• Technically demanding• Revision components often needed • Complications common

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Arthroplasty as an alternative to fixation: Shoulder

• Useful particularly for 3-part and 4-part fractures and fracture dislocations

• Early treatment best

• Good pain relief, but poor movement and function

• Soft tissues influence outcome

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Arthroplasty as an alternative to fixation: Elbow

• C3 distal humerus, below condyles, radial head

• Good results in small, uncontrolled series

• Probably better than ORIF

• More studies needed

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F. 82yrs

1 YEAR1 MONTHPOST OP

Locking plates

• Screw head threaded –engages with hole in plate

• Single mechanical unit –internal fixator

• No compressive force on periosteum

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Plecko and Kraus, Oper Orthop Traumatol 2005; 17:25-50

Fixed angle plate for shoulder

• Pullout from head less likely with diverging, fixed-angle screws

• Increases scope for ORIF as opposed to hemiarthroplasty

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Fixation augmentation with hydroxyapatite-coated screws

OsteoTite HA-coated external fixation pin

HA-coated AO/ASIF lag screw

HA-coated AO/ASIF cortical bone screw

HA-coated AO/ASIF cancellous bone screw

Magyar G et al, J Bone Joint Surg Br. 1997;79:487-9Moroni A et al, Clin. Orthop. 1998;346:171-77Moroni A et al, Clin Orthop. 2001;388:209-17Moroni A et al, J. Bone Joint Surg. Am. 2001;83-A(5):717-21Sandèn B al, J. Bone Joint Surg. Br. 2002;84(3):387-91Caja VL et al, J. Bone Joint Surg. Am. 2003;85-A(8):1527-31Moroni A et al, Clin. Orthop. 2004 ;425:87-92 Moroni A et al, J. Bone Joint Surg. Am. 2005 ;83-A(5):717-21

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HA-COATED SCREWSTANDARD SCREW

A. Moroni et al. J. Orthop. Trauma 2002; 16:257-63

Improved osseointegration with HA-coated screws

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Moroni et al. Clin Orthop Relat Res. 2004; 425:87-92

HA-coated dynamic hip screw

Study Aim:

To compare DHS fixed with standard vs HA-coated AO/ASIF screws in osteoporotic patients with trochanteric fractures

Standard HA-coated

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StandardScrews

HA-coatedScrews

ns

Study population

No. of patients 60 60

Age (yrs) 81 ± 8 81 ± 6

BMD 538 ± 105 568 ± 111

AO A1 42% 48%

AO A2 58% 52%

Moroni et al. Clin Orthop Relat Res. 2004; 425:87-92

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126

128

130

132

134

136

POST-OP 6 MONTHS

Standard ScrewsHA-Coated Screws

p=0.008

Ang

le (d

egre

es)

Moroni et al. Clin Orthop Relat Res. 2004; 425:87-92

Standard vs HA-coated screws:Femoral neck-shaft angle

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Harris Hip Score

0

20

40

60

80

100

Standard HA-Coated

p=0.0070

1

2

3

4

5

Standard HA-Coated

p<0.05

Lag Screw Cut-out

Moroni et al. Clin Orthop Relat Res. 2004; 425:87-92

Standard vs HA-coated screws

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POST-OP

2 MONTHS

6 MONTHS

F 83yrs

Standard Screw: Complications

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6 WEEKS 6 MONTHS

F 82 yrs

Possible solution: HA-coated screw

Note bone growth around the tip of the screws beyond the exit cortex

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HA-coated screws: Wrist external fixator

Caveat: HA-Coated Pins can be difficult to remove from cortical bone

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Void filling with bone substitutes

• Deformation and loss of support by crushing of cancellous bone. Relevant in metaphyseal long-bone fractures and spine

• Inert materials, such as PMMA cement, vs. potentially integrating scaffold, i.e. graft

• Autologous bone graft limited. Allograft carries risk of disease transmission. Artificial substitute desirable

• Matrix (scaffold) plus or minus inductive molecules or cells

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Void filling with bone substitutes

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Calcium phosphate cement augmentation

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Void Filling / Support of trabecular bone in metaphyseal fractures

Maintains radial length, avoids re-operation and increases grip strength.

Constantz et al. Science 1995; 267:1796-99

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Vertebral fragility fracture impairs quality of life more than we think

Kanis et al.Osteoporos Int 2001; 12:417-427

Loss of utilities, over 1 year

calculated from EQ5D

-0.35

0

-0.3

-0.25-0.2

-0.15-0.1-0.05

Vertebral Hip Shoulder Wrist

• Predicted prevalence of vertebral fractures in the E.U. – 2000 : 23.7 million

– 2050 : 37.3 million

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Vertebroplasty and kyphoplasty

• Filling void in crushed vertebral body with PMMA

• Patient prone – transpedicular injection of cement

• Vertebroplasty – high pressure injection – good pain relief

• Kyphoplasty – pre-insertion of balloon to create a void for low pressure injection – aiming for height restoration

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Balloon kyphoplasty : Can you uncrush a bone?

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Kyphoplasty

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Efficacy of vertebroplasty and kyphoplasty

• Similar efficacy in pain relief, better than conservative treatment

• Kyphoplasty fewer adverse events (leakage, VTE)– Stronger evidence for functional and QOL Improvement

• Most experience to date with late, failed conservative cases– Sagittal correction with kyphoplasty may be better

if performed earlier

Taylor et al. Spine. 2006; 31:2747-2755

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Osteoporosis therapy and fracture healing

Theoretical concern:

Reduction of bone turnover by anti-resorptive drugs may inhibit fracture healing

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Anti-resorptive drugs and fracture healing

• Large clinical trials of anti-resorptive agents– 2000 - 7000 patients over 3 years

– no adverse events related to fracture healing

• Animal studies of fracture healing – delay in remodelling of callus

– no positive effect on restoration of mechanical strength

• Bisphosphonate may delay loosening of implants

• No clinical trials in humans directly testing effect of anti-resorptive therapy on fracture healing

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Raloxifene, estrogen and alendronate affect the processes of fracture repair differently in

ovariectomized rats

• OVX vs sham-op in 3-month-old rats– Closed, nailed femoral shaft fracture

– OVX alone, or with E, raloxifene (RAL), or alendronate (ALN)

• X-ray, QCT, biomechanical testing, histology– At 6 and 16 weeks

Cao et al. J Bone Miner Res 2002; 17:2237-46

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Fracture healing properties vs sham control

6 weeks 16 weeksCallus size

Ultimate load

BMC

+

--

Callus size

Ultimate load

BMCLamellar/woven

Ovx alone +Ovx + E

Ovx + RALOvx + ALN + + + + -

• Alendronate delayed callus remodelling (lower ratio of lamellar to woven bone), but larger callus was stronger

• Alendronate delayed callus remodelling (lower ratio of lamellar to woven bone), but larger callus was stronger

Cao et al. J Bone Miner Res 2002; 17:2237-46

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Balance of risks

Theoretical worries about importance of remodelling in fracture repair

Definite increase in fracture incidence if secondary prevention not initiated

But caution before treating with rigid internal fixation, requiring osteoclast-led remodelling

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Anabolic therapy would remove this worry -preclinical evidence with PTH

• Paradoxical effect of PTH when given intermittently – anabolic for bone. Confirmed in clinical trials of osteoporosis treatment.

• Several groups show enhanced fracture healing in animal models– Andreassen 1999, 2001, 2004.

Komatsubara 2005. Alkhiary 2005

Alkhiary et al J Bone Joint Surg Am. 2005; 87A:731-41

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Moroni et al. J Bone Joint Surg Am. 2005; 87 Suppl 2:42-51

Systemic bisphosphonate therapy may enhance HA-coated screw fixation

• Prospective randomised study in externally-fixed intertrochanteric fractures– Women aged 65+ with low BMD and no prior BP therapy

– Intertrochanteric fracture (AO/OTA type A1 or A2)

• HA-coated pins in both groups– Group A: oral dose of 70 mg of Alendronate per week

– Group B: no alendronate

• Screw insertion/extraction torque measured at insertion/removal

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All the devices used in this study are FDA approvedSlides provided by A. Moroni, Bologna, Italy

External fixation device

Pre-op Post-op XX months?

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• Age (years)

• BMD

• Quality of reduction*

Good

Acceptable

Poor

82 ± 8

543 ± 87

4

3

1

78 ± 6 yrs

527 ± 23

5

2

1

Alendronate(n=8)

Control(n=8)

* Baumgaertner et al. J Bone Joint Surg Am. 1995; 77:1058-64

Baseline characteristics

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0

1000

2000

3000

4000

5000

P<0.001

Cancellous bone (femoral head)

Screw extraction torque higher for cancellous bone in ALN vs control at 3 months

0

1000

2000

3000

4000

5000Cortical bone (femoral shaft)

ns

Moroni et al. J Bone Joint Surg Am. 2005; 87 Suppl 2:42-51

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Keep the patient alive

Fix the fracture

Keep patient mobile

Keep patient from returningto your fracture unit

Quality control of process

Acute medical management

Surgical challenges

Multidisciplinary rehab

Osteoporosis managementand secondary prevention

Optimal care of fragility fracture patient:Goals, challenges and solutions

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Multidisciplinary rehabilitation• Goals

– Restore quality of life through mobility

– Prevent future fractures by preventing falls

• Should be led by the appropriate rehabilitationists

• Discharge planning – integration of medical and social services – needs to start immediately

• Nutrition a vital element – High protein diet improves recovery *

– Vit D insufficiency very common, readily treated

* Duncan et al. Age & Ageing 2006; 35:148-53

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Secondary prevention• One of the strongest predictors of fragility fracture is

having had one already– Bone strength

– Tendency to fall

• Our response to a fragility fracture must include a determined attempt to prevent another one

• Need not require orthopaedic surgeons to treat,or even remember to refer– Needs a system that achieves this automatically

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Systems for secondary prevention

• Most reliable when based on nurse specialists, e.g.– Fracture liaison nurses in fracture clinic

– Fragility fracture nurse coordinators for inpatients

• Many different models possible– Key is that responsibility is clear

• Needs local agreement on referral mechanisms between fracture service, osteoporosis service and falls service

• Vital to involve GPs because prevention has to be life-long

• Essential to empower the patient by thorough education

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Hip Fracture Audit

• Experience (e.g. in Scotland) has shown that ongoing, real-time audit, in conjunction with evidence-based guidelines, can change practice in a non-threatening way

• Preferably national or regional, so that performance can be fed back in context of peers

• Records process and outcome to one year

• Owned and controlled by the professions

• Raises the profile of osteoporosis and fragility fracture work with the managers and commissioners

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Summary

• Fragility fractures present a serious challenge to fracture services, both because of the high volume and because of their medical, surgical and logistic complexity

• Multidisciplinary working is the key to success and alliance between orthopaedics and geriatrics is particularly valuable

• Surgical technique must be adapted to take account of complications of fracture repair and healing in the elderly

• It is absolutely necessary to deliver secondary prevention reliably to every patient