Improving Patients' Outcomes After Osteoporotic Fractures

Rozalia Dimitriou; Giorgio Maria Calori; Peter V Giannoudis


Int J Clin Rheumatol. 2012;7(1):109-124. 

In This Article

Improvements in Operative Treatment of Osteoporotic Fractures

The operative treatment of osteoporotic fractures represents a challenge for the orthopedic surgeon. It often has unpredictable outcomes as a result of increased bone fragility and a high rate of failure of implant fixation.[13] In general terms, numerous techniques have been developed to optimize surgical treatment of osteoporotic fractures and allow early weight bearing when possible, including advances in implants and technique-related parameters.[13] For the latter, the aim is to decrease the risk of failure at the bone-implant interface before bony union has occurred by using techniques for relative stability with intramedullary nails and buttress fixation, controlled valgus bone impaction with tensioning internal fixation devices such as the dynamic hip screw, and bone augmentation techniques by using bone autograft or allograft, bone cement or bone substitutes.[13,14]

Research is ongoing to improve orthopedic implants with biomechanically superior technologies to allow more secure and stable constructs, such as the use of fixed-angle devices and locking plates.[13] The use of locking plates in particular has expanded significantly over the last decade for the treatment of osteoporotic fractures.[15] However, because other issues have emerged including periprosthetic fracture risk in osteoporotic bone, due to stress concentrations at the plate end compared with conventional plating, hybrid plating (combining the use of locked and nonlocked screws) has been suggested to improve fixation strength of the construct in osteoporotic bone.[16,17]

Biological processes to enhance the osteointegration of implants and improve fixation or to augment the healing potential of osteoporotic fractures have also been used.[13] These include coatings of the implants with hydroxyapatite,[18] systemic or local administration of bisphosphonates,[19] and implantation of growth factors including bone morphogenetic proteins, TGF-β or FGF.[20]

Finally, endoprosthetic replacement of unstable comminuted osteoporotic fractures is also being used as an alternative to fracture fixation for osteoporotic fractures, aiming to allow early mobilization and improve pain and overall functional outcome. Such an approach has been undertaken in extracapsular hip fractures treated with hip arthroplasty,[21,22] complex intra-articular fractures of the proximal tibia treated with primary knee replacement,[23] as well as complex distal or proximal humeral fractures treated with total elbow arthroplasty[24] or shoulder arthroplasty respectively.[25]

However, although there are numerous studies reporting on the use of various orthopedic devices and methods of biological enhancement to improve the operative treatment of osteoporotic fractures,[13–25] the majority of studies are level III and IV studies[201] and therefore, no strong recommendations can be made regarding their use in the clinical practice. High-quality evidence from randomized trials or systematic reviews and meta-analyses are required to evaluate and establish their clinical applications as well as their cost–effectiveness.