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Osteoporosis and the specialist: How do we treat the osteoporotic patient?
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IntroductionDr. Robert Heaney was a pioneer in osteoporosis research. He directed an entire metabolic wing in the medical school hospital where I trained some 50 years ago. I once mentioned that I did not understand osteoporosis. He said I would when I was 50 years of age — that either the medical community would learn more, I would learn more or both. I am well past 50 years, have 20 plus years of my own clinical research in osteoporosis and I still possess minimal understanding and have more questions than answers.
Osteoporosis was always an orphan disease. Perhaps it belonged to the endocrinologists, but they were few in numbers. The rheumatologist had an interest, but they also were in limited supply. That left primary care, internists, ob-gyn and perhaps general orthopedists. Treatment mostly consisted of estrogens and compliance was notoriously poor.
Orthopedists have the numbers, but when specialization is accounted for, the pool of potential treating general orthopedic surgeons rapidly decreases. The American Academy of Orthopaedic Surgeons, the American Orthopaedic Association and other institutions and physicians continue to encourage our involvement.
The first fractures to occur are of the distal radius at 60 years of age. These patients are the most medicinally undertreated group, perhaps due to age and the fact their “T” scores are often in the osteopenic range. Vertebral fractures follow at 65 years of age. Medicinal treatment herein is the best, but not perfect, because the literature supports it and company representatives tell us we can decrease the occurrence of another vertebral fracture by 50% if we treat the person with bisphosphonates. Hip fractures begin around 70 years of age and are often medicinally undertreated. Even if the treatment is initiated, compliance wanes with time.
Because the wrist, vertebrae and hip fractures have the potential to bypass the generalist and receive treatment from the specialist who may be less inclined to manage osteoporosis, for part 2 of this two-part Round Table discussion, I thought it might be interesting to ask specialists in hand, spine and traumatology their views on osteoporosis as well as their involvement with fracture management.
Douglas E. Garland, MD
Moderator
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Douglas E. Garland, MD
Thomas
Faciszewski, MD
David C.
Ring, MD, PhD
Michael J.
Gardner, MDDouglas E. Garland, MD: Do you approach the fragility fracture differently than routine fractures?
Thomas Faciszewski, MD: Absolutely, the approach to osteoporotic fractures is vastly different than high energy fractures through normal bone. First, by definition, once a patient suffers an osteoporotic vertebral compression fracture (VCF) they have severe osteoporosis. This has many ramifications, not the least of which is the poor bone quality which ultimately limits all forms of fracture fixation by traditional open means. The treatment algorithms of high-energy vertebral fractures should not be applied to osteoporotic VCFs.
From the treating physician’s perspective, severe osteoporosis is a marker for medical frailty as well as bone fragility. Both are systemic problems which require systemic treatment in addition to the treatment of the incident vertebral fracture. Unlike high-energy fractures which are commonly either braced or, if unstable operated on, osteoporotic compression fractures may be inherently stable depending upon their fracture pattern and morphology.
We routinely assess for dynamic mobility, which can be demonstrated in nearly one half of osteoporotic VCFs. Dynamic mobility is the inherent property of fractured vertebrae to change configuration, typically through the intravertebral fracture cleavage plane under different load-bearing conditions. This can be best seen by comparing standing lateral radiographs centered on the index vertebra to supine cross-table lateral radiographs — the vertebroplasty series.
We perform vertebroplasty series in all patients we assess for vertebroplasty and include the presence or absence of dynamic mobility into our management decision algorithm. The presence of substantial dynamic mobility predicts favorable symptomatic response to vertebroplasty, a “cleft-fill” pattern of polymethylmethacrylate (PMMA) and the possibility of some vertebral height restoration. The absence of dynamic mobility might suggest fracture healing and favor a nonoperative course of medical management including formal physical therapy and body mechanics instruction. Nonsteroidal medications have been shown to impair fracture healing, so we recommend stopping these medicines as soon as the diagnosis of osteoporotic VCF has been made.
The decision to perform vertebroplasty vs. continue medical management depends on the two patient factors of pain and functional disability. Patients may have quite substantial pain initially, but be reasonably functional which allows for outpatient treatment. If these patients fail to improve clinically, then vertebroplasty is considered. If the patient is functionally disabled from pain, then percutaneous vertebroplasty is offered, even if the patient is still in the acute phase. We mandate no minimum time period of medical management in patients who are severely disabled before considering vertebroplasty, as the quicker we can get the patient mobile the better they do medically.
The decision to perform vertebroplasty is a group decision which is made by the orthopedic spine surgeon in concert with the patient and their family as well as the medical team which includes a metabolic bone specialist.
Michael J. Gardner, MD: Absolutely. Both the fragility fracture and the fragility-fracture patient mandate unique treatment considerations.
Regarding the fracture itself, several variables are commonly seen that are specific to these injuries. Many osteoporotic fractures are highly comminuted, but can also have unrecognized comminution and nondisplaced fracture lines. When placing clamps on apparently simple spiral or oblique fracture lines, such as in the distal femur, these fragments may displace precluding direct reductions and lag screw fixation. Around the hip, more commonly indirect reduction techniques are used, so this particular problem is not as relevant. However, comminution can affect both the choice of implant and the efficacy of a certain implant.
Sliding hip screw devices for intertrochanteric hip fractures have a long and proven track record, and are appropriate for many fracture patterns. If fracture lines extend lateral or distal to the intertrochanteric line, such as with “reverse obliquity” patterns or those with subtrochanteric extension, sliding hip screws are suboptimal and an intramedullary device should be considered. Sliding hip screws also require a competent lateral buttress to minimize uncontrolled shortening, so if there is concern of a fracture involving the “lateral wall,” a nail device should also be chosen. In complex proximal-femur fragility fractures, where the fracture morphology is not completely visualized prior to operative intervention, stress (traction) radiographs or a CT scan should be considered.
Technically, we strive to obtain stable reductions and optimal implant placements to maximize stability. This includes calcar reduction when possible, and placing the femoral head element centrally and deep to the level of the subchondral bone. The goal is to provide adequate stability to allow weight bearing as tolerated postoperatively, as many geriatric patients are unable to adequately mobilize while maintaining weight bearing restrictions on the injured hip.
Secondly, fragility-fracture patients require additional preoperative work-up. This is often best accomplished with a multidisciplinary team that includes geriatricians, internists, cardiologists, and anesthesiologists, among others. Much has been published regarding the timing of hip fracture treatment and the thresholds and reasons for preoperative delay. Patients with unstable cardiac disease typically benefit from medical optimization prior to surgery. Additionally, correction of electrolyte abnormalities and dehydration, both of which are common in this patient population, is warranted.
David C. Ring, MD: Patients often ask if osteoporosis will impede healing and that doesn’t seem to be the case. Osteoporotic fractures occur with lower energy and seem to cause less stiffness and dysfunction for comparable displacement or deformity. Patients with osteoporosis also tend to have lower functional demands and be more adaptive, resilient and accepting of deformity. Older patients tend to be less enthusiastic about surgery.
Screws don’t hold well in poor quality bone, so when I’m planning operative treatment I use fixed-angle implants (blade plates or locking screws), particularly in the metaphysis. I may also use a longer plate both to improve fixation and limit the potential for a fracture at the end of the plate. In addition, I may use the soft tissue attachments to improve fixation such as the rotator cuff for proximal humerus fractures or the triceps insertion for olecranon/proximal ulna fractures. Finally, some complex fractures with poor bone quality are best treated with arthroplasty.
Garland: Is your postoperative management altered by the diagnosis of osteoporosis?
Faciszewski: The postoperative management is altered as patients with severe osteoporosis should have marked limitation in their bending, twisting and biomechanical forces across their spine not only in the perioperative period, but for the rest of their lives. Every patient who has an osteoporotic fracture will have physical therapy instruction in the immediate post fracture period. This instruction includes education about the biomechanical do’s and don’ts in concert with osteoporotic specific body positioning exercises.
The patients who had large intravertebral clefts filled with PMMA may be braced with either a thoracolumbo-sacral-orthosis (TLSO) or Jewett brace postoperatively, depending on the vertebral fracture level, to reduce stresses across this damaged vertebral segment.
The medical treatment of the patient’s osteoporosis if not addressed prior to vertebroplasty is begun as soon as possible postoperatively. Frailty, deconditioning, and social factors in the elderly may mean a lower threshold for discharge disposition to a nursing home.
Gardner: As with the preoperative management, a multidisciplinary approach, often spearheaded by a geriatrician, facilitates the coordination of care. The tenuous physiology and cardiac comorbidities of many of these patients makes them relatively sensitive to fluid shifts immediately postoperative. While intravenous antibiotics, intravenous fluids, urinary catheters and nasal oxygen are important in the first 24 hours, the goal is to discontinue these treatments as soon as is safe, as these modalities can inhibit the patient from mobilizing. Early mobilization with a physical therapist, often as early as postoperative day 1, is beneficial for multiple systems, including cardiac, pulmonary, and integument. Many of these patients are also malnourished and have clinical depression, and these should be kept in mind by the treating physicians. Initiating diagnosis and treatment for suboptimal nutrition and depression can provide a critical impetus for long-term treatment.
Ring:If I don’t think I have reliable fixation I will change the exercises. For instance I may delay starting exercises for a month, or I may avoid shoulder abduction (which places varus stress on the elbow). Older patients seem to have less pain and take less pain medication, but that is probably more related to mindset than bone quality. The role of guidance on exercises from an occupational and physical therapist has more to do with how counterintuitive it is to do painful stretches to recover, but again, that seems to have little to do with osteoporosis.
Specific to fractures of the distal radius, when using a volar locked plate I usually get stable fixation and I tend to treat osteoporotic and nonosteoporotic fractures the same. As soon as the finger and forearm motion are full, I allow patients to remove the wrist splint and work on wrist motion. I am in no rush to move the wrist in either group because I prioritize the hand and forearm and because a randomized trial showed no difference between mobilizing the wrist 10 days after surgery compared to 6 weeks after surgery.
Garland:Are there any differences in healing times or fracture complications?
Faciszewski: The healing time for osteoporotic compression fractures is quoted in the literature as being equivalent to that of fractures through bones with normal bone density. However, this is a gross generalization that does not incorporate the varied types of osteoporotic fractures. As an example, the rate of aseptic necrosis in osteoporotic VCF is much higher than that of high energy fractures through normal bone. The former is associated with a much higher rate of nonunion in all bones, with the vertebra being no exception. Intravertebral clefts and dynamic mobility are example of intrinsic fracture characteristics that have the potential to limit healing potential. Many osteoporotic patients are on steroids and this complicates healing and postoperative care. As such, there is much left to be studied in the area of bone healing as it relates to osteoporotic compression fractures.
Gardner:As far as healing times, the effect of osteoporosis on fracture healing is not entirely clear, and clinical evidence is lacking. In a 1981 study of 436 femoral neck fractures by Nieminen and colleagues, age was not a predictor of the rate of fracture union. Most of the quoted data is derived from studies of ovariectomized rats, and the majority of these data indicates no difference in the fracture healing times. One caveat is that in steroid-induced osteoporosis the attainment of callus strength is delayed, presumably due to the effect of the steroids. What is clear is that the ultimate strength of the healed bone is restored back to its baseline pre-fracture mechanical strength, which is substantially decreased compared to healthy bone.
Fracture complications are a different story. The mechanical strength and mircoarchitecture of the bone is critical for stable implant anchorage. Maintaining the intraoperative reduction is necessary for several months until fracture healing is complete. Implant “failure,” or the inability to maintain the implant’s position in the bone, resulting in fracture displacement, occurs more frequently in osteoporotic patients. It is important to emphasize that the best way to unload the implant and minimize failure is to optimize fracture reduction. This includes cortical contact when possible, and normalizing alignment of the limb and fracture site.
Ring: In the setting of distal radius fracture, median nerve dysfunction tends to be more of an exacerbation of underlying idiopathic carpal tunnel syndrome than an acute carpal tunnel syndrome. Neurapraxic injury to the median nerve is unusual in both osteoporotic and nonosteoporotic fractures. Fixation can be inadequate even with locked screws, particularly if they are too short or poorly positioned. Axial pullout is one of the more common failure modes of locked screws. Unlocked screws are problematic in osteoporotic bone. Plates with locking screws and other techniques for addressing osteoporosis can, on occasion, create more prominent implants. Prominent implants around tendons may need to be removed after fracture healing to limit risk of rupture, but otherwise, older patients often tolerate prominent implants rather than electing additional surgery.
Garland: Do you work the patient up for osteoporosis or initiate treatment?
Faciszewski:All patients who suffer an osteoporotic VCF are seen first by our metabolic bone specialist. Our triage process facilitates this process and he evaluates the patients’ bone density, their medical status and directs the initial treatment of their fracture which includes physical therapy instruction. I may see the patient at the same initial visit as the patient’s condition and/or fracture pattern mandates, but this is only at the metabolic bone specialist’s request. Our metabolic bone specialist also directs the management of the patient’s osteoporosis in concert with his or her’ primary care physician.
We have found that the management of patients is most efficient with this process as the care of these patients is complex. We recognize that this process is not commonplace and in some ways unique. The ability of the metabolic bone specialist to provide primary orthopedic management for osteoporotic vertebral compression fractures is predicated on our mutual supportive working relationship over the past 10 years. It is based upon the clinical evidence that 30% of compression fractures are asymptomatic with 70% of fractures being symptomatic. The vast majority of symptomatic fractures are effectively treated with medical and supportive management alone.
Our tertiary referral experience highlights the importance of establishing appropriate medical management, initiation of appropriate anti-osteoporosis treatment, and ruling out of other primary causes for the osteoporosis, such as tumor, as the key elements of treating these patients both acutely and to ensure better long term outcomes for patients.
Gardner: It is critical for the surgeon treating the osteoporotic hip fracture to initiate a work-up. However, this can mean multiple things. Probably the most appropriate initial diagnostic test following a hip fracture is a DXA scan. Due to many logistical reasons, it is rarely feasible to obtain a DXA scan during the acute hospitalization.
The DXA results can be used as a baseline for following the response to pharmacologic treatment for osteoporosis, but the presence of a hip fracture may be enough to warrant initiating antiresorptive medication. Additionally, an extremely high number of these patients have vitamin D deficiency. Vitamin D levels and bone turnover markers should be assessed during the hospital stay, and calcium and vitamin D should be prescribed in most cases.
I think the most important form of “initiating treatment” is to assign the patient with the diagnosis of osteoporosis, and ensure appropriate postoperative follow-up. Many institutions, ours included, have formed osteoporosis centers where long-term multidisciplinary can be coordinated, and this has helped treatment rates immensely.
Ring: I recommend that patients discuss osteoporosis with their primary care doctors. Osteoporosis can be considered a disease, but it is also a normal part of human development. Nutrition and exercises deserve attention and pharmaceutical intervention is available, but the risk/benefit ratio is something worthy of discussion.
Garland: Do you think your fellow specialists should be involved in osteoporosis management?
Faciszewski: It is my personal opinion that due to the confounding nature and sheer number and complexity of the medical problems that osteoporotic patients have, as well as the ever-changing multitude of medical and pharmacological treatment pathways, that it is best for patients with severe osteoporosis (those who have suffered even a single osteoporotic VCF to have their osteoporosis managed by/in concert with a metabolic bone specialist.
An orthopedic spine surgeon’s duty is to recognize that, by definition, any patient with an osteoporotic compression fracture has severe osteoporosis that requires appropriate evaluation and management. An orthopedic spine surgeon does not have the training background, nor is the subject material a core part of our CME programs to ensure adequate care for a patient’s osteoporosis or multitude of medical problems. As orthopedic spine surgeons we are fully qualified to surgically manage the full spectrum of osteoporotic vertebral compression fractures and provide supportive care for the fracture itself. Osteoporosis evaluation and management can be complex and is evolving and physicians skilled in this area can enhance care of orthopedic patients.
Gardner: There is no debate that orthopedic surgeons need to be involved in osteoporosis treatment on some level. What that level is, is slightly more controversial. In an ideal world, patients would be placed on antiresorptives immediately for treatment, but there are many barriers to this. These have been thoroughly explored in the literature.
It is clear that the way the medical system has evolved with surgical subspecialists treating fractures, it is not realistic to anticipate that orthopedic surgeons will ultimately be the main group treating this chronic medical disease. Having said that, it is unquestionably the orthopedic surgeon’s responsibility to be aware that patients with a fragility fracture have osteoporosis until proven otherwise, and to facilitate getting these patients plugged in to the appropriate system for timely work-up and treatment.
Ring: The pharmacological treatment of osteoporosis is complex and involves many areas of medicine. For instance, any benefits to bone from hormone replacement seem to have been offset by other risks. In addition, there is a lot of money involved and marketing is heavy. I place my trust in primary care doctors and specialists who are familiar with all of the relevant scientific data and can help patients assess their risks and benefits make a shared decision. I believe my job as the orthopedic surgeon is to inform them when an injury or illness may be related to osteoporosis and the availability of screening and treatments that should be considered with their primary care doctor.
Reference:
- Nieminen S, Nurmi M, Satokari K. Healing of femoral neck fractures; influence of fracture reduction and age. Ann Chir Gynaecol. 1981; 70:26–31.
Thomas Faciszewski, MD,can be reached at Department of Orthopedic Spine Surgery, Marshfield Clinic, 1000 N Oak Ave., Marshfield, WI 54449; 715-389-4792; e-mail: faciszewski.thomas@marshfieldclinic.org.
Michael J. Gardner, MD, can be reached at Orthopaedic Trauma Service, Department of Orthopaedic Surgery, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8233, St. Louis, MO 63110; 314-747-2523; e-mail: gardnerm@wudosis.wustl.edu.
Douglas E. Garland, MD, can be reached at 2760 Atlantic Ave., Long Beach, CA 90806; e-mail: dougarland@msn.com.
David C. Ring, MD, PhD, can be reached at Massachusetts General Hospital, Orthopaedic Hand and Upper Extremity Service; Yawkey Center, 55 Fruit St., Boston, MA 02114; 617-724-3953; e-mail: dring@partners.org.
