Common Osteoporotic Fractures: Treatment & Sequelae. Dr. Sonja Mathes Orthopaedic Surgery Medical Director Rebalance MD Wednesday, March 6 th, 2013

(1)

Common Osteoporotic Fractures:

Treatment & Sequelae

Dr. Sonja Mathes Orthopaedic Surgery

Medical Director RebalanceMD

(2)

Outline

• Review of the common osteoporotic fracture p patterns

– Hip fractures

Subtrochanteric femur fracture – Subtrochanteric femur fracture – Pelvic & Acetabular Fractures – Proximal Humerus Fracture – Wrist fracture

– Vertebral fracture

I id t t t li ti

• Incidence, treatment, recovery, complications and expected outcomes

(3)

Osteoporotic Fractures

• Many studies estimating the diseaseMany studies estimating the disease burden of OP#

• In 2000 globally estimated 9 million OP#s • In 2000, globally estimated 9 million OP#s

– 1.6 million hip 1 7 illi f

– 1.7 million forearm – 1.4 million vertebra

(4)

Which of the following topics

i

h l

?

interests you the least?

• Hip FractureHip Fracture

• Subtrochanteric Femur Fracture

P i l H F t

• Proximal Humerus Fracture • Distal Radius Fracture

(5)

Hip Fractures

• Lifetime hip fractureLifetime hip fracture risk for women:

– 1:6

• Lifetime breast cancer risk for women:

– 1:9

• Mortality for hip

fracture higher (not age adjusted)

(6)

The Hip

The

Hip

• Acetabulum • Head • Neck • Neck • Greater Trochanter • Lesser Trochanter

(7)

Blood Supply

(8)

Blood Supply

Blood

Supply

(9)

Blood Supply

Blood

Supply

(10)

Blood Supply

Blood

Supply

(11)

Blood Supply

Blood

Supply

(12)

Blood Supply

Blood

Supply

(13)

Types of Hip Fracture

(14)

Types

of

Hip

Fracture

• Subcapitalp (Femoral(

Neck)

– Undisplaced

– Displaced

(15)

Types of Hip Fracture

Types

of

Hip

Fracture

• Intertrochanteric

(16)

Types

of

Hip

Fracture

• Intertrochanteric

– Simple

– Comminuted

(17)

Types

of

Hip

Fracture

• Subtrochanteric

• Unstable & often

(18)

(19)

Who benefits from surgical

i

?

intervention?

• Surgery intervention is the rule not the g y exception

– Moribund

Unstable medical condition – Unstable medical condition

• Non-operative management:

– Bedrest, restricted weight bearing – poorlyBedrest, restricted weight bearing poorly tolerated

– Painful

Higher complication (pressure sores delirium – Higher complication (pressure sores, delirium,

pneumonia, UTI etc) – Higher mortality

(20)

Timing of Surgery

• Goal is surgery within 48hoursGoal is surgery within 48hours

– Once reversible medical conditions addressed Anti coagulation hyperglycemia anemia

– Anti-coagulation, hyperglycemia, anemia, hyperkalemia, UTI

• Surgical intervention after 48 72 hrs: • Surgical intervention after 48-72 hrs:

(21)

Goals of Surgery

• Stabilize or ‘excise’ the fractureStabilize or excise the fracture

• Allow WBAT immediately post-operatively

St bili th hi t ll th ti t t b

• Stabilize the hip to allow the patient to be properly nursed with less pain

(22)

Subcapital Hip Fractures

• Impacted p

(Undisplaced)

Bl d l t th

• Blood supply to the head is probably

i t t intact

(23)

Impacted Subcapital Fracture

• Cannulated screws • Cannulated screws

(24)

Impacted Subcapital Fracture

• “small” operation – percutaneous or 5 cmsmall operation percutaneous or 5 cm incision

• Minimal blood loss • Minimal blood loss

• WBAT post operatively • Complications:

– AVN, Non union – 10-15%

– Requires revision to hemi or total hip arthroplasty

(25)

Displaced Subcapital Fracture

• Blood supply to the h d i di t d

(26)

Displaced

Subcapital

Fracture

• Hemiarthroplastyp y • Typically cemented cemented • Can be 1 piece (monoblock) (monoblock) • Modular (head t f separate from stem)

(27)

• Total Hip p

Replacement

• Most predictable pain relief

pain relief

• Best long term f ti

(28)

Displaced Subcapital Fracture

Displaced

Subcapital

Fracture

Total Hipp Replacement:p

• 15% rate of dislocation dislocation • Contra‐indicated in dementia dementia

• Best for pre‐existing

th iti hi h arthritis or high

(29)

Recognize this?

(30)

Mrs. IM 94F

• Winds gusting 60-g g 90k

• Had her daughterHad her daughter drive her to the

grocery store grocery store instead of cart

• ‘blown over in the • blown over in the

(31)

Intertrochanteric Fractures

Intertrochanteric

Fractures

• Simplep “2‐part”p

(32)

Intertrochanteric Fractures

fracture

(33)

Intertrochanteric Fractures

Intertrochanteric

Fractures

fracture

• The screw slides to

compress the compress the

(34)

Post Operative Course

• Winds died downWinds died down

• Delirium post op day 1, 2, 3 (mild) UTI id tifi d d t t d

• UTI identified and treated • Mobilized with walker day 3

(35)

Intertrochanteric Fracture

• Comminuted “4-part” fracture • Both trochanters off off

(36)

Intertrochanteric Fracture

• Excessive slidingg – Altered anatomy – Prolonged pain – Prominent hardware – Screw cut out

(37)

Mrs DB 93 years young: simple fall

Mrs. DB 93 years young: simple fall

• Lives independently in p y retirement village

• Slipped going to the bathroom during

bathroom during

intermission of Friday night movie

• Normally ambulates with • Normally ambulates with

cane, walker outside • Bright, medically stable • Desperately wants to

know how “Australia” ends

(38)

Pelvic x-ray

Pelvic x ray

(39)

Shoulder x-rays

Shoulder x rays

(40)

Mrs DB wrist xrays

Mrs. DB wrist xrays

(41)

Mrs DB:Treatment

(42)

Mrs DB: Treatment

Wrist: Non operative

Proximal Humerus:

operative: good for h b b t l i ll d

Wrist: Non operative _{rehab but large surgically and}

(43)

Mrs DB: Post Operatively

• Post op Hb 90 day 1, 77 day2 – xfusion • NWB left arm • NWB left arm • WBAT Left leg

• Unable to mobilize with physiotherapy

physiotherapy

• At 6 weeks, proximal

humerus fracture ‘sticky’ enough to PWB through g g arm

• Transferred to Aberdeen • 4 months post op, moves

i t i h

(44)

Mrs DB

Mrs. DB

• All is well until 18 months laterAll is well until 18 months later • Develops acute pain left groin

N t hi t

• No trauma history

• Unable to weight bear

• Had been walking about 1-2 km daily with 4 ww

(45)

X-rays in ER

X rays in ER

(46)

Mrs DB – now 95y/oF

Mrs. DB now 95y/oF

• Has been on fosamax since fallHas been on fosamax since fall

• On exam, marked tenderness to hip rotation

rotation

• Localized to groin

• Now confined to wheelchair

• Only able to take a few steps with y p assistance

(47)

Differential Diagnosis

• Non-union of fractureNon union of fracture • Infection

P t t ti th iti

• Post traumatic arthritis • New fracture

(48)

CT Scan: undisplaced acetabular

f f

(49)

Management

• Treated non-operatively with protected WBTreated non operatively with protected WB • Pain resolved over 2 months

G d ll t d t lki

(50)

Outcomes After Hip Fracture

• Best predictor of post fracture function:Best predictor of post fracture function:

– Pre-fracture function

All fracture patients will have significant • All fracture patients will have significant

drop in QoL scores

S ill i th t f t

– Scores will go up in the year post fracture – Scores remain lower than matched cohorts

(51)

Outcomes

• 10% of fracture patients have persistent10% of fracture patients have persistent disability related to hip

• 19% will require • 19% will require

institutionalization/augmented care

O l 50% t t f t f ti

(52)

Post Hip Fracture Mortality

• Wide range in reported rates:Wide range in reported rates:

– 12-30% at 4-12 months

Higher mortality predicted on basis of – Higher mortality predicted on basis of

• Comorbidities

• Perioperative deliriumPerioperative delirium

(53)

What’s the most common fracture

f

hi f

?

(54)

What’s the most common fracture

f

hi f

?

after a hip fracture?

(55)

Subtrochanteric Fractures

• Often higher g

energy fractures

• Region of stress inRegion of stress in femur

(56)

Subtrochanteric Fractures

• Cephalomedullaryy nail – Cephalo = head – Medullary = medullary canal

(57)

Mrs. IM

(58)

Mrs IM

Mrs. IM

• 74F Japanese-American74F Japanese American

• Spends spring in Victoria because they love the flowers

• 4 month history of bilateral thigh pain

• Known OP with 10 years of fosamax usey

• Had been briefly wheelchair bound because of pain

• No cause identified

(59)

(60)

Presumptive Diagnosis

• Atypical bisphosphonate subtrochantericAtypical bisphosphonate subtrochanteric stress fracture

• Ddx:Ddx:

– Stress fracture

– Pathologic Fracture secondary osteoporosisPathologic Fracture secondary osteoporosis – Pathologic fracture secondary to malignancy

• Had work up to exclude obvious primaryHad work up to exclude obvious primary malignancy

(61)

(62)

(63)

Post-operative Management

Post operative Management

• Stable construct on R operated femurStable construct on R operated femur • Persistent pain on L femur

X d b h t h

• X-ray and bone scan show stress changes • 70-80% of symptomatic stress changes

will complete fracture

• Suggested that she remain NWB on L leg gg g until she has prophylactic nailing

(64)

Pelvic Insufficiency Fractures

• Includes fractures ofIncludes fractures of

– Inferior & superior pubic rami Sacrum

– Sacrum

• Commonly, low energy or no energy ttrauma

• Present with pain +/- inability to WB • Often missed on xray

(65)

Pelvic Insufficiency Fractures

• Stable Fracture PatternsStable Fracture Patterns

• No indications for surgical intervention • Symptomatic management:

• Symptomatic management:

– Brief period of bedrest

– Protected weightbearing with walker – Protected weightbearing with walker – Analgesics (tylenol preferred)

– Early mobilization & activation as toleratedEarly mobilization & activation as tolerated

– Expectation of symptom improvement over 3-12 months

(66)

Mrs. FB 91 F

OA bil

l hi

R L

(67)

6 months later:

b d idd

f

l

h

(68)

Post Bilateral Total Hip Replacement – now

/ l b k/ l i

(69)

(70)

Sacrum, rami & symphysis

i

ffi i

f

(71)

Management

• SymptomaticSymptomatic • Osteoporosis referral t itid – teraparitide

(72)

Proximal Humerus Fractures

• Typically occur fromTypically occur from FOOSH or direct blow to shoulder

• Can present with

marked ecchymosis, extending to chest wall and distally to hand

(73)

Management

• Non-Operative (70-80%) – SlingSling – Hanging cast • Operative • Operative – Percutaneous Fixation ORIF – ORIF – Hemi-Arthroplasty

(74)

• Non-operative treatment protocol: p p

• For NON or MINIMALLY DISPLACED Fractures:

X t 7 10 d & 3 k

– X-ray at 7-10 days & 3 weeks – ensure no displacement

– Sling Full time for three weeksg

• Daily elbow/wrist/hand ROM exercises • Gentle pendulars

– 3-6 weeks: PROM non weightbearing3 6 weeks: PROM, non weightbearing

• Pendular exercies; assisted PROM • d/c use of sling

(75)

Non Operative Proximal Humerus

– @ 6 weeks: usually clinical union – fracture is@ 6 weeks: usually clinical union fracture is minimally tender and proximal humerus and shaft ‘move as one’

(76)

• Outcomes:Outcomes:

– ROM returns around 12-24 weeks post #

Many lose terminal forward elevation internal – Many lose terminal forward elevation, internal

rotation and will have ‘impingment symptoms’ if malunited

if malunited

– Vast majority can comfortably get hand to top of head for self care

(77)

Mrs BB: 75F

Fracture initially undisplaced Fracture initially undisplaced

(78)

Treated with Open Reduction, Internal Fixation

ith P i l H L ki Pl t

(79)

Standard vs Locking Plate

T

h

l

(80)

Impossible to get ‘good bite’

Impossible to get good bite

(81)

Locking Plate Technology

(82)

Proximal Humerus Locking Plate:

fi

d

l d

i

(83)

Complications

• Some series report upSome series report up to 11% fixation failure

(84)

Mrs JB: 77F

Mrs. JB: 77F

(85)

(86)

(87)

Distal Radius Fractures

(88)

Distal Radius Fractures

• 33 most common osteoporotic fracturerd most common osteoporotic fracture • Much less likely to result in loss of

independence independence

• 11% chance of long term disability

• Majority can be managed non-operatively • Displaced/shortened/articularp

(89)

Predictors of Poor Outcome

Dorsal Tilt >20 degrees Shortening> Shortening> 1cm Articular step > 3mm

(90)

Natural History Study

• UKUK

• Evaluated patients with significant radiographic DR malunion

radiographic DR malunion • fractures 10-30 years prior

• No significant functional difference

(91)

Non-operative Management of

Di

l R di

F

Distal Radius Fractures

• What I do: • Loss of reduction: • Treat with cast right

away

– Even if doing closed

– 85% occur within first 3 weeks

– Still in operative window b f i

Even if doing closed reduction

– Warn re compartment syndrome/acute CTS

before union occurs

– After 3-4 weeks, requires osteotomy

• Encourage early finger/elbow ROM • F/u @ 7/14/21 days-F/u @ 7/14/21 days

with x-ray through cast • Remove cast @ 6

weeks and start ROM weeks and start ROM

(92)

Mrs DE 74F RHD

Mrs. DE 74F RHD

(93)

20 °Dorsal Tilt & Comminution

20 Dorsal Tilt & Comminution

(94)

Volar Locking Plate

(95)

Volar Distal Radius Locking

Plate

(96)

K Wires

• Nothing to buttressNothing to buttress the posterior

comminution

• OP fractures tend to collapse/shorten even with k wires

(97)

ORIF Distal Radius Fracture

• Surgical day care g y • Immediately begin procedure • Operative time 45-90 i y g mobilizing fingers/elbows D NOT li minutes

• “half cast” or volar

splint post operatively

• Do NOT use sling • Switch to removal

splint @ 2 3 weeks splint post operatively

• NWB wrist splint @ 2-3 weeks • Start ROM • WBAT @ 5-6 weeks • WBAT @ 5-6 weeks • Full recovery 4-6 months

(98)

Long Term Outcomes of OP

F

Forearm Fractures

• Unlikely to lead toUnlikely to lead to • Upper extremity institutionalization • 50% feel result Upper extremity dysfunction compromises ADLs % unsatisfactory @ 6months

• Limits use of walking aides

• 20% persistent long term pain disability

(99)

Mr GB 72M EtOH

Mr. GB 72M EtOH

(100)

Had closed reduction in ED

-d

(101)

Post Reduction Care

• When should I seeWhen should I see • 7-10 days with x-ray! this patient back?

(102)

Seen at 7 weeks post fracture

(103)

Instituting Osteoporosis

Treatment After Fracture

(104)

Initiation of Bisphosphonate

T

Af

F

Treatment After Fracture

• 2 PRCTS2 PRCTS

– 1 wrist fractures

1 intertrochanteric hip fractures – 1 intertrochanteric hip fractures

• Compared early versus later

bi h h t t t t d t f

bisphosphonate treatment and rates of non union

• No increased non-union rates with bisphosphonates

(105)

When to start treatment?

• As soon as you canAs soon as you can

(106)

Vertebral Insufficiency Fractures

• DISCLAIMERDISCLAIMER::

– This is really not my area of expertise Spoke with Radiologists in Victoria and – Spoke with Radiologists in Victoria and

Vancouver

– Dr John Sun Neurosurgery -local expert – Dr. John Sun, Neurosurgery -local expert

(107)

Vertebral Compression Fractures

• Estimated 40,000-50,000 per annum inEstimated 40,000 50,000 per annum in Canada

• Thoracic and Lumbar

• Approximately 1/3 develop chronic debilitating pain;

• most resolve in 3-6/12

• In the short term, may require prolonged bed rest or hospital admission

(108)

Vertebroplasty

Injection of Barium tinted Injection of Barium tinted

Polymethylmethacrylate (bone cement)

(109)

(110)

• Blinded PRCT compared vertebroplasty toBlinded PRCT compared vertebroplasty to sham injection in painful OP compression #s

#s

• #s confirmed by MRI

12 th d ti

• <12 months duration

• Sham: identical treatment except no PMMA injected into vertebra – but prepared

(111)

(112)

Results

(113)

Results @ 1 & 6 Months

(114)

Discussion

• Essentially no benefit of vertebroplastyEssentially no benefit of vertebroplasty over sham

• Concerns: • Concerns:

– Lack of power analysis

30% f ti t h d l th 6 k f

– 30% of patients had less than 6 weeks of symptoms

M ti t h d l ti l ild l f

– Many patients had relatively mild loss of height

(115)

Local Experience

• Victoria:Victoria:

– Vertebroplasty performed by IVR

– Numbers were higher – perhaps 4/week; nowNumbers were higher perhaps 4/week; now 1 every 1-2 weeks

– No catastrophic complications

• Vancouver General

– Similar story – previously 5-6/week – Now 1-2/week

(116)

Procedure

• Typically day careTypically day care

• IV sedation with anesthesia on stand by

M it d f 4h t

• Monitored for 4hrs post • d/c

• Many patients better within 48 hrs • Radiologists do not follow upRadiologists do not follow up

(117)

Mrs. AT 83F 2 ½ months severe

b

k

i

(118)

Bone Scan with SPECT CT

(119)

Cement Extravasation into i b l interverterbral disc space

(120)

Restoration of Kyphosis

(121)

Local Neurosurgery Experience

i h h

k

D J h S

with thanks to Dr. John Sun

• Kyphoplasty:Kyphoplasty:

– Performed under GA/day care

Insertion of balloon into vertebral body – Insertion of balloon into vertebral body – Both pedicles

to restore height via inflation of balloon (up to – to restore height via inflation of balloon (up to

400 psi)

Create space – Create space – Inject PMMA

(122)

Kyphoplasty

• 70-80% report satisfaction with good pain70 80% report satisfaction with good pain control

• Can do up to 3 levels (commonly adjacent) • Can do up to 3 levels (commonly adjacent) • No significant complications in his practice

(123)

How to access kyphoplasty

• Suggested work up for all painful fractures:Suggested work up for all painful fractures:

– Plain films of t/l spine

Bone scan with SPECT CT to confirm active # – Bone scan with SPECT CT to confirm active # – Clinical correlation of level of pain with

radiographic abnormality radiographic abnormality

– If not improving after 3/12, consider referral

• Dr Sun tries to see patients within 4 weeks • Dr. Sun tries to see patients within 4 weeks • Kyphoplasty within 4-8 weeks

(124)

When & How to Access an

Musculoskeletal Care Referral

Dr. Sonja Mathes, Orthopaedic Surgery

Medical Director, RebalanceMD

P t i C CME E t F b 12th ₂₀₁₃

Partners in Care CME Event – February 12th_{, 2013}

Victoria, BC

(125)

Background

(126)

Background

• January, 2011January, 2011

– Orthopaedic surgeons agree to form clinic together

– Had been many longstanding discussions that this was the right thing to do for patient care

– Engaged Stefan Fletcher, Physiotherapist, to be our CEO

Planning/discussions/agreements in principle – Planning/discussions/agreements in principle

to move forward over 2011 – RebalanceMD was born

(127)

Motivation behind Rebalance

MD

Motivation behind Rebalance

• Frustration with gaps inefficiencies & lackFrustration with gaps, inefficiencies & lack of care coordination

(128)

What is Rebalance

MD

?

What is Rebalance

?

• Aspire to be a:Aspire to be a:

“Centre of Excellence in

Interdisciplinary Musculoskeletal Care” Interdisciplinary Musculoskeletal Care

• Our core values:

– Excellence – Integrity

– Innovation

(129)

Who are we?

C l d hi • Core leadership:

– Stefan & 13 MDs • Clinic composed of: • Clinic composed of:

– Victoria Orthopaedic Surgeons (total 16) – Physical and Rehabilitation Medicine:Physical and Rehabilitation Medicine:

• Drs. James Filbey & Todd Yip – Sports Medicine Physicians

• Drs. Richard Backus, Stu Gershman, Alain LeBlanc, Alex Brothers, Paddy McCluskey

– Osteoporosis Medicine:p

(130)

Location & Services

• January 2013 in 12 000 sq ft space atJanuary, 2013 in 12,000 sq ft space at “Uptown”, Victoria

• Clinic composed of: • Clinic composed of:

– MDs (MSP)

Ph i th Cli i

– Physiotherapy Clinic

– One Bracing -- Orthotics & Bracing Clinic* – Radiology Suite*

(131)

How are we going to address

th G

i C

?

the Gaps in Care?

• ByBy rebalancingrebalancing how we provide care:how we provide care:

– Single Entry Model with Triage Coordination

– First Available Appropriate Surgeon Triage – “FAAST”pp p g g – Urgent Access Musculoskeletal Care

– Comprehensive pre and post-operative i t di i li i ti Ph i i interdisciplinary care incorporating Physician Extenders

(132)

(133)

Our work with Partners in Care

• Meetings q4-8 weeks started in April 2012Meetings q4 8 weeks started in April, 2012 • Addressed communication issues

Id tif i d t i t t i ith

• Identifying and trying to correct issues with referral challenges

(134)

Referral Form Trial

• RebalanceRebalanceMD goal: single entry referralgoal: single entry referral with standardized referral form

• Drafts reviewed and discussed in detail • Drafts reviewed and discussed in detail • Trial groups with cross section of GPs

d l d

developed

• Trial underway since June

(135)

(136)

(137)

(138)

(139)

If my patient chooses to see the

FAAST

h

ill h

?

FAAST, what will happen?

• Referral will be triaged and imaging reviewedReferral will be triaged and imaging reviewed by an MSK expert

• Depending on condition and patient’s p g p symptoms, they could be assessed by:

– Orthopaedic surgeon – Sports medicine

– Non-operative surgeon Physical Medicine

– Physical Medicine

• If assessed by ‘non-operative’ and needs surgery – referral to surgeon will be

surgery referral to surgeon will be expedited

(140)

(141)

(142)

(143)

What X-rays to order?

What X rays to order?

• “Ortho views”Ortho views

(144)

Mrs LJ 88F

Mrs. LJ 88F

(145)

Reported As:

(146)

Mrs LJ

Mrs. LJ

(147)

(148)

Reported As:

(149)

Same patient –

i

/

i h b

i

(150)

FAAST – to date

FAAST to date

• Started in June (15 docs); graduallyStarted in June (15 docs); gradually increasing

• Nov/Dec 150 referrals each monthsNov/Dec 150 referrals each months • Jan 260

• Feb 300 • Feb 300

• Total of 1600 FAAST referrals received to date

date

– 1200 seen within 3-6 weeks – 400 waiting for appts currently – 400 waiting for appts currently