Symposium explores fragility fracture management and prevention strategies

Fragility fractures—low-energy fractures sustained from a fall from standing—are a major problem among our nation’s elderly population. These potentially life-threatening injuries will become even more prevalent in the future, according to Samir Mehta, MD.

“At least 1.5 million people need medical care for fragility fractures annually,” said Dr. Mehta, noting that an “epidemic” of fragility fractures is expected as 78 million baby boomers reach age 65 and beyond.

Dr. Mehta served as moderator of a symposium at the 2010 Annual Meeting that explored some of the latest fracture management and prevention strategies.

“We need to improve and optimize fragility fracture care, particularly for hip fractures, which can be difficult to reduce and to keep reduced,” he said.

“We must also raise orthopaedists’ and patients’ awareness about how these injuries can be prevented,” added Dr. Mehta.

Repairing the fractures
When treating fragility fractures, said Walter W. Virkus, MD, orthopaedists should use similar strategies as are used to treat metastatic disease.

“Surgeons always want to avoid multiple operations, particularly when treating metastatic disease and fragility fractures,” he said. “With both conditions, avoiding risky constructs and protecting as much of the involved bone as possible is advised. Also, fail-proof fixation should be the goal because patients are not going to comply with weight-bearing restrictions.”

Locking plates, which have improved fixation in poor quality bone, offer substantial advantages in patients with fragility fractures, as do contoured plates.

“Contoured plates often allow the surgeon to insert a longer plate without making as big an incision,” said Dr. Virkus. He noted, however, that nails should be used whenever possible, and the decision to use nails or plates should be based on the fracture pattern.

Dr. Virkus warned that orthopaedists should not count on improving biology or stability postoperatively and recommended avoiding open reduction and internal fixation (ORIF) when possible. When ORIF is necessary, he and the other orthopaedic surgeons at his institution use longer plates.

“In addition,” he said, “with periarticular fractures, joint replacement is often preferred over reconstruction in some locations.”

He noted that intertrochanteric fractures are one of the most common types of fragility fractures in elderly patients.

“Most surgeons would agree that surgical technique is much more important than the type of implant used to repair inter-trochanteric fractures,” said Dr. Virkus. “Most constructs are designed for controlled collapse, which can be good because this minimizes cutout from the femoral head. This type of implant design can also have drawbacks, however, because excessive collapse can result in significant limb length discrepancy, impingement, and pain.”

He noted that the risk of periprosthetic fracture exists regardless of the type of implant used.

Dr. Virkus said that with stable, two-part fractures, a two-hole compression hip screw is a viable choice because “it has the best data to support it and is cost-effective,” while intramedullary hip screws are the device of choice for three- or four-part fractures.

“The surgeon must decide whether to use a short or long implant,” he said. “The trend is to use long nails that go all the way down to the distal femur. From a pathological fracture point of view, it is important to lock both sides whenever possible.”

Preventing future fractures
After an orthopaedic surgeon performs surgery to repair a fragility fracture, said Jaimo Ahn, MD, his or her goal is to help the patient heal and to prevent future falls.

“Fixing fragility fractures is an important step,” he said, “but that is not going to change the epidemiology of what is occurring with these patients. As patients age, their bone and muscle strength decreases, making them prone to losing their balance and less able to protect themselves from a fall. Treatment strategies must take the metabolic changes related to aging into account.”

While taking the patient’s history, said Dr. Ahn, orthopaedists should pay particular attention to self-reported difficulty with walking and previous history of falls, because these factors are predictive of more falls and fractures in the future. Dr. Ahn also emphasized the importance of obtaining baseline laboratory values and having the patient undergo a metabolic consultation for osteoporosis.

“If appropriate, therapy for osteoporosis should be initiated,” he said.

Because smoking and drinking more than three servings of alcohol a day have been associated with decreased bone strength and increased risk of falling, orthopaedists should advise patients to curtail these activities.

“Nutrition is another important component,” said Dr. Ahn. “Patients who have a body mass index lower than 18.5 are likely to be malnourished. Orthopaedists should consider ordering a nutrition work-up and possible nutritional supplementation.

“Bisphosphonates have been shown to be successful medications, but long-term use may be problematic,” said Dr. Ahn, adding that more data is needed on potential long-term therapy-related complications and fractures.

Dr. Ahn also noted that patients should engage in a resistance training program to improve bone health.

“Exercise decreases the rate of bone loss and has been associated with decreased rate of hip fractures,” he said. “Patients should be enrolled in fall prevention programs, and orthopaedists should emphasize the need for lifelong exercise to prevent more falls and fractures.”

Jennie McKee is a staff writer for AAOS Now. She can be reached at mckee@aaos.org

Disclosure information: Dr. Mehta—AO, Smith & Nephew, Wolters Kluwer Health–Lippincott Williams & Wilkins; Dr. Kates—Eli Lilly, Synthes; Dr. Virkus—Stryker, Cardomems, Novartis; Dr. Ahn—no conflicts.

Standardizing care
According to Stephen L. Kates, MD, a multidisciplinary approach that uses standardized order sets can improve care for patients with fragility fractures.

“Using a multidisciplinary approach is important because elderly hip fracture patients have many comorbidities that may be more significant than surgery in determining their outcomes,” said Dr. Kates. “Our goal is to reduce the mortality rate and provide patients with good functional outcomes.”

He noted that approximately 250 U.S. hospitals are in the process of adopting or have already adopted standardized care pathways. These standardized pathways include standardized order sets, which can provide a comprehensive set of orders for admission and postoperative care.

“Such a program saves time and makes it easier to take good care of patients,” he said. “It reduces adverse events as well as cancellations of cases. Standardized orders can be designed to help hospitals meet state, federal, and Joint Commission regulatory requirements.”

Orthopaedists should work with pharmacists, physical therapists, medical physicians, and other relevant groups to create standardized order sets. The order sets should be reviewed by the hospital’s orders or forms committee to ensure that they meet hospital guidelines.

“The best champion for the process,” said Dr. Kates, “is a determined surgeon who really wants to see this happen. In addition, it’s important to choose someone from the medicine or geriatric service to serve as a partner in this process.”

He recommended following certain metrics—such as length of stay, mortality, and complication rate—and reviewing the program at specified intervals.

“It is critical to have transparency with this process and share outcomes with one’s colleagues,” he said.

At Dr. Kates’ institution, which uses standardized order sets for patients with fragility fractures, all surgeries for these patients are “essentially done in less than 24 hours.”

“Our infection rate—including wound, pulmonary, and urinary infections—is 2.6 percent, and we have reduced our length of stay to 4.6 days,” said Dr. Kates. “Our in-hospital mortality is 1.5 percent, which is much lower than the national average of 4 percent, and the readmission rate is about 9.7 percent, which is about half the national average of 20 percent.”

Bottom line

• Orthopaedists should avoid multiple surgeries on patients with fragility fractures, protect as much of the involved bone as possible, and make fixation as fail-proof as possible.
• Nonsurgical treatments that emphasize improving bone strength can help prevent future falls and fractures.
• Standardized care pathways can help save time, improve patient outcomes, and decrease surgery cancellations.