Download Hip fracture

ORTHOPAEDIC SURGEON
AND OSTEOPOROSIS
Nguyễn Văn Quang
Department of Sports Medicine
Phạm Ngọc Thạch University School of Medicine
INTRODUCTION
Osteoporosis
Fracture
Public health problem
Magnitude of the Problem
Osteoporotic Fracture
Emergency
In-patient
number
Garvan Institute of Medical Research
Garvan Institute of Medical Research
Mortality and morbidity due to hip
fracture is high :
- Mortality is 10-20% higher than
subjects of the same age and sex .
- 15-20% remain in long term care
institutions .
- 25-35% lose their functional
independence
How about orthopedic surgeon ?
The Involvement of Orthopedic Surgeon
In 56 Danish orthopaedic departments:
- Seven(13%) referred their patients with a
low energy fracture for a bone-density scan .
- Six (11 %) treated these patients for
osteoporosis
Eiken 1996.
In USA
1994-1997 :1162 women( > 50 y.o.) who
had a distal radial fracture
- 266 pts (22,9%) medical treatment of
osteoporosis
- 32 pts (2,8%) bone-density scan
- Twenty women(1,9%) bone-density
scan + drug treatment
Freedman KB &al (2000) :Treatment of Osteoporosis
: are physicians missing an opportunity ?
JBJS 82A ,1063-70
REASON-WHY
1- The formation of OS was concentrated
mainly on trauma-orthopeadics and the
high pressure in practice of OS  few
time for osteoporosis , rheumatology
The crowded patients in out-patient room
In operating room
And on call …
2- The overload of traumatic patients
in the ward and on call .
3-Some orthopaedic surgeon think that
it is too late to alter the natural history
of osteoporosis at this late stage when
a fragility fracture has occurred
SEVERAL LINES OF EVIDENCE
1- The risk of fractures(hip,spine wrist)
increase with increasing patient age
2- Small changes in bone density can lead
to substantial reduction in fracture risk .
3- The risk of a subsequent hip fracture
following a wrist fracture is higher among
women who are seventy years of age or
older than who are younger .
4- Activity daily living and lifestyle factors
could have significant effects on orthopaedic
diseases .
5- Orthopaedic surgeons evaluate the
complications and the sequela of the
muscular-skeletal diseases, so they may
be in the best position to manage
osteoporosis and fracture .
Incidence of Fracture by Age
Rate per 100,000 population
500
Women
400
300
Men
200
100
0
0-4
5-14
1524
2534
3544
4554
5564
6574
7584
85+
Garvan Institute of Medical Research
Age specific incidence rates for hip, vertebral, and
distal forearm fractures in men and women
( CUHK Jockey Club Centre for Osteoporosis Care and Control)
Men
Women
Incidence/100,000 person-yr
4000
Hip
3000
Hip
2000
Vertebrae
Vertebrae
Colles’
1000
Colles’
0
35-39
85
Age group, yr
85
Proportion of women with fracture (%)
Cumulative proportions of women
with fracture (Osteo arm, FIT)
Clinical vertebral fracture
Hip fracture
(RR=0.55)
4
4
(RR=0.47)
(3.4%) 3.5
3
3
2.5
Placebo
2
(2%)
2
(1.2%) 1.5
1
1
Alendronate
0.5
0
Placebo
(0.8%)
Alendronate
0
12 18 24 30 36
6
0
Time from baseline (months)
P<0.05
12 18 24 30 36
6
0
Time from baseline (months)
(Black, 2000)
RISK OF SUBSEQUENT FRACTURE
Women and men aged 60 to 69 years :
Absolute refracture rates of
36/1000 person-years ( Women)
and 37/1000 person-years (Men)
Center JR,Bliuc D,Nguyen TV ,Eisman JA :Risk of Subsequent
Fracture After Low-Trauma Fracture in Men and Women
JAMA. 2007;297:387-394.
4- Activity daily living and lifestyle
factors could have significant effects
on orthopaedic diseases .
JBJS 73B 3 511 1991
The alcohol abusers developed significantly
more early complications, especially infections,
after surgery.
5- Orthopaedic surgeons evaluate the
complications and the sequela of the
muscular-skeletal diseases, so they
may be in the best position to
manage osteoporosis and fracture .
( alendronate ,NSAIDs ,Antacid
drugs,Vitamine C)
Alendronate improves pin fixation in
cancellous bone in elderly female patients
with osteoporosis
89-year-old woman with pertrochanteric fracture
( External fixation + alendronate 70 mg/week)
Preop
Postop D 1 Postop 3 months
AJSM 2007 35 8 1 326
NSAIDs, with the exception of ibuprofen
and paracetamol, had a detrimental effect
on healing strength at the bone-tendon
junction.
Long-term Proton Pump Inhibitor Therapy and
Risk of Hip Fracture
Yu-Xiao Yang, MD, MSCE; James D. Lewis, MD, MSCE; Solomon
Epstein, MD; David C. Metz, MD
JAMA. 2006;296:2947-2953
A study of 135,000 people 50 or older
1- high doses of PPIs > 1 year :
2.6 times more likely to break a hip.
2- smaller doses 1 to 4 years
1.2 to 1.6 times more likely to break a hip.
The risk of a fracture increased with the
length of time taking PPIs.
Antacid drugs  gastric acid secretion by
up to 99%   ionized calcium
 Calcium absorption  Osteoporosis
  Fracture.
Vestergaard P, Rejnmark L, Mosekilde L.(2006): Proton pump
inhibitors, histamine h(2) receptor antagonists, and other
antacid medications and the risk of fracture.
Calcif Tissue Int.79:76-83
T.Alcantara-Martos & al : JBJS 89B 3 402 2007
EVOLUTION OF THE ORTHOPAEDIC
PRACTICE IN MANAGEMENT OF
OSTEOPOROTIC FRACTURES
Eiken 1996 : 13%
In 56 Danish orthopaedic departments:
- Seven(13%) referred their patients with a
low energy fracture for a bone-density scan .
1997 : 1,9% - 22,3%
Freedman KB &al (2000) :Treatment of Osteoporosis
: are physicians missing an opportunity ?
JBJS 82A ,1063-70
American National Osteoporosis Foundation
Guidelines -2000
Survey 300 patients of 3 university hospital
( New York ,Philadelphia) in 4 years ( 19972000).
In 2006 questionnaires to 171 OS in USA
- 107/171(63%) usables surveils returned
68%
CONCLUSION
Osteoporosis and osteoporotic fractures
may one day become the primary and the
most serious orthopedic disorder that orthedic
surgeon have to deal with .
The management of osteoporotic fracture was
combined 3 parts :
- Orthopaedic treatment of fracture
- Pharmacological treatment of osteoporosis
- Prevention of subsequent fractures (fall )
Orthopedic surgeons manage the
patient as a whole ( Fracture +
Osteoporosis +others problems ) , not
only fracture.
Thank You