1. Fixation Options in Osteoporotic Bone
Jeff Anglen, MD FACS
Indiana University
Special Thanks to Larry Marsh, MD

2. www.ota.org Baltimore, Maryland USA
Orthopaedic Trauma Association th Annual Meeting – 16 October 2010

3. Based on US Census Bureau Data

4. Age related changes in physiology
Decreased bone mass
Bone mineral density peaks age 25-30
Declines .3-.5% per year (variable)
↑ Falls + weaker bone = Fracture

5. Surgical Indications are different in Elderly Patients
RISK
BENEFIT
Functional demands are different
Long term results less important
Surgery is more difficult, less predictable
Risk of complications is higher
Medical - systemic
Surgical - local

6. Images courtesy of Larry Marsh, MD

7. Unpredictable or worse outcomes Example: ORIF of tibial plateau fx
Schwartsman R, et al. Am. J. Orthop. 1998; 27: % Unsatisfactory in pts > 50 yo
Ali AM, et al. J. Orthop. Trauma 2002; 16: % fixation failure in pts > 60 yo

8. 60 yo female significant osteopenia
Images courtesy of Larry Marsh, MD

9. 3 months
6 months
Post op
Images courtesy of Larry Marsh, MD

10. Infected 1 year hardware removal ROM: 20o-90o terrible result
Images courtesy of Larry Marsh, MD

11. 76 yo female
Tripped and fell
Images courtesy of Larry Marsh, MD

12. Treated in cast brace 3 year follow up Slight valgus knee
Assymptomatic
Images courtesy of Larry Marsh, MD

13. Fractures in elderly patients
Low energy mechanisms
Different patterns:
Metaphyseal compression
Comminution
Splinters or spikes
Deeply impacted articular surfaces

14. Femoral artery
Images courtesy of Larry Marsh, MD

15. Images courtesy of Larry Marsh, MD

16. Images courtesy of Larry Marsh, MD

17. The “Gull Sign”
J Ortho Trauma
Vol

18. Alternatives to ORIF Closed management
Fragment excision/soft tissue repair
Olecranon
Patella
Arthroplasty
Proximal humerus
Femoral neck
Distal humerus
Acetabulum
Knee

20. Femoral neck fracture ORIF has: Less blood loss Shorter op time
Lower infection rate
But
Higher RE-operation rate! Bhandari et al. JBJS Am 2003

21. If you decide to ORIF - Nails rather than plates when possible
Limited or Percutaneous approaches
May accept a little shortening for cortical contact
Longer plates, fewer screws
Locking plates
Allograft rather than autograft, consider BMP
Augment fixation

22. Locking Plates

23. Biomechanics of Locking plates More stable fixation: Testing Data
LOAD
Low density foam simulating osteopenic Bone
4.5 mm Narrow LCP
Apply a load and measure deflection
Testing on traditional vs locked plate constructs.

24. Locked Plate and Screw Testing
Osteopenic Bone Model (Low density foam)
1.7X
1.5X
Notable points:
Simulated osteopenic bone of low density foam
Traditional and locking constructs tested
Unicortical and bi-cortical constructs tested
Lavendar line-(3) 4.5mm traditional cortical screws
Loads at which these constructs begin to fail- First “tick” or Yield Point
1st review benefit of adding one locked screw to an osteopenic bone. Increases resistance to 1.5X greater axial loads
2nd note that load carrying capability of uni-cortical locking screws is similar to that of bicortical cortex screws.

25. Augmenting the bone
PMMA
Calcium Phosphate cement
Allograft struts

26. Ca Phosphate cement as an aid to internal fixation of the proximal humerus Kwon et al JBJS 2002
Slide courtesy of Larry Marsh, MD

27. Ca-P cement in a 62 yo female with split depression plateau fracture
Slide courtesy of Larry Marsh, MD

29. Intramedullary
Fibular strut graft

30. Endosteal
Plate

31. Summary
Recognize different operative indications – use more conservative care
Choose the right techniques
Consider arthroplasty
Fixation choices
Nails
Minimal exposures
Locking plates
Grafting
Bone augmentation

32. Don’t Forget to Treat the Disease: Osteoporosis
Calcium and Vitamin D
Biphosponates when indicated
Exercise counseling

33. Jeff Anglen, MD janglen@iupui.edu
Thank You
Jeff Anglen, MD