SYNTHESIS OF CONTROLATERAL HIP FRACTURE IN OSTEOPOROTIC PATIENTS – PROPHYLACTIC TREATMENT

Cristea St., Olaru R., Groseanu F., Prundeanu A., Gartonea D., Dragosloveanu S.
Clinic of Orthopaedic and Trauma Surgery, St. Pantelimon Hospital, Bucharest, Romania

KEY WORDS: prophylactic osteosinthesis, MIS, hip fracture, osteoporosis

ABSTRACT
Introduction: the study tried to evaluate the advantages of mini-invasive prophylactic synthesis of contra lateral hip fractures in osteoporotic patients. Material and method: 4 patients have been operated between 2009-2010 with hip fractures in osteoporotic patients. Neck fractures Garden IV in 2 patients and pertrochanteric fractures Kyle III and IV in two others patients. The fracture site was operated in dorsal decubitus under spinal anesthesia, we took advantage of this operation and anesthesia to performe a minimal invasive percutaneous synthesis for the nonfracture controlateral side. We used a simple implant, a quickly method during the same surgery time and anesthesia. The K wires with injected cement were percutaneously inserted. Through a 5 mm skin incision, a channel is created in the proximal femur bone and the implant, made of a fabric pouch hosting Titanium rods, is built percutaneously within the femur. A small amount of bone cement is then added, and interdigitates to the osteoporotic bone to further fixate the implant. Results: Rehabilitation was obtained and full weight bearing was allowed immediately. The potential benefits expected with the use of this minimally invasive method are: Quick procedure – 15 min, No soft tissue or bone damage, No bleeding, short rehabilitation period, reduced morbidity and mortality, Low cost, same drape, single anesthesia. No hip fracture occurs since now at theses 4 patients. Conclusions: The method is simple, reproducible and economically. The osteoporotic patient will be operated during the same anesthesia after the operation of fractured hip. This is a simple method the preventive treatment of the contra lateral side at the same time with surgery treatment of fracture of all patients. Maybe in to the future it will be usefull the prophylactic injection of the osteoporotic hip only by biological cement.



Introduction: the study tried to evaluate the advantages of mini-invasive prophylactic synthesis of controlateral hip fractures in osteoporotic patients. Osteoporosis is a common disease of the elderly, mainly affecting women over the age of 65, and is associated with a high morbidity, mortality and a severe and escalating socio economic problem 1. It is characterized by a low bone mass, resulting in a susceptibility to fractures 2. The major part of osteoporotic related fractures is hip fractures which occur spontaneously or after minor falls.
Hip fractures are referred to as the “death fractures” due to the severe morbidity and mortality rates encountered 3-5. In fact one third of patients do not survive beyond one year after fracturing their hip 6 and the incidence of death from a hip fracture equals the breast cancer mortality rate 7.
Patient who fractured their hip are at high risk of fracture reoccurrence.15-16 The incidence is excessively high during the first 12 months (men) and 19 months (women) following the first hip fracture15. 89%-92% of the reoccurring fracture will arise on the contralateral side.15, 18
The necessity to take preventive steps in order to avoid contralateral fractures is obvious, but due to the above mentioned reasons (i.e. osteoporotic low bone quality and therefore loosening of implant, and risk of long invasive procedures) all other treatments did not succeed sufficiently.
• The study tried to evaluate the advantages of mini-invasive prophylactic synthesis of controlateral hip fractures in osteoporotic patients.
• The current treatments for osteoporotic hip fractures such as parallel cannulated screws, side plates, compression sliding hip screws, etc present a some complications.
For this reason we used a simple method to stabilize the contralateral hip and to prevent the fracture using a minimally invasive technique. The method is simple, reproductible and economically.

Postoperative X Ray on trial cadaveric bone23

Section of postoperative specimen cadaveric bone operated by this technique23
Material and method: 4 osteoporotic patients with hip fractures have been operated between 2009-2010 in our clinic. The criteria for case selection were severe osteoporosis patients with fracture of the hip, Garden IV neck fractures or pertrochanteric fractures Kyle III or IV.
In two patients with neck fractures Garden IV a hip prosthesis was performed. In other two patients with pertrochanteric fractures Kyle III and IV a dynamic hip screw system DHS was implanted.
To improve resistance and to prevent new fractures on controlateral nonfracturated osteoporotic hip, we injected cement and K wires, in controlateral hip fracture, during the same intervention, using a single anesthesia.
This is a minim invasive method, for preventing of fractures at the contra lateral side, of osteoporotic patients. This short series of patients are part of an international study with more than 100 patients. The fracture site was operated in dorsal decubitus under spinal anesthesia; we took adventage of this operation and anesthesia to perform a minimal invasive percutaneous synthesis for the nonfracture controlateral side. This second operation was made for preventing of fractures at the contra lateral side. We used a simple implant, a quickly method during the same surgery time and anesthesia. The K wires with injected cement were percutaneously inserted. Through a 5 mm skin incision, a channel is created in the proximal femur bone and the implant, made of a fabric pouch hosting Titanium rods, is built percutaneously within the femur. A small amount of bone cement is then added, and interdigitates to the osteoporotic bone to further fixate the implant.



Pre and Postoperative X Ray Femoral neck fracture operated on controlateral side by MIS prophylactic synthesis


Pre and Postoperative X Ray Cominuted Pertrochanteric fracture operated on controlateral side by MIS prophylactic synthesis

This system of synthesis contains a set of Titanium (Ti-6Al-4V) rods of 3 mm diameter. It was inserted percutaneously into a polymer fabric pouch, followed by injection of small amount of polymethylmethacrylate (PMMA) bone cement. Rods length ranges between 50 mm to 120 mm (in 10 mm increments). Up to 5 rods are introduced into the pre-inserted fabric pouch, using designated introducer. The cement injection allows rigid fixation of the implants rods, as well as slight interdigitation into the surrounding cancellous bone, contributing to better fixation of the implant to the bone (The Ce-Cure System CE marked)23.
Results: Rehabilitation was obtained and full weight bearing was allowed immediately. The potential benefits expected with the use of this minimally invasive method are: quick procedure – 15 min, no soft tissue or bone damage, no bleeding, short rehabilitation period, reduced morbidity and mortality, low cost, same drape, single anesthesia.
The proximal extremity of femur became a solid structure and the osteoporotic patient who already suffered a contralateral fracture will be secured for future fractures.
This short series of patients are part of an international study with more than 100 patients. No hip fracture occurs since now at theses 4 patients.
Discussion: This preventive operation of non fractured hip osteoporotic patients and controlateral side hip fracture, is a minim invasive method. By injecting percutaneously of this system of synthesis23, we improve the structure of the osteoporotic hip, and prevent future fractures.
Theoretical speaking, in osteoporotic patients a new fracture can occur. This new structure improved by injected of cement, offers resistance which prevents further neck fractures, but a fracture can occur below the level fixed. This is a hypothetical situation, in our series no hip fracture has occurred untill now. However, to prevent the interfere of the pins and interdigitated cement, and the big screw of the new implant DSH or gamma nail, in case of a pertrochanteric fracture, maybe in the future it will be usefull the prophylactic injection of the osteoporotic hip only by biological cement.

Osteoporotic fractures can lead to pain, surgery, immobilization, disability, and social dependency. Patients are at great risk of recurrent hospitalization19 fracture20 and institutionalazation21 and therefore consequence of enormous costs. Continued growth in the elderly population will further raise the incidence of fractures and their associated costs dramatically. It has been suggested that the annual incidence of hip-fractures will increase to 3 million worldwide by the year 2025 8, triple by the year 2050 9 and might even pass 10 million by 2050 in Asia 10, and the associated costs will rise correspondingly 8. Presently, the costs related to osteoporotic are estimated up to 10–20 billion dollars per year in the United States, of which 60% are due to hip fractures 10-12. About 300,000 hospital admissions, with an estimated 9 billion dollars direct medical cost, are annual sequel of hip fractures in the United States 13, 14. It is therefore desirable to prevent fractures in those people at high risk.
Patient who fractured their hip are at high risk of fracture reoccurrence15-17. The incidence is excessively high during the first 12 months (men) and 19 months (women) following the first hip fracture15. 89%-92% of the reoccurring fracture will arise on the contralateral side15, 18.
In view of these findings it is crucial not only to treat the existing fracture, but to immediately prevent the occurrence of fractures in the susceptible contralateral hip side. As Nymark. T. states in his article “preventive strategies must be initiated immediately after the first fracture and should have immediate effects due to the extraordinary high risk of second fractures during the first months following the first hip fracture”.15
The current treatments for osteoporotic hip fractures such as parallel cannulated screws, side plates, compression sliding hip screws, etc present a few drawbacks22:
• Complications such as cutout and lack of fracture stability due to the osteoporotic poor bone quality.
• Invasive treatments therefore associated with high intra and post operative risks like long anesthesia, extensive bleeding, fat embolism, and infection.
• Long rehabilitation periods with high hospitalization costs due to invasive treatments which are prone to complications.
For this reason we imaginated a simple method to stabilize the contralateral hip and to prevent the fracture using a minimally invasive technique. The method is simple, reproductible and economically. The patient will be operated during the same anesthesia after the operation of fractured hip. This protocol enables a true percutaneous procedure performed throughout a 5mm cannula. Through a 5 mm skin incision, a channel is created in the proximal femur bone and the implant, made of a fabric pouch hosting Titanium rods, is built percutaneously within the femur. A small amount of bone cement is then added, and interdigitates to the osteoporotic bone to further fixate the implant 23-25.

The goal of the present study is to realize using a simple method the preventive treatment of the contralateral side at the same time with surgery treatment of fracture of all patients.
The potential benefits expected with the use of this minimally invasive method are:
1. Quick procedure – 15 min
2. No soft tissue or bone damage
3. No bleeding.
4. Local anesthesia
5. Short rehabilitation period
6. Reduced morbidity
7. Reduced mortality
8. Low cost
Conclusions: The method is simple, reproducible and economically. The osteoporotic patient will be operated during the same anesthesia after the operation of fractured hip. This is a simple method the preventive treatment of the contra lateral side at the same time with surgery treatment of fracture of all patients.
Maybe in to the future it will be usefull the prophylactic injection of the osteoporotic hip only by biological cement.

REFERENCES

1. Barrett-Connor, E., 1995. The economic and human costs of osteoporotic fracture. Am. J. Med. A 2, 3S–8.

2. Melton III LJ. How many women have osteoporosis now? J Bone Miner Res 1995;10:175–7.
3. Ira P. Scott DL, O’neill TW, Pritchard C, Woolf AD, Davis MJ. Quality of life, morbidity, and mortality after low trauma hip fractures in men. Ann Rheum Dis 2005

4. White B.L, Fisher W.D., Laurin C.A. Rate of mortality for elderly patients after fracture of the hip in the 1980’s. J of Bone and Joint Surgery. VOL 69-A, NO. 9, 1987

5. Steen Jensen,J. Mortality after Hip Fractures. Acta Orthop. Scandinavica, 50: 161-167,1979.

6. Gordon P.C. The probability of death following a fracture of the hip. Canadian Med. Asson. J., 105:47-62,1971

7. Keene GS, Parker MJ, Pryor GA. Mortality and morbidity after hip fractures. BMJ 1993;307:1248–50.

8. Resch H, Gollob E, Kudlacek S, Pietschmann P. Osteoporosis in the man. Wien Med Wochenschr 2001;151:457–63.

9. Cummings SR, Rubin SM, Black D. The future of hip fractures in the United States. Numbers, costs, and potential effects of postmenopausal estrogen. Clin Orthop Relat Res 1990:163–6.

10. Elffors L. Are osteoporotic fractures due to osteoporosis? Impacts of a frailty pandemic in an aging world. Aging (Milano) 1998;10:191– 204.

11. Ray WA, Taylor JA, Meador KG, et al. Arandomized trial of a consultation service to reduce falls in nursing homes. JAMA 1997;278:557–62.

12. Johnell O. The socioeconomic burden of fractures: today and in the 21st century. Am J Med 1997;103:20S–5S.

13. Stevens JA, Olson S. Reducing falls and resulting hip fractures among older women. Centers for Disease Control and Prevention. MMWR, Medical and Mortality Weekly Report. Ref Type: Report. 49 (RR02), 1-12. 31-3-2000.

14. Wehren LE, Magaziner J. Hip fracture: risk factors and outcomes. Curr Osteoporos Rep 2003;1:78–85.

15. T. Nymark. Short Time-Frame from the first to the Second Hip Fractures in the Funen Country Hip Fracture Study. Osteoporos.Int 17:1353-1357
16. Melton L.J. Hip Fracture Recurrence a Population Based Study. Clinical Orthopedics and Related Research. 167: 131-8 July 1981

17. Klotzbuecher M.C. Patients with Prior Fractures Have an Increased Risk of Future Fractures: A Summery of the Literature and Statistical Synthesis. J Of Bone & Mineral Research. Vol 15, N 4, 2000

18. Schroder, Henrik M, Occurrence and Incidence of the Second Hip Fracture. Clinical Orthopedics and Related Research. 289: 166-169 April, 1993.

19. Wolinsky FD, Fitzgerald JF, Stump TE. The effect of hip fracture on mortality, hospitalization, and functional status: a prospect study. Am J Public Health. 1997;87:398-403.

20. Johnell O, Nilsson BE. Hip fracture and accident disposition. Acta Orthop Scand. 1985;56:302-304.
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21. Bonar SK, Tinetti ME, Speechley M, Cooney LM. Factors associated with short-versus long-term skilled nursing facility placement among community-living hip fracture patients. J Am Geriatr Soc. 1990;38:1139-1144.

22. Parker J. M. Cost Benefit Analysis of Hip Fracture Treatment. J Bone Joint Surg (Br) 1992; 74-B : 261-4

23. Beckmanna J., Ferguson S.J. , Gebauer M., Luering C.,. Gasser B, Heini P. E Femoroplasty – augmentation of the proximal femur with composite bone cement - feasibility, biomechanical properties and osteosynthesis potential. Medical Engineering & Physics 29 (2007) 755–764

24. Heini P. F., Torsten F., Fankhauser C., Gasser B., Ganz R. Femoroplasty-augmentation of mechanical properties in the osteoporotic proximal femur: a biomechanical investigation of PMMA reinforcement in cadaver bones. Clinical biomechanics. 19 (2004) 506-512

25. M Zlowodzki, O Ayieni, BA Petrisor, M Bhandari, Femoral Neck Shortening After Fracture Fixation with Multiple Cancellous Screws: Incidence and Effect on Function, J Trauma 2008;64:163-169.

Pera, Aurel (2013), “The Social Aspects of Technology-enhanced Learning Situations,” Geopolitics, History, and International Relations 5(2): 118–123.
REFERENCES

1. Barrett-Connor, E., (1995), “The economic and human costs of osteoporotic fracture”. Am. J. Med. A2,3S–8.

2. Melton III LJ., (1995), “How many women have osteoporosis now?” J Bone Miner Res 1995;10:175–7.

3. Ira P. Scott DL, O’Neill TW, Pritchard C, Woolf AD, Davis MJ. ,(2005), “Quality of life, morbidity, and mortality after low trauma hip fractures in men.” Ann Rheum. Dis. 2005

4. White B.L, Fisher W.D., Laurin C.A.,(1987),” Rate of mortality for elderly patients after fracture of the hip in the 1980’s”, J of Bone and Joint Surgery. Vol 69-A, No. 9, 1987

5. Steen Jensen,J. , (1979), “Mortality after Hip Fractures”. Acta Orthop. Scandinavica, 50: 161-167,1979.

6. Gordon P.C., (1971),”The probability of death following a fracture of the hip”. Canadian Med. Asson. J., 105:47-62,1971

7. Keene GS, Parker MJ, Pryor GA., (1993),”Mortality and morbidity after hip fractures”. BMJ 1993;307:1248–50.

8. Resch H, Gollob E, Kudlacek S, Pietschmann P. ,(2001), “Osteoporosis in the man”, Wien Med Wochenschr 2001;151:457–63.

9. Cummings SR, Rubin SM, Black D. ,(1990),”The future of hip fractures in the United States. Numbers, costs, and potential effects of postmenopausal estrogen.” Clin Orthop Relat Res 1990:163–6.

10. Elffors L.,(1998),”Are osteoporotic fractures due to osteoporosis? Impacts of a frailty pandemic in an aging world. “Aging (Milano) 1998;10:191– 204.

11. Ray WA, Taylor JA, Meador KG, et al. , (1997), “A randomized trial of a consultation service to reduce falls in nursing homes.” JAMA 1997;278:557–62.

12. Johnell O.,(1997),” The socioeconomic burden of fractures: today and in the 21st century.” Am J Med 1997;103:20S–5S.

13. Stevens JA, Olson S. ,(2000),”Reducing falls and resulting hip fractures among older women.” Centers for Disease Control and Prevention. MMWR, Medical and Mortality Weekly Report. Ref Type: Report. 49 (RR02), 1-12. 31-3-2000.

14. Wehren LE, Magaziner J. ,(2003),”Hip fracture: risk factors and outcomes.” Curr Osteoporos Rep 2003;1:78–85.

15. T. Nymark, (2001), “Short Time-Frame from the first to the Second Hip Fractures in the Funen Country Hip Fracture Study.” Osteoporos.Int 17:1353-1357

16. Melton L.J., (1981), “Hip Fracture Recurrence a Population Based Study.” Clinical Orthopedics and Related Research. 167: 131-8 July 1981

17. Klotzbuecher M.C., (2000), “Patients with Prior Fractures Have an Increased Risk of Future Fractures: A Summary of the Literature and Statistical Synthesis.” J. Of Bone & Mineral Research. Vol 15, N 4, 2000

18. Schroder, Henrik M,(1993),”Occurrence and Incidence of the Second Hip Fracture.” Clinical Orthopedics and Related Research. 289: 166-169 April, 1993.

19. Wolinsky FD, Fitzgerald JF, Stump TE.,(1997),”The effect of hip fracture on mortality, hospitalization, and functional status: a prospect study.” Am J Public Health. 1997;87:398-403.

20. Johnell O, Nilsson BE.,(1985), “ Hip fracture and accident disposition.” Acta Orthop Scand. 1985;56:302-304.

21. Bonar SK, Tinetti ME, Speechley M, Cooney LM.,(1990),” Factors associated with short-versus long-term skilled nursing facility placement among community-living hip fracture patients.” J Am Geriatr Soc. 1990;38:1139-1144.

22. Parker J. M.,(1992),” Cost Benefit Analysis of Hip Fracture Treatment.” J Bone Joint Surg (Br) 1992; 74-B: 261-4

23. Beckmanna J., Ferguson S.J., Gebauer M., Luering C., Gasser B, Heini P. E,(2007),” Femoroplasty – augmentation of the proximal femur with composite bone cement - feasibility, biomechanical properties and osteosynthesis potential.” Medical Engineering & Physics 29 (2007) 755–764

24. Heini P. F., Torsten F., Fankhauser C., Gasser B., Ganz R.,(2004),” Femoroplasty-augmentation of mechanical properties in the osteoporotic proximal femur: a biomechanical investigation of PMMA reinforcement in cadaver bones.” Clinical biomechanics 19 (2004) 506-512

25. M Zlowodzki, O Ayieni, BA Petrisor, M Bhandari,(2008),” Femoral Neck Shortening After Fracture Fixation with Multiple Cancellous Screws: Incidence and Effect on Function”, J Trauma 2008;64:163-169.