Problems and Solutions of Osteoporotic Fractures

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Problems (and Solutions) of Osteoporotic Fractures

• Eric Meinberg, MD
• Wake Medical Center
• Raleigh, NC
• January 19, 2008

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Osteoporotic Fractures

• Elderly patients are an orthopaedic challenge
• Disproportionate number of fractures
• Patients may be unable to function independently
• Numbers are increasing
• Our goal is to restore pre-injury level of
  function

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The Scope of the Problem

• 2.5 million office visits for osteoporotic
  fractures
• 450,000 hospital admissions
• 180,000 nursing home placements
• 14 billion estimated cost

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The Scope of the Problem

• 2.5 million office visits for osteoporotic
  fractures
• 450,000 hospital admissions
• 180,000 nursing home placements
• 14 billion estimated cost
• As of 1995!

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The Scope of the Problem

• 2.5 million office visits for osteoporotic
  fractures
• 450,000 hospital admissions
• 180,000 nursing home placements
• 14 billion estimated cost
• As of 1995!
• Expeced to triple by 2040

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Osteopenia The Problem

• Osteoporosis is a decreased bone density with
  normal bone mineralization
• Osteomalacia is a decreased bone matrix
  mineralization with or without a change in bone
  density
• Some degree of osteopenia is found in virtually
  all healthy elderly patients
• DEXA scan 2.5 SD below healthy control

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Patients The Other Problem

• Medical co-morbidities
• Cardiac disease
• Pulmonary disease
• Diabetes
• Peripheral neuropathy
• Peripheral vascular disease
• Malignancy
• Dementia
• Poor nutritional status
• Poor strength and exercise tolerance

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Other Causes of Osteopenia

• Osteoporosis is ubiquitous
• Other causes should be investigated
• Nutritional deficiency
• Malabsorption syndromes
• Hyperparathyroidism
• Cushings disease
• Tumors

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Issues for the Orthopaedic Surgeon

• Osteopenia complicates fracture treatment and
  healing
• Internal fixation compromised
• Poor screw purchase
• Increased risk of screw pull out
• Increased risk of non-union
• Bone augmentation (bone graft, substitutes) may
  be indicated
• Patients cannot tolerate immobilization
• All or nothing

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Issues for the Orthopaedic Surgeon

• Patients have lower physical demands
• Arthroplasty may be a preferable primary or
  salvage option
• New technologies
• Locked plating
• Biologics
• Old technologies
• Nails
• External fixators
• Casts

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Issues for the Orthopaedic Surgeon

• Proper technique has never been more important
• Residual deformity is better accepted
• Most fractures must be addressed as in young
  people
• Nonoperative treatment may be more dangerous

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Cases
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Case 1

• 88 yo woman with DM Type 2 and severe neuropathy
  falls down a flight of stairs
• Obvious deformity to both arms and pain in right
  shoulder

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Left Wrist
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Right Wrist
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Right Shoulder
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Treatment Options?
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ORIF and External Fixation
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Tension-band and Enders Nails
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Final Follow-up
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Lessons Learned

• Dont make the same mistake twice
• Use simple, effective techniques

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Case 2

• 84 year old woman falls over with chest pain
• Obvious pain and deformity of knee
• Severe cardiomyopathy
• Type 2 DM
• Lung cancer

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Options?
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!
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One year follow-up
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Lessons Learned

• Cement augmentation of metaphyseal defects
• Range of motion
• Good outcome despite signficant orthopaedic and
  medical challenges

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Case 3

• 78 yo woman falls in hospital lobby during JCAHO
  site review (in front of reviewers)
• Open periprosthetic distal femur fracture
• Treated with LISS plate
• Progressed with standard protocol

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Returns 6 months later

• Good motion
• No pain
• Baseline function
• Can feel her knee move from side to side!

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Now what?
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LCP with Bone Graft
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Lessons Learned

• Unicortical locked plating may fail
• Know implant options
• Locking nuts, bicortical locking screws
• Change practice based on experiences

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Case 4

• 87 yo woman falls on steps of church
• Obvious pain and deformity of right hip

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Treatment options?
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Postop x-rays
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FAILURE!(x-rays missing)

• Why?

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Tip-Apex Distance
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Tip-Apex Distance
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Lessons

• Hide ugly x-rays
• Surgical technique is very important
• Osteopenic bone is unforgiving

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Case 5

• 66 yo man is hit by truck bumper trying to pull
  tractor from mud
• Obvious pain and deformity of right knee, wrist,
  and elbow
• Previous history of tibial plateau fracture
  before you were born

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Injury Films
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Injury Films
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Injury Films
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Options?
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Right Knee Postop
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Right Elbow Postop
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Right Elbow at Six Months
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HW Removal, HO excision, Capsular Relase
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Knee 1 yr Postop
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Intraoperative X-Ray
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Postop
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Lessons Learned

• Stable fixation to regain motion
• Rebuild foundation for salvage when good
  primary results are unlikely
• Convert complex problems into simple ones

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