FRACTURE FIXATION IN

OSTEOPOROTIC BONE
Stephen Kates, MD
Hansjӧrg Wyss Professor of Orthopaedic Surgery
Department of Orthopedics and Rehabilitation
Associate Director, Center for Musculoskeletal
Research

AGS University of Rochester Medical Center

Michael Blauth
Norbert Suhm
Jorg Goldhahn

THE AMERICAN GERIATRICS SOCIETY

Geriatrics Health Professionals.
Leading change. Improving care for older adults.
 LEARNING OUTCOMES

• Understand the factors influencing fixation in

cortical and trabecular bone affected with
osteoporosis

• What implant characteristics help with fixation?

• What aspects of surgical fixation are important?

• Understand basic metabolic bone work-up

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 DEFINITIONS

• Insufficiency fracture: bone fails with normal

weight-bearing

• Fragility fracture: result of a fall from a

standing height or less

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 CONTENTS

• Osteoporotic cortical bone

 Biomechanical properties
 Choice of implants
 Surgical technique

• Trabecular bone
 Biomechanical properties
 Choice of implants
 Surgical technique

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 CONTENTS

• Osteoporotic cortical bone

 Biomechanical properties
 Choice of implants
 Surgical technique

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 BONE MASS CHANGES
DURING LIFE
• Peak bone mass is reached at age 25
• Heredity
• Medications
• Diet, tobacco, and alcohol
• Race / weight

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 CONTENTS

• Osteoporotic cortical bone

 Biomechanical properties
 Choice of implants
 Surgical technique

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LOCKED-PLATE PRINCIPLE

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PULLOUT OF REGULAR SCREWS

by bending load
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SHEARING CONVENTIONAL PLATE
OR SCREW DOWN

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RESISTANCE AGAINST BENDING LOAD

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RESISTANCE AGAINST BENDING
LOAD IN LOCKED PLATE

Plate-screw connection
is solid
Screw-bone interface
Fails as a unit

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 CONTENTS

• Osteoporotic cortical bone

 Biomechanical properties
 Choice of implants
 Surgical technique

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 UNI- VS. BICORTICAL SCREW FIXATION

female

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FAILURE WITH UNICORTICAL SCREWS

Thin cortices: choose screw diameter

as large as possible

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5 days later 10 months
postop.

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 BIOMECHANICS: NORMAL BONE
Load (N)

+36%
600 +18%
+6%
500

4.5 mm 4.0 mm 4.0 mm 5.0 mm

400 Cortex, Locking, Locking, Locking,
bicortical unicortical bicortical bicortical

300

200

100

0 Slide 17
 BIOMECHANICS:
OSTEOPENIC BONE
Load (N)

600

500 +82% +91%

400
+17%
300
4.5 mm 4.0 mm 4.0 mm 5.0 mm
200 Cortex, Locking, Locking, Locking,
bicortical unicortical bicortical bicortical

100

0 Slide 18
BRIDGING WITH LOCKED IMPLANT

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 CONCEPTS OF PLATE FIXATION IN
OSTEOPOROTIC BONE
• ? compression technique

• Bridge plating useful

• Neutralization plates useful

• Long plate for bone protection

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 CONTENTS

• Trabecular bone
 Biomechanical properties
 Choice of implants
 Surgical technique

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 OSTEOPOROSIS

Normal bone Osteoporosis

In osteoporotic metaphyseal bone:

•Fewer trabeculae for screws to engage
•Loss of critical bony interconnections
•Thinner internal support

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 SIGNS YOUR PATIENT HAS
POOR-QUALITY BONE
• Poor dentition: teeth are formed similarly to
bone
• Multiple vertebral compression fractures
• Previous hip, radius, or tibial plateau fracture
• End-stage renal disease
• On steroid therapy
• Anticonvulsant use

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OSTEOPOROTIC TRABECULAR BONE:
CLINICAL CONSEQUENCES
• Cut out
• Loss of screw fixation
• Spontaneous fractures

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 CONTENTS

• Trabecular bone
 Biomechanical properties
 Choice of implants
 Surgical technique

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 Flat surface,
increased area

Lag screw Less loss of bone with helical blade (right) Helical blade
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 CHOICE OF IMPLANT:
ONE FIXED ANGLE VS. MANY
Elderly woman who fell down one step

One fixed angle with blade plate Multiple fixed angles, longer implant

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 VARUS COLLAPSE
DUE TO LACK OF MEDIAL BUTTRESS

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 CONTENTS

• Trabecular bone
 Biomechanical properties
 Choice of implants
 Surgical technique

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INTRA-OP IMPACTION

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Augmentation to Improve Screw Fixation
Enlarges the bone implant surface area

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NOT FDA APPROVED!
AUGMENTATION IN PRACTICE

32

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IF BONE IS VERY POOR, CONSIDER
PROSTHETIC REPLACEMENT

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DON’T FORGET THE SOFT TISSUES

The wound must heal also

Skin is also 98 years old

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 BASIC OSTEOPOROSIS WORK-UP:
METABOLIC
• 25-OH vitamin D level
• Intact PTH level
• Calcium
• Phosphate
• TSH
• Albumin level

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 RADIOLOGIC WORK-UP OF
OSTEOPOROSIS: DEXA SCAN
• DEXA is gold standard
T score is comparison to normal young bone
Z score is comparison to peers

• Treat with fragility fracture and osteoporosis,

osteopenia

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 VITAMIN D REPLETION
• Vitamin D2 50,000 units PO
Level 010 ng/dL: 3 times / week
Level 1120 ng/dL: 2 times/week
Level 2132 ng/dL: 1 time/week

• For 612 weeks, then recheck level

• Maintain with vitamin D3 1200 IU/day

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 TREATMENTS
AFTER VITAMIN D REPLETION
• For viable patients:
Bisphosphonates
Selective estrogen receptor modulators
(SERMs)
Parathyroid hormone

• Don’t forget the bone itself: treat the

osteoporosis or refer

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 TAKE-HOME MESSAGES
• Age & bone quality affect cortical and trabecular
bone in different ways
• Absolute stability often not possible
• Principles of fixation:
 Angular stability
 Fracture reduction
 Long bridging plates
 Enlarged surface area of implant / bone
 Augmentation
 Prosthetic replacement

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 THANK YOU FOR YOUR TIME!

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