Management Of Current Osteoporotic Fracture During Medical Anti osteoporotic Treatment

Hazem Abdel Azeem

ESOG workshop Alex , October 2012

Fractured under treatment

Female 78 Diabetic , Smoker , Chesty On Alendronate for 3 years Continued after the 1st fracture

 The occurrence of a fragility fracture while on osteoporosis treatment does not necessarily mean that the treatment was ineffective, as it is known that fracture rates are only reduced by 2560% .

Fracture Healing & Remodeling process are natural phenomena

 Fracture Healing & Remodeling process are natural phenomena

Remodeling

Hard Callus
Soft Callus Inflammation Injury

Stability

Types of bone healing :

- Callus healing
( Natural )

- Direct healing:
Contact Healing OR Gap healing

Stages of natural bone healing Cellular functions

II

III

IV

Stages of natural bone healing Stage 1

II

III

IV

10

10

Stages of natural bone healing Stage 2

II

III

IV

11

11

Natural bone healing Stage 3 Granulation phase

II

III

IV

Osteoblast
12

12

Natural bone healing Stage 4

II

III

IV

Remodelling

13

Osteoclast consolidation

13

Natural bone healing Stage 5

II

III

IV

Remodeling
Cortical fibres continuation Osteoclast
14

14

Splinting with a long plate, bendng forces equally distributed, no peak stresses

14 months postoperatively

Contact healing
No fracture gap Cutting cones directly cross fracture line Capillary bud &Osteoclast

Osteoblast & Collagen

17

Gap Healing
Small stable gaps <0.5 mm Capillary ingrowth into gap This fills the gap so that cutting cones can then start to penetrate across Followed by deposition of lamellar bone Capillary + Osteoclast + Osteoblast
18

Direct or contact & Gap healing

No building Osteonal remodelling No callus , Bone movement & Remodelling starts immediately , Osteoblast & Osteoclasts Coupled & functions Together fools the bone into Rigid fixation

thinking it Is wasnt broken

19

Chris van der Verkan

19

Anatomical reduction & absolute stability

79-year-old female

Osteoclast Bone catabolism and remodelling

The role of osteoclasts in fracture repair : In the initial inflammatory phase and subsequent bone formation during the repair phase the osteoclast has no role whereas in the remodelling phase : coupled remodelling of woven bone to lamellar bone at the end of fracture repair depends on osteoclast activity.
Fracture healing Remodeling

Hard Callus
Soft Callus Inflammation Injury

 Female 72 Not on antiosteoporotic treatment Proximal femoral nail Issue of medical anti osteoporotic treatment

Questions
Issues of osteoporotic fracture &medical treatment effects
Would bone anabolics help fracture healing Would anti catabolics ( anti resorpatives ) help OR impair fracture healing

When to start medical treatment after fracture Issue of medical treatment and implant stabilisation

Evidence for anti-osteoporosis therapy in acute fracture situationsRecommendations of a multidisciplinary workshop of the International Society for Fracture Repair

Jrg Goldhahn Schulthess Klinik Zurich, Switzerland AO Clinical Priority Program Fracture Fixation in Osteoporotic Bone E-mail address: goj@kws.ch. Corresponding author. David Little The Children's Hospital at Westmead, New South Wales, Australia Paul Mitchell Faculty of Education Health and Sciences, University of Derby, Derby, UK Nicola Fazzalari Bone and Joint Research Laboratory, SA Pathology and Hanson Institute, Adelaide, Australia Ian R. Reid Department of Medicine, Faculty of Medical and Health Sciences, University of Auckland, Auckland, New Zealand

Per Aspenberg Orthopaedic Section, Department of Clinical and Experimental Medicine, Linkping University, Sweden David Marsh Institute of Orthopaedics and Musculoskeletal Science, UCL, Royal National Orthopaedic Hospital, Stanmore, UK on behalf of the ISFR working group drugs and fracture repair1

Study is done on animal model

1. to review the interaction of anti osteoporosis drugs and fracture healing 2. to review the interaction of anti osteoporosis drugs and internal fixation implants 3. to review the issues around prevention of 2ry fragility fractures
4. to discuss what clinical healthcare systems are required for effective delivery of care; and 5. to identify research questions that need to be addressed to facilitate more effective secondary prevention.

Osteoporosis drugs and bone repair

It is expected that anabolic agents used to treat osteoporosis would have a beneficial effect on fracture healing. However, most patients who need treatment for osteoporosis will currently receive anticatabolic agents ( antiresorpative ), and it is important to know whether this may have any disadvantage for the healing of incident fractures.

Vitamin D- And Calcium Intake

Good for fracture healing Necessary for the use of anti osteoporotic drugs This maximises the effects of drugs and avoids hypocalcaemia

Alendronate
Alendronate did not interfere with initial union but led to increased callus size and decreased remodelling. Bisphosphonates have an effect on (callusfree) direct fracture healing . Direct healing in a mechanically rigid fixation relies on osteoclastic activity for the remodelling of the fracture surfaces.

Estrogen and Raloxifen SERM

In a comparative study in ovariectomized rats, Cao et al. [21] found no major effect of raloxifene and oestrogen on fracture healing responses.

PTH Teriparatide
In rodents, intermittent PTH stimulated fracture healing , with doses as low as 10 g/kg/day having a positive effect , larger doses accelerated remodelling and improved material properties . It could promote healing during all phases through stimulating the osteoblasts as bone builders and osteoclasts as bone remodelers as well as regulating the their coupling functions

strontium ranelate
Strontium ranelate, showed no effect on fracture healing in this animal study (in rats) .

When should the first dose be given after fracture?

WILL DEPEND UPON THE WAY YOU EXPECT YOUR FRACTURE TO HEAL : Bone anabolic :
Treatment may be initiated before discharge from the acute fracture ward in all types of fracture healing

Anti resorpative may be in intravenous bolus of bisphosphonates only in callus haeling cases

Fractured under treatment

96-year-old female

postoperative

Shall we continue medical treatment and how

Female 96 Diabetic , Smoker , Chesty On Alendronate for 3 years Continued after the 1st fracture

Medical treatment fractured patients already on osteoporosis treatment

In these cases, the physician should take the opportunity to review the osteoporosis treatment and consider whether it remains appropriate or whether a change in therapy is justified.

 There have been recent reports of femoral diaphyseal fractures in patients on long-term bisphosphonate treatment. Schilcher and Aspenberg calculated an increased density for fractured patients while on bisphosphonate of 1/1000 per year . These subjects are unlikely to benefit from continuation of bisphosphonate treatment and may need consideration of an anabolic agent, either systemically (e.g. PTH)

Osteoporosis drugs and implant anchorage

Biomechanical tests and clinical experience have shown that implant anchorage is impaired in osteoporotic bone. In animal studies, implants failed earlier (via cutout or cut-through)

68 ys active lady low energy trauma

 This effect has been reproduced in a patient level 1 study utilizing an external fixator for treatment of proximal femur fractures. Extraction torque was significantly higher in patients treated with bisphosphonate

Osteoporosis drugs ( Alendronates & PTH ) improved implant fixation in animal models

 Peri-operative treatment have shown improvement the fixation of total knee replacements, measured as a reduction of the postoperative migration

 Thank you

5 days later

10 months postoperatively

Monocortical instead of bicortical screws

71-year-old male

Definition of Osteoporosis
Osteoporosis is a skeletal disorder characterized by compromised bone strength predisposing a person to an increased risk of fracture. 1

Normal
1. Consenses Development Conference, JAMA 2001; 285: 785-95.

Osteoporosis

Rapid Deterioration of Microarchitecture parameters

Amount of Bone Bone volume Trabecula r Status Trabecular number Trabecular separation Porosity

Baseline

Marrow Star Volume

1 Year
Control Patients

Borah et al. OI 2002 World Congress on Osteoporosis , Dufre e, et al. OI 2002 World Congress on Osteoporosis sn