The Different Modalities The Different Modalities of of

Treatment of Osteoporosis FractureTreatment of Osteoporosis Fracture

Kuo-Ti Peng, M.D.Kuo-Ti Peng, M.D.

Department of Orthopedics,Department of Orthopedics,

Chang Gung Memorial Hospital at Chia-YiChang Gung Memorial Hospital at Chia-Yi

OsteoporosisOsteoporosis

A common chronic conditionA common chronic condition

Aged populations, especially Aged populations, especially postmenopausal postmenopausal

womenwomen

Risk of Risk of fragility fracturefragility fracture

Socioeconomic burdenSocioeconomic burden

Fragility Fracture Fragility Fracture

Cause Cause ··· ··· low energy traumalow energy trauma event, like a fall event, like a fall

from standing height, lifting a goods,from standing height, lifting a goods,……

Aged population, usually post-menopausal Aged population, usually post-menopausal

womenwomen Incidence : Incidence : when Age > 50 yowhen Age > 50 yo

Female ··· 50% / Male ··· 30%Female ··· 50% / Male ··· 30%

Female ··· > 1/3 throughout whole lifeFemale ··· > 1/3 throughout whole life

Usually associated with osteoporosisUsually associated with osteoporosis

Most of the Osteoporosis Fractures Most of the Osteoporosis Fractures

Managed by Managed by orthopedic surgeonsorthopedic surgeons

usually the first and frequently the only usually the first and frequently the only

physician to see the patientsphysician to see the patients

Primary advocator Primary advocator proper managementproper management

Need “Need “Osteoporosis evaluationOsteoporosis evaluation””

AAOS Recommendation for AAOS Recommendation for Fragility Fracture Fragility Fracture

““Osteoporosis” is a Osteoporosis” is a predisposing factorpredisposing factor To evaluate and treat underlying osteoporosis To evaluate and treat underlying osteoporosis

to reduce the risk of future to reduce the risk of future additional fractureadditional fracture To investigate the relationship between osteoporosis To investigate the relationship between osteoporosis

and fragility fractureand fragility fracture To establish partnership within the medical and To establish partnership within the medical and

nursing community nursing community facilitate the management facilitate the management To establish the To establish the clinical pathwayclinical pathway

Fracture in the Elderly Fracture in the Elderly

PainPain

Loss of functionLoss of function

Financial burdenFinancial burden

- - direct vs indirect health care costdirect vs indirect health care cost

1995 1995 Osteoporosis Fracture (U.S.A) Osteoporosis Fracture (U.S.A)

432,000 432,000 hospitalizationhospitalization

2.5 million physician visit2.5 million physician visit

180,000 nursing home admission180,000 nursing home admission

17 billion, Annual direct cost17 billion, Annual direct cost

The “previous fracture” is the “strongest” risk The “previous fracture” is the “strongest” risk

factor for “new fracture”factor for “new fracture”

Clinical Pathway for Management Clinical Pathway for Management of Osteoporosis Fracture (N=385) of Osteoporosis Fracture (N=385)

2/3 2/3 antiresorption agents antiresorption agents

> 80% Calcium and with Vitamin D> 80% Calcium and with Vitamin D

- - Chevalley et al …Osteoporosis Int Chevalley et al …Osteoporosis Int

2002;13:450-4552002;13:450-455

Scope of the Problems Scope of the Problems

To occur at many skeletal sites To occur at many skeletal sites

- Hip- Hip

- Spine- Spine

- Wrist- Wrist

- Proximal humerus- Proximal humerus

Hip Fracture Hip Fracture

The The major causes of complicationsmajor causes of complications associated associated with osteoporosiswith osteoporosis

25% 25% ··· die within 1 year··· die within 1 year 50% ··· long-term disability50% ··· long-term disability 25% ··· long-term nursing home care25% ··· long-term nursing home care Complications ··· pressure sore, pneumonia, Complications ··· pressure sore, pneumonia,

UTI and depressionUTI and depression M M : F = 1/3 to 1/2 of similar age, yet higher : F = 1/3 to 1/2 of similar age, yet higher

mortality in malemortality in male

Osteoporosis Hip FractureOsteoporosis Hip Fracture

Hip fracture is the major adverse clinical and Hip fracture is the major adverse clinical and public health consequence associated with public health consequence associated with osteoporosis. osteoporosis.

As populations are aging the incidence of hip As populations are aging the incidence of hip fractures is increasing. fractures is increasing.

The The lifetime risklifetime risk for sustaining hip fracture is for sustaining hip fracture is estimated at estimated at 18% in women and 6% in male18% in women and 6% in male. .

- - Annals of the Rheumatic Diseases. January 2006 Annals of the Rheumatic Diseases. January 2006 --

Epidemiology of hip fractures Epidemiology of hip fractures

There were an estimated There were an estimated 1.7 million1.7 million hip hip fractures in fractures in 19901990, and it has been , and it has been projected that up to projected that up to 6.3 million 6.3 million hip hip fractures will occur annually by fractures will occur annually by 20502050..

- Jan 2005 J Bone Joint Surg - Jan 2005 J Bone Joint Surg Am. - Am. -

Risk Risk

Osteoporotic fractures are an important Osteoporotic fractures are an important cause of disability.cause of disability.OsteoporosisOsteoporosis was associated with a hip was associated with a hip fracture rate approximately fracture rate approximately 4 times4 times that of that of normal BMD (95% CI, 3.59-4.53) normal BMD (95% CI, 3.59-4.53) OsteopeniaOsteopenia was associated with a was associated with a 1.8-fold1.8-fold higher rate (95% CI, 1.49-2.18). higher rate (95% CI, 1.49-2.18).

- Dec 2001 JMMA -- Dec 2001 JMMA -

Mortality Mortality

Hip fracture is associated with a Hip fracture is associated with a 17-31%17-31% mortality mortality in the year following fracture.in the year following fracture.

- Jan 2005 J Bone Joint Surg Am. - - Jan 2005 J Bone Joint Surg Am. -

Kaplan-Meier Survival Curves Kaplan-Meier Survival Curves After Hip FractureAfter Hip Fracture

- - Annals of the Rheumatic Diseases. January 2006 -Annals of the Rheumatic Diseases. January 2006 -

Lancet Ltd. May 18, 2002Lancet Ltd. May 18, 2002

Lancet Ltd. May 18, 2002Lancet Ltd. May 18, 2002

Survival ProbabilitySurvival Probability

CGMH Experience CGMH Experience

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

Proportion in Orthopaedic admission: Proportion in Orthopaedic admission:

0.073 (346 / 4760), 95% CI=(0.066, 0.080)0.073 (346 / 4760), 95% CI=(0.066, 0.080)

Proportion in CGMH admission numbersProportion in CGMH admission numbers

0.006(346 / 55282), 95% CI (0.006, 0.007)0.006(346 / 55282), 95% CI (0.006, 0.007)

CGMH Experience CGMH Experience

ManagementManagement

0

50

100

150

200

1

Hemiarthroplasty :155 casesORIF: 191 cases

Femoral neck Femoral neck fracturefracture

Intertrochateric Intertrochateric fracturefracture

BipolarBipolar 81 (23.4%)81 (23.4%)

MooreMoore 74 (21.4%)74 (21.4%)

DHSDHS 138 (39.9%)138 (39.9%)

Cannulated Cannulated screwsscrews

28 (8.1%)28 (8.1%)

Recon nail Recon nail Gamma nailGamma nail

24 (6.9%)24 (6.9%)

Other fracture episode in follow-upOther fracture episode in follow-up

Case numbersCase numbers ProportionProportion

(95% CI)(95% CI)

Contralateral Contralateral femoral fracturefemoral fracture 1818

0.052 0.052

(0.033,0.081)(0.033,0.081)

Spine compression Spine compression fracturefracture 22

0.0060.006

(0.002,0.021)(0.002,0.021)

Distal radial Distal radial fracturefracture 22

0.006 0.006

(0.002,0.021)(0.002,0.021)

Case PresentationCase Presentation

A 90 y/o male, right intertrochanteric fractureA 90 y/o male, right intertrochanteric fracture

Treated by hip compression screwTreated by hip compression screw

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

A 84 y/o female, left intertrochanteric fractureA 84 y/o female, left intertrochanteric fracture

Treated by cemented hip compression screwTreated by cemented hip compression screw

A 70 y/o female, left intertrochanteric fractureA 70 y/o female, left intertrochanteric fracture

Treated by Gamma nailTreated by Gamma nail

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

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

A 79 y/o femoral, A 79 y/o femoral, L1 compression fracture for months,L1 compression fracture for months,

OPD treatment OPD treatment

Left femoral neck fracture,Left femoral neck fracture,2 weeks later 2 weeks later

Treated with Bipolar hemiarthroplastyTreated with Bipolar hemiarthroplasty

Combined surgery, Combined surgery, L1 VertebroplastyL1 Vertebroplasty

A 79 y/o male, left femoral neck fractureA 79 y/o male, left femoral neck fracture

Treated with Bipolar hemiarthroplastyTreated with Bipolar hemiarthroplasty

5 5 months later, months later, right intertrochanteric fractureright intertrochanteric fracture

Treated with DHS and derotation screwTreated with DHS and derotation screw

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

Right femoral neck fractureRight femoral neck fracture

Treated with Moore hemiarthroplastyTreated with Moore hemiarthroplasty

Complication of Hemiarthroplasty Complication of Hemiarthroplasty

Case numbersCase numbers

ProportionProportion

(95% CI)(95% CI)

DislocationDislocation 22

0.0130.013

(0.004,0.046)(0.004,0.046)

Superficial wound Superficial wound infection (medical infection (medical

treatment and treatment and subsidedsubsided

11

0.0060.006

(0.001,0.036)(0.001,0.036)

Complication of ORIFComplication of ORIF

Case numbersCase numbers

ProportionProportion

(95% CI)(95% CI)

Failed fixationFailed fixation 3/1913/191

0.0160.016

(0.005,0.045)(0.005,0.045)

Wound infection Wound infection (need debridment)(need debridment) 3/1913/191

0.0160.016

(0.005,0.045)(0.005,0.045)

Hemiarthroplasty VS. ORIFHemiarthroplasty VS. ORIF

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

Complication of HemiarthroplastyComplication of Hemiarthroplasty

Hemiarthroplasty may cause dislocation, Hemiarthroplasty may cause dislocation, loosening, and peri-prosthetic fracture, loosening, and peri-prosthetic fracture, which together have an overall incidence which together have an overall incidence of 5–15%. of 5–15%.

- BMJ. 335(7632):1220-1221, December 15, - BMJ. 335(7632):1220-1221, December 15, 2007. 2007.

Complication of ORIFComplication of ORIF

In all, 94% of the patients in the sliding hip In all, 94% of the patients in the sliding hip screw group healed without complication.screw group healed without complication.

Complication including femoral head necrosis, Complication including femoral head necrosis, one lag screw cutout, and hip pain. one lag screw cutout, and hip pain.

- J Trauma. 2006 Feb;60(2):325-8 - J Trauma. 2006 Feb;60(2):325-8

A 72 y/o femaleA 72 y/o femaleLeft femoral intertrochanteric fractureLeft femoral intertrochanteric fracture

Treated with DHS ( non-cemented)Treated with DHS ( non-cemented)

Failed fixation, 2 weeks laterFailed fixation, 2 weeks later

Treated with Treated with Bipolar hemiarthroplastyBipolar hemiarthroplasty

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

Fell accident with hip dislocation Fell accident with hip dislocation 3 weeks later3 weeks later

Closed reduction without periprosthetic Closed reduction without periprosthetic fracturefracture

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

Osteoporosis and iatrogenic proximal Osteoporosis and iatrogenic proximal femoral fracture, periprosthetic fracturefemoral fracture, periprosthetic fracture

Need cement and wire fixation

General Recommendations General Recommendations

To reduce risk factorsTo reduce risk factors To participate weight-bearing exercise To participate weight-bearing exercise ··· walking··· walking To quit smokingTo quit smoking To reduce or stop alcohol intake To reduce or stop alcohol intake To prevent fallingTo prevent falling Calcium Calcium >> 1200 mg/day 1200 mg/day Vitamin D 800 IU/dayVitamin D 800 IU/day Antiresorption agents Antiresorption agents ………………………………

Prevention of Falls Prevention of Falls

ExerciseExercise

Reduction of medicationsReduction of medications

Environment modificationEnvironment modification

Balance and strengthening training Balance and strengthening training

Conclusions (I) Conclusions (I)

The patients with osteoporosis fracture have a The patients with osteoporosis fracture have a

risk of suffering a new fracturerisk of suffering a new fracture

Optimal care of osteoporosis fracture includes Optimal care of osteoporosis fracture includes

treatment of presenting fracture as well as treatment of presenting fracture as well as

prevention of subsequent fracture prevention of subsequent fracture

Conclusions (II) Conclusions (II)

The proper treatment of osteoporosis proved The proper treatment of osteoporosis proved

to reduce the risk for new fractureto reduce the risk for new fracture

The orthopedic surgeon can substantially The orthopedic surgeon can substantially

improve the long-term outcome for these improve the long-term outcome for these

patients patients

Thank You For Your Kind Attention!!!