Leading osteoporosis experts debate the key distal radius fracture issues

One question: Do BMD testing, bone fillers and certain techniques produce better results?

Issue: Issue 2 2006

Orthopaedic surgeons face many challenges getting distal radius fractures of osteoporotic bone to heal. Despite all the proven approaches, it appears that nearly as many treatment challenges and unanswered questions remain.

During a recent workshop co-sponsored by the International Society for Fracture Repair (ISFR) and the International Osteoporosis Foundation (IOF), a panel of international osteoporosis experts discussed some of the “burning issues” concerning distal radius fractures and possible solutions to those problems.

Antonio Moroni, MD [photo]
Antonio Moroni

Moderator Antonio Moroni, MD, at the Rizzoli Orthopaedic Institute and the University of Bologna, Italy, and four panelists from the United States, Switzerland and Germany discussed several topics during the one-hour session. They ranged from accurate assessment of bone mineral density and issues concerning conservative fracture treatment, to pros and cons of increased mobilization and which fixation methods yield the best results based on indication.

“The greatest progress has been the development of angular stable ‘locking’ plates, which afford much more predictability in the surgical management of fractures with underlying osteoporosis,” panelist Jesse B. Jupiter, MD, told Orthopaedics Today after the workshop.

BMD assessment

Jesse B. Jupiter, MD [photo]
Jesse B. Jupiter

Eighteen invited orthopaedic surgeons attended the panel discussion and used an automated polling system to answer questions Moroni asked them.

When asked if bone mineral density (BMD) assessments of the operated area prior to surgery help 55% of attendees said “yes.” Knowing bone density in the fracture area of an osteoporotic patient during surgery could help to improve fixation and possibly reduce the implant loosening incidence, Moroni told Orthopaedics Today.

However, some easier and equally effective ways of determining bone density might prove just as useful, said Charles P. Melone Jr., MD, at Beth Israel Medical Center and Albert Einstein School of Medicine, New York. Alternative BMD evaluation methods include patient fracture history, fracture pattern, radiographs and age. “A special test is not needed,” he said. Panelists also debated whether additional costs associated with BMD assessment ultimately help avoid extra implant costs.

Conservative treatments

Charles P. Melone Jr., MD [photo]
Charles P. Melone Jr.

The group discussed fracture features that typically help determine whether conservative or surgical treatment is appropriate, such as the amount of displacement, stability and propensity for reduction. Jupiter said if a fracture needing reduction is stable after the volar cortices are engaged — and it is not widely displaced or impacted — it will likely remain stable. In that case, conservative treatment could be used, said Jupiter, who is at Massachusetts General Hospital and Harvard Medical School, Boston.

When the panelists asked the audience about what types of fractures they thought were indicated for conservative treatment, 85% of them cited AO/OTA type A1, A2 and A3 distal radius fractures. Moroni, who was surprised by the response, countered, “Most type A fractures do require reduction.”

Panelist Burkhardt Wippermann, MD, said any fracture needing reduction also needed fixation. Wippermann is from the trauma department at Hildesheim Klinikum in Hildesheim, Germany.

Thirty percent of those polled thought that when using a conservative treatment, less than three weeks of immobilization was sufficient; 45% voted for three to four weeks, and 25% for more than four weeks.

Device vs. surgeon preference

Burkhardt Wippermann, MD [photo]
Burkhardt Wippermann

Panelists also suggested that plate fixation might be becoming more popular with clinicians than the more standard fixation methods, like percutaneous pinning and external fixation, with or without Kirschner wires. Melone attributed this trend to the fact that plating gives the surgeon a good look at the fracture before fixing it. Plating may also give patients an earlier return to motion. Despite reportedly good results with external fixation, however, the follow-up it requires can be extremely demanding, he added.

Intramedullary (IM) devices are among the most popular fixation methods used by audience members; 75% said they use IM fixation 75% of the time. Commenting on the increasing variety of IM implants sold, Jupiter said some of the newer ones appear to work best with simple fractures.

“So one has to wonder that, if they are best for simple fracture, are they really needed?” he said. “I believe recognition of the complexity of these fractures, as well as the multitude of factors affecting the prognosis, are far more important to optimal treatment than the fixation device,” Melone told Orthopaedics Today. “In fact, too much emphasis has been placed on the device, when in reality the surgeon’s preference and expertise are more important.”

The panelists considered one new approach to osteoporotic fractures: placing biologic or mechanical fillers at the site, like calcium phosphate cement, with or without adding another kind of fixation. Thirty-five percent of the audience said they had never used that technique.

Pietro Regazzoni, MD [photo]
Pietro Regazzoni

Panelist Pietro Regazzoni, MD, University of Basel, Switzerland, said the most important feature that he looks for when selecting a mechanical filler for a previously unoperated fresh fracture is good handling characteristics. A secondary concern is cost.

He often uses allograft bone as a “filling” option. But when any kind of biological problem with a distal radius fracture, like poor anatomical position, along with a mechanical problem, is suspected, Regazzoni said he would definitely use autograft and not even consider another approach.

“Calcium phosphate cement and indications for nonoperative treatment [of osteoporotic fractures] are two topics that remain to be evaluated,” Jupiter said.

Melone acknowledged the recent progress made in treating distal forearm fracture in osteoporotic patients. “One of the greatest advances has been recognition of the major impact of osteoporosis on management of distal radius fractures, including its effect on incidence, treatment and prognosis,” he told Orthopaedics Today.

For more information:
Moroni A, Jupiter J, Melone C, et al. Panel discussion: Burning issues and general discussion. Presented at the 2nd ISFR-IOF Workshop on Osteoporotic Distal Forearm Fractures. Oct. 7-9, 2005. Rome.