Osteoporotic Hip and Spine Fractures

Osteoporosis has a wider impact that extends beyond hip and spine fractures. Treating these fractures is necessary and they often bring significant lifestyle changes for both the patient and their family. The role of the orthopedic surgeon is essential, not just for treating such injuries but also for offering advice on preventing future osteoporotic fractures.

The incidence of hip fractures in elderly patients is increasing as the population ages, possibly due to the higher occurrence of osteoporosis. Hip fractures can impact individuals of any age, gender, or race. The focus shifts to aftercare and the subsequent decrease in both health and independence.

It is necessary to address the underlying cause of the fracture with both the patient and their family. Treating osteoporosis in patients who have experienced previous fractures resulted in a 50% decrease in the likelihood of experiencing future fractures.

Patients and their families should receive adequate advice prior to undergoing surgery to address concerns regarding the return to pre-fracture mobility. Individuals who are independent ambulators and do not use assistive devices have the highest risk of not regaining mobility after hip fracture surgery. Therefore, our doctors at Complete Orthopedics will discuss the potential outcomes of the surgery with patients and their families beforehand.

Hip fractures are widely recognized as an injury that can lead to higher rates of morbidity and mortality. Following a hip fracture, there are various complications that may arise:

• Admission to an intensive care unit
• Development of deep venous thrombosis
• Wound dehiscence
• Bedsores
• Pneumonia
• Fixation failure
• Death

Surgical Treatment of Osteoporotic Hip Fractures

To avoid causing significant delays in surgery, it is crucial to limit the number of unnecessary tests that do not have a significant impact on the outcome. In some cases, conducting preoperative cardiac tests on hip fracture patients can result in delayed surgery, increased costs, and no improvement in morbidity or mortality outcomes.

It is essential to address any treatable risk factors that the patient may have in order to optimize their condition. Effectively managing elderly patients with hip fracture involves collaborative communication and effort among the anesthesia team, the surgeon, and the medical team.

When selecting an implant for geriatric proximal femur fracture treatment, it is important to consider factors such as the fracture pattern, bone quality, mobility, mental status, presence of arthritis, and the surgeon’s experience.

Femoral Neck Fractures

When treating femoral neck fractures, it is important to take into account the type of fracture, the patient’s physiological age, and the presence of symptomatic arthritis. Cannulated screw fixation is a viable treatment option for nondisplaced fractures and valgus-impacted fractures. For displaced fractures, treatment options are:

• Closed reduction and percutaneous pinning, Closed or open reduction
• Fixation using a sliding hip screw with or without a derotation screw
• Hemiarthroplasty
• Total hip arthroplasty

Total hip arthroplasty (THA) is a beneficial treatment option. Patients who undergo THA experience enhanced measures of treatment success and reduced pain, but they may also have a higher risk of dislocation. The ideal candidate for the procedure is mentally alert and physically active patient with some previously existing degenerative alterations.

When treating patients with hemiarthroplasty, our doctors have to decide between using a unipolar or bipolar arthroplasty. While there is no significant difference in clinical outcomes between unipolar and bipolar arthroplasty, patients who undergo the former procedure have a higher rate of acetabular erosion.

Intertrochanteric/Subtrochanteric Fractures

Implant selection should be based on the stability of the fracture pattern. A stable intertrochanteric fracture can be addressed using either an intramedullary nail or a sliding hip screw device. In cases of unstable fracture patterns, an intramedullary nail (IMN) is considered the preferred treatment.

To achieve success with IMN, obtaining accurate anterior-posterior and lateral views through appropriate preoperative fluoroscopic imaging, along with full-length femur films, is crucial. This is particularly important because most nail systems have a greater radius of curvature compared to the femur. As a result, the nail is often straighter than the femur, posing a risk of anterior cortical penetration.

To minimize the risk of anterior cortical penetration and ensure proper positioning of the femoral nail, it is recommended to start the procedure at the middle one-third of the greater trochanter and use lateral fluoroscopic images to confirm the mid-axial position of the nail. Manufacturers provide reduction aids to assist in aligning the guidewire to the mid portion of the femur.

When dealing with osteoporotic bone, utilizing an implant that extends throughout the entire bone can be beneficial in preventing stress risers at the end of a shorter nail and providing extensive support to the bone.

Atypical Femur Fractures

Atypical Femur Fractures are a specific type of fractures that occur with low-energy trauma and are frequently linked to bisphosphonate use. Fractures in this category occur in the proximal femur below the lesser trochanter and exhibit distinctive radiographic features:

• Cortical beaking
• Focal lateral cortical thickening
• Short oblique
• Transverse in nature

Bone biomechanical properties have a relationship with the prolonged use of bisphosphonates. Compared to women who didn’t receive treatment, the bone showed lower mineral crystallinity, increased collagen maturity, reduced elastic modulus, and contact hardness.

According to the literature, stress fractures that are not displaced and occur after bisphosphonate use can initially be managed without surgery. However, these fractures may eventually become displaced and require fixation, resulting in a longer hospital stay compared to patients who received prophylactic treatment as described by the authors.

Vertebral Compression Fractures

Elderly patients often experience pain and reduced quality of life due to vertebral compression fractures (VCFs), which are a frequent cause of this condition. Disabling pain is a common complaint among patients. Spinal deformity may worsen over time, which can have an impact on lung function, leading to a decrease in vital capacity and functional levels, ultimately affecting mortality rates.

Furthermore, there is a heightened risk of experiencing additional compression fractures. When evaluating these patients, it is crucial to conduct a thorough examination that includes clinical, radiographic, and laboratory studies. This is necessary to rule out the possibility of a metastatic process or infection.

The initial approach to treatment should involve noninvasive methods, and pain and/or spasm can be managed with medication. Other available treatment options involve modifying activity levels and undergoing physical therapy, which should focus on strengthening the core muscles.

Surgical intervention for vertebral collapse may involve vertebral augmentation, which can be performed using either vertebroplasty (VP) or kyphoplasty (KP). These procedures utilize cement and are conducted under fluoroscopic imaging.

• VP offers several benefits, including a shorter procedure time, a less invasive approach, and greater durability. However, it has some drawbacks, such as the fact that fractures may be stabilized in their current position without restoring vertebral height or correcting kyphotic deformity, and risk of cement leakage and potential neurological complications.
• KP is a minimally invasive procedure, but it still carries a risk of cement-related complications. It has several advantages, such as improvements in both subjective and objective measures of quality of life and function. KP is not recommended for patients experiencing pain caused by a fixed deformity, instability, or a combination of both.

As the population continues to age, osteoporotic fractures of the hip and spine are becoming increasingly prevalent, posing a significant health problem and a considerable economic burden to society.

It is essential to promptly evaluate and treat a patient who has experienced an osteoporotic hip or spine fracture, using a collaborative team-based approach. As the elderly population may not have a high tolerance for undergoing repeat procedures, it is crucial to prioritize minimizing complications and morbidity.

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