Management of patients with incident fractures during osteoporosis treatment

Official recommendations are available for detecting osteoporosis and initiating osteoporosis medications in postmenopausal women. However, there are no recommendations about the management of patients with incident fractures despite osteoporosis therapy. Second-line osteoporosis treatments have been evaluated only based on laboratory and absorptiometry criteria. Nevertheless, we will try to answer the following questions: (1) What criteria should be used to determine whether a fracture during osteoporosis treatment indicates treatment failure (low-energy fracture, fracture not due to an intercurrent health condition, fracture of the type targeted by the osteoporosis treatment, sufficient treatment duration at occurrence of the fracture, and good adherence to the treatment and to vitamin D supplementation)? (2) In patients with treatment failure or an inadequate clinical response, defined as a fracture despite adherence to osteoporosis therapy for at least 1 year, what are the best treatment strategies?     

Improving osteoporosis management in patients with fractures

A history of fracture is an independent risk factor for future fractures, but patients who have sustained a fracture are rarely evaluated for osteoporosis (OP). The objective of this study was to determine if a simple intervention in a general orthopedic clinic would lead to more fracture patients receiving evaluation and treatment for OP. Patients with a history of fracture visiting a weekly orthopedic clinic during a 6-month intervention period were educated about OP, and a bone mineral density (BMD) test was offered. The number of BMD tests performed and other OP-specific actions taken as a result of the intervention were compared with a 6-month pre-intervention period. The prevalence of OP in those who underwent BMD testing was examined. In the pre-intervention period, only 12.7% (16 of 126) had a BMD test as compared with 62.5% of the 136 intervention-period subjects (odds ratio [OR] 11.5, 95% confidence interval [CI] 6.1, 21.4). Based on BMD test results, 11.9% of the pre-intervention patients, and 41.9% of the intervention patients received OP-specific recommendations (OR 5.3, 95% CI 2.8, 10.1). The intervention led to more patients being treated for low bone mass (9.5% vs 23.5%); OR 2.9, 95% CI 1.4, 5.9. Low bone mass was common among all types of fracture patients: 20% had osteoporosis and 41%, osteopenia. BMD testing in patients with fractures should identify those at risk for future fractures, leading to appropriate treatment.     

PKP手术在胸腰椎骨质疏松性骨折中的应用

目的总结2003年4月～2005年5月胸腰椎骨质疏松性骨折患者中进行经皮椎体后凸成形术(PKP)的经验和体会。方法测量接受PKP手术治疗的26例患者术前术后X线侧位片的椎体高度和Cobbs角度的改变情况,分析手术的有效性和安全性。结果全部病例疼痛完全解除或者有明显缓解,术后椎体高度平均恢复32%,Cobbs角平均纠正24.7°,没有发生严重后果。结论PKP是一种有效、安全的微创手术,能够迅速地改善临床症状,重建脊柱稳定性,具有较好的近期治疗效果。     

经皮后凸成形术在治疗骨质疏松性椎体压缩骨折中的应用

[目的]总结经皮后凸成形术在治疗骨质疏松性椎体压缩骨折中的经验和体会.[方法]回顾性分析应用经皮后凸成形术治疗的胸腰椎压缩骨折患者31例46椎,男9例,女22例,年龄61～78岁,平均68岁,椎体骨折位于T7～L3,术前对31例患者均拍摄X线片、CT及MRI,手术采用局部浸润麻醉,经双侧入路球囊扩张注射PMMA骨水泥20例,单侧注射11例,手术前后进行VAS评分、椎体矢状面指数及前后凸Cobb's角测量,进行配对t检验统计分析.[结果]所有患者随访6～30个月,平均18个月,VAS评分由术前平均8.7分降为术后2.5分(P<0.001),终末随访为2.8分,椎体矢状面指数(SI)由术前平均54%恢复至术后88%(P<0.001),终末随访为83%,Cobb's角由术前平均23°恢复为4.8°(P<0.001),终末随访为5.5°,术后93%的患者疼痛明显减轻或消失,无感染及胸肋部刺激性疼痛,无循环及呼吸系统并发症,4例术中发生少量骨水泥渗漏至椎体旁,经术中及术后长期观察,未造成任何神经及血管并发症.[结论]经皮后凸成形术在治疗胸腰椎骨质疏松性骨折中有确切缓解疼痛及恢复椎体高度和形态的作用,是一种理想的治疗方法.     

Successful direct intervention for osteoporosis in patients with minimal trauma fractures

Summary

In this study, we offered osteoporosis investigation and treatment directly to patients at out-patient fracture clinics shortly after they sustained minimal trauma fractures. We achieved long-term compliance to the recommended investigation and treatment in 80% of patients. This approach is much more successful than previous interventions.

Introduction

Osteoporosis remains under-treated in minimal-trauma fracture subjects. The aim of this study was to determine if direct intervention at orthopaedic fracture clinics would improve post-fracture management in these subjects.

Methods

From March 2004 to March 2006, 155 consecutive minimal-trauma fracture subjects (mean age 64.0?±?17.6) attending fracture clinics at St. Vincent’s Hospital, Sydney, had a specific medical assessment, following which they were recommended BMD and laboratory testing. Treatment recommendations were given after review of investigations with further follow-up at a median of 8.6 months following therapy. Comparison of outcomes was made with a similar group of patients given written information 2 years prior.

Results

At baseline, 47% of patients had prior fractures, but only 26% had had BMD screening. Twenty-one percent were on anti-resorptive therapy, and 15% were on calcium/vitamin D. Following intervention, 83% had a BMD and of these, 68% had a T-score < ?1.0. Of treatment naïve patients, 44% were recommended anti-resorptive therapy and 56% were recommended calcium/vitamin D. Compliance was 80% for anti-resorptive and 76% for calcium/vitamin D. Female gender and lower BMD were predictors of compliance.

Conclusion

Compared with information-based intervention, direct intervention improved management two to fivefold, maintaining long-term treatment in 90% of osteoporotic and 73% of osteopenic subjects requiring therapy.

     

Management of postoperative complications in spinal surgery patients with osteoporosis

Osteoporosis is a relatively common finding in patients undergoing spine surgery. Osteoporosis increases the risk for complications secondary to implant or bone union failure, including proximal junctional failure and pseudarthrosis. In cases of severe symptoms or progressive deformity, pathology-driven revision surgery may be required. In general, posterior surgery is commonly advocated in cases of fixed deformity with additional osteotomies and decompressions as needed. Conversely, an anterior approach is typically reserved for cases with flexible deformity and anterior compressive structures. In these cases, the use of autograft is also recommended in order to facilitate bone osseo-integration.     

Metatarsal insufficiency fractures in previously undiagnosed osteoporosis patients.

This paper, along with a review of osteoporosis, examines 21 patients (15 women and 6 men) who presented to the senior author between May 1997 and January 1999 with unexplained metatarsal fractures. All 21 patients agreed to bone density testing. Twenty of the 21 had bone densities significantly below the mean for corresponding age, gender, and race. The average bone density for the 21 patients was 2.1 standard deviations below the expected mean for the corresponding 30-year-old reference population and 1.7 standard deviations below the mean for an age, gender, weight, and ethnicity matched population. Distribution and location of the fractures were also investigated. The Body Mass Indices were calculated for all 21 patients, but did not seem to play a role in the fractures. Pertinent medical histories and possible factors for comorbidity are also presented. In all cases successful treatment consisted of guarded weightbearing in a padded boot. The authors conclude that there is a previously unreported correlation between metatarsal insufficiency fractures and low bone mass in both genders, confirmed by the abnormal bone mineral density testing. They also point out that men should be made aware that they can suffer from this disease.     

椎弓根后路固定在骨质疏松伴脊柱胸腰段爆裂型骨折中的应用

中老年人多数存在不同程度的骨质疏松。我们在1998年5月—2002年2月手术治疗共23例脊柱胸腰段爆裂型骨折的中老年人，对其手术操作和内固定的选择采取相应的变化，总结如下。     

椎弓根螺钉短节段固定联合椎体成形术治疗单节段胸腰段骨质疏松性椎体爆裂骨折

【摘要】 目的：探讨椎弓根螺钉短节段固定联合椎体成形术治疗单节段胸腰段骨质疏松性椎体爆裂骨折的临床疗效。方法：回顾性分析我院2008年1月～2012年3月收治的86例单节段胸腰段爆裂椎体骨折患者的临床资料,对其中32例合并骨质疏松症的患者进行随访分析。男14例,女18例;年龄56～78岁,平均64.5岁;跌倒伤14例,车祸伤9例,高处坠落伤5例,重物砸伤4例;骨折节段：T11 3例;T12 10例;L1 15例;L2 4例。手术时均在骨折上下椎置入椎弓根螺钉,安装连接棒,通过体位结合撑开实现骨折椎体复位,然后在伤椎注入骨水泥。应用VAS及SF-36量表评估患者疼痛及生活质量改变情况,通过X线片测量计算伤椎椎体前缘高度恢复、受伤节段后凸矫正及丢失情况,随访观察治疗效果。结果：所有患者均顺利完成手术,术中无明显并发症。随访12～36个月,平均16.5个月。术后VAS评分（2.43±1.81分）及末次随访时VAS评分（2.17±1.81分）与术前（7.67±2.25分）比较差异有统计学意义（P<0.05）;末次随访SF-36评分（123.5±22.3分）与术前（95.7±17.5分）比较差异有统计学意义（P<0.05）。术前Cobb角为22.3°±3.6°,术后Cobb角矫正至5.2°±1.2°,末次随访时为6.0°±2.3°,丢失0.8°±1.5°;术前椎体高度（56.4±5.8）%,术后椎体高度恢复至（95.3±2.9）%,末次随访时为（91.4±3.7）%,丢失（4.0±2.5）%。3例出现椎旁静脉骨水泥栓塞,无明显症状,无内固定断裂。结论：后路短节段椎弓根螺钉固定联合椎体成形术能够有效恢复并维持伤椎高度,减少后凸畸形矫正丢失及内固定失败的发生,具有良好的疗效。     

骨质疏松性脊柱骨折

骨质疏松性脊柱骨折的发病率随着年龄的增加而迅速增长 ,也是再次发生骨折的危险因素 ,我们应该将BMD下降和初次骨折的发生结合起来评价骨折再次发生的危险程度 ,特别是对脊椎骨折的临床评估并没有足够的重视。放射学照像检查评估脊椎骨折是公认的方法 ,特别是具有高分辨率的侧位脊柱影像为脊椎骨折的评估与判断提高了可行的、低辐射的诊断方法。本文对不同评估方法进行了介绍。     

对骨质疏松性骨折不要忽视对骨质疏松症的治疗

目的为了解和掌握骨科医生对骨质疏松症的重视程度,设法提高他们对骨质疏松性骨折的治疗方法,提高疗效。方法将中国骨质疏松杂志自1995年8月创刊以来至2010年8月所有治疗骨质疏松性骨折的文章都阅读一遍,同时统计各种治疗方法及是否同时应用治疗骨质疏松的药物。结果有关治疗骨质疏松性骨折的文章有49篇,共治疗骨质疏松性骨折患者3402例,其中男1160例,女2242例。在49篇文章中未同时应用治疗骨质疏松药物的有36篇,占总治疗篇数的73.46%,同时应用治疗骨质疏松药物的有13篇,占总治疗篇数的26.54%。结论绝大多数骨科医生都不重视对骨质疏松的治疗,只重视对骨折本身的治疗。     

Multiple insufficiency fractures with severe osteoporosis

Multiple insufficiency fracture is a rare injury. We report a 63-year-old woman who spontaneously developed insufficiency fractures at multiple sites including ribs, sacrum, pubis, ischium, acetabulum, metatarsal bone, and femoral neck. The patient had severe osteoporosis with a bone mineral density of 0.267g/cm², although there was no evidence of bone metabolic disease or metastatic bone tumor. Risk factors for osteoporosis in this case were her postmenopausal state and a history of gastrectomy. Interestingly, the serum level of insulin-like growth factor I, recognized as a growth factor that stimulates bone formation, was markedly decreased, and the patient had had viral hepatitis C. It was speculated that the synergistic effects of these disorders might have produced the osteoporosis, leading ultimately to the multiple insufficiency fractures.     

Validity of the DEXA diagnosis of involutional osteoporosis in patients with femoral neck fractures

Background:

There exists no study comparing dual energy X-ray absorptimetry (DEXA) with histomorphometry to evaluate its accuracy and validity as an assessment tool. A prospective study was done comparing the measurements of osteoporosis in patients with femoral neck fractures using the histological method of diagnosis and in the same patients with DEXA postoperatively.

Patients and Methods:

The histological method depends on histomorphometric analysis of bone biopsies taken from the neck of femur during surgical treatment of the fracture. We depend on three indices in histomorphometric analysis: these are osteoid seam width, osteoblast surface, and osteoid surface. The radiological method depends on the measurement of the bone mineral density using DEXA for fractured patients with the scan performed onto the contralateral nonfractured hips and lumbar spines.

Results:

We found positive histological histomorphometric parameters of osteoporosis in 68% of patients with the femoral neck fracture, and there is a moderate correlation between histological histomorphometric analysis and DEXA in the diagnosis of osteoporosis in these patients. In our study, DEXA can detect up to 88.2% of possible cases of osteoporosis (sensitivity 88.2%), but the specificity of this diagnostic tool is 62.5% at a t-score of ≤ −2, i.e., it is sensitive but less specific. The mean difference in the t-score in femoral DEXA and lumbar DEXA is almost zero.

Conclusions:

DEXA is a noninvasive and an affordable and easy method for the diagnosis of osteoporosis but less efficient than the histological histomorphometric method of diagnosis with a low specificity. We also found that the mean difference in the t-score in femoral DEXA and lumbar DEXA is almost zero, so DEXA of one region can reflect the change in the other region and there is no need for DEXA of both regions as a routine unless indicated for a special reason. This avoids exposing the patient to unnecessary risk of radiation and reduces cost.     

Cement-augmented anterior screw fixation of Type II odontoid fractures in elderly patients with osteoporosis

Background contextClosed reduction and internal fixation by an anterior approach is an established option for operative treatment of displaced Type II odontoid fractures. In elderly patients, however, inadequate screw purchase in osteoporotic bone can result in severe procedure-related complications.PurposeTo improve the stability of odontoid fracture screw fixation in the elderly using a new technique that includes injection of polymethylmethacrylat (PMMA) cement into the C2 body.Study designRetrospective review of hospital and outpatient records as well as radiographs of elderly patients treated in a university hospital department of orthopedic surgery.Patient sampleTwenty-four elderly patients (8 males and 16 females; mean age, 81 years; range, 62–98 years) with Type II fractures of the dens.Outcome measuresComplications, cement leakage (symptomatic/asymptomatic), operation time, loss of reduction, pseudarthrosis and revision surgery, patient complaints, return to normal activities, and signs of neurologic complications were all documented.MethodsAfter closed reduction and anterior approach to the inferior border of C2, a guide wire is advanced to the tip of the odontoid under biplanar fluoroscopic control. Before the insertion of one cannulated, self-drilling, short thread screws, a 12 gauge Yamshidi cannula is inserted from anterior and 1 to 3 mL of high-viscosity PMMA cement is injected into the anteroinferior portion of the C2 body. During polymerization of the cement, the screws are further inserted using a lag-screw compression technique. The cervical spine then is immobilized with a soft collar for 8 weeks postoperatively.ResultsAnatomical reduction of the dens was achieved in all 24 patients. Mean operative time was 64 minutes (40–90 minutes). Early loss of reduction occurred in three patients, but revision surgery was indicated in only one patient 2 days after primary surgery. One patient died within the first eight postoperative weeks, one within 3 months after surgery. In five patients, asymptomatic cement leakage was observed (into the C1–C2 joint in three patients, into the fracture in two). Conventional radiologic follow-up at 2 and 6 months confirmed anatomical healing in 16 of the19 patients with complete follow-up. In two patients, the fractures healed in slight dorsal angulation; one patient developed a asymptomatic pseudarthrosis. All patients were able to resume their pretrauma level of activity.ConclusionsCement augmentation of the screw in Type II odontoid fractures in elderly patients is technically feasible in a clinical setting with a low complication rate. This technique may improve screw purchase, especially in the osteoporotic C2 body.     

单侧经皮椎体成形术治疗老年骨质疏松性椎体压缩骨折

目的观察单侧经皮椎体成形术(PVP)治疗老年骨质疏松性椎体压缩骨折的临床疗效。方法选取57例(71个椎体)骨质疏松性椎体压缩骨折患者进行单侧PVP术治疗。观察术前、术后72 h、6个月疼痛VAS评分及椎体前缘、中间高度、椎体后凸Cobb角变化。结果患者均获随访6个月,除3例疼痛恢复不明显外,其余患者术后疼痛均缓解。VAS评分:术前(8.10±0.82)分,术后72 h(3.12±1.13)分,术后6个月(2.83±0.90)分,术后72 h、6个月与术前比较差异有统计学意义(P0.05),术后两时段比较差异无统计学意义(P0.05)。与术前比较,手术后X线片测量椎体前缘、中间高度、椎体后凸Cobb角有改善,但差异无统计学意义(P0.05)。结论 PVP术操作简单、创伤小、效果明显,是治疗老年骨质疏松性椎体压缩性骨折安全、有效的方法。     

Estimating the excess costs for patients with incident fractures, prevalent fractures, and nonfracture osteoporosis

Summary

Based on a population age 50+, significant excess costs relative to matched controls exist for patients with incident fractures that are similar in relative magnitude to other chronic diseases such as stroke or heart disease. Prevalent fractures also have significant excess costs that are similar in relative magnitude to asthma/chronic obstructive pulmonary disease.

Introduction

Cost of illness studies for osteoporosis that only include incident fractures may ignore the long-term cost of prevalent fractures and primary preventive care. We estimated the excess costs for patients with incident fractures, prevalent fractures, and nonfracture osteoporosis relative to matched controls.

Methods

Men and women age 50+ were selected from administrative records in the province of Manitoba, Canada for the fiscal year 2007–2008. Three types of cases were identified: (1) patients with incident fractures in the current year (2007–2008), (2) patients with prevalent fractures in previous years (1995–2007), and (3) nonfracture osteoporosis patients identified by specific pharmacotherapy or low bone mineral density. Excess resource utilization and costs were estimated by subtracting control means from case means.

Results

Seventy-three percent of provincial population age 50+ (52 % of all men and 91 % of all women) were included (121,937 cases, 162,171 controls). There were 3,776 cases with incident fracture (1,273 men and 2,503 women), 43,406 cases with prevalent fractures (15,784 men and 27,622 women) and 74,755 nonfracture osteoporosis cases (7,705 men and 67,050 women). All incident fractures had significant excess costs. Incident hip fractures had the highest excess cost: men $44,963 (95 % CI: $38,498–51,428) and women $45,715 (95 % CI: $36,998–54,433). Prevalent fractures (other than miscellaneous or wrist fractures) also had significant excess costs. No significant excess costs existed for nonfracture osteoporosis.

Conclusion

Significant excess costs exist for patients with incident fractures and with prevalent hip, vertebral, humerus, multiple, and traumatic fractures. Ignoring prevalent fractures underestimate the true cost of osteoporosis.     

老年骨质疏松患者股骨粗隆间骨折治疗的研究

目的 比较不同方法治疗老年骨质疏松患者股骨粗隆间骨折的结果.方法 从1990年至2006年我院收治老年骨质疏松股骨粗隆间骨折患者49例,分别采用保守治疗、外固定架及多种内固定器材手术治疗并比较疗效.结果 术后平均随访3年,并发症最少的是采用重建交锁髓内钉内固定治疗.结论 股骨重建交锁髓内钉是目前治疗股骨粗隆间骨折的一种较好的方法.在实际操作中常发生导针或防旋钉将主钉向上推移的现象,导致拉力钉在股骨颈中位置偏上,应在定位钻孔时施加外力固定.防止主钉上移.伴有骨质疏松老年转子部骨折,普遍伴有大转子粉碎骨折,术中一定要在透视下探入主钉导针,避免形成假道,加重股骨近端及大转子的破坏程度不利于骨折愈合.另外,应注意因严重骨质疏松患者内固定螺钉在股骨头内深度不够不能有效固定的问题,拉力螺钉应在股骨颈中下1/3处深及股骨头下0.5～1.0 cm位置,拧入到钉尾靠近骨皮质时要注意,防止原地空转破坏骨孔道螺纹,降低拉力螺钉的固定力.