the different modalities of treatment of osteoporosis fracture kuo-ti peng, m.d. kuo-ti peng, m.d....
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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!!!