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Osteoporosis and

fragility fractures:
An Expanding Epidemic
Definition Of Osteoporosis
“ … a syste m ic ske le ta ld ise a se
ch a ra cte rize d b y lo w b o n e m a ss
a n d m icro - a rch ite ctu ra l
d e te rio ra tio n o f b o n e tissu e ,
le a d in g to e n h a n ce d b o n e
fra g ility a n d a co n se q u e n t
in cre a se in fra ctu re risk .”

World Health Organization (WHO), 1994

Fragility fractures are

• 1 in 2 women and 1 in 5 men over age 50 will suffer

a fracture in their remaining life time1
• 55% of persons over age 50 are at increased risk of
fracture due to low bone mass
• At age 50, a woman’s lifetime risk of fracture
exceeds combined risk of breast, ovarian &
uterine cancer
• At age 50, a man’s lifetime risk of fracture exceeds
risk of prostate cancer

.Johnell et al. Osteoporos Int. 2005; 16: S3-7

Osteoporotic fractures:
Comparison with other
2000 annual
all ages
Annual incidence x

1 500 000
250 000

250 000
1000 forearm
annual estimate
250 000
women 29 +
513 000 annual estimate
500 women 30 +

750 000
228 000 1996 new
l 184 300 cases ,
all ages
Osteoporotic Heart Stroke Breast
fractures attack cancer

American Heart Association, 1996

American Cancer Society, 1996
Riggs & Melton, Bone, 1995; 17(5 suppl):505S-511S
Consequences of Hip
One year after hip fracture
Unable to carry out at
least one independent
activity of daily
living 80 %
Unable to
Patients independentl
(%) y
disability 40 %
Death within
one year 30 %
20 %

Cooper. Am J Med 1997; 103(2A):12s-19s.

Consequences Of Vertebral
• Acute and chronic pain
– Narcotic use, decrease mobility
• Loss of height & deformity
– Reduced pulmonary function
– Kyphosis, protuberant abdomen
• Diminished quality of life:
– Loss of self-esteem, distorted body image, sleep
disorders, depression, loss of independence
• Increased fracture risk
• Increased mortality
Consequences Of Distal
Radius Fractures
• The most common fracture in women
at middle age
– Incidence increases just after
• The most common fracture in men
below 70 years
• Only 50% report good functional
outcome at 6 months
• Up to 30% of individuals suffer long-
term complications

O'Neill et al. Osteoporos Int. 2001; 12:555-558

Mortality due to hip fracture vs.
(deaths per 100,000 in older

H ip fra ctu re Stroke

Sw eden 177 154
D e n m a rk 154 180
G e rm a n y 131 190

Hip fracture data: age 80; Kanis. J Bone Miner Res. 2002; 17:1237
Stroke data: ages 65-74; Sans et al. Eur Heart J 1997; 18:1231
Mortality after
Osteoporotic Fracture in
Men And Women
5 - year prospective cohort study

A g e -sta n d a rd ize d m o rta lity ra tio

Fra ctu re W om en M en

Proxim a l fe m u r 2 .2 3 .2

V e rte b ra l 1 .7 2 .4

O th e r m a jo r 1 .9 2 .2

Center et al. Lancet 1999; 353:878-882

Prior fracture increases
the risk
of subsequent fracture
Risk of subsequent fracture
Site of prior Hip Spine Forearm Minor fracture

Hip 2.3 2.5 1.4 1.9
Spine 2.3 4.4 1.4 1.8
Forearm 1.9 1.7 3.3 2.4
Minor fracture 2.0 1.9 1.8 1.9

prior fracture increases the risk of new fracture 2- to 5-fol

Klotzbuecher et al. J Bone Miner Res 2000; 15:721-727

Orthopaedic surgeons have a
unique opportunity
• Fragility fracture is often the first indication a
patient has osteoporosis

• Orthopaedic surgeons are often the first and may
be the only physician seen by fracture patients
and can serve a pivotal role in optimizing
treatment, not only of the fracture, but also of
the underlying disease

1.Eastell et al. QJM 2001; 94:575-59

2.Bouxsein et al. J Am Acad Ortho Surg. 2004; 12:385-95
Multinational Survey of
Osteoporotic Fracture Management

 Survey of 3422 orthopaedic surgeons from 6


• 90% do not routinely measure bone density following the first


• 75% are lacking appropriate knowledge about osteoporosis

Dreinhöfer et al. Osteoporos Int 2005; 16:S44-S54

Major Risk Factors For
• Prior fragility fracture
• Increased age
• Low bone mineral density
• Low body weight
• Family history of osteoporotic fracture
• Glucocorticoid use
• Smoking

Osteoporotic Fracture
Women Men
Incidence per 100 , 000

2,000 Hip
person - years

Vertebrae Vertebrae

Forearm Forearm

35 55 75 35 55 75
Cooper et al. Trends Endocrinol Metab 1992; 3:224
Remaining Lifetime Fracture Risk (%) In
Caucasian Population At The Age Of 50

Typ e o f fra ctu re M en W om en

Forearm 4.6 20.8

Hip 10.7 22.9
Spine 8.3 15.1
Proximal humerus 4.1 12.9
Other 22.4 46.4

Johnell et al. Osteoporos Int. 2005; 16 Suppl 2:S3-7

Millions of fragility fractures a year –
with current orthopaedic
most fractures will heal…

B u t is th a t e n o u g h ?
Challenges In
• Awareness and knowledge about osteoporosis is low
among fracture patients

• Despite availability of therapies proven to reduce
fracture risk, even in patients who have already
suffered a fracture, diagnosis and treatment of
osteoporosis among fragility fracture patients
remains low
Treatment Of Osteoporosis:
Are Physicians Missing An
• Among 1162 women with distal radius fracture, at 6 mo

– 266 (23%) prescribed osteoporosis med

– 33 (2.8%) had bone density test
– 20 (1.7%) had bone density + OP therapy
 883 (76%) received neither bone density test nor medical
treatment of osteoporosis

• Among 1654 patients (age > 50 yrs) admitted to

hospital for a fracture resulting from a fall: ~ 50%
hip fracture, at 1 yr
– 247 (15%) prescribed osteoporosis med
– Women: 3 times more likely to receive treatment than men
(19% vs 5%)
Freedman et al. J Bone Joint Surg 2000; 82-A:1063-70
Panneman et al. Osteoporos Int. 2004; 15:120-4
Awareness and knowledge about
in fracture patients is low
3 8 5 p a tie n ts w ith fra g ility fra ctu re s

“ H a ve yo u e ve r h e a rd o f o ste o p o ro sis? ”

N O : 20 % YES: 80 %

“ D o yo u th in k th a t th e fra ctu re yo u h a ve exp e rie n ce d

co u ld b e d u e to fra g ility o f yo u r b o n e s? “

N O : 73 % YES: 27 %

An Osteoporosis Clinical Pathway for the Medical Management

of Patients with Low Trauma Fracture

Chevalley et al. Osteoporos Int. 2002; 13:450-455

Optimal care of the fragility
fracture patient
• Diagnosis of “fragility” fracture
– Identify “fragility” fracture & underlying disease,
incorporate into existing workup
– Influences treatment plan from the onset
• General fracture management
– Stabilize patient, pain relief, fracture care
• Rehabilitation
– Minimize dependence, maximize mobility
• Secondary prevention
– Treat and monitor underlying disease, prevent future
D ia g n o se fra g ility
fra ctu re

A ccid e n t p a tte rn

D e fin itio n o f fra g ility fra ctu re :

Fra ctu re d u rin g a ctivity th a t w o u ld n o t n o rm a lly in ju re

yo u n g h e a lth y b o n e ( ie
. ., fa llfro m sta n d in g h e ig h t o r
le ss)
F ra g ility fra ctu re ?

R isk
A ccid e n t p a tte rn
a sse ssm e n t

M e ch a n ism o f in ju ry: R isk fa cto rs fo r p rim a ry a n d

se co n d a ry O P
Lo w tra u m a ?
R isk fa cto rs fo r fra ctu re
Fa llfro m sta n d in g
h e ig h t o r le ss ? R isk fa cto rs fo r fa ll
“ Fra g ility ” fra ctu re ?
High Risk For Secondary
• Severe chronic liver or kidney diseases
• Steroid medication (>7.5mg for more than 6
• Malabsorption (eg. Crohn´s disease)
• Rheumatoid arthritis
• Systemic inflammatory disorders
• Hyperthyroidism
• Primary hyperparathyroidism
• Antiepileptic medication
Fragility fracture patient assessment
* In addition to routine pre-op or fracture evaluation

• Family history of OP
• Menarche / Menopause
• Nutrition
• Medications
– (past and present)
H isto ry • Level of activity
• Fracture history
• Fall history & risk factors for falls
• Smoking, alcohol intake
• Risk factors for secondary OP
• Prior level of function
F ra g ility fra ctu re p a tie n t a sse ssm e n t
In addition to routine pre-op or fracture evaluation

• Height
• Weight
• Limb exam
– ROM, strength, deformity,
pain, neurovascular
P h y sica l
• Spine exam
Exam  – pain, deformity, mobility
• Functional status
Laboratory tests *


•Blood count - * These are in addition to

routine pre-op labs such as
•Calcium coagulation studies
•Phosphate - These are screening labs,
more may be indicated based
•Alkaline Phosphatase (AP) on these results
•Renal function studies
•Basal TSH
•Intact PTH
•Vit D (25 and 1.25)

Bone mineral density and spine
radiograph for vertebral fracture
• Bone mineral density assessment by DXA
– Establish severity of osteoporosis
– Baseline for monitoring treatment efficacy

• Consider spine radiographs (thoracic and lumbar,
AP and ML views) for patients with:
– Back pain
– Loss of height > 4 cm
– Progressive kyphosis

Complexity Of Elderly
• Mean age hip • Impaired metabolic
fracture = 80 yrs response to injury
– Hyponatraemia
• Comorbidities • Management problems

• – Consent
– Renal - dialysis
– Theatre scheduling
– COPD - home O2 • – Discharge planning
– Diabetes
– Delirium / dementia
• Polypharmacy
– Warfarin
– Pseudo-obstruction
– Plavix
– Alcohol abuse
– Neurotropics

Technical Challenges Of Fracture Fixation
In Osteoporotic Bone

• Impaired ability of osteoporotic bone to hold

screws or support implants
• Crushing of cancellous bone with subsequent voids
after fracture reduction

These factors can lead to a higher risk of

failure at the implant - bone interface before
healing achieved
Special considerations in
of fragility fractures
• Arthroplasty / Hemiarthroplasty
– Also allows early mobilization, may be less painful
• Implants designed for osteoporotic bone
– Fixed angle locking plates
– Hydroxyapatite-coated screws
• Use of IM nail instead of onlay devices
(plates and screws) for diaphyseal fractures
• Void filling with cement or bone graft
Possible Indications For

H ip S h o u ld e r K nee E lb o w

Images courtesy of John Keating

Hip Shoulder
hemiarthroplasty arthroplasty
and widely
to ORIF in
But current
y use is •Useful particularly for 3-part
increasing and 4-part fractures and
fracture dislocations
•Early treatment best
•Good pain relief, but poor
movement and function
•Soft tissues influence outcome

Keating et al. J Bone Joint Surg. 2006; 88(A):249-60

Example of fixed angle
locking plates

• Screw head threaded –

engages with hole in
• Single mechanical unit –
internal fixator
• No compressive force on

Female 82 yrs

Plecko and Kraus, Oper Orthop Traumatol.2005; 17:25-50

Fixation augmentation with
hydroxyapatite-coated screws

OsteoTite HA-coated external fixation pin

HA-coated AO/ASIF lag screw

HA-coated AO/ASIF cortical bone screw

HA-coated AO/ASIF cancellous bone screw

Magyar G et al, J Bone Joint Surg Br. 1997 May;79(3):487-9

Moroni A et al, Clin. Orthop. 1998 Jan;(346):171-77
Moroni A et al, Clin Orthop. 2001 Jul(388):209-17
Moroni A et al, J. Bone Joint Surg. Am. 2001 May;83-A(5):717-21
Sandèn B al, J. Bone Joint Surg. Br. 2002 Apr;84(3):387-91
Caja VL et al, J. Bone Joint Surg. Am. 2003 Aug;85-A(8):1527-31
Moroni A et al, Clin. Orthop. 2004 Aug;(425):87-92
Moroni A et al, J. Bone Joint Surg. Am. 2005 May;83-A(5):717-21
HA-coated dynamic hip screw improved outcomes
in osteoporotic patients with hip fracture

 DHS fixed with standard vs HA-

coated AO/ASIF screws in
osteoporotic patients with
trochanteric fractures

S ta n d a rd H A -co a te d
1 . H A -co a te d scre w s m a in ta in e d b e tte r n e ck sh a ft a n g le a t 6 m o
2 . Pa tie n ts w ith H A -co a te d d e vice h a d b e tte r H a rris h ip sco re s a n d
fa r le ss cu t o u t o f la g scre w
Moroni et al. J Bone Joint Surg Am 2005; 87:753-9

















Tre a tm e n1ts
O p tio n s
1.Conservative (bed rest, pain medication and back braces) .
5.Balloon Kyphoplasty.
7.B-Twin VBR (Vertebral Body Reconstruction).
9.Sky Bone Expander System
V e rte b ro p la sty
 D isa d v a n ta g e s
• Quick procedure •B o n e fille r le a ka g e o f 3 0 -
• Low cost 7 0 % re p o rte d .
• Injection of •R isk o f b o n e fille r
bone filler le a ka g e in to th e ca n a l
reduces pain o r b lo o d ve sse ls
• •N o fra ctu re re d u ctio n o r
h e ig h t re sto ra tio n
• •

Balloon Kyphoplasty
Advantages Disadvantages
•Relative correction of the •Not directional
kyphosis •The balloon may expand to the weak
•Less risk of bone filler parts of the vertebral body
leakage compared to (compliant balloon)
vertebroplasty •20% balloon rupture during
• procedure reported1.
•May reduce only fresh fractures

1 Lieberman IH, Dudeney S, Reinhardt M- K, Bell G. Initial outcome and efficacy of 'kyphoplasty' in the
treatment of painful osteoporotic vertebral compression fractures. Spine 2001; 26( 14): 1631- 37.
Rehabilitation in the fragility
fracture patient
Balance (position sense,
 Goal is to improve reaction)

strength, balance, Mechanical vibration plate

position sense, reactions Limb and core strength
Mobility in activities of
– Improve level of
daily living
function /
independence Safety in gait and transfers
– Decrease risk of falls
Sensory and visual limitations
– Decrease risk of
fractures Home safety evaluation and
Rehabilitation of fragility
fracture patient: Fall
Guideline for the prevention of falls in older persons
American Geriatrics Society, British Geriatrics Society, American Academy of Orthopaedic Surgeons
Panel on Falls Prevention. J Am Geriatr Soc (2001) 49: 664-672

Interventions for preventing falls in elderly people (Review)

LD Gillespie et al, Cochrane Database Syst Rev (2003)

A multidisciplinary, multifactorial intervention program

reduces postoperative falls and injuries after femoral neck fracture
M. Stenvall et al, Osteoporosis International (2007) 18: 167-75
Secondary Prevention
• Further evaluation of underlying disease
– Bone mineral density
– Rule out secondary causes of osteoporosis
– Initiate osteoporosis therapy, as indicated
– Fall prevention

• Inform patient and primary MD doctor of probable
fragility fracture and osteoporosis

• Ensure patient has follow-up care with PT and
physician treating osteoporosis
Interventions to reduce
future fracture risk

• Basics
– Nutrition, exercise, fall prevention strategies
– Modify risk factors as able (smoking, excess alcohol)
– Treat co-morbidities (i.e., endocrine disorder?)

• Pharmacological agents

Interventions: General
• Regular physical activity
– Maintaining safe ambulatory status, indep ADLs
– Daily limb and core home exercise routine
• Sufficient intake of calcium and vitamin D
– daily 1000-1500 mg calcium, 400-800 IU vitamin D
– by foods or foods and supplements combined
• Adequate nutrition
• Avoid cigarettes, excess alcohol
Pharmacological agents

• Alendronate •R a loxife n e ( E V IS TA ® )

• Risedronate (ACTONEL®)
• Ibandronate (BONVIVA®) S tim u la to rs o f b o n e fo rm a tio n
• Zolendronate •rh -P T H ( FO R T E O ® )
H o rm o n e th e ra p y M ixe d m o d e o f a ctio n
•E stro g e n / p ro g e stin •S tro n tiu m ra n e la te ( P R O T E LO S ® )

Effect on vertebral fracture risk Effect on non-vertebral fracture risk

Osteoporosis With prior Osteoporosis With prior fractures


Alendronate + + NA + (incl. hip)

Risedronate + + NA + (incl. hip)
Ibandronate NA + NA +
HRT + + + +
Raloxifene + + NA NA

Teriparatide and NA + NA +
Strontium ranelate + + + (incl. hip) + (incl. hip)

NA , No evidence available ; + , effective drug ; a women with a prior

vertebral fracture

Adapted from Boonen S. et al. 2005; Osteoporos Int; 16:239-54

• Fractures are common. Fractures will be more
• Osteoporotic fractures are associated with increased
morbidity & mortality
• A fracture is among the strongest risk factors for
future fracture. Refracture rate is high
• Majority of patients with fragility fractures are not
evaluated or treated for osteoporosis
• Effective treatments are available
• Orthopaedic surgeons are usually the treating
physician and can take an active role in optimizing
care of the fragility fracture patient